Curbside Consult with Dr. Jayne 5/21/12

Mr. H posted the results of a recent poll asking whether it’s OK to ask emergency department patients to pay before treating them for non-emergent problems. The vast majority of HIStalk readers responding thought it would be OK.

Since I’ve spent the better part of the last week working the ED, I have to say I agree. Normally I don’t work this many shifts, but the combined stresses of recent changes in our nursing ratios that resulted in some “blue flu” among the nursing staff seems to have inspired an unusual number of call-ins among the medical staff as well. (Either that, or my partners just want to get a jump on their summer vacations.)

Most of my shifts were on the lower acuity side of the ED, which suits me just fine. The full-time docs can handle all the gunshots, “fit for confinement” exams, strokes, heart attacks, and major trauma, thank you very much. I’m perfectly happy to handle fractures, asthma exacerbations, lacerations, and minor trauma. This week, however, we had a boom in patients who simply should not have been in the ED.

This was a bit of a bummer from an electronic documentation standpoint. Our recent upgrade brought us the ability to have condition-specific defaults, and I had spent a fair amount of time building out my personal templates for the conditions I typically see. I did not, however, spend any time building templates for problems that might be best handled at home with a wet paper towel and a nap. The highlight reel:

• A teenager with an insect bite. His mother wrote a note giving permission for a neighbor to bring him in. He noticed the bite in the morning before school when it wasn’t bothering him at all, but mom decided at 10 p.m. that she wanted to know what kind of insect it was that bit him. Unfortunately, I am not an entomologist.
• A high school senior with mild sunburn who wanted to know what she could put on it to make it go away before graduation (which was the next day.)
• An adult male with a 0.5 cm lump on his arm that had been there for six months. That prompted him to arrive at 1 a.m. “just to get checked out,” although he couldn’t say why he was coming in NOW.

I’m pretty sure that if someone in the waiting room would have told them it would be a minimum of a two and a half hour wait and a $200 charge, these three musketeers (and the dozens like them) would probably have chosen to go home. I wish we could have a seasoned registered nurse stationed in the waiting room, administering simple first aid and counseling patients to follow up with a primary physician or a walk-in clinic in a day or two rather than using scarce ED resources. While I was dealing with them, we had an elderly woman with a complex fracture of her upper arm, several patients with lacerations, and a chap with a knee the size of a grapefruit that needed my attention.

Unfortunately, fallout from the Emergency Medical Treatment and Active Labor Act (EMTALA) makes it difficult for us to employ creative strategies to reserve the ED for appropriate use. Becoming law in 1986 as part of the COBRA legislation, EMTALA seemed like a good idea at the time. Although EMTALA was intended to ensure that patients presenting with emergent conditions were not turned away for inability to pay or other discriminatory reasons, the unintended consequence is a generalized fear of saying “no” to anyone who walks in the door.

The Code specifically defines an “emergency medical condition.” More than half of my patients this week failed to meet that standard, yet they had full visits anyway. We had to document each visit in detail, including a full review of systems, counseling on advance directives, nutritional screening, and more. (We also had to arrange transportation home for the mom who brought her daughter by ambulance for a splinter, but that’s another story entirely.)

I wasn’t in practice prior to 1986 so I can’t say what it was like, but I can’t imagine it was as chaotic and soul-sucking as it is now. I was, however, in the trenches when E&M Coding appeared on the scene, and I experienced first-hand the ridiculous make-work that ensued.

Looking at the track record for federal meddling in health care, it’s hard for me to think that the changes occurring as a result of Meaningful Use will turn out well in the long run. I may have Certified EHR Technology and full command of the Meaningful Use program. I can cite all the measures verbatim even after a couple of glasses of wine. I have more timely access to old charts (which are now actually legible) and better drug interaction checking, but other than that, the benefits still seem elusive.

How do you think we’ll feel in 25 years when we look back at Meaningful Use? E-mail me.

E-mail Dr. Jayne.