Emergency Medicine in the Age of Aquarius

An Emergency Department (ED) is one of those things that you hate to need, and you love to hate. EDs have been much-maligned, characterized as error-prone money-wasters and “loss leaders.” Some healthcare policy-makers have targeted EDs as major contributors to healthcare costs spiraling out of control. They could not be more wrong.

A few decades back, many hospitals were staffed by local physicians who had little or no specialized training in trauma or critical care. Worse, the coverage was incomplete, requiring night and weekend shifts to be filled by resident physicians (“moonlighters”) who had not yet completed their training. The nursing and other staff also lacked specialized training and tended to be pulled in from other departments. Rural and community hospitals could not always afford technologies like CT or MRI scanners, which limited diagnostic and treatment options. Intubating a patient in a dark, narrow semi-trailer in the parking lot because that’s where the (rented) CT scanner was located was not unheard of.  Not the care you’d choose if given the option.

Thankfully, much has changed. The skills and capabilities of the teams providing this complex and crucial endeavor have grown exponentially, spilling out into even the smallest hospitals. Organizations like American College of Emergency Physicians (, the American Board of Emergency Medicine (, the Emergency Nursing Association (, and the Society for Academic Emergency Medicine ( have promulgated evidenced-based training and standards for the practice of emergency medicine that has given America an enviable resource.

We now have over 42,000 dedicated ED physicians and over 180,000 ED nurses in the United States. The majority of these providers now have specialized training and certification that uniquely qualifies them for their challenging roles. Hospitals are better-equipped and more prepared to meet the acute care needs of their communities. EMS and ambulance systems have become more organized and efficient and offer more services in the field. Furthermore, the regionalization of trauma care has assured that severely injured patients quickly reach the most appropriate care.

The ED has become center stage for diagnosis and treatment of many acute problems. EDs handle 28 percent of all US acute care visits and two-thirds of the acute care for the uninsured. The CDC reported in 2012 that one in five Americans visits the ED at least once a year. Primary care physicians are directing more patients to the ED as they can do more complex workups, provide diagnostic services not available in outpatient offices, absorb overflow, and handle unscheduled urgencies. The ED also sees most of the poor and uninsured because they turn no one away.

Calling Emergency Departments loss leaders is wrong. It is true that EDs order a lot of expensive tests. It is true that they duplicate tests when they don’t have outside results. It is true that some physicians order extra tests to protect themselves. Yet EDs still only account for 4% of the 2.6 trillion dollars we spend on health care every year. 31% goes to inpatient care, which EDs often avoid by providing outpatient workups and determining that patients don’t need to be in the hospital. It is true that 55% of ED care goes uncompensated, cutting overall hospital profits. But EDs generate up to 70% of inpatient admissions, from which hospitals make most of their money. But far more important than all of these financial considerations is the fact that EDs provide unparalleled diagnostic and treatment capabilities, 24/7, to anyone and everyone. This requires a massive effort that should make us all proud, grateful, and supportive.

Support means understanding the challenges currently facing EDs; support means being part of the solution, instead of complaining every time they fall short of our expectations. We love to let our Facebook friends know how we spent 5 hours in the ED. But do we ask why? Between 2001 and 2008, use of EDs increased at twice the rate of population growth while hospitals closed nearly 200,000 beds. When you increase inflow and decrease outflow simultaneously, you get people sitting around. EDs have responded by adding beds and providers. But this is a gradual and expensive solution. What we need is an affordable way to see more patients in less time, without decreasing quality of care. The industry terms are “throughput” and “patient processing,” but I don’t like these terms because they make us sound like cheese. A better term is “flow.”

How can we improve patient flow in the ED? Individual hospitals typically spends millions of dollars to get answers to this question. They hire consultants to analyze where patients pile up, where staff are overly taxed and where they are sitting around, where supplies run out and where they stack up and other operational details. Recommendations for staffing, layout, and operational changes are obtained, but implementing them is costly and difficult. Worse, the consultations need to be repeated every year or two because so many factors change.

Not long ago, better ways were only in our dreams. Why not use computers to figure this stuff out? Artificial intelligence (AI) is a branch of computer science that solves real-world logistical problems by teaching a computer to “think” like the greatest problem solvers on the planet: us.  From humble beginnings at Dartmouth and MIT in the 1950s, AI science and technology have grown remarkably and now pervade our world to the point where we take it for granted (like asking your phone to find you a local Italian restaurant). AI has had many successes in health care, such as expert systems that render diagnoses based on signs, symptoms, and interactive interviews. “Decision support” is a less threatening term for AI embedded in medical systems, and can make suggestions and deliver warnings in real time, at the point of care. Using natural language processing of the electronic medical record to understand the context and then applying rules and inference, decision support systems can recommend alternative treatments, provide warnings about drug interactions, or alert users to a departure from hospital policy.

AI research has also produced powerful new approaches to complex logistical problems. Older approaches either took to long to consider every possibility (brute force algorithms) or settled for better but not best solutions (greedy algorithms). Newer approaches like machine learning, neural networks, and genetic algorithms let us tackle bigger, more complex problems in a reasonable amount of computing time to find truly optimal solutions.

Computer solutions that could revolutionize ED patient flow now employ modeling and simulation to predict bottlenecks. Imagine knowing that in 6 hours you are going to have double the load on radiology, or that your ED average wait is going to triple in 3 hours. Now imagine being able to do something about it. AI-driven optimization algorithms provide real-time advice on how to schedule staff and other resources to avoid problems. The systems can also analyze historical patterns and offer long-term optimization advice. Knowing when and exactly how to move resources reduces wait times and allows more patients to be served. It also improves patient safety and enhances patient satisfaction. This technology is available at a fraction of the cost of flying consultants in, and advice is offered every day instead of every 1-2 years.

There are many more insights to come in this new age of medical informatics. The impact of these emerging technologies on the difficult, complex problems facing healthcare is only beginning. AI has already proven to be useful enough to know it is a good path. As we really put our backs into designing tools for the connected, data-rich world that is upon us, we can expect game-changing results.

Every 2,160 years the sun’s position at the time of the vernal equinox moves into a new constellation. There’s debate about dates because bulls, rams, scorpions, and lions are rather fuzzy when they are made of stars, but many astronomers believe we have arrived at the Age of Aquarius. Aquarius is associated with flight and freedom, idealism and democracy, with truth and perseverance, and, most interestingly, with electricity, computers, and modernization. Whether you pay any mind to the stars or not, you’re going to notice.



White paper: Potentia Analytics, Inc.

Computational Intelligence in Medical Informatics

Intelligent Provider Scheduling | Patient Flow Optimization | Predictive Analytics