Sklar, David P. MD; Handel, Daniel A. MD, MPH; Hoekstra, James MD; Baren, Jill M. MD, MBE; Zink, Brian MD; Hedges, Jerris R. MD
Although emergency medicine (EM) was defined in the past by its location (the emergency room), it will more likely be defined in the future by the management of time-dependent conditions. Evolving from a location attached to a hospital where patients could receive care after doctors' offices closed and where those without insurance, appointments, or connections within the community could arrive and expect medical care regardless of financial resources or personal circumstances,1 the emergency department (ED) of the future will define itself by its ability to provide timely diagnosis and treatment for an increasing number of conditions for which seconds or minutes will determine the ultimate outcome. However, delays due to crowding and inefficiency have created a dynamic tension in current ED practice, and the future of EM will be determined by the resolution of this conflict. We present a picture of EM by reviewing the forces that formed the specialty and suggesting how these forces will guide the future of EM over the next 10 to 15 years. We also review the predictions made in an article, published 10 years ago,2 on the future of EM and discuss three possible scenarios for EM's future. We conclude with a focus on the implications of the most likely scenario for education and research.
The History of EM: Different Times, Similar Themes
EM arose because of public demand for high-quality acute care services and to serve as a link between out-of-hospital and in-hospital critical care. The Hill–Burton legislation of 1946 spurred the construction of new hospitals around the country, and larger, more commercial hospitals and medical centers became the epicenters of medical communities.3 Medical insurance, which expanded greatly in the 1950s, typically paid for hospital—but not outpatient—services. In the late 1950s, hospitals, rather than doctors' offices or the home, became the favored sites for diagnostic testing and around-the-clock medical care. Doctors began tying their practices to hospitals in more formal arrangements.1 The passage of Medicare and Medicaid in 1965 further stimulated demands for emergency services from the millions of newly insured Americans without provision for increased access to primary care. Predictably, patients went to EDs when they could not access health care elsewhere.1,4
Emergency physicians organized in 1968 to form the American College of Emergency Physicians (ACEP). Residency programs developed in the early 1970s, and, in 1979, the American Board of Medical Specialties approved the American Board of Emergency Medicine. The field has since had marked growth and now comprises more than 140 approved residency training programs.5
Despite hospital closings and reductions in services, visits to EDs have increased, continuing to grow at a rate of about 3.2% per year, to a total of 119 million visits a year in 2006.6 Reports of temporary boarding in the ED of admitted patients for whom no bed is yet ready began in 1990,7 and this practice has increased to a crisis level since then; its prevalence causes ED crowding, which diverts the attention of ED nurses and support staff and puts the original purpose of EDs in jeopardy.
In reviewing the nearly 50 years of EM history since EM practice arose as a distinct new entity in medicine in the United States, starting with Alexandria Hospital (Alexandria, Virginia) in 1961, Zink1 found similarities between conditions existing in 1961 and the current climate. We are faced with an aging population, a greater and ever-increasing number of uninsured, a crisis in primary care access, an overall physician shortage, and an increase in hospital-centered care. For example, the percentage of uninsured patients less than 65 years old increased from 14.5% in 1984 to 17.0% in 2006. From 1997 to 2006, the percentage of adults at least 75 years old who visited an ED in the United States increased from 24.3% to 28.9%.8 These same factors led to a marked upswing in ED visits in the 1950s, and their effect is still seen in a proportionally similar increase in volume over the past decade.
A decade ago, a task force of the Society for Academic Emergency Medicine (SAEM) used a similar approach in an attempt to look 5, 10, and 20 years into the future of the specialty of EM.2 The task force accurately predicted identifying the increasing importance and growth of electronic information systems, the crowding of EDs with greater numbers of increasingly ill elders, and the growth of home care, telemedicine, and EM research. However, the task force did not foresee the crowding effect of the temporary boarding of admitted patients in the ED or the failures of managed care and primary care that resulted in increased fragmentation and higher costs of care and in the lack of a coordinated system of care for chronically ill patients. The task force assumed that systems of gatekeepers for primary care would lead to physician surpluses in many specialties, including EM. In fact, a health care reimbursement system based more on episodic care than on health maintenance has not led to the expected increase in the numbers of primary care providers. Furthermore, the longevity of elders who have more complex health and social conditions—often with multiple chronic diseases—has led to a greater demand for both primary care and specialty services, including EM.
