Emergency Care: A Story of Extraordinary Success and Lingering Challenge
Brendan Carr, MD, MA, MS, directs the Emergency Care Coordination Center and is on the faculty of the Perelman School of Medicine at the University of Pennsylvania. He is an alumnus of the Robert Wood Johnson Foundation (RWJF) Clinical Scholars program (2008-2010).
Human Capital Blog: The Emergency Care Coordination Center (ECCC) was created in 2006 by presidential directive in response to pressing needs in the nation’s emergency medical care system. Can you describe those needs?
Brendan Carr: I’ll try my best. While the landmark Institute of Medicine (IOM) report on the future of emergency care really brought much of this into focus in 2006, the story of the emergency care system’s struggles extends back well before that. The IOM reports on the health care system’s response to injuries (Accidental Death and Disability in 1966 and Injury in America in 1985) really foreshadowed the shortcomings of acute care delivery. At the time, we understood that rapid intervention in trauma was lifesaving and that our delivery system wasn’t keeping pace with the science of emergency care.
Over the last few decades, we’ve really come face to face with this reality on a broader scale. Our growing appreciation for the importance of early diagnostics and intervention, combined with increased awareness about the importance of creating a patient-centered health care system, have highlighted the mismatch between the demand for care and the product that we deliver. The emergency care system’s crisis is really the health system’s crisis.
Hospitals are crowded and, as a result, patients end up spending lots of time in the emergency department (ED) waiting to be seen or waiting for a hospital bed to open up. When the health care system shifted its focus from delivering inpatient care to delivering outpatient care, we failed to create a back-up plan for what patients are supposed to do when they have a complication after day surgery, chemotherapy, or any other hi-tech intervention.
Disparities in outcomes exist across hospitals and even within hospitals as a result of insurance type or the time of day that you happen to get sick. Americans have trouble seeing a primary care physician because we train too many sub-specialists, but the emergency medical literature is filled with tales of the crisis in on-call sub-specialist availability. It isn’t possible to identify one thing underlying the challenges associated with delivering high-quality emergency care. The emergency care system is the canary in the coal mine. The IOM told this story in three volumes in 2006, the president signed Homeland Security Presidential Directive 21 in 2007, and the ECCC was chartered in 2009.
HCB: How would you describe the quality of emergency care today, and what are its main challenges?
Carr: Wow. Where to start? It is really a story of extraordinary success and lingering challenges. As a result of the Emergency Medical Treatment & Labor Act, any hospital that receives payment from the federal government (Medicare or Medicaid) is required to screen and stabilize anyone presenting for care. While there has been much dialogue around this “unfunded mandate” in the emergency care community, the truth is that it is also core to the spirit of the emergency care system. The 911 system doesn’t pre-screen your insurance status before dispatching an ambulance, and emergency departments focus on minimizing door to doctor time—no matter how (or whether) you’re paying the bill. It is an exceptional thing when you stop to think about it. Despite all of the dialogue around the shortcomings of the American health care system, this is a great thing and the specialty is proud of that culture.
That said, there is a lot of work still to be done. And I would argue that there are two really big domains that we should be focused on: the patient level and the population level. The patient level is where we’ve made the most progress. The quality movement in medicine is rooted in individual outcomes because that is how we think about our care being delivered. We want to know if we will have a good outcome, if we will undergo unnecessary testing or procedures. And it makes sense to describe surgical complication rates and hospital infection rates and the like so that we can become savvy consumers.
“This is the time to re-invent care delivery.”
But emergency care has a dual mission that isn’t well represented in traditional quality measurement. While the focus is of course on the individual once he or she presents for an emergency condition, the planning really needs to be at the population level. In many ways, emergency care is a blend between public health and health care. I know that thousands of citizens in the tri-state area will suffer severe injury this year. And that thousands more will have acute ischemic strokes, acute myocardial infarctions, and sudden cardiac arrest. But I don’t know who they are yet, and the only way to be ready to serve them individually is to build a system of care that is ready to serve the whole of the population.
