System Dynamics and Dysfunctionalities ... - Wiley Online Library

PRESENTATION

System Dynamics and Dysfunctionalities: Levers for Overcoming Emergency Department Overcrowding Gordon D. Schiff, MD

Abstract Overcrowding of U.S. emergency departments (EDs) is a widely recognized and growing problem. This presentation offers the perspectives of a primary care physician (PCP) examining the problem at three levels: global health policy, quality process improvement, and more intimate clinical caring. It posits that ED overcrowding is actually a symptom of 10 more fundamental problems in U.S. health care and EDs: variations ⁄ supply-demand mismatch; primary care provider shortfalls; limited after-hours access; admission throughput challenges; clinical challenges related to discontinuity patients; clinical challenges related to those with special needs; interruptions; testing logistical challenges; suboptimal information systems; and fragmented ⁄ dysfunctional health insurance system, leaving many un- and underinsured. ACADEMIC EMERGENCY MEDICINE 2011; 18:1255–1261 ª 2011 by the Society for Academic Emergency Medicine

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his conference permits us to step back from the daily frenzy and frustrations of caring for patients in overcrowded emergency departments (EDs) to think more broadly about causes and approaches for addressing the growing problem of overcrowding.1 While not an emergency physician (EP), I spent many hours working in the emergency room at Cook County Hospital (and its overflow area for less urgent patients) From the Brigham and Women’s Hospital Center for Patient Safety Research and Practice, Division of General Medicine ⁄ Primary Care Brigham and Women’s Hospital, Harvard Medical School, Boston, MA. Received July 20, 2011; revision received August 23, 2011; accepted August 23, 2011. This manuscript represents a component of the 2011 Academic Emergency Medicine Consensus Conference entitled ‘‘Interventions to Assure Quality in the Crowded Emergency Department (ED)’’ held in Boston, MA. Funding for this conference was made possible (in part) by 1R13HS020139-01 from the Agency for Healthcare Research and Quality (AHRQ). The views expressed in written conference materials or publications and by speakers and moderators do not necessarily reflect the official policies of the Department of Health and Human Services, nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government. This issue of Academic Emergency Medicine is funded by the Robert Wood Johnson Foundation. The authors have no potential conflicts of interest to disclose. Supervising Editor: James Miner, MD. Address for correspondence and reprints: Gordon Schiff, MD; e-mail: [email protected].

ª 2011 by the Society for Academic Emergency Medicine doi: 10.1111/j.1553-2712.2011.01225.x

as a trainee and junior attending. We liked to say that County’s ER (the real ER, on which the famous TV series is based), like everything at County, is so far behind … it’s ahead. And indeed we were decades ahead of the national crisis in nearly always being overcrowded, largely as we are seeing today, as a result of backup from inpatient overcrowding. Adding insult to injury, private hospitals in Chicago liberally sent us patients, at times unstable patients, often claiming their ‘‘beds were full,’’ when in fact the patient had an original diagnosis of AIDS (AIDS—acute insurance deficiency syndrome). Our studies2,3 on these problems at County in the 1980s led to the passage of EMTALA, which stemmed some of the worst abuses, but obviously did little to fix the underlying problems.4 One of the special privileges of working at a place like Cook County was the fact that we were face to face with larger policy and social forces every day. County’s gift was giving us a zoom lens, teaching and forcing us to telescope between the macro and micro views. I will borrow this zoom lens, moving back and forth, in and out, between three vantage points: more global health policy perspectives, the midrange views afforded by quality process improvement, and the intimacy of the close clinical attachment related to deeply caring for our patients. While the crisis of ‘‘overcrowding’’ is the chief complaint that brought us together for this consensus conference, we know that this is really a symptom of deeper problems. I will touch on 10 of these (Table 1). These problems seem both simultaneously overwhelmingly insoluble and loaded with opportunities to make

ISSN 1069-6563 PII ISSN 1069-6563583

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LEVERS FOR OVERCOMING OVERCROWDING

Table 1 Overcrowding: Chief Complaint—or Symptoms of Deeper Problems 1. 2. 3. 4. 5. 6.