The SAEM task force predicted there would be an oversupply of emergency physicians,1 but recent workforce needs analyses have shown that the current supply of board-certified emergency physicians will not meet the demand for the foreseeable future.9 The prediction of greater health insurance coverage also has not come true,2 as 15% of the U.S. population was still uninsured as of 2007.10 In addition, whereas the growth of EM research has been substantial, few collaborative international research efforts have come to fruition.
The Environment of Health Care in the Future
Several trends will affect the future of EM. The following sections are areas whose current trajectories will not be sustainable in a viable health care system of the future.
The continued rise in the cost of health care is not sustainable. The United States spends more money per capita on health care than does any other country in the world, yet the receipt of health care is uneven; despite large total U.S. health care expenditures, national health measures of quality tend to be lower than those in comparably developed countries. Sixteen percent of the 2005 U.S. Gross Domestic Product was spent on health care, and that proportion has increased annually.11 Governmental expenditures through the Centers for Medicare and Medicaid Services (CMS) and other federal sources are approaching 50% of the current health care budget, and they account for 55% of hospital income.12 As the population ages and the number of wage earners relative to the number of Medicare beneficiaries decreases, there will be increasing pressures to reduce spending. Service prioritization for management of complex, chronic care seems likely in a cost-conscious future, and thus finite resources will be focused on areas where they can have the greatest impact on outcomes. The costs of medical liability are also much greater than those in other countries, and those costs inhibit improvements in patient safety that are based on improvements in the delivery of health services; thus, reform will be necessary.
U.S. quality parameters lag behind those of other countries. Overall lifespan, disease-based, and overall quality measures are not keeping in stride with the rising cost of U.S. health care, which creates a national disparity between the amount spent and the outcomes obtained.12 In response, CMS has identified quality standards for the care of patients with high-impact diagnoses such as myocardial infarction, heart failure, pneumonia, and surgical procedures.13 Private payers are likely to eventually follow suit. These standards mirror the evidenced-based guidelines developed for the treatment of a wide range of disease states, and they have been, and will continue to be, linked to reimbursement. The list of quality measures will grow, especially in the face of declining resources to pay for expensive therapies. ACEP has been very prolific in its production of practice guidelines: More than 40 clinical policies for its members are in place.14 The development of guidelines requiring the highest quality of evidence will replace expert opinion and lower levels of evidence and will serve to maximize improvements in patient outcomes.15 The challenge for EM will be to develop quality measures that are not primarily focused on processes of care that have previously been associated with favorable outcomes in certain settings. Such measures are tempting, given the ease of measurement, especially via review of electronic health records (EHRs), but an overdependence on such measures may stifle true innovation that would lead to even better clinical outcomes or more cost-effective care via alternative processes.
Coverage of the uninsured
As mentioned, uninsured patients made up 15% of the total U.S. population in 2007,10 and the proportion is likely to grow in the near future. These patients often depend on EDs as the medical safety net for their health care. Universal coverage of the presently uninsured, as advocated by political candidates from both major political parties in the United States, may have profound effects on the fiscal health of EM. On the one hand, instant insurance for these patients can bring a financial windfall to EDs that have been incurring large burdens of uncompensated care. On the other hand, universal coverage probably will be costly to the population at large, and, thus, it will come with limits and restrictions on ED use, as well as with reductions in reimbursements to physicians and hospitals. Moreover, as the state of Massachusetts has discovered over the past three years, universal coverage does not equate with universal access: The average wait for a new patient appointment with an internist increased from 33 days in 2006 to 52 days in 2007.16
Technology drives a significant amount of the growth in EM. The ED remains one of the few places where computed tomography, magnetic resonance imaging, ultrasound, laboratory testing, and diagnostic protocols are available around the clock and in one location. Patients' demands for technology will continue to grow as well-informed consumers and concerns about liability drive the need for more-certain diagnostics. Diagnostics and imaging devices will become less invasive. For example, noninvasive hemodynamic monitoring devices have been found to be comparable with invasive Swan–Ganz catheters.17 With the explosion of available data that can be used to manage patient care, the organization and coordination of these data are of the upmost importance. The use of information systems and EHRs will allow information about patients to be transmitted from remote locations. What started as ED-specific information systems will eventually transition to hospital-wide EHR systems. Telemedicine, in which medical information is transmitted through electronic communication networks, will call for linkage of the ED to homes, rural sites, prisons, and locations outside the country. Training in the use of telemedicine will become a required element of residency training.
