Vol 6 pp 333-338.
: 988 %gamon
EMERGENCY SERVICES AND HEALTH MAINTENANCE ORGANIZATIONS: AN HMO PERSPECTIVE
William E. Daley, Reprint
PrInted jr- :he USA
Emergency G Richard
and G. Richard Braen,
Serwes, Brlgham &Women’s Hospital. Harvard Medical Braen. Emergency Serwes. Brlgham &Women’s Hospital 75 Francls Street. Boston. MA 02115
q Abstract-Described is the emergency triage referral system developed by a health maintenance organization. Based in an emergency department and staffed by emergency clinicians, this HMO triage system uses existing emergency medical services and enhances the delivery of prehospital care.
emergency physicians take a keen interest in allocating resources according to the best possible assessment of need. Yet as emergency physicians trained to recognize acute emergencies and to appreciate the crucial contributions of a local EMS network, HMO emergency physicians can serve as true advocates of an expanded HMO program that can combine some of the best attributes of both systems. We describe here the early evolution of such a program, now functioning at the Harvard Community Health Plan, or HCHP, the largest closed panel HMO in New England.
C7 Keywords-emergency medical services; health maintenance organizations; prehospital care; telephone triage
The growth of prepaid health care systems, most visibly represented by the health maintenance organization (HMO), has had an enormous impact on the practice of medicine in the United States. HMO enrollment now totals 21 million patients in 44 states.’ Virtually every metropolitan area has at least one, if not several, HMOs. The development of prepaid health care on this scale has come at least 15 years after the tremendous advances made in the organization and delivery of prehospital care. The integration of HMO delivery of care with that of local emergency medical services (EMSs) has not, until recently, been addressed.: Many HMOs are only now becoming large enough to support their own emergency services, staffed by emergency physicians. These emergency physicians have a different perspective on prehospital care than that held by HMO-based primary care physicians, the traditional “gatekeepers” of the prepaid system. In their position with HMOs, subscribing to the same practice principles as other HMO physicians, these
Harvard Community Health Plan (HCHP), staffed by 337 physicians, 193 nurse practitioners, and 40 physician assistants, most of whom are in primary care specialties, serves 219,239 members in 8 health centers. HCHP members live throughout New England, but the majority are located within a 30 mile radius of Boston, incorporating 150 towns and cities. Access to prehospital care within this area is non-uniform, and in most communities access to ambulance/EMS service is through a seven digit number. A minority of communities utilize a “911” system. In addition, advanced life support (ALS) capability is the exception rather than the rule outside of metropolitan Boston. Most small communities within this area rely upon basic life support (BLS) providers that are either town employees (fire, police), volunteers, or commercial ambulance vendors dispatched through the local authority. Many people living in this area are unfamiliar
Emergency Forum is coordinated by G. Richard Braen, MD, Brigham and Women’s Hospital, Harvard Medical School, Boston. -RECEIVED: 27 April 1987; ACCEPTED: 21 September 1987 0736-4679’88 $3.00 + .07i ======
334 with the access number of prehospital care within their community and are additionally unfamiliar with the level of care that will be provided once help is summoned. (Metropolitan Boston Hospital Commission, unpublished telephone survey 1983-84). HCHP recently completed an agreement with the Brigham and Women’s Hospital (BWH), a major Harvard Medical School teaching hospital, that provides for the hospitalization of HCHP members at that institution. The agreement reflects the process of vertical integration of health care services that is occurring nationwide. This agreement provided for the establishment of a separate emergency service (solely for HCHP members) located at the Brigham and Women’s Hospital. This service is staffed by attending HCHP emergency physicians, and oversees the coordination of emergency care for HCHP members. With this service, the HMO has expanded its staff to include a core group of emergency physicians who are familiar with access to and utilization of prehospital care. Plans are now underway to integrate this HCHP program more fully with the BWH emergency service. HCHP has also established an emergency telephone triage facility located in the HCHP Emergency Service. This service is staffed by a group of experienced nurse practitioners and physician’s assistants, all of whom practice emergency medicine as well as emergency telephone triage. They are backed up 24 hours a day by an on-site emergency physician, who is available for advice and consultation. They answer designated emergency numbers that are made available to HCHP members, and handle all routine health inquiries after HCHP health centers have closed. Current volume totals approximately 400 telephone calls per 24 hours, with 250 of these occurring between 8 pm and 8 am. Clinicians use protocols written by emergency physicians that are explicit but also allow for individual practitioner discretion. Each emergency complaint (epistaxis, head injury) is framed first an an algorithm, followed by 3 to 5 pages of discussion that explains the clinical response behind the decision tress indicated by the algorithm. (See Tables 1, 2 and 3 for examples of the algorithms used in this system.) In addition, the telephone triage center has resource materials that include community-specific information on access to prehospital care, a medical library, a [email protected]