Peak and valley variations, but mostly in overloaded state. Shortfalls of primary care to capacity ⁄ ability to intercept ⁄ decrease demand, as well as take handoffs from ED. After-hours access to primary care. Admission throughput—full beds leading to ED boarding. Clinical challenges assessing ‘‘unknown’’ patients. Special population challenges: mentally ill, homeless, substance dependent, oncology, cardiology, complex medical patients. 7. Frequent and major interruptions and distractions. 8. Testing logistics ⁄ issues: delays, decision-making, follow-up. 9. Lack of unified, efficient information systems—for access prior history, tests, assessments, meds, easy documentation. 10. Dysfunctional health insurance system—lack of universal coverage, fragmented rather than unified system.

concrete, meaningful incremental improvements that can make a difference and perhaps even help catalyze larger change. As I zoom in and out, hopefully a wider but also more closeup view of these problems can emerge. Doing full justice to this daunting list is not possible; rather I will focus on a half-dozen high leverage areas for improvement. These include designing more robust follow-up ⁄ feedback safety nets; the need for a new science of ‘‘uncertainty safety’’ as part of rethinking diagnosis reliability in the ED; streamlining and strengthening electronic medical record (EMR) clinical documentation functionality to increase quality to support cognition, decision-making to offset information overload, and improve production efficiencies; enhancing the ED-imaging interface and higher-level collaboration with primary care physicians (PCPs); and finally engineering ‘‘pull systems’’ for admissions ⁄ discharges. WHAT IS CAUSING ED OVERCROWDING? While popular stereotypes blame frivolous overuse and hordes of uninsured patients, the organizers of the conference wisely and categorically dismiss these victim-blaming prejudiced and scientifically inaccurate explanations in the proposal for this conference: The causes of crowding are multifactorial. There is a widespread misconception among the public, policymakers, and the lay press that crowding is primarily caused by large influxes of patient arrivals to the ED, particularly among the uninsured and ⁄ or the poor. However, studies conducted over the past decade have consistently found that the strongest predictor of crowding is inpatient bed availability. As a small reality test, I did a quick poll of several ED colleagues in the United States and Canada. There was remarkable consistency. Despite some predictable variations (e.g., public hospital had a bigger problem with a lack of primary care), overall this quick snapshot using the widely used three-component conceptual model (input, throughput, output), supplemented by my own subcategories, reinforced the sense that bed availability was the largest driver of the problem, with multiple other contributors playing smaller but definite roles (Table 2).

As is reflected by these admittedly subjective weightings by a range of experienced EPs, inappropriate overuse comprises perhaps 5% of the problem. This number closely matches the Centers for Disease Control and Prevention estimate that only 8% of ED visits are for a nonurgent problem.1 Further, from the patients’ vantage point it is difficult to fault sick people for exercising what they perceive as their best options based on their fears, knowledge, and other ‘‘patientcentered’’ choices. WHO CAN TELL IF AN ED VISIT IS APPROPRIATE? An example Dr. Pat Crosskerry offers is a subconjunctival hemorrhage, which physicians know is generally quite benign and hardly a life-threatening emergency, but for a patient can be extremely frightening—how does the patient know that he or she is not (as one of his patients worried) ‘‘bleeding his or her brains out.’’ Likewise, I will relate a personal story, similar to what I suspect each of us could also share from personal, family, or professional encounters. As a third-year medical student, about to start my medicine clerkship, I experienced sudden onset of chest pain radiating down my left arm associated with shortness of breath and an indescribable but powerful feeling of impending doom. I went to the ED convinced I was experiencing a near-fatal heart attack. The EPs were not only unimpressed that I had an acute MI, but readily dismissed me, with a diagnosis of ‘‘medical student anxiety syndrome.’’ A few days later, still having nagging left-sided chest pain and dyspnea, I began noticing a grade 6 ⁄ 6 heart murmur (could hear across room without a stethoscope). My roommate, who had completed his medicine clerkship, diagnosed acute pericarditis—yet another misdiagnosis. Finally, several days later I was able to see my PCP who immediately recognized my Hammans sign and evidence of mediastinal emphysema and ordered the chest x-ray that showed a 40% pneumothorax. Five years later, now a medical chief resident, I experienced what I thought was an acute recurrence based on very similar symptoms, reinforced by my now broader medical knowledge that spontaneous pneumothorax frequently recurred.5 Thus, I presented to the ED to obtain a chest x-ray. Much to my surprise, it was normal. Blue Cross denied reimbursement for the visit, since there were (in their post hoc review) no findings

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Table 2 ED Overcrowding: Where Do the Problem and Opportunities to Improve Lie?

