Patient Flow E-Newsletter
Volume 3, Issue 2
Thursday, August 3, 2006

Perspectives
Interview with John Lumpkin, MD, MPH, on the recent Institute of Medicine (IOM) Report that cites America’s Emergency Departments as “at the Breaking Point”

IOM Report Diagnoses Problem, But Pressure Needed to Provide the Cure

When the Institute of Medicine issued its report last month on the state of emergency medicine, the message was loud and clear: Help needed in the emergency room - stat!

Characterizing America's emergency departments (ED) as "at the breaking point," the report said hospitals are ill-equipped to handle massive casualties that could result from a terrorist attack or pandemic. It cast a spotlight on a system it said is notable for its inadequate funding, crowded conditions, long periods on diversion status, and patients who too often receive emergency care at a facility that is not best equipped to treat them.

To help remedy the problem, the IOM called for setting up regionalized patient routing systems that direct emergency patients to the hospital best equipped to treat their condition, rather than the closest facility. It also called on the federal government to reimburse hospital emergency departments caring for uninsured patients, and said more money is needed for emergency preparedness.

John Lumpkin, M.D., M.P.H., is an emergency physician who is a senior vice president and director of the Health Care Group for the Robert Wood Johnson Foundation. He previously served as director of the Illinois Department of Public Health and has been a close observer of the nation's emergency care system.

Interview: John R. Lumpkin, M.D., M.P.H., Robert Wood Johnson Foundation

Q. Before we discuss the IOM report, how would you say the state of emergency care has improved in America in the last few decades?
I believe the transformation in the emergency care system in the past 25 years is nothing short of phenomenal. When I started working in the ER, as it was then known, the doctor providing your care was likely to be a rotating member of the hospital staff assigned to a shift in the ER. If a patient showed up having a heart attack and there was an ophthalmologist on duty in the ER that night, that was the luck of the draw. Now with training and education and certification, we have specialists in emergency medicine at every level - doctors, surgeons, nurses, technicians. We have incredibly sophisticated technology and world-class trauma centers. There is a lot to be proud of and a whole lot that we're doing right. But there are problems that limit our effectiveness and this report draws those problems into daylight, which is a needed step.

Q. What is the reaction you are hearing from policymakers, physicians and hospital leaders to the IOM report?
People are glad that this story is being told. There is an understanding among many people that emergency medical staff have struggled in the trenches without recognition or relief for too long, so there's a certain optimism that something might finally be done.

Q. Why do you think the IOM chose to focus on the ED at this time?
The emergency medical system has been suffering for quite awhile and is near a crisis point. Unfortunately, in health care today a crisis seems to be needed for someone to pay attention. We're also witnessing the maturing of emergency medicine as a medical specialty, which has certainly enhanced the stature of emergency care. And even though a lot of physicians, including myself, have been worried about emergency preparedness for many, many years, that's also reached a sort of maturity due to increased awareness of terrorism. So I think from the perspective of the IOM, the timing for this report was right.

Q. What in your view is at the root of the crisis in emergency medicine?
Although it is an overused analogy, there is sort of a "perfect storm" situation here, which if you read the book, The Perfect Storm, you know was not a single storm, but a convergence of a number of storms in one area. That's what is happening in America's emergency departments. Patient visits have increased very dramatically in a very short period of time. Even though visits are up, the number of hospital beds is down, and space in the ED is tight. Funding is low for a number of reasons, but demands for better emergency preparedness continue. And of course the number of uninsured Americans is rising.

Q. Have EMTALA requirements to treat uninsured patients who arrive at an ED in an emergent condition exacerbated the problems?
EMTALA put an exclamation point on these problems, it didn't cause them. EMTALA resulted because there were notable cases where patients were shuttled from hospital to hospital because of their inability to pay, so it was an appropriate reaction. That certainly is not the way people should be treated. The evidence does show that the uninsured are more likely to use the emergency department as a chief source of care, so if the number of uninsured Americans increases, that certainly is a factor. But the far bigger factor in terms of uninsured patients is that they are more likely to delay care because of cost. So when they arrive in the emergency department, they are sicker with medical problems that are more difficult and often more expensive to treat.

Q. Among other funding recommendations, the IOM recommends providing federal funds to hospitals for treating uninsured patents. How do you think Congress will react?
It's hard to predict how Congress will react to a funding request, but we all know that emergency care cuts across every race and socio-economic status. Any one could need an emergency department at any time - whether you are a member of Congress or living on the street. Some possible solutions involve providing more money to hospitals for treating uninsured patients. I think giving more money to the ED to treat uninsured patients is putting a bandage on the problem of the growing number of Americans who don't have health coverage. That doesn't mean that bandages shouldn't be applied, but it won't fix the root of the problem. We need to look at the health care system in a comprehensive way and reduce the number of uninsured Americans altogether. I am hopeful that some of the suggestions that the IOM has identified will precipitate the appropriate action in Congress.

Q. The IOM has routinely supported increased performance measures for physicians. What is your reaction to standardized performance measures in the ED?
Every industry in America has looked at ways to improve quality, and one of those ways is to adopt standardized measures of performance. That is a fact of life in the 21st century and it has to be recognized and supported by the medical community. It certainly doesn't mean that funding should be tied specifically to those measures, and any resulting practice guidelines and measurements need to be sensitive to the unique nature of specialty medicine, including emergency care. But in cases where appropriate care is given only half the time, we need a better system and I am glad IOM has been a leader in recognizing that.

Q. Do you think regional coordination, where the patient is sent to the ED that is best equipped to handle his/her medical condition regardless of location, a good idea?
Sending the patient to the best hospital for treating their illness is clearly the right thing to do as long as those determinations are based on evidence. For trauma patients, a trauma center is clearly best equipped to save lives. Of course, the severity of the illness will always have to be weighed against transit time. But I think this recommendation reflects the maturity of the emergency medical system, where different emergency departments are better equipped for different cases. The IOM was right to recommend this as a way to increase quality.

Q. What do you believe people outside of Washington can do to advance the issues highlighted in the IOM report?
There are very important recommendations for all sectors in this report. Executive agencies and Congress need to make emergency trauma care a central focus, fund the safety net, commit to performance measures and quality systems, and make sure that EDs have the right resources to take emergency preparedness seriously.

Urgent Matters is creating the awareness needed to address these issues. While these recommendations need to be dealt with largely in Washington, emergency physicians and hospital leaders have to press for action outside of Washington, back where real people live, so that our leaders hear these messages and know they must take action.

The Foundation takes a very active role in doing this as well, and we remain committed to improving quality of care and increasing coverage opportunities for all Americans. We are also taking a leadership role in encouraging the use of informatics to provide better care. We believe personal health records and electronic data exchange, for example, have a very important role in improving emergency medicine and can help save lives and are increasingly engaged in that.

The most important thing is that we cannot let this report be put on the shelf. We have to make sure these issues remain in the public consciousness and not assume that someone else will fight this battle.