SJRMC CRITICAL CARE BUILDING “If only I had a crystal ball…”

I don’t. So I had our residents participate in an exercise where they brainstormed on what the ED of the future will require. I thought as they are part of the future of medicine they would have some great ideas. How right I was!

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I gave them as background the following:

  • That currently EDs account for about 4% of HealthCare costs
  • Control upwards of 15-25% of expenditures (admissions)
  • Patients managed at home will become increasingly complex
  • Expectations are that more acute/chronic treatment will be outside of in-patient hospital units

I then gave them a specific patient in the year 2030:

  • 64 year-old recently retired physician (me in 17 years)
  • Complaining of fever, chills and abdominal pain with a history of diabetes and hypertension
  • Most medical records not at this institution

I then asked then to describe the necessary changes, improvements, technologies, that would be needed to care efficiently for 250,000 patients a year (our current volume 150,000)  and provide proper, coordinated care for the above patient. I asked them to consider the following:

  • Emphasis on coordinated care
  • Integration of technologies
  • Information management
  • Patient flow


Being a group firmly planted in Generation Y they were very comfortable and specific on the need in terms of technology. They wanted healthcare technology to be as universal, easy to operate and intuitively obvious as what the make use of on a daily basis now.

A number of their suggestions were focused on electronic medical records and the need for them to be more portable, multimedia, and interactive.  Aside from the obvious need for a universal medical record they also suggested:

  • Incorporation of photos especially of wounds for comparison
  • Fingerprint ID
  • Personalized electronic discharge instructions (to phone/email, etc)
  • Personalized charting software
  • Improved dictation systems
  • System integration (one screen for all records – ED, past hospitalizations, Radiology, Lab, PMPs)

Their other technology improvements were focused on very specific patients issues:

  • I-Cloud Microblood Chip (implanted blood analyzer)
  • Affordable Pad-based ultrasounds
  • Advanced, non-radioactive cardiac imaging
  • Video-Chat for prehospital calls and communicating with other physicians
  • At-home telemetry
  • Universal health care provider communications (eliminate answering services)
  • Virtual Translation services
  • Wireless EKG
  • Jetpacks for patient transport (my favorite!)

health care system


To be clear systems are not all about computers but rather the structures humans create to accomplish specific tasks. Health Care systems are by nature complex, dynamic and tightly coupled (See posts on High Reliability ED). For many physicians in training this is not a well understood concept. Residents, to be honest, spend most of their time mastering the medical parts of health care and do not generally look at the systems they work in. However, our residents did a great job suggesting needed additions to our current systems to improve the efficiency and coordination of care.

  • Expanded use of observation units
  • Telephone triage (prior to arrival)
  • On-site access to primary care (directly from triage)
  • In-house pharmacies in EDs
  • Shuttle systems for getting patients from ED directly to primary care sites
  • Kiosks for patient entered medical data (chief complaint, meds, allergies, review of systems)
  • Multidisciplinary facilities (coupling primary and specialty care closer to EDs)
  • Personnel Optimization
    • Increased specialization of different roles of health care providers
    • More systematic assignment of personnel to meet flow demands
  • Improved safety checks prior to discharge to reduce bounce-backs


Finally, the residents brainstormed on what other changes in the culture of both Medicine and being a Patient. Almost universally the group agreed that patient accountability (the flip side of the medical coin) was the number one concern. Their desire was for patients to feel more ownership and responsibility in their own care.  This seemed to be in response to the increased expectations placed on physicians in improving the value of care.

Other areas they sought improvement included:

  • Better integration between community/schools and the health care system
  • Palliative Care  teams available in the ED
  • Improved communication between Private physicians and the ED (both directions)
  • “Super Gyms” – integration between wellness facilities and hospitals
    • to improve life-style modifications.
  • Informative health videos in ER waiting rooms
  • Outpatient pain management referred directly from ED

This exercise was hugely entertaining and enjoyable for all who participated. If you would like to share your views please feel free to add a comment!