As healthcare continues to evolve, strengthening the relationship between the emergency department (ED) and the hospital is essential for practice survival and success. Maintaining open communications, altering administrators' long-held views about the ED, engaging in strategic planning and developing new service lines will go a long way toward ensuring the ongoing viability of the group, a McKesson expert says.

"The best ED practices we see are those that view the hospital as both a client and a partner," said David Berry, specialty vice president – emergency medicine for McKesson Business Performance Services (McKesson). "They understand that it is in everyone's best interest to become fully engaged in the overall clinical, operational and strategic planning process."

Berry said one of the biggest roadblocks to closer hospital-ED ties has been the long-standing perception among many hospital administrators that the ED is simply a loss leader; an isolated department that provides necessary but costly services at a single point on the care continuum. However, the reality is that EDs are an increasingly important gateway for hospitals. Between 1993 and 2006, hospital admissions through the ED in the U.S. grew by 50%.¹ Today, approximately 70% of admissions arise from the emergency department.²

The clinical and operational role of the ED also is being extended beyond emergent care. As the accountable care organization model gains traction, EDs are increasingly seen as vehicles for providing improved population health management and high-quality, lower-cost care through greater collaboration with primary care physicians.

Opening doors
Creating a framework for optimizing the role of the ED begins with leadership engagement, Berry said. Practices should develop formal processes to allow for regular communication with referring physicians, nursing and support staff and hospital administrators. The objective is to collectively identify and address not only ongoing operational issues but also strategic challenges and opportunities.

As part of this process, groups can significantly enhance their value to the broader organization by developing and sharing information about admissions, acuity, average turnaround times, length of stay, referral patterns and the like. Much of this knowledge can be harnessed through claims data to help identify trends enterprise-wide and to improve the performance of the ED. 

Implementing evidence-based guidelines and developing mechanisms that allow for regular consultation with other hospital clinicians on the most complex cases can likewise strengthen the practice's standing by helping improve care and reducing liability exposure.

"On an ongoing basis, the physician group should assist hospital leadership in understanding everything the practice is doing and is willing to do to make ED care and the patient experience as cost-effective and as state-of-the-art as possible," Berry said.

A seat at the table  
Beyond improving overall clinical operations, one of the most important reasons for adopting a collaborative approach with hospital leadership is to make sure the ED's interests are represented as delivery models shift toward value-based and accountable care, Berry said.

Admittedly, Berry said, designing reimbursement mechanisms that reward care quality, appropriate utilization and cost reduction in the ED presents a special challenge, given the diversity of services provided and the legal requirement that emergency rooms treat all comers, regardless of their ability to pay. But it is precisely for that reason that groups should have a seat at the table, Berry said. Practices must be in a position to influence the discussion and shape the direction of the value-based care model in order to protect and sustain their own economic viability. 

Moreover, maturing accountable care organizations will increasingly rely on population health management, or the use of detailed clinical and financial data to improve and better manage the quality, continuity and efficiency of care. Because EDs already serve as a primary gateway for hospital admissions, they are ideally positioned to play a central role in improving care coordination and helping reduce admissions. Key to this approach is increased collaboration and partnerships with primary care physicians and case managers, according to a recent report by the Rand Corporation.

"In addition to serving as an increasingly important portal of hospital admissions, EDs support primary care practices by performing complex diagnostic workup and handling overflow, after-hours and weekend demand for care," the report states.³

"As a result of these shifts in practice, emergency physicians are increasingly serving as the major decision-maker for approximately half of all hospital admissions in the United States. This role has important financial implications, not only because admissions generate the bulk of facility revenue for hospitals, but also because inpatient care accounts for 31% of national healthcare spending."4

Expanding service lines
Value-based reimbursement and accountable care will create important new opportunities for expanding the role of the ED, but developing and perfecting these systems will require time, trial and error. In the interim, Berry said, practices can find other avenues to add value to the organization by exploring new service lines.

These could include providing observation services to help reduce unnecessary admissions, opening urgent care or outlying free-standing EDs, developing hospitalist practices and even exploring joint telemedicine opportunities to extend care into rural, underserved areas.

"Hospitals have to compete fiercely for marketshare, and the ED practice can help them do that by expanding their reach and brand with business lines that make sense for both the hospital and the practice," Berry said.

¹Kristy Gonzalez Morganti, et al, "The Evolving Role of Emergency Departments in the United States," The Rand Corporation, 2013, http://www.rand.org/content/dam/rand/pubs/research_reports/RR200/RR280/RAND_RR280.pdf (PDF, 99 MB)
² "The Role and Value of the Emergency Department in an Accountable Care Organization," American College of Emergency Physicians information paper, November 2015, http://www.acep.org/workarea/DownloadAsset.aspx?id=103616
³ Kristy Gonzalez Morganti, et al, "The Evolving Role of Emergency Departments in the United States," The Rand Corporation, 2013, http://www.rand.org/content/dam/rand/pubs/research_reports/RR200/RR280/RAND_RR280.pdf (PDF, 99 MB) 
4Ibid.