By Jim Strafford

Scribing, particularly in Emergency Medicine (EM), has been something of a phenomenon during the past decade. Scribes are typically employed by third party vendors such as Scribe America as well as directly by provider groups. Scribe America has experienced phenomenal growth and now employs over 2500 scribes; physician group CEP America employs over 600 scribes for their ED and Hospitalist Practices. What accounts for the scribe boom, and how do we measure the impact of scribes on the Acute Care Continuum?

A Very Brief History

Scribes appear throughout ancient history as “record keepers” who copied legal texts and other documents. Scribes also appear many times in Scripture. They were influential in government and religious circles until the printing press essentially killed the demand for scribes. Flash forward to the 1970s, when a study in the Annals of Emergency Medicine found that scribes who “shadow physicians” and act as “human tape recorders” improved ED efficiency. However, between the 1970s and early 2000s, scribes were rare. An oncology practice where I consulted in the 1990s used scribes, but I saw very few of them in emergency medicine until recently.

By Al'ai Alvarez, MD

The emergency department (ED) of the future will likely be, as Wesley Curry, MD, points out, a very busy place with an incredibly high volume of patients walking through the door. We can expect the private ED of tomorrow to resemble the county ED of today. If so, I look forward to being an emergency physician in the future, and I think you will too.

That is because I have had the pleasure of working at one of the busiest emergency departments in California. Santa Clara Valley Medical Center [SCVMC] is a level one trauma center treating about 140,000 patients per year. Because we are a public hospital, resources are scarce, volume is very high, staffing is low, and patients often come to us without prior access to primary care. As a result, by the time they arrive in the ED, they are very sick. Despite what others might consider “overwhelming” or a “harsh environment,” I am honored to be a part of a strong group of physicians and healthcare workers providing care to so many medically underserved patients. This is, in fact, the environment that I was looking for when I started my career.

By Janet Young, MD

We have the best healthcare in the world. Yet so many hospitals are struggling to make ends meet. And there are too many people in the US who do not have the money to be able to buy health insurance. How can we make our excellent medical care available to everyone who needs it? I think the Affordable Care Act is an important step in this direction, even if it is not perfect. It is a clear indication that the problem is at the top of our national agenda, and that we are trying to solve it.

One of the imperfections is the Cadillac tax provision. It’s a 40% tax on employers for healthcare plans which go above $10,200 for individual coverage and $27,500 for family coverage, adjusted for consumer price inflation. It is slated to go into effect in 2018.

Until this tax begins, employers can attract employees with the tax-free perk of luxury health insurance policies. The tax is intended to create more fairness across the employment spectrum. While well intended, however, the net effect of this tax is likely to be a negative one. At the current rate of healthcare inflation, approximately 75% of insurance plans will be above this level in the next decade, and thus subject to the tax. In order to avoid this tax, employers are likely to reduce benefits. So the question is: how will this affect our patients and providers?

By Gary Li, MD, FACEP

Recently in this blog I discussed the increasing resource utilization in the ED. I made the point that, as individuals, we need to include the value, risks, benefits, and costs of all tests, treatments, and interventions. At the organizational level, we should narrow practice variation to where it is supported by evidence and collaborate throughout the care continuum to avoid inappropriate utilization (whatever our relationships to other physician groups or organizations). I noted that, with changing payment structures and incentives/penalties, if we as physicians and physician organizations do not take the lead in these matters, we will either be left behind or be subject to rules created by others, or both.

Interestingly, there are other forces that are conspiring to increase ED utilization and length of stay (LOS). Perhaps counter-intuitively, I do not consider this all bad—in fact, I believe it actually demonstrates the value of EDs and emergency medicine physicians in the changing acute care paradigm. And it is in no way mutually exclusive to providing appropriate utilization and care for specific patients, which we should always do.

Our bi-weekly news updates are designed to keep you up to date with current developments relating to the Acute Care Continuum. Feel free to share your perspective on these stories or link to articles that you have found relevant to today’s healthcare environment.

Today, we look at the impact the emergency department (ED) is having on admission rates and healthcare costs.

By Michael L. Harrington, MBA, MA

Over the years of working in healthcare and having direct encounters with large and small emergency departments (EDs), I have heard the relationship between the ED and inpatient service described in lots of ways, sometimes even with expletives. However, I think the phrase ‘the Inpatient sneezes and the ED gets pneumonia’ best paints the picture of this relationship.

I’m sure each of us may have a different phrase or description, but what is important is the existing relationship and the work that is needed to improve patient flow between these departments. Paying attention to this concept of flow is a much better focus than saying we have to fix the ED, because in fact it can be factors outside of the ED that can influence its function the most.

The labored breathing and fatigue suffered by the ED these days are not problems endogenous to the ED itself—they are caused by exogenous factors. The clogged passages are caused by large increases in community demand for ED services. Similarly, even small changes in inpatient strategy back up into the ED and cause congestion. While the ED does need to heal from within to handle these challenges, it is important that we recognize and neutralize the actual sources of the infection.

By Katherine Ahern, MIMS

When the Literary Digest conducted a poll to predict the winner of the 1936 presidential election, the results were clear: Alfred Landon would overwhelmingly defeat Franklin Delano Roosevelt. The Literary Digest was confident about its results: after all, they had surveyed 10 million people and received 2.4 million responses. But they could not have been more wrong. Why? Those 10 million people were drawn from a pool of Literary Digest subscribers, automobile owners, and telephone owners. In 1936, automobiles, phones, and subscriptions to the Literary Digest were available only to the rich. These selection factors skewed the results toward Landon, the choice of the wealthy.

The systemic failure of their sampling technique is cited in most introductory statistics textbooks, since it shows so clearly how bad sampling can lead to wrong conclusions. Roosevelt won in the most lopsided victory in American history.