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Breaking News: Experts Warn of EMTALA Violations as EDs Turn to Reservation Systems

SoRelle, Ruth MPH

doi: 10.1097/01.EEM.0000427051.89363.59
Breaking News


Can the solution to long hours in the waiting room of the emergency department be as simple as point-and-click?

Companies that provide such services tout their online reservation system as a way to reduce that frustrating time, but there are caveats. They can reduce waits and make emergency departments more efficient — when everything goes right. And then there is the not-so-minor issue of EMTALA complicating things.

Park Plaza Hospital, a Tenet hospital near the edge of the Texas Medical Center in Houston, uses a special web-based service called InQuicker to allow a certain subset of the emergency department patients to make free reservations for treatment free. The service advises at the bottom of its web page that patients whose problems turn out to be nonurgent can seek care at an urgent care or primary care center nearby. Those who continue on to “check in” receive a notice that they will receive a medical screening exam regardless of their ability to pay, and that the exam will determine if the condition is a medical emergency. If it is not, the patient may be required to make a co-payment or be responsible for other charges after treatment. Patients with emergencies who come to the ED at the same time may be seen before patients with the reservations, the site advises.

InQuicker is only one of many such services, but its name appears frequently in news articles and on websites. Chris Song, the spokesman for InQuicker, eagerly points out that his company, which provides its reservation services to hospitals, urgent care clinics, and primary care offices, has 192 providers in 23 states. Some of those charge up to $25 to provide the service, although Mr. Song said “there is a move for them to drop their online fees in the near future.” The vast majority of their services are provided free to patients.

Mr. Song said the service allows providers a way to stand out in their communities as innovators focused on clinical care and patient satisfaction, showing respect for the patient's time and convenience while serving as an efficiency move for the hospital. “In any emergency department, there will busy times and not-busy times. And in any emergency department, you are going to see patients with a lower acuity. InQuicker enables hospitals to offset some of the low-acuity traffic by offering appointments when volume is low.”

But Richard Turner, MD, a spokesman for the American College of Emergency Physicians and an emergency physician practicing in California, said the service seems counterintuitive. “First is practicality. People are coming to the emergency department because they have something they think is urgent or life-threatening. Are they going to say, ‘I have something life-threatening. Can I make an appointment?’”

He said patients do come to EDs for subacute problems that they have often had for weeks or months. “In that case, it's still counterintuitive,” he said. “They have had it this long and know it's not urgent or an emergency. They should be seeking care from their primary care physician. They may be in a community where they don't have a primary care physician or cannot make an appointment for days or weeks. Something is wrong with the health care delivery system in that situation. Every system should have a situation where you can make urgent or emergent appointments for their clientele.”

Most EDs are moving toward putting patients in beds immediately, Dr. Turner said: get them in, determine their acuity, and get them on their way — discharged or admitted. “How is it going to work if they call in, and say, ‘Do you have a slot for an appointment?’ I'm not against it, but it's a lot like saying let's go to the hardware store to buy groceries,” he said.

Robert Bitterman, MD, JD, the president of the Bitterman Health Law Consulting Group with offices in Charlotte, NC, and Harbor Springs, MI, said he thinks the services, of which InQuicker is only one, may violate the federal Emergency Medical Treatment and Active Labor Treatment Act. “This system would work for urgent care, a physician's office, even a fast track clinic,” he said, but added that the system actually allows the patient to check into the emergency department before coming to the facility. “It is better seen as a mechanism to ‘hold a place in line’ and receive a ‘projected treatment time’ when visiting a specific emergency department,” he wrote in an article in the May 2012 ED Legal Letter. “The issue,” he wrote in regard to EMTALA, “then becomes whether the hospital's process for screening the pre-registered patient is uniform, non-disparate, and non-discriminatory compared to the hospital's process for screening patients who register upon arrival to the ED.”

EMTALA is written to prevent discrimination, but the courts have held that treating patients differently in the emergency department for nonmedical reasons is generally considered against the law. Patients who are seen before patients who just walked in because they paid for preregistration “is clearly illegal under EMTALA,” Dr. Bitterman said.

It may be considered illegal even if the hospitals do not charge for the preregistration, he said, although that is not clear-cut. The Centers for Medicare and Medicaid and the courts would likely focus on the possibility that the medical screening exam process is not the same for everyone, even if the patient did not pay a fee for preregistration. Dr. Bitterman said, however, services that require hospitals to accept patient information with the online appointment request, which many do to determine if patients should come in more quickly than by appointment, are increasing the hospitals' liability.

Kenneth Iserson, MD, MBA, the president emeritus of emergency medicine at the University of Arizona in Tucson and an ethicist, said “first-come, first-served is a valid triage method for those without life-threatening problems or in severe pain,” but he questioned whether computer questions or a telephone call can determine accurately the severity of a patient's problem.

“The system is ethical if it makes exceptions for those with life-threatening problems or in severe pain, the system is open to everyone to use, the general public knows about the system, and walk-in patients are told of expected scheduled patients so they can decide if they want to stay,” he noted.

Dr. Turner said he thinks the system would work best in urgent care or acute care centers. Patients who just show up at the ED with problems that are not life-threatening spend a lot of time waiting. Often they are triaged to a fast track or urgent care system. “That would be the appropriate place for this,” he said. “It would also provide more reliable appointments for the patients.”

Ryan Stanton, MD, the director of emergency medicine at UK (University of Kentucky) HealthCare Good Samaritan Hospital in Lexington, said he had some reservations about the practice. “If it's an emergency, you don't need a reservation. But a good number of our cases are urgencies for patients who don't have access to care, and you need to get those people seen. It would do us a favor and them a service if they could come in during a slower time. Yet it goes against every idea that's in emergency medicine,” he said.

Emergency departments are intended to pull together the gaps in the health care system and help patients find the care they need. “I think what you will see down the road is a more hybrid model where we diversify in emergency medicine,” Dr. Stanton said. “We are talking about setting up a walk-in urgent clinic associated with the emergency department so we can screen patients. Once we find they are more of a clinic visit, we can send them to that clinic.”

Mr. Song of InQuicker pointed out that his service is provided in urgent care clinics and primary care offices as well as the emergency department. The service can notify patients that they may be delayed if a major accident or incident suddenly overwhelms the emergency department. “That's a level of communication between the patient and provider that you don't get in the emergency waiting room,” he said. “Our service enables you to check in and wait online; you are simply waiting in a different environment.”

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