Upstream No PCP Lack after-hours access from usual source care Could be safely handled nonemergency by PCP Inappropriate patient utilization choices Chronic mental illness, substance abuse, homelessness Seasonal ⁄ surge demands Intra-ED Flow Increased volume numbers patients Inadequate space for demand ⁄ census Insufficient staffing for volume ⁄ peaks Throughput efficiencies for radiology Throughput efficiencies for lab tests Clinical documentation, other EMR inefficiencies Language barrier interpreter services delays Delays related to specialist ⁄ consultations Observation unit issues: space, staff, policies Other ⁄ general workflow inefficiencies Downstream Inpatient bed unavailability for required admissions Lack mechanisms for ‘‘safe’’ follow-up checking (nurses phoning) Lack mechanisms for ‘‘safe’’ early discharge pending labs PCP not readily available to ‘‘pull’’ for follow-up Social service resources, discharge option

18 4 3 4 1 4 2 20 2 2 2 2 2 1 1 2 1 4 63 35 7 4 10 7

Min

Max

1 1 1 0 2 1

10 6 8 2 9 4

1 1 1 0 0 0 0 1 0 1

3 4 5 5 5 3 2 6 2 7

19 3 3 2 2

58 12 5 15 13

All values reported are percentages. EMR = electronic medical record; PCP = primary care physician. *Focus group ⁄ poll of 10 selected EPs in U.S. in Canada.

to justify coming to the ED. I guess they were smarter than me about knowing what I did, or did not, have. Another 5 years after that, now an experienced internal medicine attending physician, I was mowing our tiny lawn and experienced a vague twinge of chest pain. After ignoring and dismissing the pain for 8 hours, my wife convinced me to go to the ED. Sure enough, I had a 20% pneumothorax. Thus, my batting average in ‘‘knowing’’ what was wrong with me, in predicting the right diagnosis and knowing when and whether to use the ED, was pretty close to zero. It would be hard to have a more ‘‘informed’’ consumer as a patient than me, yet my decision-making related to what was wrong with me and when I should go to the ED showed that I was pretty ignorant, at least in retrospect. FINANCIAL BARRIERS THE ANSWER TO OVERCROWDING? Whether imposing a high copayment or having to pay the full bill (as part of a high-deductible health insurance plan) would have sharpened my clinical acumen in deciding whether to seek or avoid coming to the ED for my pneumothorax is questionable. Unfortunately, much of health policy aimed at holding down costs is based on such questionable logic. As the economic recession continues to grow, so are the painful economic consequences (including bankruptcy, home foreclosure, and diverting money from putting food on the table) of accessing medical care. We see stories such as the one on page 1 of the New York Times last

month with the headline ‘‘Health Insurers Making Record Profits as Many Postpone Care.’’6 Hopefully we are not heading in the direction of the paradox memorialized in an essay by the poet Eduardo Galeano. ‘‘The World Bank praises the privatization of public health in Zambia.’’ It is a model for the rest of Africa. There are no more waiting lines at hospitals. ‘‘The Zambian Post Daily completes the idea: There are no more waiting lines at hospitals because now people die at home.’’7 More productive (and ethical) approaches lie in delving more deeply into who is actually coming to EDs and why and then seeking opportunities to put in place effective programs to deal with the problems driving utilization and crowding. One study to better understand where such improvement opportunities existed, performed at my current hospital (Boston’s Brigham and Women’s), analyzed the diagnoses for the lower acuity patients (note: low acuity is not synonymous with nonacute). It identified thousands of annual visits for conditions such as back pain, sprains, pharyngitis, skin rash, dental problems, and mild respiratory illness. No doubt many of these visits could have been treated by PCPs, particularly if they provided urgent care access and services. This finding correlates with data showing that ED visits decreased as the proportion of physicians (in a metropolitan area) increased.8 More interesting was the finding from the Brigham group that a much larger opportunity (in terms of numbers of visits) existed in developing special care programs for mental health and substance abuse patients, most of whose visits were not triaged as being low acuity.

