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Open Access and Saving Lives.

6 April 2014

Despite the fact that I write fairly little here about science, I do in fact consider myself at least vaguely a science blogger. And specifically, a blogger with something occasional to say about health care delivery, in that that’s what I do as a matter of my livelihood. For my first year at MECMC, I’ve been building simulations of surgical and inpatient facilities, but for most of my career leading up till now, I was a specialist in emergency medicine delivery. And my academic appointment at ILU is in the department of emergency medicine.

Emergency medicine is in real crisis in the United States. The reason for this is that a huge number of people use the emergency room as their basic source of primary care. This is for several reasons. In some cases, it’s because people cannot afford to go to a primary care physician, and so health concerns are left ignored until they become emergencies. Sometimes, it’s because they don’t have insurance, and the emergency room will give everyone at least a basic evaluation regardless of insurance status, including life-saving treatment. And sometimes it’s cultural; many people come from cultures where appointment-based healthcare simply doesn’t exist. A senior MD giving a briefing in my hospital recently talked about how at hospitals in China, people needing to see a doctor never make appointments, and MDs don’t accept them. Everyone queues. That’s the delivery model.

Another critical reason is delays for service. Particularly in large healthcare delivery systems, like the VA, it can sometimes take months to make an appointment to see a physician, including primary care. Resultingly, people with minor ailments well within the wheelhouse of primary care end up coming to the emergency room because it’s the only “clinic” they can get appointments in. This results in EDs being crowded with patients which don’t really need to be there. And overcrowding is known to be associated with increased mortality, and other degradations of care (Bernstein et al, 2009 Acad Emerg Med 16(1):1–10).

I believe (and would love to model) that open access scheduling at primary care (and other primary-type specialist clinics like pediatrics, dermatology, etc.) would address this significantly. Open access scheduling means that many appointments, perhaps 50-75% of them, are not filled until within some time threshold, like 48 hours of the appointment time. The remaining 25-50% are used for planned follow-ups and ordinary scheduled physicals, etc.. The result is that patients are very likely to be able to get an appointment same day, or nearly same day. Planned maintenance care is still available. The trade off is that physicians and clinics cannot be certain of their patient-load in advance.

But, if a clinic is running with a standard 3 month or more waiting list for an appointment, they are very likely to be able to maintain a full load of patients when adopting an open access model. And they will be able to see a large number of patients who might otherwise be forced to seek care at the emergency room. Reduction of these patients crowding the ED will, unequivocally, save lives.

Now, implementing open access scheduling in a primary care clinic is non-trivial. The transition period is difficult and uncertain. Determining the threshold time period to use to limit appointments required examining the rate of requests and doing some mathematics (ahem – I consult). But, open access scheduling models are shown to, theoretically, at least, outperform traditional scheduling in many key metrics. (Robinson & Chen, 2010, Manufacturing & Service Operations Research 12(2): 330-346).

Misuse of the emergency room is crucial to address, because a well-running ED is a fundamental point of care in a system which is, despite its many flaws, one of the best there is in the world at rescue and resuscitation of critically ill patients. This endeavor requires the ED to function smoothly so that those critically ill patients may be fed through to the operating rooms and intensive care units which maintain and treat those patients once they’ve been stabilized in the ED. Crowding, and misuse, thwarts that core mission of the ED. And kills people.

2 Comments leave one →
  1. Syd permalink
    6 April 2014 19:29

    Something has got to work better than the current cumbersome system. I hope that you do get a chance to model the open access system.

  2. Anonymousbiophys permalink
    8 April 2014 20:48

    The elephant in the room is the perception of an emergency–in terms of ED care. The definition of an emergency within an ED is far from the lay persons definition. What many, if not all, ED’s triage to areas such as “fast track” are *that* individuals emergency. A person who is triaged as low acuity may not think to contact their primary care physician because they truly believe they have an emergency. This is a difficult parameter to account for in a theoretical accessment of general healthcare. You are suggesting that primary care should adopt a model that urgent care centers have tried to fill in an effort to reduce the burden on ED’s (at least that is what I gather from your post–please correct me if I am wrong.) I would argue that ED’s should recognize that >60% of their patients will not be acute and design ERs to accommodate this fact. If an ED would parse at least 50% of their beds to non-acute patients (maybe even staff FP physicians) this would greatly ease the burden on ER staff.

    Now, the biggest argument against this is long term care for diagnoses that require follow-up. Well, for this we must change our thinking about the compartmentalization of care that is currently the standard. Why can’t an ED offer follow-up care? Can’t they expand further and offer FP? Maybe, just maybe, in this model–with medical records that reflect a persons complete history– can’t any FP physician manage this persons care? This would increase the revenue for an ED and relieve the burden of non-acute patients.

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