Reference system, and immediate on-line access to each HCHP member’s medical record in CRT format using a CO-STAR medical record database.3 A quality review program analyzes problem telephone encounters as well as individual performance. All phone calls are recorded and become retrievable
Willlam E. Daley, Jenntfer Leaning,
for review on a daily basis. Every morning at change of shift, the nighttime phone staff signs off to the clinical staff at each health center those cases that are pending at home or in area emergency departments. At that time the emergency physician is available for informal review of the previous night’s problems. Once a week a more formal “phone rounds” takes place. The emergency physician designated to conduct rounds that morning goes over one or two significant clinical or system issues that may have arisen during the preceding week. The current structure of the quality review program is explicit, driven by problems that providers recognize at the time or by complaints the programs receive. In an average month, the telecommunications system receives from one to two complaints for the 12,000 calls it handles. The computerized medical record and continual recording system offer many opportunities for developing implicit review procedures. Several are now in planning phases, but none have yet been instituted. It is the philosophy at HCHP that emergency services be used appropriately, for both quality of care reasons and cost considerations. A significant number of emergency department visits may be inappropriate4J and expensive. In an environment of cost containment, these calls may restrict the HMO from delivering of services in other areas. In addition, patient encounters with emergency services outside of the HMO system do not promote continuity of care, an attribute of HCHP’s service that staff and members value highly. From the perspective of HCHP primary care physicians, patients seen in outside emergency facilities may receive incomplete discharge instructions, with followup delegated to a physician who does not have documentation of the patient’s emergency visit. (Harvard Community Health Plan, unpublished study: Quality of Care Measurement Study, 1986.) HCHP has also found that however good the local public relations effort, patients are often unclear about how and when to access prehospital care. Many patients become confused or do not think well during a medical crisis, and require firm direction in the appropriate action to take. Patient perceptions of what constitutes a true life-threatening emergency vary widely and unpredictably. Some patients will overestimate the severity of the illness, whereas others will underestimate it. In addition, most current prehospital care systems operate on limited patient information without rapid access to medical records. Personnel in such systems are generally unwilling or unable to give telephone advice while help is on the way (such as providing instructions for clearing an obstructed airway, controlling bleeding, positioning an
EMS and HMOs
-- - --.--..
Patient must gency facility
be evaluated unless health
2 hours. Site of visit will usually be nearest open and capable of 2-hour visit turnaround.
must be seen within 6 hours may be substituted for a visit
or, based upon if appropriate.
MD Transportation Classifications A Ambulance
Ambulance transport to nearest emergency facility preferred, but under certain conditions, patient may be driven by friend or family member to nearest facility. Under no circumstances should patient be allowed to drive self.
Mode of transport location.
Transport via ambulance preferred, but automobile acceptable under certain conditions; patient must be seen within 2 hours; site of visit will probably be emergency facility but could be health center, if appropriate.
+ I - Ambulance
‘Some discretion may be used in this step. :c 1986 Harvard Community Health Plan Emergency
(either by telephone may drive self.
last 12 hours
Obtain demographic data complaint of DIFFICULTY BREATHING
infection) of inahler ?) recent reduction in dose asthma ( when, how long)
Ask about history of:
Are you having difficulty speaking ? Are you getting tired out ? Are you sweating ? First asthma attack ? History of anaphylexis or severe allergies
Heart trouble Duration of attack Progression of symtoms in Presence of fever Color of phlegm (suggests Current medications (abuse Use of oral steroids now or Recent hospitalizations for Age >50
Follow-up al. Patient
1. 2. 3. 4. 5.
William E. Daley, Jennifer
G. Richard Braen
Table 3. Summary of Phone Triage of Chest Pain
Obtain demographic data -Age Establish complaint of CHEST PAfN
> 40. male 60. female
1. ” Are you short of breath or having trouble breathing? ” 2. ” How did the pain start, how severe is it and where does it radiate? ” 3. ” Crushing pafn, severe pain or sudden onsetUnremitting 4. ” Do you have a history of heart disease, hypertension, diabetes, or smoking?. 5. ” Have you had a Mow to the chest area recently (within 48 hours)’ ? NO 1. Define the nature of the pain more precisely Location Quality Onset Duration 2. Ask about associated
1. 2. 3. 4. 5. 6.
