Aug 8 2013

Emergency Department as Community Microcosm, Data Hub: Q&A with Jeremy Brown

file Dr. Jeremy Brown, NIH Office of Emergency Care Research

The National Institutes of Health’s Office of Emergency Care Research (OECR), established in 2012, will now be under the leadership of Jeremy Brown, MD. Brown was recently appointed as the first permanent director of OECR, which is housed in NIH’s National Institute of General Medical Sciences.

Before joining NIH, Brown was  an associate professor of emergency medicine and chief of the clinical research section in the Department of Emergency Medicine at The George Washington University. Additionally, he served as an attending physician in the emergency department of  the Washington, D.C., VA Medical Center. According to the acting director of the National Institute of General Medical Sciences, Judith H. Greenberg, PhD, “Brown brings an impressive mix of clinical expertise, research experience, management abilities and communication skills to this important new position.”

Part of Brown’s research includes how to introduce routine HIV screening—a public health intervention—in hospital emergency departments. Previous studies have found these screenings to be cost-effective and frequently welcomed by patients. This is just one of the many ways in which steps could be taken in the emergency room setting to help improve the data available to assist public health efforts across the country. By using emergency departments as sites for collecting data on the status of the public’s health, more targeted efforts for prevention can be implemented.

NewPublicHealth spoke with Dr. Brown on the evidence that shows support for the collaboration between emergency departments and efforts to improve public health, as well as his new role and what he sees for the future of emergency departments.

NewPublicHealth: How is the transition into this new position going so far and how are you pulling from previous experiences to help with new challenges in this position?

Jeremy Brown: This is the beginning of my fourth week here; it is a new program and a new project really for both me as its first permanent director and for the NIH as well. They’ve never had an office that has addressed this particular part of our nation’s health and I think it’s going to be a learning experience on both sides.

So far, I’ve been really struck by the extremely warm reception that I’ve had from people within institutes and centers with whom I’ve had meetings. Currently, my agenda is really to meet with as many people as possible within NIH whose work touches on emergency medicine and other time sensitive medical issues.

In terms of the latter, I started a brand new HIV screening project from scratch at GW, it hadn’t been done there previously and it really had only been done in a couple of places in the U.S. before. That required the marshaling of a lot of different aspects of both the hospital, the nursing staff, and emergency physicians to get that up and running.

NPH: What other public health initiatives do you think emergency departments can take the lead on to improve public health?

Brown: The role of EDs in public health is one that ED physicians grapple with. On the one hand, it’s the only point of contact with the medical provider for many people, even those with insurance…and so it makes sense to use the opportunity to address a much wider range of medical issues than those which brought the patient to the ED.

On the other hand, EDs, as we all know, are very busy places where the wait for services can sometimes be long, and so the question is does it make sense to delay the care of another patient because the ED is addressing a public health issue…And this actually has been a point of lively discussion amongst the emergency medicine community. In fact, the question of what public health interventions, or more precisely, what preventative care needs are most appropriately addressed in the ED has been carefully examined by the Society for Academic Emergency Medicine which looked at the issue from the only way it should be looked at, namely from an evidenced-based position.

In a paper published in 2000, they examined 17 preventative care interventions with possible applicability to the emergency department, and of those 17, they found five for which there was enough evidence to support offering them in the emergency department and those five are HIV screening in certain populations, hypertension screening, adult pneumococcal vaccinations the referral of children without a primary care doctor to continuing care, and smoking cessation counseling.

NPH: How can emergency department data be used to help improve public health overall?

Brown: This is a really key point, and I think the other issue is to emphasize that smart decisions about public health issues need to be based on good data. We have pretty good data, for instance, from the National Hospital Ambulatory Medical Care Survey, which is part of the CDC, already collects data about ED visits across the U.S. each year using hospital EDs as collection sites. They use about close to 400 EDs as collection sites and then weighing the data, using statistical methods to come up with a national estimation of both the number of ED visits and the specific kind of visits that are going on. So when I quoted earlier about 10 million ED visits a year for abdominal pain, we get that data from this important healthcare survey.

But with the penetration of the electronic medical record into health systems generally and into EDs, in particular, the possibility of collecting data in real time about ED visits are truly phenomenal. But, of course, the data that exists can only be collected when computer platforms are able to speak to each other and when there is both the IT support and the financial support to collect the data and this is not a cheap undertaking, but it is one that is vitally important to the future of our nation’s health.

NPH: Do you think, overall, as we get all of this massive data and public health and healthcare find new and more data-informed ways to work together, are we on the verge of a revolution in these kinds of partnerships?

Brown:  Well, I’m actually a little bit skeptical of the big changes that might come along through data. But there is no doubt that the advances that we’ve seen and what people are now calling smart policing where police are sent, on the basis of geospatial software combining with crime statistics so that the police go to the areas. I think the equivalent is very attainable in a short order in public health areas, and again, the emergency department is a vital ally in this fight. And frustratingly, the data is already there.

NPH: Do you have anything else you’d like to add to our discussion? Anything that you would want public health professionals to know about what they can learn from emergency departments?

Brown: I think one of the key messages I would give is to really think of your community hospital’s emergency department or your local teaching hospital’s health department as a microcosm and as a laboratory of the community’s health and health needs. Even in communities where there is a very good penetration of health insurance, there very often is a shortage of primary care trained staff…So, they’re using their emergency department for more health care needs than the emergency department was perhaps designed for.

Thinking of the emergency department as a place to get answers to really key questions about many aspects of healthcare is really what I would emphasize…So many patients are being sent to emergency departments to get CAT scans and blood tests and see specialists because their primary care physicians are simply unable to organize and order these tests in an appropriately short amount of time.

The role of the emergency department has changed over time from, as I say, this sort of safety net to now a place where actually a lot of patient workup is being done and that is frustrating for people who come there with an emergent. And the majority of patients, four out of five patients arrive in the emergency department by themselves, they drive themselves there and they leave by the same way. So the majority of patients who are sitting in our emergency departments across the country are not particularly or acutely ill, but nevertheless, they require the services of the emergency department.

Tags: Access to Health Care, Health Data and IT, Public and Community Health, Research