The way to fix the emergency room is to fix primary care
Why simply making primary care more convenient will go a long way in reducing overcrowding in the ED
We live in an economy that is defined by convenience.
The success of today’s most notable companies is based on their ability to save you time, money, and/or effort. Uber and Lyft can get you from Point A to Point B faster (and cheaper) than a traditional cab; Foodora and DoorDash can show and bring you any cuisine instead of having to separately call individual restaurants; Google can increasingly bring you perfectly curated search results for whatever you are looking for online (when was the last time you had to go to the forsaken Page 2 of a Google search?).
Fundamentally speaking, these are all companies facilitating a type of transaction that existed long before their platforms took root — door-to-door transportation, food delivery, internet browsing — but they are doing it in a way that, as evidenced by their growth, is more convenient and useful to end users.
Although companies like this continue to face varying levels of resistance from certain stakeholder groups, they remain dominant because consumer demand always prevails — the customer is always right.
But why isn’t the same happening in healthcare, and more specifically, within primary care?
We have both the technology and demand to modernize how we deliver certain healthcare services — like primary care — but our traditional (and archaic) bricks-and-mortar approach is still overwhelmingly and unjustifiably the norm.
A quick Google search will tell you that primary care is “healthcare at a basic rather than specialized level for people making an initial approach to a doctor or nurse for treatment.” It is the ideal gateway into the formal healthcare system; it either fixes the problem at the point of entry or redirects you to a part of the system that can.
For example, a visit to your family doctor because you have a sore throat or your child has an earache is considered primary care. A visit to the emergency room because there is a bone sticking out of your leg after a boating accident is not. The problem is many of those sore throats and earaches are making their way into the emergency room alongside those compound fractures because there is no other convenient option available.
Where does that leave us?
With increasingly overwhelmed emergency rooms and outdated primary care.
Death, taxes, and packed emergency departments
An unfortunate staple of almost any hospital in the US, Ontario (where I’m from), or the world, is a busy emergency department (ED). Stats vary depending on where you are, but almost every jurisdiction has an often-criticized ED wait time. After all, when you are dealing with an emergency — whether actual or just perceived — any wait feels too long.
In the US, the average hospital ED patient waits 2.25 hours before being discharged. In Ontario, the wait is 3.9 and 2.4 hours, for high-acuity (more serious) and low-acuity (less serious) respectively. Not exactly the allotment of time you would associate with the word “emergency”. The picture gets even more grim in Ontario if you are getting admitted to the hospital from the ED — the average person is waiting 16 hours(!) to do so.
So while you woke up, ate breakfast, went to work, read this article, came home, ate dinner, watched a movie, brushed your teeth, and got into bed, there was someone with a serious illness in an emergency room (or hallway) waiting that whole time to get an inpatient bed.
Not all emergencies are created equal
As previously alluded to, many of the people that go to the ED shouldn’t be there. Or rather, are not using the healthcare system in the way it was intended. To quantify the extent of this misuse, let’s quickly run through some stats from both the US and Ontario.
According to a 2013 study by Truven Health Analytics, 71% of ED visits in the US did not require emergency services. Granted this study only looked at visits made by patients with employer-sponsored insurance coverage, a look at the broader US data likely is not far off.
The latest national data from the CDC is from 2016, and in that year there were just under 146 million visits to the ED. Approximately 102 million (70%) of those visits were assigned a number on the five-point Emergency Severity Index (ESI), basically meaning the triage nurse officially classified the urgency level of the visit.
The graph below shows how these 102 million visits were distributed across the five severity levels.
So based on CDC data, at a minimum, 41% of the categorized ED visits could’ve/should’ve been handled elsewhere (i.e. primary care); at a maximum, this number balloons as high as 87%. Although the actual number likely falls closer to the minimum, I think we can still agree that ultimately there are an absurd amount of people accessing care in a non-ideal and expensive way.
