Each year in the United States, there are 130.4 million visits to the emergency department. These visits, especially nonemergency visits, are costly not only to the patient, but also to the health system. The average cost of an ER visit is $1,233, approximately 40% higher than the average monthly rent in America, which is $871. Approximately 65% of all ER visits do not warrant a visit to the ER. Our current ER system fails to reduce reoccurring, nonemergency ER visits that could otherwise be addressed in a primary care setting. In addition, the current fee-for-service model does not incentivize health systems to prevent unnecessary visits. In the ER, our disease-focused model of care encourages providers to focus on the patient’s chief complaint, often neglecting other critical aspects of a patient’s case that may have led them to the ER.
Many ideas have been proposed to reduce nonemergency visits, including increased cost sharing to reduce the cost of preventive primary care visits. In addition, strategies should be devised to address the problem when it occurs, in the ER. Shifting towards personalization of care could reduce the burden of nonemergency ER visits by 1) using personalized medicine to reduce adverse drug events associated with chronic disease medications and 2) preventing reoccurrence of nonemergency ER visits by implementing personalized health care to develop personalized, coordinated health plans.
The most frequent reasons for seeking ER services are often avoidable and tend to be the result of chronic disease complications. Patients with chronic diseases like asthma, diabetes, chronic heart failure (CHF) and chronic pain, may experience adverse drug events (ADEs). Approximately $3.5 billion are spent yearly on the costs associated with ADEs, which account for at least 700,000 annual ER visits within the Medicare patient population. This could be a result of mismanaged care, low health literacy, or lack of patient engagement. Since sequencing the human genome in 2003, personalized medicine technology allows us to identify a patient’s genetic risk to certain medications using pharmacogenomics, preventing a physician from prescribing ineffective or adverse reaction-inducing medications. This information would allow for more accurate decisions on which medications and dosages will be most effective for the patient. To better address ADEs in the ER, the electronic medical record could be designed with built in clinical reminders for when an ADE could be triggered this is especially important in the busy ER setting.
To prevent the reoccurrence of nonemergency visits, a clinical workflow called Personalized Health Planning (PHP) could be used in the ER. PHP is a clinical workflow for developing a personalized health plan for the patient, centered on personalized, proactive, patient-centered care. PHP could be implemented using a dedicated PHP team, consisting of a physician or physician assistant, a nurse or nurse assistant, and/or social workers. The electronic medical record (EMR) could allow ER providers to refer high frequency patients (those with ≥ 3 annual ER visits) to the PHP team. The PHP team would then meet with the patient to begin managing the patient’s case and creating a personalized health plan with the patient. The EMR would enable the PHP team to monitor various aspects of the patient’s engagement, such as whether prescriptions have been filled and other medical visits have been made. The EMR would also allow PHP team providers to make referrals to the patient’s primary care provider.
In following the PHP workflow, the social worker or nurse’s aid would guide the patient in completing a personalized health inventory (PHI) to assess patient preferences and health goals. The provider would then assess the patient’s health risks and, with the patient, set shared goals that would engage the patient in considering how they could avoid the ER in the future. An important aspect of PHP in the ER is educating the patient to triage their own symptoms; it will be essential that patients know how to identify and categorize their symptoms as emergent or nonemergent. By the end of the consult, the PHP team would create a personalized health plan in the EMR for the PCP to see. Case management of nonnemergent ER users by the PHP team would be the first steps in coordinating the patient’s care, setting shared goals, and connecting them with their PCP for follow-up on their personalized health plan. Initiating PHP in the ER would be effective because it engages the patient in the process at the time of their ER visit, before their memory of the incident wanes of they are lost to follow-up.