Chest pain typical or atypical for AMI Persistent pain Fever Significant respiratory symptoms Persistent emesis or diaphoresis Hernoptysis
Vomiting or diaphoresis FeWr SOWTachypnea Emesis Cough Hemoptysis 7. Any patient who has any item positive jxq on screening of past history
3. Screen past medical history. CHF Congenital cardiac disease DVT by history PE by history GOPD Hypercoagufable state ScPs./conjugated estrogens Prolonged immobilization Recent surgery
History of pneumothorax Marfan’s syndrome Recent viral infection History of G.I. disease G.I. [email protected]
ETOH use/abuse Familial hypercholesterolemia Postpartum
unconscious patient, or administering cardiopulmonary resuscitation). HCHP emergency physicians have recently succeeded in improving the wording and explanatory scope of the emergency benefit statement for patients, one of the items suggested as being an impediment to prehospital care.* Now the wording more clearly defines an emergency and encourages the member when necessary to seek immediate care via the 911 system,6 since preauthorization in critical situations wastes time and delays access to care. These modifications grew out of discussions with the local EMS community. HCHP anticipates further cooperative work with the EMS committees in the HCHP service area regarding the issues of how to educate patients and physicians in the use of prehospital and emergency care. The three cases below, all of which presented by telephone to the HCHP Emergency Service in the last
NO 1 ws
patients with chest pain should be seen. The most important triage decision involves assessment of acuity and method of transport.
several months, illustrate how the HMO provider may enhance delivery of prehospital care while continuing to utilize existing systems.
Case 1 An 82-year-old male with recent history of epigastric distress called the HCHP Emergency Services complaining of chest pain and difficulty breathing. The physician’s assistant handling the call elicited a history of severe chest pain and mild shortness of breath and, according to established guidelines, determined that this was an emergency situation and called an ambulance for the patient. The patient expressed a desire to drive himself to the hospital. The patient was told “We don’t want you driving, so we’ve sent an ambulance for you.” The physician’s assistant stayed on the line with the patient, persuading him to wait
EMS and HMOs
for the ambulance and not take his car. The conversation revealed that the patient was an elderly man who lived alone, and was afraid of the “unnecessary commotion” that an ambulance would cause in the neighborhood. When the ambulance arrived, the patient agreed to travel in it and was transported to the HCHP Emergency Services. The patient arrived in the ED complaining of chest pain. He was mildly short of breath and diaphoretic. After stabilization and evaluation he was transferred to the ICU where he evolved an acute anteroseptal myocardial infarction. He had an uncomplicated hospital course and was discharged in 11 days.
The HCHP Emergency Service received a call from the father of a 23-month-old male child who stated “I think he’s having another attack of his respiratory problem.” The computer medical record indicated a past history of cerebral palsy and recurrent respiratory infection. The physician’s assistant handling the call ascertained that the child’s respiratory rate was 70 per minute as related by the father. An immediate call was placed to EMS stating that an ambulance was necessary for a child in respiratory distress. The following is a time sequence of what transpired: 1737: One clinician calls EMS with request for ambulance. A second clinician stays on line with father giving instructions for monitoring child. 1738: Child begins to have seizures. Clinician instructs father in proper positioning to prevent aspiration and ensure adequate airway. 1742: Father remains on line. Child’s respiratory status has worsened, and seizures have become repetitive, although child remains awake between seizures. 1749: A second call to EMS is placed by Emergency Service clinician, to verify ambulance dispatch and to question the delay in response. Clinician is informed that ambulance will arrive in four to five minutes, the delay being due to ambulance unavailability. Father is now agitated and upset, concerned about the prolonged delay. He is calmed by one clinician while the other calls EMS again, repeating the request. 175 1: Ambulance arrives. The child was taken to the closest pediatric emergency facility, located six blocks from his residence, arriving there at 1806. The child was treated in the
emergency department for status epilepticus, experiencing seizure activity for nearly an hour, and was subsequently admitted to the Pediatric Intensive Care Unit. The child later improved and was discharged.