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INTRA-ED FLOODING: FLOW AND EFFICIENCIES Recent news filled with memorable images of the record flooding of the Mississippi River conjures up a parallel metaphor of ED flooding. Thinking about decreasing upstream demands, intra-ED flow and efficiencies, and downstream flow blockages brings us to the next set of questions regarding what EDs might do internally to buffer the upstream and downstream factors that seem out of their direct control. Thus many EDs have worked on throughput efficiencies for improving their processes for assessing, testing, and readying patients for discharge. Acknowledging that EDs have been working a variety of fronts to look for improvement opportunities, here I wish to touch on several emerging, relatively untapped promising leverage points. Radiology use in the ED is one levee that is overflowing. Over the past decade, use of CT scans alone has increased fourfold (from 2.8% to 13.9% of all ED visits).9 Putting aside serious concerns about cost and radiation exposure, there are a host of areas for improvement for processes improvement, particularly in the interface between the ordering clinicians and the radiology department. As outlined by Jones and Crock10 (Australian radiology and ED physicians who have collaborated on a number of projects), there are numerous areas where an enhanced interface between these two departments—their staff, their handoffs, joint grappling with the clinical question—could be substantially improved (Table 3). Each of these areas represents recognized and often unrecognized speed bumps in caring for patients that ultimately contribute to ED crowding by creating rework, friction, delays, and misdiagnoses. FACILITATING DIAGNOSIS Many of us working in the area of diagnosis error and improvement believe that conceptualizing a ‘‘diagnostic time out’’ (like a preprocedure time out) could be helpful in better choosing, performing, and interpreting tests. Questions such as when should we have such time outs (after all, we want to speed, not arrest

Table 3 Areas for Improvement ED—Radiology Interface Unnecessary imaging test requested leading to potential delayed diagnosis condition not requiring imaging Wrong imaging test requested unable to answer the clinical question Wrong patient or wrong body part imaged Test not performed in a timely fashion resulting in delayed diagnosis Test performed incorrectly Inadequate image quality Imaging test not interpreted in a timely fashion Interpretation ⁄ reporting error by radiology (or ED) failures in perception, data gathering, synthesis Error in timely transmission or receipt of report Report not understood, synthesized, acted on by receiver Modified from Jones and Crock.10

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throughput) are paramount. But there is often a need to stop and ask questions such as are we sure this imaging test is needed (will it influence my treatment); is this the right test for the clinical question; what pitfalls (false negatives ⁄ positives) and safety issues need to be considered; what else are we overlooking; is there something about the results that does not fit with the clinical picture; and do the radiologists and the clinicians understand each other’s findings and do the conclusions align?10 Because diagnosis is so central to the role of the ED, other diagnosis issues also warrant attention. One, the subject of a session at the 2010 Diagnosis Error in Medicine Conference in Toronto, centers around the question of the calibration of accuracy vs. confidence. Research from psychology shows that there is a disconnect between accuracy and confidence.11 Those whose accuracy is poorer, and situations where the accuracy of decisions is lower, unfortunately are not those where the confidence is least. Ideally this relationship should be perfectly calibrated, so that when we are more certain, we are more often right about what is wrong with the patient and vice versa. This is particularly important in the ED, where there is so much uncertainty as well as danger from being wrong. It is not just a matter of being overly confident (i.e., arrogantly dismissing a patient or complaint as nonserious when in fact it is a harbinger of an overlooked serious diagnosis). Inappropriate underconfidence can also be a big problem in the ED, as physicians lacking appropriate confidence (overall, or in a particular case) can be paralyzed, delaying more rapid throughput and ⁄ or ordering excessive testing and observation. What is needed is not just a more accurately calibrated linear confidence scale, but richer approaches to dealing with ubiquitous uncertainties omnipresent in the practice of EM. We need to create a more advanced science of ‘‘uncertainty safety.’’ One element is the need to place safety nets under our diagnoses, so we can (in many cases) safely send patients home even when uncertain about exactly what is wrong.12,13 I find it amazing that most EDs lack a systematic method for automatically following up discharged patients to ensure that they are improving as expected. With new technology such as interactive voice response (IVR), calling patients to do this should be relatively easy. We have been piloting using IVR calls post–acute care visits in three clinics in an AHRQ-funded project at the University of Alabama, as well as following up patients started on new medications here in our primary care clinics at Brigham and Women’s clinics.14 ENHANCING USEFULNESS EFFICIENCY OF EMR

