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Keynote Address—Redefining Regionalization: Merging Systems to Create Networks

2010; Wiley; Volume: 17; Issue: 12 Linguagem: Inglês

10.1111/j.1553-2712.2010.00945.x

1553-2712

Ricardo Martínez López,

European Union Policy and Governance

Editor’s note: The following is a transcript of Dr. Martinez’ keynote address at the 2010 Academic Emergency Medicine consensus conference, “Beyond Regionalization: Integrated Networks of Care “ “Provide optimal care based on the patient’s location and condition.”—Future of Emergency Care. Hospital-Based Emergency Care: At the Breaking Point.1 Thank you for the opportunity to be here with you today. Part of my early career was very much involved in the development of trauma centers and trauma systems, and I was a participant in preventable death studies in the 1980s. Having risen from the ranks of being an EMT, I trained at and still work in Level I trauma centers and tertiary care centers, but I have also worked in small rural facilities and smaller suburban hospitals. In my current role as president of the Schumacher Group’s Division East, I oversee about 90 emergency departments (EDs) with a split of about one-third large, one-third medium, and one-third smaller facilities. Each of these facilities is decidedly different, with different resources and different needs. What I hope to offer to you today is a shared perspective of our past and our future, so that we can join together to help us all move to the next level in system development. I have always been very simple and I offer that approach by starting with a story that can demonstrate my main point. I recently came running off the plane in my hometown of Atlanta and took the shuttle to the parking lot to get my car so that I could get home quickly for a webinar that I was participating in. Focused on this issue, I got off the shuttle at my car, was handed my parking ticket from the shuttle driver, grabbed my briefcase and suitcase, placed them in my vehicle trunk, placed my coat on a hanger in the back seat, and jumped up front behind the wheel. That’s when I noticed I could not find that stupid piece of paper that I needed in order to pay. What the heck happened to it? I got out of the car and searched under the seat, on the dash, in the back seat, and throughout the trunk, but to no avail. I started waving for the shuttle driver, hoping that she had forgotten to give me the ticket. It started to rain, but I persisted to jump, wave, and get on my hands and knees to look under the car before I finally repeated my search through the car, before again jumping and waving for the shuttle driver again. Finally—she sees me! I continued to search frantically until the shuttle driver drove up. Just as she did so, I began to yell to her, and I suddenly realized where that stupid piece of paper was. It was in my mouth. Since I first told that story, I have been inundated with messages from colleagues who have had similar experiences. So, let’s all acknowledge that we have moments when we are so focused on one thing, that we neglect to see what is right in front of (or actually in) our faces. Sometimes our focus drives what we do and we don’t see what is obvious. The purpose of this meeting is to reflect, learn, and look around the landscape and ask ourselves these three questions: where are we now, where do we want to go, and how will we get there? Based on recommendations in the landmark report entitled Accidental Death and Disability: The Neglected Disease of Modern Society,2 the driving force behind regionalization since the 1970s has been the mantra “Get the right patient to the right care at the right time.” This strong focus has led to the growth of emergency medical services (EMS), trauma, and cardiac care systems across the nation and continues to drive our systems development to this day. This original model changed the world and led to many improvements in patient care. This room is full of dedicated builders who made that dream a reality. There is a lot to be proud of. On the other hand, emerging criticisms of this model are that it was designed for low-frequency, high-impact events, has a frustratingly low uptake in the marketplace, and in the current format may not meet our emerging and future needs. Improvements must be made on the current model in order to have a system that meets everyone’s needs, including those of the physicians, patients, and hospitals that participate. Let’s look at some of the current challenges. There is a maldistribution of the workforce and resources within emergency care. Tertiary care and larger urban hospitals house a majority of the residency-trained, board-certified emergency physicians, specialist consultants, interventions, and equipment. The 2006 IOM report on the Future of Emergency Care notes that about 62% of physicians practicing in EDs are board-certified and that 38% are not. Hospitals located in the smaller suburban and rural regions have a larger number of noncertified physicians working in EDs, a scarcity of specialists, and fewer resources. When these smaller, lesser-staffed hospitals receive patients with high-frequency, moderate-impact issues, such as abdominal pain, chest pain, fever, headache, and injuries, they are often forced to transfer them up to other hospitals and providers for additional cognitive evaluation or for specialized procedures and equipment. This inefficient transfer mechanism creates a “one-way valve” in which patients are transferred upstream to hospitals with the most resources aggregated. This results not in the ideal of a planned, accountable, coordinated, and regionalized system, but in what is instead termed centralization—the unplanned, unscheduled, and uncoordinated dumping of complex patients on big facilities perceived to have limitless resources. The economics of this system of transfers cause strains for patients and their families, for local facilities, for providers, and for the community. There are winners and losers. Smaller hospitals lose revenue and capability when too many patients are transferred out instead of cared for locally. Many rural and smaller hospitals “opt out” of participation in current systems simply because it has a negative effect on their operations, and while large hospitals may recognize a financial gain, they may also be crowded and burdened by patients they do not perceive to need tertiary care center care. For patients, the current model forces them to be moved out of their local care network and often disrupts their relationship with their provider. In addition, a large number of transferred patients are discharged from the ED of the receiving facility after evaluation. For the latter, numbers are very difficult to find because we simply do not track it, but anecdotally, the estimate from at least three tertiary care facilities surveyed was around 70%. If the real number is only one-third or even one-seventh of that, it is still amazingly high, and reflects the inefficiency of the system. Not only is this system inefficient at an operational level, but the current process of patient transfers proves difficult for physicians who try to operate within it, and the lack of shared information, feedback, and communication does not increase the capabilities or professionalism of providers equally within the system. We need a system that maximizes access and quality while minimizing any adverse or negative effects on participants. Did you realize that the majority of hospitals in the United States have fewer than 20,000 ED visits? Yet the predominant view in the literature is proffered by those who work in larger urban and tertiary care centers and does not reflect the needs of all facilities or participants. The