The HCHP Emergency Service received a call from the father of a previously healthy 21-month-old male child. The father described the child as having just ingested a plum seed with subsequent development of respiratory distress. Attempts to remove the foreign body by the father had been unsuccessful. The nurse practitioner handling the telephone call quickly determined that the child was probably suffering from a complete upper airway obstruction. While an ambulance was dispatched, the clinician instructed the father in additional maneuvers to clear the obstruction, including advice about proper positioning and back blows. The obstruction was relieved by the first attempt, and the child began crying, indicating relief of obstruction. The patient was transported by ambulance to a nearby pediatric emergency facility for evaluation and treatment and was discharged from the Emergency Service in good condition the same day.
Some seriously ill patients never enter the pre-hospital care system because they are confused about how to gain access to it, or because they underestimate or deny the severity of the illness. For these subsets of patients, a skilled clinician who is familiar with the presentation of emergency conditions as well as with the local prehospital care resources may enhance the delivery of prehospital care. The patient membership of many HMO’s may be distributed over a wide geographical area, as is the case with HCHP. The service area frequently crosses the boundaries of municipalities, counties, and even states. In those areas where the access to prehospital care is non-uniform, where the local level of response is variable from community to community, and where the run-response time is erratic, the HMO and its providers are in a unique position to guide the patient in seeking prehospital care and in ensuring that a patient receives it as expeditiously as possible. Finally, HMO clinicians experienced in emergency medicine may be uniquely able to render life-saving instructions over the telephone while help is enroute. Traditionally, with few exceptions, emergency depart-
Willlam E. Daley, Jennifer
ments as well as local EMS dispatchers have been reluctant to give such advice. As an HMO grows in size, it must consider the development of a rational telecommunications system that facilitates communication between patients and providers. Many medical consumers who now join HMOs expect access to a skilled clinician 24 hours a day, seven days a week. Members also expect medical advice from these clinicians over the telephone. Increasingly, the health care delivery system is responding to these expectations, partly in recognition of market pressures, and partly in the spirit of sustaining a consistent coordinated service. At HCHP, the task of 24-hour availability of telephone advice is managed by a core group of emergency medicine practitioners in a hospital-based emergency service. This function is supported by a well-designed telecommunications center, 24-hour on-site emergency physician backup, and triage protocols written and monitored by emergency physicians. If the communications structure is well designed and well supported, it is possible for the HMO to assure the proper delivery of prehospital care to HMO members. As the first contact point for many sick patients, and as the primary care provider for all its members, the HMO is well positioned to educate its subscribers in the appropriate use of prehospital care. Clear, detailed and realistic benefit statements covering ambulance and emergency service utilization are required.7 Toward this goal, HMOs should
seriously consider using emergency physicians as consultants or as staff physicians to develop and implement guidelines for optimal emergency care. Furthermore, HMOs should critically examine how their own practitioners utilize local prehospital care systems to ensure that the HMO does not impede access to those seriously ill patients who require emergency transport and treatment. Benefit statements should be flexible enough to facilitate this process, telephone and clinical protocols should be formulated for the triage of patients, and all HMO practitioners should be instructed in the proper use of the EMS system. Such changes will occur only if the individual HMO works actively with local EMS systems to provide patients with optimal access to prehospital care. As both systems continue to develop and expand, there will be many opportunities for fruitful interaction. We have been encouraged by our recent experience with the regional EMS committees in our area. With imaginative and persistent discussion and mutual education, we think it is very possible for the EMS community and practitioners in HMOs to work together to ensure that patients obtain excellent emergency care, where and when they need it.
On September 8,1987, the HCHP Emergency Service merged with the BWH Emergency Service. Attending physicians cover that service 24 hours per day.
REFERENCES 1. National HMO Census, 1985. Interstudy 1986; 8-9. 2. Kerr HD: Prehospital emergency services and health maintenance organizations. Ann Emerg Med 1986; 151727-729. 3. Barnett G: Computer Stored Ambulatory Record (CO-STAR). National Center for Health Services Research, Research Digest Series; U.S. Department of Health Education and Welfare, 1976. 4. Guterman J: The 1980 patient urgency study. Ann Emerg Med 1985; 14:1191-1198.
5. Buesching D: Inappropriate emergency department visits. Ann Emerg Med 1985; 14~672-676. 6. Member handbook. Harvard Community Health Plan, Boston, MA 1987. 7. Knopp R: Impact of HMOs on emergency medical services. Ann Emerg Med 1986; 15:730.