***This article originally appeared in Healthy Debate***
Hospitals sit at the heart of our healthcare system, acting as a vital access point for lifesaving and critical care. However, across Canada, an unfortunate feature of almost every hospital is a crowded emergency department (ED). With crowded EDs come long waits for the individuals and families wanting to access essential emergency services. The latest report from Health Quality Ontario suggests that individuals in Ontario are waiting on average 3.9 and 2.4 hours in EDs for more serious and less serious issues, respectively.
These wait times are the result of a number of systemic issues that our health system has been trying to address for years, but it fundamentally comes down to a restrictive and reactive care delivery model, which leads to a perpetual mismatch of supply and demand. Because of our continued dependence on physical infrastructure and in-person care, the dedicated individuals that work within our EDs are always fighting an uphill battle in terms of providing timely access to our citizens.
For example, if you show up to an ED today, regardless of how many patients are waiting with you or the severity of your condition, the ED’s ability to clear their queue and see you in a timely fashion will forever be limited by the number of physicians they physically have on-shift at that time. This has been the model for generations, but it doesn’t have to be.
In an ideal state, the staff in the ED will have access to virtual physician support so that those low-acuity — or less serious — cases can be swiftly handled virtually, via telemedicine, freeing up on-the-ground resources to handle those high-acuity cases that require more intensive attention.
Although this model is still far from the norm, there are examples of organizations globally who have taken that step, and the benefits are clear. New York-Presbyterian/Weill Cornell Medicine (NYP) implemented a virtual care diversion program for their ED and slashed low-acuity wait times from 2.5 hours — nearly identical to the current low-acuity wait times in Ontario — down to 30 minutes. With this program, NYP has also been able to keep ED revisit rates at about half the national average in the US.
But this model not only holds the potential to lower ED wait times, improve patient satisfaction, and more appropriately leverage ED resources across Canada; it could also hold the potential to unlock millions in health system savings.
According to the Canadian Institute for Health Information (CIHI), in 2009, the average cost of an ED visit in Canada was $166, excluding any costs associated with testing or imaging done for the presenting patient. Adjusting this figure to account for a decade’s worth of inflation would suggest that an ED visit today costs approximately $207.
Beyond the massive economic impact that long waits have through lost productivity and earned income for patients, an ED where physician availability is no longer an unknown or bottleneck would lead to more predictable and efficient workflows — and that leads to less costly visits. If we are able to make visits 15% more efficient through virtual ED diversion, the potential savings to the system are staggering.
In 2014/2015, 1 in 3 visits to Ontarian EDs were made by patients with low-acuity conditions that did not require hospital admission. Apply that to the 5.9 million ED visits that took place in Ontario in 2017/2018, and that’s potentially 2 million ED visits that could be more appropriately handled via virtual care. Apply the 15% efficiency gain per visit potentially made possible with virtual ED diversion and that’s up to $62 million in system savings in Ontario alone. That’s $62 million that could be used to recruit and train the health workforce of the future; to increase our limited capacity to deliver additional care in our homes and communities, a proven method for reducing hallway medicine; or to invest more in modern technology that can continue to help us unlock new delivery models and bend the cost curve.
The buzz around virtual care is at an all-time high, to the point where the mainstream use of virtual delivery models is no longer an if, but a when. Our neighbours to the south have shown that ED diversion is a logical — and proven — place to start. After hearing about the NYP ED diversion program, the vice chair of emergency medicine at Massachusetts General Hospital — one of the top hospitals in the world — said, “ten years from now, tele-emergency medicine will be the standard across the country.”
There is no reason why the same can’t be said about Canada.
We have the technology to make ED diversion across the country a reality and, as shown above, a clear clinical and financial case to justify any government investment into the launching of these programs. The final missing piece is broad support from payers so that it is clear to our hospitals that they will be financially empowered to implement and sustain these programs over the long-term.