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Harvard physicians (mostly non-EPs) were recently surveyed by CRICO ⁄ RMF (Cambridge, MA; their malpractice insurer), on their views of their EMR. Despite working with what is considered to be one of the leading, state-of-the-art, clinician-built systems, their frustrations and desires for improvements were evident. Leading their wish lists: 65% wished for better ways to identify outstanding patient issues, 61% wanted easier


ways to enter information at the point of care, 60% sought better ways to recognize patients clinical problems, and 57% wished for improved access to other information sources at the point of care.15 Worse yet, our Brigham ED resident physicians are currently still documenting on paper (residents write paper notes and attendings dictate a note that is often not in the computer when I try to find out what has happened to my patients 1 or 2 days later). As EDs around the country become more fully computerized, we must address questions about quality and efficiency. According to a seminal report released last year by the National Academy of Science, entitled Computational Technology for Effective Health Care: Immediate Steps and Strategic Directions, ‘‘clinicians spend a great deal of time and energy searching and sifting through raw data about patients and trying to integrate these data, with their general medical knowledge to form mental abstractions and associations relevant to the patient’s situation. Such sifting efforts force clinicians to devote precious cognitive resources to the details of data and make it more likely that they will overlook some important higher-order consideration.’’16 These words perfectly describe many millions of wasted hours in our nation’s EDs. Missing information about a patient’s past history, medications, and tests is

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ubiquitous. Seemingly paradoxical is the opposite problem of information overload. It is increasingly impossible for EPs to review all available online documents and data. Finding the needle of desired information in the haystack of computerized scanned, dictated, poorly organized template notes and scattered lab reports is destined to surpass unavailable information as the major problem. One could say that needed information has gone from being ‘‘missing’’ to ‘‘hiding’’ or at least certainly not instantly available in the format needed for quick access and review. If we are looking for better ways to support and streamline diagnosis in the ED, reengineering EMRs and clinical documentation is critical. We recently published a discussion of 15 ways EMR systems should be redesigned to support diagnosis workflow.17 Table 4 is a modified version as it applies to the ED setting. Beyond reengineering internal ED workflow and documentation, the EMR needs to be deployed to facilitate communication and handoffs particularly to the PCP. Here again, the pioneering system at Brigham is both a model and an illustration of wished-for features to truly make this work effectively and efficiently. Figure 1 illustrates a wonderful system we have in place whereby I am automatically notified each time one of my patients comes to the ED. Upon discharge, an e-mail such as the

Table 4 Goals and Features of Redesigned EHR Systems to Support ED Diagnosis and Workflow Role for Electronic Documentation Providing access to information Recording and sharing assessments Maintaining dynamic patient history Integrating ⁄ maintaining problem lists Tracking medications Tracking tests Ensuring coordination and reliable handoffs Safety need for patient follow-up Providing feedback Providing prompts Buffering interruptions providing placeholder for resumption of work Calculating Bayesian probabilities Providing access to information sources Real-time consultations Increasing efficiency

Goals and Features Ensure ease, speed, selectivity, filtering information searches; to aid cognition through aggregation, trending, contextual relevance, and minimizing of superfluous data. Provide a space for recording thoughtful, succinct assessments, differential diagnoses, contingencies, unanswered questions; facilitate sharing and review of assessments by both patient and other clinicians. Carry forward information for recall, avoiding repetitive patient querying and recording while minimizing erroneous copying and pasting. Ensure that problem lists are integrated into workflow and facilitate continuous updating. Record of medications patient actually taking, patient responses to medications and adverse effects to avert misdiagnoses and ensure timely recognition of medication problems. Integrate management of diagnostic test results into workflow to facilitate appropriate ordering, review, assessment, action, handoffs, and documentation. Aggregate ⁄ integrate data from acute and chronic care episode encounters into quick snapshot ⁄ synthesis from prior, to subsequent providers. Facilitate patient education about potential red-flag symptoms to watch for; track follow-up. Automatic provision of feedback to upstream clinicians (including recent EP from recent visits), facilitating learning from outcomes of diagnostic decisions. Provide checklists to minimize reliance on memory and directed questioning to aid in diagnostic thoroughness and problem solving. Delineate clearly in the record where clinician should resume work after interruption, preventing lapses in data collection and thought process. Embed calculator into notes to reduce errors and minimize biases in subjective estimation of diagnostic probabilities. Provide instant access to knowledge resources through context-specific ‘‘infobuttons’’ triggered by keywords in notes that link user to relevant textbooks and guidelines. Integrate immediate online or telephone access to consultants to answer questions related to referral triage, testing strategies, or definitive diagnostic assessments. The holy grail. Can more thoughtful design, workflow integration, easing and distribution of documentation burden speed up charting, workflow, thereby freeing time for communication and cognition?

