State of Emergency

"We were able to start tracking probably four or five days ahead of colleagues in the area . . . just because we were fairly nimble with our ability in using the instant programming within the Medhost EDIS," says White. In fact, White credits technology for a lot of Tomball's success in cutting down the ED wait time from 220 minutes to 180—not just EDIS, but an electronic health record system, as well.

Tracking both patients and tests is simpler and more efficient since converting from paper to electronic charts, says Glen Blaschke, MD, an emergency physician at Tomball.

When a hospital doesn't have the resources to invest in additional imaging equipment specifically for the ED, as Sharp has done, an EHR notification system can be a cheaper way to shave time off the turnaround time for diagnostic tests, and ultimately, release or admit patients faster. "One of the things that plays a big part of determining when a patient can go home is waiting on tests," says Blaschke.

"Time was being wasted checking in the computer over and over again or checking for . . . the information available to make this decision . . . to admit them or discharge them. The EHR has greatly improved that efficiency," says Blaschke.

Emergency Reform

Few sectors of healthcare have more at stake in Washington's healthcare reform debate than emergency medicine, and in few sectors is the impact of reform as difficult to predict.

Some components that have been under debate in reform legislation—including universal coverage, a public option, and a greater focus on primary care—have the potential to improve significantly the circumstances in which EDs deliver care. But they also have the potential to make them worse.

On the one hand, universal coverage could improve the ED payer mix by cutting down the amount of uncompensated care, says Lynn Massingale, MD, FACEP, executive chairman of Team Health, a Knoxville, TN-based provider of ED clinical outsourcing. "On the patients we see that have no coverage of any sort, we collect about five cents on the dollar. Any payment is better than that."

But the payment mechanism matters. The effectiveness of a public insurance option, for instance, would ultimately depend on how it pays outpatient physicians. If a public option reimburses at similar rates as Medicare and Medicaid, the hospital would still see a jump from uninsured patients getting coverage, but there's a danger that primary care physicians wouldn't see patients on the new plan. Emergency departments could then see an influx of newly-insured patients who used the ED for nonemergencies.

"What we've seen in Massachusetts, and also to an extent in Tennessee when they started TennCare, is when you give access to care to people who haven't had access to care, they come most often to the ED," explains Sandra Schneider, MD, FACEP, vice president of the American College of Emergency Physicians and professor of emergency medicine at the University of Rochester (NY) Medical Center.

The good news is the problem received high-profile attention since the debate began. Shortly after taking over the role, HHS Secretary Kathleen Sebelius remarked that "our healthcare system has forced too many uninsured, rural, and low-income Americans to depend on the emergency room for the care they need. We cannot wait for reform that gives all Americans the high-quality affordable care they need and helps prevent illnesses from turning into emergencies."

Whether reform would actually improve EDs, however, is hard to predict.