“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!

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!)
SYSTEMS
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!
David
The residents have done an excellent job with identifying the solutions to the very barriers we presently face in ED care delivery. The availability of comprehensive information across the spectrum is not there unless the patient has been in a single system and primary care access is challenging. The organizations with the goal of enabling information to flow across time,locations, and providers will be successful in the future.
This exercise illuminated many of the problems that current hospital configurations face. Many of the solutions offerred are excellent, and some are truly innovative. This is an excellent exercise that challenges your residents to think about how they could do their daily tasks better, with the goal that the patient will be better served.
Perhaps one other approach would be to change the interface between the ED and the rest of the Hospital. Right now the ED is the Doorway to the Hospital for many patients. Would it be worthwhile to have the ED function in other roles? Perhaps it could be used to replace some of the free-standing centers (SurgiCenters, Endoscopy centers, etc.) and thus it could be used by hospital in-patients as well as outpatients? It could house services that are intrinsic to the ED but that could be used for in-hospital patients as well.
Well done, David. Congratulations.
Terry. Appreciate your comments and am intrigued by the other roles concepts. I think it is also time to start integrating other specialties into the ED
David,
Thank you for teaching your residents to be proactive in there future! The evolving role of Physicians in our healthcare system needs forward thinking Physician trainers such as yourself to light some fires in the younger caregivers. I found your article to be of great interest and full of good ideas. I also see were much of this “wish list” is indeed already possible (except the jet pack driven patient transport). When we consider the motivators of progress in our profession and and what keeps new integration technologies from becoming common place it is frustrating. Contending with HIPAA compliance and techno GURUS that have figured out how to remotely control insulin and morphine pumps by accessing IT systems via wireless ECG machines-the future of our specialty will be full of interesting innovations. I completely agree with Terry’s comments regarding more care and expanded roles of non hospital based remote EDs. Here in Texas this is already happening with Free-Standing ERs developing. The next step will be Free-Standing ERs adjoined to Outpatient Surgery Centers and Outpatient Primary Clinics. This model is showing success in Texas due to “Patient and Physician Demands”. It appears that the Market will continue to dictate how we deliver of care.
Sadly I believe that the Affordable Care Act may propel our system into a two tier system. At our facility we have already opted out of all “government funded programs” so that we may have the freedom to more competitively offer our paying patients lower cost and better service.
Terry-Thank you for this thought provoking article!
Henry Higgins MD
Austin, Texas
Henry. Great comments! I am happy that others are enjoying this post
Great Blog David
Nicely presented material and you have a deeper understanding of EM than most.
You mention “complex, dynamic and tightly coupled”.. so you get the “complex adaptive systems” nature of EM.
Its taking time to get that thinking out there..
I’m a fellow emergency physician with similar interests..
You may find some these articles resonate..
http://frectal.com/2012/03/30/emergency-departments-tackling-complex-systems-on-the-edge-of-chaos/
Have you come across Cynefin?
http://frectal.com/2013/04/30/video-simple-complex-complicated-chaotic-in-emergency-medicine/
Appreciate you also mentioning the “obvious need for a universal medical record” .. see here , from another part of my life..
http://frectal.com/book/healthcare-change-the-way-forward/
Look forward to connecting..
and thank you..
Tony
If we used the spoke wheel concept, I think we could better serve the population with less stress on our system. A central entering point and a great triage method would allow patients to be ported to the proper spoke for further evaluation and treatment.