So, I think we are right now seeing Quality 1.0 for emergency care in which we ask, “Do we perform efficient workups and promptly deliver the right interventions to those in need?” This work is important and we’re making good headway. The challenge for the future will be to determine if our primary care settings, emergency medical services (EMS) systems, and competing hospitals and health care systems can be incentivized to cooperate to assure optimal outcomes for the population. We talk about the concept of “co-opetition” a lot at ECCC. While we want competition to drive us all to be better, sometimes we need to cooperate to make that happen.
HCB: How will an aging population and an influx of newly insured people affect the nation’s emergency care system in the future?
Carr: I don’t think we’ve been framing the question correctly. I think that we should be asking what system of care we will build to meet that unscheduled needs of the population. We have framed much of this dialogue around how new entrants into the system will be absorbed by the existing system. This focus can make us miss the point that this is the time to re-invent care delivery.
We plan to host a series of dialogues to try to bridge the emergency care community, the primary care community, the acute care community (urgent care clinics, etc.), and payers to sketch a vision of how we want acute unscheduled care to be delivered. We’ll involve patients in the dialogue and make sure that we build a system that meets their needs. I can’t wait to see the private sector innovate as we invent the future of health care delivery.
HCB: The ECCC’s mission is to lead the U.S. government’s efforts to create an emergency care system that is patient- and community-centered, integrated into the broader health care system, high quality, and prepared to respond in times of public health emergencies. How will you achieve that goal as the ECCC’s new director?
Carr: By leveraging the substantial efforts of the government and the private sector that are already working on all four parts of our mission. The first piece—patient and community centeredness—is happening all around us. Whether through the efforts of the Patient-Centered Outcomes Research Institute (PCORI) or the efforts of the IOM and the Centers for Medicare & Medicaid Services (CMS) to improve community and population health, there are many efforts underway, and I think we can best be involved by articulating the importance of planning for the reality of unscheduled care.
And I think it’s the same for developing a path forward for integrating emergency care into the health care system and working hard to improve quality. The acute care voice has not been prominently heard in the efforts that are underway to improve the care delivery experience, but lots of really smart and dedicated people are working in this space. I hope that we will help them to see that emergency care isn’t a carve-out of the system but a critical part of health care delivery.
And the last piece is what holds it all together. If we make sure that the system is operating at its best every day, it will be ready to help us to respond in the nation’s time of need. We have a lot of help in the disaster response and recovery space, but it takes a bit of time for the nation’s substantial assets to be deployed. The private system needs to hold the line until reinforcements arrive and to be integrated into state and federal preparedness efforts.
HCB: You are an alumnus of the RWJF Clinical Scholars program. Did that experience prepare you for this position and, if so, how?
Carr: Certainly. The Clinical Scholars program taught me that it was ok to get outside of the traditional medical box. I trained in emergency medicine and surgical critical care and imagined I would spend half of my time in the ED and half in the intensive care unit. That isn’t exactly the way things came together. I couldn’t be more excited about the diverse set of activities that make up my professional life right now, but they are not the traditional pathway by any stretch of the imagination. I still see patients and write papers, but the Clinical Scholars program gave me the confidence to bridge my academic interests to the policy realm. I don’t know what’s next, but I look forward to whatever the next challenge might be.
HCB: As faculty in emergency medicine and epidemiology at the Perelman School of Medicine at the University of Pennsylvania, you studied injury epidemiology and emergency care system design. How will your prior academic research influence your work at the ECCC?
Carr: I think that my background in academia serves me well in this role. At times it is easy to lose sight of the big picture when we are deep in the weeds of getting the day-to-day work done in the federal government. But coming from a culture of developing an important question that impacts health care delivery, diving deep into how to rigorously answer that question, and then managing a research team over the course of several years in order to develop a final product that zooms back out and tells the story from beginning to end has been an asset.
I’m fortunate that much of what I’ve done in my academic life is directly translatable to my work at ECCC; not only is the skillset transferrable but so is the subject matter. And I couldn’t have landed in a place with a subject matter that is more important and interesting to me. It is important to always stay connected to why you’re doing what you’re doing—and I get a good look at the cracks in the health care system every time I work in the ED. It is a great privilege to translate the urgency of our work to my colleagues in the policy realm.