Demographic trends will lead to a growing population of elders with multiple chronic illnesses. Elders are admitted to the hospital between 32% and 51% of the time when they present to the ED: This fact represents a growing burden both to the ED and to inpatient services.18 Younger patients with severe, complex, chronic diseases also will require constant oversight and timely support as their life expectancy grows.
Specialization and regionalization of care
As the best time-sensitive and/or technology-based care for specific diseases is identified, it will become necessary to regionalize such care to centers that have the technology and specialists to deliver it. EM will be integral to regionalized care. EM professionals coordinate emergency medical services (EMS), which can initiate care and determine the appropriate hospital destination for patients with acute illness. In most communities, trauma systems are the most developed regionalized system of care, with destination protocols for acutely injured patients. Treatment of myocardial infarction,19 stroke,20 burns,21 transplant emergencies,22 pediatrics patients,23 obstetrics patients,24 and psychiatric emergencies25 is undergoing regionalization to some degree, on the basis of a combination of the capabilities or certification of the receiving hospital and the corresponding best practices as identified by evidenced-based guidelines. Regionalization seems to improve outcomes even as it allows a concentration of resources in specific centers, which reduces the cost of an individual hospital's overhead, and it will also encourage the development of teams that work together to solve specific problems.23 Specialists will be accessed through the ED for treatment of acute problems, and areas of ED specialization, such as observation medicine, ultrasound, toxicology, pediatrics, and telemedicine, will attract EM residency graduates and provide additional support for specialty care and regionalization.
Alternative venues of care
Social support networks of oversight and care for vulnerable populations, including those with mental health issues and/or substance and alcohol abuse, may direct care away from health care facilities to other settings, such as welfare services and local police services.26 These measures are designed to reduce the cost of care in high-impact disease states, such as chronic obstructive pulmonary disease, congestive heart failure, and diabetes, that are complicated by homelessness and mental health problems. An infusion of new efforts for preventive care of these patients may reduce their annual cost of care and similarly reduce their use of the ED.26 For minor acute problems, acute care clinics will proliferate in pharmacies, malls, and hotels, although at a slower rate than in the past.27 For chronic care, the establishment of the “medical home,” which includes in-home management of complications and decompensation, will help patients avoid visits to the ED.28
Improbable but potentially significant scenarios can have a significant impact on emergency care. A severe epidemic could kill 10% to 20% of the world's population, mostly the elderly, the disabled, and the chronically ill. Catastrophic natural disasters and gradual climate changes could have sudden and long-term impacts, respectively, on the health of the population. Disasters could both directly affect the health of patients and cripple the technology and infrastructure that we rely on to provide modern health care. Conversely, a discovery or new technology could change the nature of diagnosis or treatment of emergency conditions. A war or financial crisis could cause significant deaths or economic crises that could force the creation of a socialized, government-controlled health system. Although they are difficult to plan for, improbable scenarios such as these may occur and may alter the impact of other forces. In turn, these forces are a factor that will affect the current relationship of costs and availability of services, thus accelerating the pessimistic scenario.
Future Emergency Care Scenarios
The three scenarios discussed above are derived from different assumptions that incorporate the forces we have described but that assume the primacy of different forces. From these scenarios, we are able to generate a more concrete prediction model for the future, as shown in the following three scenarios.
A pessimistic scenario—if cost is the major driver
If cost is the major driver, spending and reimbursement reductions are the dominant methods used to reduce health care costs. As a result, severe funding shortages, workforce limits, and crowded EDs will make the specialty increasingly unpopular. In urban and suburban areas where uncompensated care is common, the ED will become financially nonviable, and the health care system's “surge capacity” in the event of mass-casualty incidents will be lost. Emergency physicians' salaries will stagnate and even drop as money is diverted to medical homes, primary care, and preventive care. Hospitals will be forced to subsidize care in the ED, emergency care resources will shrink, and EM physicians will be encouraged to direct patients to an assigned medical home rather than perform ED-based workups of patients who are not critically ill. In rural and some urban areas, physicians will be replaced by teams of physician assistants (PAs) who will provide care with little backup or support. Even in this cost-driven scenario, timely emergency care interventions will grow in areas of medical care that are proven to reduce costly hospitalization and prevent disability, but they may bypass the ED and take place in operating rooms, catheterization labs, or critical care units.
