Hurry up and wait

The ER at Boston Medical Center is in many ways the ultimate in place to do a rotation: the most traumas, the most indigent population, and the most turnover in Boston. In Thursday's front-page story by Scott Allen in the Boston Globe, we see that through systems management, BMC is moving patients through faster:

The secret lies in a radical idea for medicine, but one that has guided airport managers and restaurant hostesses for years: Keep the customers moving.

...The hospital's changes since last fall have reduced the typical ER stay by 30 minutes, to 3 hours and 45 minutes. That's still half an hour above the US average, but impressive considering Boston Medical Center's heavy patient volume and difficult caseload.

Patients receiving treatment yesterday said the emergency staff is attentive and aggressive and has reasurred them that they won't be forgotten.

Alexis Morales, 36, said doctors went to work on him moments after he arrived with breathing problems from an asthma attack, giving him epinephrine and other medications to open constricted airways so that he wouldn't need a breathing tube. An hour after he arrived, still wearing his landscaping boots, Morales was breathing on his own in an ER bed, praising BMC's care.

"When I first started working here, not a lot of people said 'thank you,' " said Morales's nurse, Bree Sullivan, who has worked in the ER for 2 years.

Likewise, Caryn Hibbard, 32, said she was impressed by how quickly doctors ordered a CAT scan after she told them that doctors at another hospital had failed to find the cause of abdominal pain that had begun several days earlier.

Other interviewees (and bloggers) are also enthusiastic about these changes. The reporter gets a revealing quote:

"I won't be surprised if five years from now, this is the biggest change in healthcare," said Dr. Donald Berwick, president of the Institute for Healthcare Improvement of Boston, an influential think tank that last week hosted a session on BMC's reforms for hospital officials from around the country. "We have to bring the science [of management] back into healthcare in a way that we haven't in a very long time."

Berwick is talking about hospital efficiency, of course, but he forgets that the "science of management" was brought to bear on healthcare, big-time, in the last decade. HMO's, provider networks, copays, preferred drug lists... all this management kept health care costs stable through the 90's, despite growing dissatisfaction from patients about lack of choice, lack of access, and a time crunch.

In an emergency, however, the time crunch is desirable, and patients ("customers", now) may not mind being shuffled around anonymously. After all, when you're sick, it feels good to know someone's doing something.

But this is why I'm somewhat pessimistic the changes at BMC are going to last. First, there's the lesson from highway engineers: adding extra lanes doesn't cut traffic, it just attracts more cars.

On the individual level, making ER stays less time-consuming and unpleasant will make patients less likely to go to through their overbooked primary care physician (if they have one) and more likely to present at the local ER.

On a larger scale, what will happen if efficiency rises in the top regional ERs? Small community emergency departments are under enormous financial pressure as it is, and this could tip them over, causing a commensurate rise in traffic at the regional centers.

The second reason these gains may not last is the bottome line. The Globe article reveals that consultants and accreditation agencies are trying to spread the success of the BMC initiatives to other ERs. But they're motivated by patient safety and satisfaction, which didn't count for much during the HMO revolution. It's not obvious to me that higher turnover translates to higher profits in Emergency medicine (even if it seems to be the case in primary care). Also, any cost savings will wipe themselves out when the speedy care leads to more frequent ER visits from those least able to pay.

If hospitals and insurance agencies find that improving efficiency doesn't improve their bottom line, these positive changes will be resisted. Don't hold your breath waiting for them at your local ER.