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Managing the Care Transition: The Impact of the ED Disposition Decision

I loved working nights as an emergency department physician. The challenge and adrenaline rush of saving lives, caring for patients and bringing order to chaos keeps me driven. In recent years, change has been noticeably evident. Increasingly, emphasis is being placed on collecting data for quality measure reporting and resource utilization monitoring.

As the lone doctor working in the ED during early morning shifts, I order more CT scans than my colleagues who see patients with sore throats and other less-serious ailments in the fast-track area of the ED. At 2 a.m., I often see the sickest and most serious cases from heart attacks to head injuries. At that hour, I am unable to access the patient's full record because the medical records department is closed. Nor can I often talk to the patient’s primary care physician. Working in a data- and resource-poor environment, I have to make the best decisions under the circumstances to order diagnostics, provide treatment and then either admit, observe or discharge the patient.

For ED physicians across the country, changes like these — benchmarking data, health reform, the implementation of EHRs, etc. — are beginning to affect the practice of medicine. Hospitals now depend on physicians and nurses to capture data to help them meet meaningful use and reform requirements to earn incentive dollars and avoid financial penalties. According to recent study published in The New England Journal of Medicine, this data is being amassed for payors to ration reimbursement, and if like the Premier pay-for-performance program, may likely have no effect on patient outcomes.

For that reason plus many others, the decision to admit or discharge is the most cost-conscious and impactful action an emergency physician can make.

For me, the handwriting is on the wall: The role of the ED physician is forever changing, not altogether for the good. As the government imposes new cost-cutting moves to reduce the cost of caring for elderly and disadvantaged patients with chronic conditions, the private payors will likely follow suit. In the not-too-distant future, we may see physicians having to justify nearly every care decision before they can even implement it. In the ED, physicians will face increasing pressures to make the "right" financial decision or put their jobs or their contracts with the hospital in jeopardy.

Admission decisions under fee for service

Admission decisions are dramatically influencing revenue and risk under value-based purchasing. CMS requires physicians and hospitals to report certain quality metric data to avoid payment adjustments. Accountable care organizations will participate in financial rewards by reducing total Medicare expenditures for its enrollees. Value-based purchasing will adjust Medicare payments based upon performance against quality metric thresholds, not outcomes. In the near future, CMS will bundle payments for high-cost diagnoses, such as congestive heart failure. Reimbursement for these bundled conditions will be standardized, regardless of the resources actually necessary to care for the patient. The impending 30-day readmission program will reduce Medicare reimbursement for certain patients and diagnoses if they are readmitted to the hospital within 30 days for that same condition. These are just a few of the programs we will soon have to navigate to optimize reimbursement for care we are mandated to provide.

Here again the ED physician is caught in the middle between the hospital and the payor, and the most critical fiscal decision becomes whether to admit or discharge. Once the patient is admitted into the inpatient environment, costs skyrocket and the hospital could face penalties in cases of readmission. The pressure to reduce costs and penalties by not admitting patients will inevitably lead to changes for the ED. Observation services and improved care coordination become critical tools in the fight to survive financially.

Innovative approaches can aid disposition decision

Fortunately, innovative approaches, including technology and services (such as the availability of 24-hour case management professionals), can help providers in the ED and across the hospital improve the appropriateness of their disposition decision. They can mitigate the impact of cost containment measures by ensuring patients receive the hospital and post-discharge follow-up care they need.

Additionally, ED physician electronic documentation and accurate coding has an impact on business operations and patient outcomes. Proper documentation to support the level of services provided is always important on the front end so claims aren't denied on the back end. More directly, it can mean the difference between the hospital getting reimbursed or losing thousands of dollars per patient. Complete documentation can also ensure the patient hand-off process and the ensuing continuity of care are smooth and seamless with the next care team.

Health information exchanges and other data-sharing strategies can help promote the availability of data to providers. ED physicians working in the middle of the night could have access to critical pieces of the patient's medical history without delay.

Alternate care models, such as "hospital at home," also offer the promise of providing care within patients' homes, with the same or better outcomes at a significantly lower cost than the acute-care setting. Some healthcare systems are even appointing their paramedics as providers of front-line care. As an example, dedicated professionals are charged with routinely calling patients with congestive heart failure who frequently utilize hospital and emergency medical services. Paramedics take their vitals, measure their weight and dispense diuretics or Lasix at a substantially lower cost than the clinical- or acute-care settings.

Providers can help cut down readmissions by helping educate patients on managing their condition, what symptoms to look out for, and what follow up is required. Technology that helps manage transitions of care can help optimize care provision. Mobile apps are helping patients take a more proactive role in managing their own post-discharge medical care. For example, the patient with congestive heart failure could use a tablet PC or mobile app to send weight and other health information to his or her primary care physician. If the patient's weight increases — a critical factor for these patients — the primary care physician's office could take proactive steps to help prevent disease exacerbations.

All of these sweeping regulatory and health reform changes can be unsettling to doctors like me. But seeing this as an opportunity to advocate for physicians and patients is one reason why I hung up my white coat and stethoscope and left the ED on a full-time basis after more than a decade to become the chief medical informatics officer for a healthcare IT vendor. I now have the chance to shape the future of technologies that will help providers deliver better and more affordable care in the ED. In this capacity, I can influence healthcare delivery for more than 100,000 patients a day. I can care for thousands more patients indirectly than what was possible within clinical shifts, which makes this distinctive career path immensely satisfying.    

As T-System’s Vice President and Chief Medical Informatics Officer, Robert Hitchcock, MD, FACEP, is committed to advancing EHR adoption and healthcare IT public policy to improve the quality, safety and efficiency of emergency department medicine. Dr. Hitchcock has more than 20 years of experience in healthcare and has been a practicing emergency physician for more than a decade. He is an Emergency Department Practice Management Association board member.

More Articles on Emergency Department Utilization:

Top 10 Diagnoses for One-Time ED Users and Super-Users in New York City
Study: Hospitalist Team in ED Reduces Diversion
CDC: 4 Factors Associated With Longer ED Wait Times in 2009


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