Institute of of Medicine
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1 Institute of of Medicine Regionalizing Emergency Care Systems to Serve Accountable Care Organizations David J. Magid, MD MPH Colorado Permanente Medical Group Institute for Health Research, Kaiser Permanente Colorado University of Colorado Health Sciences Center
2 Current Fragmented Healthcare System Patients often encounter multiple professionals across different settings Limited access to medical records Poor communication between providers Poor care coordination Faulty transitions between settings
3 Accountable Institute Care of Medicine Organizations Local delivery systems of physicians and the hospitals where they work or admit their patients Extended hospital medical staff Foster shared accountability among providers Support development of shared EHRs Improve quality and affordability Existing Accountable Care Organizations MD-Hospital Practice Networks (Academic Centers) Integrated Delivery Systems (Mayo, Intermountain Health) Fisher, ES, Creating Accountable Care Organizations, Health Affairs, 2007
4 Current Institute Emergency of Medicine Care Systems Rational for Regionalization Improve Outcomes Improve Efficiency Reduce Waste Regionalized for Major Trauma Stroke Sick Pediatric Patients?? Accountable Care Organizations??
5 Current Institute Emergency of Medicine Care Systems Why Regionalize to Accountable Care Organizations? Consider the following scenarios
6 An eighty year old man with vomiting and confusion brought by EMS to Elsewhere General Hospital, medical records unavailable, workup reveals UTI, pt Rx with IVF, returns to baseline MS and is discharged on Cipro Pt returns one week later with UGI bleed and INR=10 resulting from an interaction between Cipro and Coumadin 80 yo Male with Vomiting and Confusion
7 80 yo Male with Vomiting and Confusion An eighty year old man with vomiting and confusion Brought by EMS to Elsewhere General Hospital, medical records unavailable, workup reveals UTI, pt Rx with IVF, returns to baseline MS and is discharged on Cipro Pt returns one week later with UGI bleed and INR=10 resulting from an interaction between Cipro and Coumadin Brought by EMS to Accountable General Hospital, records show pt on Coumadin
8 A fifty year old female with chest pressure brought by EMS to Elsewhere GH, records unavailable, pt is anxious, PE nm, ECG NS-changes, Trop nm, admitted overnight, recurrent CP, cardiac cath nm
9 A fifty year old female brought by EMS to Elsewhere GH, records unavailable, pt is anxious, PE nm, ECG NS-changes, Trop nm, admitted overnight, recurrent CP, cardiac cath nm Brought by EMS to Accountable GH medical record shows multiple visits for CP Pt had normal ETT 6 mo ago Pt had normal cardiac cath 3 mo ago Pt reassured, d/c with PCP follow-up
10 45 yo Male with Cough and SOB A forty-five year old with cough and SOB brought by EMS to Elsewhere GH, CXR shows LLL infiltrate, CBC reveals HCT 30%. ED MD prescribes antibiotics and advises patient to followup with PCP for evaluation of anemia Pt presents 1-yr later with wt loss/fatigue, Dx with stage III colon CA. Pt has surgery to remove tumor/nodes followed by both chemo & radiation Rx
11 A forty-five year old male with cough and SOB brought by EMS to Elsewhere GH, CXR shows LLL infiltrate, CBC reveals HCT 30%. ED MD prescribes antibiotics and advises patient to follow-up with PCP for evaluation of anemia. Pt presents 1-yr later with wt loss/fatigue, Dx with stage III colon CA. Pt has surgery to remove tumor/nodes followed by both chemo and radiation therapy Brought by EMS to Accountable GH. ED MD notes anemia, sends priority message to PCP Pts colonoscopy reveals stage I colon CA that is removed. No additional treatment is required.
12 Accountable Care Organizations The Case for Regionalization Institute of Medicine Information (EHR) Decreased Waste Patient Improved Outcomes Systems Improved Care Coordination
13 Current Institute Emergency of Medicine Care Systems Why are we not Regionalizing to Accountable Care Organizations? Consider the following case study
14 Denver/Boulder Institute of Medicine Metro Area Almost 3 million residents 19 Hospitals Over 50 Ambulance Transport Agencies Destination Policies are geographically based, not patient-centered Fragmented system does not support dynamic positioning of ambulances Patients routinely taken to Elsewhere General Hospital
15 Denver Metro Area KPCO Core Hospitals Boulder miles Exempla Good Samaritan Hospital Broomfield Weld Jefferson Exempla Saint Joseph Hospital Denver Adams Swedish Medical Center Arapahoe Douglas
16 Denver Metro Area All Hospitals Boulder 0 miles Boulder Community Exempla Good Samaritan Hospital Weld Broomfield Platte Valley Medical Center Avista Adventist Hospital Presbyterian/ St. Luke's Medical Center North Suburban Medical Center St. Anthony Hospital North Jefferson Denver Exempla Saint Joseph Hospital The Children's Hospital National Jewish Medical and Research Adams Center St. Anthony Central Denver Health Medical Center Rose Medical Center University of Colorado Hospital Swedish Medical Center Medical Center of Aurora Porter Adventist Hospital Littleton Adventist Hospital Parker Adventist Hospital Arapahoe Sky Ridge Medical Center Douglas
17 Barriers to Regionalization to Accountable Care Organizations Cultural Factors Transport Distances/Limited Coverage Areas Financial Incentives
18 Summary Regionalizing emergency care systems to Accountable Care Organizations Improve health outcomes Improve efficiency Reduce waste However, in the current fragmented healthcare system there are significant barriers to achieving this goal
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