An optimistic scenario—if quality and technology are the major drivers
In the optimistic scenario, time to treatment, patient satisfaction, and patient outcomes will be the dominant forces shaping the future of EM. In a health care scenario in which cost is less of an issue than it currently is, and in an effort to improve throughput and patient satisfaction, EDs will be freed from boarding admitted patients, even temporarily. They will become the diagnostic center for health care facilities and individual patients. Time-sensitive illnesses such as myocardial infarction, sepsis, stroke, and trauma will be more quickly and accurately identified, and rapid entry into and receipt of care in the ED will reverse pathologic processes that used to cause death and disability. Specific areas for care of time-sensitive conditions will develop, and, subsequently, specialized training will be given. Resources will be put in place to allow the ED to deal with surge conditions, disaster scenarios, and an ever-increasing patient volume. ED workforce needs will be balanced with each emergency physician's ability to see a certain volume of patients. Technological advances in diagnostic imaging and informatics will provide large information databases on each patient and on all disease possibilities and treatment options. EDs will become the center for out-of-hospital care via the Internet and the use of telemedicine technologies, and EDs will integrate medical homes with inpatient and outpatient services. Linkages to patients in their homes through the Internet will allow for reductions in EMS use and will permit directed treatment of conditions that do not require hospitalization. Patient care will be seen more as a longitudinal continuum of care than as periodic episodes of care, and technology will be used to coordinate and manage the continuity of care.
The most probable scenario—the cost/quality balance and the increase in time sensitivity
With the major drivers of care protocols being quality and cost, EM will be required to show that quality care will ultimately reduce cost. Research in practice areas that overlap health services and clinical improvement will be increasingly important and will warrant funding by EM organizations and foundations. Growth will be in areas of demonstrated quality and cost reduction: time-sensitive conditions, disease-state-specific care pathways, guideline-based clinical protocols, checklists, and reductions in the variability of care—as in sepsis care and abdominal pain workups. Observational and short-stay diagnostic strategies will flourish to reduce inpatient costs and improve patient satisfaction. Information technology will bring needed information about patients and disease management together to assist health care workers in real time, thus driving quality up while reducing costs by better resource utilization. This change will be accomplished by minimizing the duplicate ordering of tests and by improving the accessibility of data at the point of patient care. The use of teams of physicians, PAs, nurse practitioners (NPs), and technicians will reduce overall physician workforce needs. Regionalization of certain types of specialty care for acute coronary syndromes, trauma, strokes, pediatric patients, and psychiatric diseases will drive ED subspecialization in certain tertiary centers. Time-sensitive conditions will be increasingly identified; rapid transport and diagnostic and therapeutic advances to reduce morbidity and mortality of trauma, infectious diseases, and cardiovascular diseases will flourish. Patients' demands for access and satisfaction—the original drivers of the development of the specialty—will continue to influence emergency physician evaluation and will lead to greater availability of boutique emergency practices in hotels, homes, malls, and workplaces.
Future EM activities
Less than 20 years ago, the number of National Institutes of Health (NIH)-funded EM investigators was extremely small, and annual NIH funding allocated to departments of EM represented approximately 0.03% of the total NIH budget.29 By 2007, funding had tripled from that of 20 years ago, but it is still far from adequate. An exponential rise in NIH funding allocated to EM investigators is anticipated in the next decade, for several reasons. First, the numbers of EM residency graduates entering academic careers on graduation are increasing, and EM now claims among the highest percentages of all specialties.30 With an expanded appreciation of the effects of EM practice on time-sensitive conditions within the NIH, increases in funding for training grants will be aimed at developing high-quality basic, translational, and clinical EM researchers. Some EM researchers will continue to be trained by investigators in other specialties, but most will be trained by other EM researchers who themselves have undergone formal research training. Increases in funding will, in turn, trigger the creation within academic EDs of a better research training infrastructure for residents, fellows, and faculty.
In the past decade, several population- or disease-focused EM research networks have been successfully established and have begun to conduct high-quality clinical research. Examples include the Neurological Emergencies Treatment Trial network (funded by the National Institute of Neurological Disorders and Stroke),31 the Pediatric Emergency Care Applied Research Network (funded by the Department of Health and Human Services [DHHS]),32 and the Resuscitation Outcomes Consortium (funded by the National Heart, Lung, and Blood Institute).33 These networks will continue to perform clinical trials answering important clinical questions that are specific to the practice of EM. Over the next decade, a cross-disciplinary network for emergency care research will be formed and used by the Clinical and Translational Science Award centers and by NIH institutes focused on specific diseases. This robust and versatile emergency care research network will study acute care diagnostic and therapeutic strategies on a broad scale and will have the added value of testing these strategies in diverse and underserved populations.