Modified from Schiff and Bates.17

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Figure 1. System in place whereby I am automatically notified each time one of my patients comes to the ED.

one illustrated is generated. While I value such notification, think about my workflow. I would like to pick up the phone to call the patient to discuss how he or she was doing and arrange any needed follow-up. Ideally, I would want to review the ED note in real time as I talked to the patient to intelligently review the findings, assessment, ED course, and discharge plan. However, this notification lacks the patient’s contact information (why couldn’t they have included the patient’s phone along with the discharge diagnosis?), so I have to open our EMR and find the patient (no hot link), which takes several minutes. While I can usually manually look up and find the phone number, there is generally no ED note to be found (as mentioned above, resident note is on paper, attending is a delayed dictated note). I suspect manual systems that fax the ED note to the PCP, which exist in some community hospital settings, probably do a better job than we do with our powerful IT system. DISIMPACTING DOWNSTREAM BLOCKAGES There is a strong consensus that the factor making the greatest contribution to ED overcrowding is obstructed throughput to inpatient admissions. In preparing this presentation on ED overcrowding, I wondered what expertise I, as a non-EP, have to speak on this topic. Also, I was busy because my time to prepare this talk coincided with a 2-week block as an inpatient attending. So I not only lacked expertise but also time to prepare. Then it dawned on me that the problem is me, or at least my inpatient service—not discharging patients in a timely enough way to open beds for new admissions. I often joked during my 35 years working with the ED at Cook County that treating ED overcrowding by expanding the number of beds in the ED is like trying to treat a bowel obstruction by stretching the mouth! Clearly we need to disimpact things at the other end. Thus, I looked at my logs for the 17 days on inpatient

service and counted the number of bed days needlessly lost to bed-blocking patient situations. Out of a total of 106 patient bed-days on my service, 21 were purely for patients awaiting placement, and another eight were occupied by patients awaiting delayed procedures. Thus, a total 29 of 106 or 27.4% of the bed-days were, by my conservative estimates, unnecessarily unavailable to ED admissions. One particularly frustrating patient situation was a woman admitted for severe hypoglycemia resulting from a suicide attempt with insulin. Once medically stable, she clearly needed discharge to a facility that had psychiatric services. But she also had multiple medical problems (ENT cancer requiring enteral feeding, alcoholic cirrhosis). No medical facility would take her because of the psychiatry issues. And no psychiatric facility would admit her because of her medical issues. At first I thought this was impossible, that there must be one skilled nursing bed somewhere in the city of Boston for this unfortunate woman. I struggled, working with the psychiatry attending and the discharge planning nurses, for nearly the entire 2 weeks. When I handed off the service to the new attending, she was still there. There is a profound concept in Japanese ⁄ Lean quality theory that I have only barely begun to grasp—the power of ‘‘pull’’ systems.18 When it comes to admissions, we have a ‘‘push’’ system. Instead of an empty bed smoothly pulling a patient from the ED into it, we have a system where the ED has to push to find ⁄ make a bed for a needed admission. Rather than smooth continuous flow, we have batching and backing up of boarded patients in hallways and overflow areas. Rather than frictionless flow, we have the wasted energy from the friction and hassle of fighting to try to free up a bed. Some might argue that empty beds would provoke supply-induced demand and lead to unnecessary admissions lubricated by available beds. While this requires a longer discussion and more empiric data, the reflex to govern utilization appropriateness by creating barriers, borders, and backup of