current system works best for those small number of patients who are currently selected out for care, but what does the current model offer for that larger number of patients who do not have a critical issue such as major trauma, STEMI, or acute stroke, but still have time-sensitive conditions such as chest pain, abdominal pain, headache, infection, or injury? These patients represent the vast majority of ED patients, yet the current model essentially excludes them. We can do better. A good place to start is by focusing on quality. While Accidental Death and Disability was a game changer, so too are more modern reports that are driving change. In 2001, the IOM published a report entitled Crossing the Quality Chasm: A New Health System for the 21st Century,3 which identified six key attributes of quality health care: patient-centered, safe, effective, efficient, timely, and equitable. These attributes of quality health care have been driving the programs, dashboards, and metrics for physicians and hospitals over these past few years. For example, the rise of the Hospital Core Measures and Physician Quality Reporting Initiative data is an offshoot of this desire for effectiveness measures. Patient-centered care has given rise to measuring patient satisfaction. Other measures that reflect these aims abound, such as length of stay (efficient), time to treatment (timely), and left without treatment (patient safety). This report also presented redesign imperatives for building systems of quality care. In order to move forward, care processes must be reengineered. The effective use of information technologies, and better knowledge and skills management, will provide improved delivery of quality care. The development of effective teams is crucial to the success of any delivery system. The emergency department provides a great environment for teamwork and collaboration due to its fluid nature. Last, the coordination of care across patient conditions, services, and sites of care over time will strengthen patient care. So what is the market saying to us, when 40 years after the current model was created, we are still fighting to get it distributed? What would a manufacturer such as Apple do if its products had such weak market penetration? Perhaps the model is wrong and does not meet the needs of the end user. Therefore, let’s simply change the model. The challenges with the current system include time, distance, and geography, especially if located in a smaller facility. There is restricted access to timely information, including a lack of technological devices that prevents physicians from accessing patient information when needed. Workforce shortages include both numbers and maldistribution of providers and health workers, as well as access to providers who are in rural areas. This is exacerbated by an aging population and the growth of patients with chronic disease who will need care over the coming years. Clearly, the current model is not sustainable. However, there is plenty of opportunity as well. Resources abound—they are just poorly distributed. Today, there is rapid growth in electronic and digital data, images, and records that make the movement and sharing of data easier. This is coupled with the growth of high-speed connections, both wired and wireless, and the rapid adoption of “smart phones” and tablet computers. At state and local levels, the development of health information exchanges provides secure ways to share and interface among data sources. These changes in technology offer opportunities to redesign and reengineer the system, as well as improve collaboration among the components. Technologies can leverage our ability to scale cognitive resources and integrate others. The move toward quality and value-based payments will help support reporting of quality measures not only about the patient, but about the system itself. This important area of work—quality metrics for system performance—will require the attention of the EM research community. The care resources available fall into three basic categories: specialized equipment and technology such as cardiac catheterization labs and imaging, procedural skills such as surgical techniques and balloons, and cognitive skills. These resources are either fixed or mobile. Generally, the first two are fixed and the latter, cognitive skills, is mobile. The patient must be moved to fixed resources, but cognitive skills remain mobile and can be moved directly to the patient’s bedside. The moving of cognitive resources is already occurring through teleradiology, telestroke, and remote intensive care unit care, but much more can be done. Electronic collaboration allows for a patient care consultation, patient monitoring, imaging/electrocardiogram review and interpretation, education and training for physicians, and the transfer of care and treatment planning. More of our patients can benefit, and more providers will learn and increase their capacities and capabilities. Can we build a care system that is more patient-centered, efficient, effective, timely, safe, and equitable? Absolutely. Rather than the traditional unidirectional flow of care, a funnel in which patients aggregate up, we must build systems of care in which all participants benefit and care flows multidirectionally into integrated networks of care. The new mantra for the development of these integrated networks of emergency care is to “get the right resource to the right patient at the right place at the right time.” Rather than just using a top-down approach, these networks can simply grow by emulating methods of growing wireless networks from one geographic location and expanding outward to create larger networks. The steps that are needed to build these networks of care are straightforward: Categorize the emergency departments, the patients, and the resources. The traditional methods of quantifying the resource need to be examined with the future in mind. Change the driving goal of regionalization from just moving patients to also moving resources. Match these resources with the needs of the patients, providers, and facilities. Develop a simple and easily understood model so that it is readily spread and scaled. Deliver clear, concise, reportable quality care measures for the patient, facility, provider, system, and population levels. Continuously measure, monitor, deliver, and improve quality. So what do we need to do next? Change the name, change the goals, change the rules, and change the world. Changing the name from the traditional focus on “regionalization” to redesigning and developing new “integrated networks” of emergency care, we can begin anew and build on the past, but not be bound by it. We must change the driving force from getting the right patients to the right place at the right time, to getting the right resource to the right patient at the right place at the right time, and do the greatest good for the greatest number of patients. Changing the rules means that the system must drive value through measurable quality and have something for all those who participate. Do no harm to those in the network. It has to be win–win. What we have built to this date is an amazing testimony to your leadership, vision, and hard work. Leadership does count. Look around you today and you see that everything you see once started as a dream in someone’s mind. People took that vision and made it into a reality. My challenge to each and every one of you is to take the lessons learned from the past and the dreams of the future and use your leadership skills to take our reality to the next level—that of integrated networks of emergency care. Thank you very much. The author thanks Dr. Brendan Carr and Erin Quinn for their help with the manuscript.