EM research will continue to grapple with unscheduled patient visits, the need to obtain data from multiple locations and multiple providers, the need to act in a time-sensitive fashion, and the presence of barriers to informed consent. Given the time-sensitive nature of emergency conditions, and the fact that the critical condition of many patients prevents them from being able to give consent to research in the ED, informed consent is a major concern. The EM research community will respond to federal, state, and local initiatives to perform quality research in the realms of health services, quality, cost-effectiveness, and disaster preparedness and management. More research will focus on these areas, and additional funding opportunities will be provided by the Centers for Disease Control and the Agency for Healthcare Quality and Research.
The recent Institute of Medicine Report entitled “Hospital-Based Emergency Care: At the Breaking Point”34 provided the EM research community with an opportunity for the implementation of many of these recommendations and the realization of many of these goals.35 The report called for DHHS to examine the current gaps and opportunities in emergency and trauma care research and to recommend a strategy for the optional organization and funding of research efforts. SAEM and ACEP have taken key steps to ensure that this recommendation will be implemented. Because it is based on critical input from EM investigators, such a large-scale study will likely reveal an immense need for additional EM research that is focused on the identification and treatment of time-sensitive illnesses and injuries. The hypothesis of EM research, that “rapid diagnosis and early intervention in acute illness or acutely decompensated chronic illness improves [sic] patient outcomes,”36 will increasingly be tested and funded.
As EM knowledge and skills continue to grow, more and more medical schools will require their integration into undergraduate medical education. Medical education will use a patient-centered model that encompasses preventive care, acute care, and chronic care across all specialties, and EM will become an important intersection of many aspects of medical education. EM education has benefited by having an agreed-on core content known as the “model of emergency medicine.”37 Whereas the model was originally conceived as a listing of key conditions and symptoms to direct the training of residents and the testing of residents before certification, practicing EM physicians have provided input into the model and have developed a matrix of conditions, clinical acuity frames, and key tasks. This model has incorporated the core competencies identified by the Accreditation Council for Graduate Medical Education. It will form the basis for the EM education of medical students, PAs, and NPs and will continue to evolve to incorporate the changes in the emergency care system. Implementation of the model will increasingly use new educational technology, such as simulation and standardized patients. The future of EM education will move from clinical care experience to simulation for procedural training, team training, and critical care scenarios, and simulation will also be used for formative and summative evaluations. Some of the simulated experiences will involve trained standardized patients, and others will involve the use of mannequins, virtual reality, or other modalities. EM education also will increasingly involve training in evidence-based medicine literature searching and analysis. The accumulation of procedural and diagnostic experience to allow for the development of expertise, as described by Ericcson,38 will be affected by duty hours restrictions, and those effects may lead to longer training periods.38 Within 20 years, residency training will expand to provide a sufficient workforce—in conjunction with PAs and NPs who will become incorporated into a team-based system of care, to staff all EDs. Flexibility in scheduling and part-time work will continue to attract students who are trying to balance personal and workplace responsibilities.
The future of EM will be characterized by increasing education about and research into time-sensitive conditions, the development of standardized disease-management protocols and guidelines, and the availability and use of technology for information management and diagnostic investigations. The trend toward regionalization will accelerate, creating centers with unique areas of subspecialized emergency care. Rural EDs will become part of a network linked via telemedicine, and they may increasingly be staffed by nonphysician providers. Cost, quality, and technology will have major influences on the future development of EM. The availability of flexible working hours will be attractive to a workforce demanding the possibility of balancing family and career. Academic EM will increasingly partner with basic and clinical scientists in multidisciplinary translational research. State and federal health insurance coverage of the uninsured will reduce the burden of uncompensated care in the ED, but it may temporarily lead to further crowding until problems with access to primary care are addressed. The need for rapid diagnosis and rapid initiation of treatment in increasing numbers of conditions will apply pressure on EDs to function effectively and quickly, but the burden of serving as an overflow area for unavailable hospital and community services will make smooth functioning difficult. Resolutions of this tension will vary, depending on whether cost or quality concerns predominate.
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