ED beds needed for acutely ill patients, strikes me (and I suspect most of us here today) as a misguided and wasteful (not to mention unsafe) approach. Rather than a well-calibrated balance of supply and demand, and a sound set of guidelines and criteria for admission, we are turning EDs into wrestling rings and unsafe venues. Finally, and again the problem points back to me, is that question of how we PCPs, along with and other components of the ambulatory health care system, can help expedite discharges from the ED? A well-functioning pull system has barely been imagined, let alone implemented for such throughput. In my view it would be one based on every patient having a well-supported and continuous PCP relationship (something that is being undermined as we speak by insurers who are telling my patients they can no longer continue getting care from physicians like me at academic centers without steep financial penalties), skillful teams who quickly embrace the most complex medical and psychosocial patients and problems, instant 24 ⁄ 7 access (phone, Internet) to me and others who intimately know the patient, and a host of supports to sustain my ability to play this role. Patient-centered medical home initiatives tilt in this direction, but if they are to be more than just pay-for-performance style-point scorecards, or empty shells propping up the status quo, there needs to be much more support for meaningful relationships with patients and smooth, supported pull systems. It is this goal and vision to better care for the patients by working smarter and better with each other that will restore joy and efficiencies in our overcrowding EDs. The author acknowledges Karen Cosby, Pat Crosskerry, Candace McNaughton, Steven Russ, Jeff Schaider, Wesley Self, Corey Slovis, and Jay Schuur for sharing their views on causes of ED overcrowding (contributing to Table 2).

References 1. Kellermann AL, Martinez R. The ER, 50 years on. N Engl J Med. 2011; 364:2278–9. 2. Schiff RL, Ansell DA, Schlosser JE, Idris AH, Morrison A, Whitman S. Transfers to a public hospital. A prospective study of 467 patients. N Engl J Med. 1986; 314:552–7. 3. Schiff G, Angus K, Razafinarivo S. The base of the iceberg. Outpatient dumping in Chicago. Health PAC Bull. 1984; 15:14–6. 4. Institute of Medicine. Hospital-based Emergency Care at the Breaking Point. Washington DC: National Academies Press, 2006.

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5. Lichter I, Gwynne JF. Spontaneous pneumothorax in young subjects. Thorax. 1971; 26:409–17. 6. Abelson R. Health insurers making record profits as many postpone care. New York Times. May 13, 2011. 7. Galeano E. The World Is a Great Paradox. Available at: http://www.rootsie.com/forum/index.php?topic= 265.0. Accessed Sep 21, 2011. 8. Kravet SJ, Shore AD, Miller R, Green GB, Kolodner K, Wright SM. Health care utilization and the proportion of primary care physicians. Am J Med. 2008; 121:142–8. 9. Smith-Bindman R, Lipson J, Marcus R, et al. Radiation dose associated with common computed tomography examinations and the associated lifetime attributable risk of cancer. Arch Intern Med. 2009; 169:2078–86. 10. Jones DN, Crock C. Parallel diagnostic universes: one patient. How radiologists and emergency physicians share diagnostic error. J Med Imag Radiat Oncol. 2009; 53:143–51. 11. Shynkaruk JM, Thompson VA. Confidence and accuracy in deductive reasoning. Mem Cognit. 2006; 34:619–32. 12. Schiff GD. Minimizing diagnostic error: the importance of follow-up and feedback. Am J Med. 2008; 121(5 Suppl):S38–42. 13. Wears RL, Schiff GD. One cheer for feedback. Ann Emerg Med. 2005; 45:24. 14. Haas JS, Iyer A, Orav EJ, Schiff GD, Bates DW. Participation in an ambulatory e-pharmacovigilance system. Pharmacoepidemiol Drug Saf. 2010; 19:961– 9. 15. Augella T. MDs and the Government Want Better Electronic Medical Records: Can CRICO help? CRICO ⁄ RMF Insight 2011. Available at: http:// www.rmf.harvard.edu/education-interventions/cricormf-insight/archives/012011/art1.htm. Accessed Sep 21, 2011. 16. Stead WW, Lin H; National Research Council (U.S.). Committee on Engaging the Computer Science Research Community in Health Care Informatics. Computational Technology for Effective Health Care: Immediate Steps and Strategic Directions. Washington, DC: National Academies Press, 2009. 17. Schiff GD, Bates DW. Can electronic clinical documentation help prevent diagnostic errors? N Engl J Med. 2010; 362:1066–9. 18. Womack JP, Jones DT. Lean Thinking: Banish Waste and Create Wealth in Your Corporation. New York, NY: Free Press, 2003.