Despite this reality, we can’t necessarily fault patients for flooding to their local ED for basic healthcare needs; they are doing so because, despite the aforementioned wait times, it is the most convenient option they have available. Often times, the choice ends up being between waiting a few hours in an ED or waiting a few days (or weeks) for an appointment with your family doctor. And most people know that these minor complaints don’t belong in the ED — in Ontario, 2 out of 5 people reported that their ED visit was for something their family doctor could have managed had they been available. But alas, they weren’t.
So what can we do?
The problem with primary care is that it never got the convenience memo. It rested on the assumption that people will put up with a laundry list of annoyances — waiting on hold, lack of appointment time choices, travel times, dated home decor magazines in the waiting room — for the privilege of telling their health problems to a familiar face in a familiar building. Maybe that was universally accepted at one time, but millennials have made it clear that it won’t fly anymore.
So put simply, primary care needs to up the convenience. If more convenient options become widely available in the primary care realm, less people will flock to the ED.
The good news: there are convenient options out there.
Primary care’s innovation apathy has led to the creation of more user-centred options, namely virtual care. Services like Doctor on Demand and Maple give you access to virtual medical services in minutes, but despite the growth of virtual primary care, it is still pebbles compared to the volumes seen in traditional primary care (especially in Canada). And that is because, at least in part, it is constantly being treated as a threat by old-school physicians and policymakers. We need to start better integrating traditional primary care with virtual care, instead of pitting them against each other. Virtual care can no longer be viewed as a parallel competitor, but a ubiquitous feature of primary care as a whole.
Although virtual primary care is great for many conditions — and the list keeps growing — the lack of physical touch still puts some limits on what it should be used for. But before jumping straight to the traditional office visit (or the ED), there is another promising development in primary care that is inspired by the roots of medicine itself: the resurgence of house calls.
In the good old days, physician house calls were the norm, and now there are players trying to bring this back in a big way.
Heal is a California-based company which, through a technology platform, allows consumers to book an in-home doctor visit at a time of their choosing between 8am-8pm, any day of the year. Heal estimates that its first 40,000 patient visits have resulted in more than $21 million in cost savings and reduced unnecessary trips to the ED by a staggering 62%.
This isn’t anything new, as there is plenty of smaller-scale academic research out there to support the claim that house calls reduce ED visits and hospitalizations, which is why there are similar services popping up with high hopes, like MediSeen and HouseCallsNow in Ontario. But again, like virtual care, none of these platforms are well integrated with existing primary care practices (or the broader health system).
A new primary care pathway needs to developed, encouraged, and promoted that better aligns to customer-centricity and the current landscape of what is available. From a cost perspective, we should be building a funnel where only true emergencies end up in the ED. And from an experience perspective, we should be building a system that caters to the patient, instead of the other way around.
The option should not just be choosing between your family doctor — who may or may not be able to see you on the same or next day — and going to emergency; there should be several gateways to catch these costly non-emergency ED visits ahead of time, while bringing care to the patient where it makes sense for them.
If virtual primary care, in-home primary care, and in-office primary care work together, there should be enough capacity to do just that.
Knowing that, in all likelihood, approximately 50% of ED visits could be handled by effective primary care, we should be prioritizing the modernization of primary care to realize these benefits. And although the benefits transcend the boundaries of the emergency room, imagine a world where we cut out 50% of ED visits because primary care became convenient and integrated — ED wait times would go down, patient satisfaction would go up, and the system as a whole would reap massive financial savings.
In all areas of life, we as a species are becoming increasingly impatient with inconvenient and/or inefficient services because there is a universal appreciation that time is as precious a resource there is. But we have been conditioned (or forced) to give healthcare a pass — and for what?
Whether by design or not, human beings always find a way to make their lives easier. In fact, one could argue that the foundation of human progress is built on the singular goal of finding “the more convenient way”, regardless of the task at hand.
We need to start applying this thinking to primary care, but in a holistic, meaningful way, because only then will we unlock the downstream impacts — like better emergency services — that we have fruitlessly chased for so long.
We have already spent too much of our time waiting in family doctor offices and emergency rooms around the world, but let’s design a more convenient system that works for everybody so our future generations won’t have to.