Why your next emergency room bed should be in the cloud

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  • David Walker says:

    Assumption #1 – incorrect. Limiting factor in clearing pts is not #of docs; it’s Emerg beds filled with admitted pts
    Assumption #2- incorrect. Low acuity pts are not resource intensive, utilizing few nursing and doctor resources. They utilize far below average $. Saving $ means reducing staffing – which is deployed for the steady supply of sick and injured.
    However, I do believe virtual care will play an important role in all of health care.

    • Peter F. says:

      I’d agree with you that ED beds being filled with admitted patients is a limiting factor, but that doesn’t mean that physician headcount cannot be one as well – I believe both apply, and they apply differently depending on the type of patient. For individuals presenting with high-acuity conditions, lack of available beds is definitely the primary limiting factor to timely access to care, but for individuals presenting with low-acuity conditions, I’d argue that lack of physician/clinician availability is equally as important (if not more).

      Your point around the second assumption is totally valid as the CIHI figure cited does not differentiate between average costs for high and low acuity cases.

      But glad to hear that you are an overall believer in virtual care – the sooner more of us are in this camp, the sooner we can implement and scale new care delivery models, and modernize our health system.

    • CanERMD says:

      We are seeing these assumptions to be correct during COVID crisis – 1) we do need to limit low acuity patients from the ER and are seeing drops in volumes now – the calm before the storm and 2) we do need to increase access to docs and nurses to some degree

  • Mary Sutherland says:

    Really maple? The company that prescribes opioids by text message giving lessons to fix public healthcare?

    • Brendon says:

      Not really sure where you’re getting your information from – this Global New report suggests otherwise:


      “Maple physicians cannot prescribed controlled medications, like opioids, and they’re also not yet able to order diagnostic testing, though Belchetz is hopeful that will change within the next few months.”

    • John Doe says:

      Just hating on maple because they are a “company” makes no sense. They’ve stepped up in a big way to help with COVID virtual care. Public health systems needs a hand in times like these. Whether it’s virtual care or making ventilators. Cautionary tale to the health care high and mighty…

  • Chris G. says:

    Interesting read but several eyebrow-raising points:
    – Please elaborate on your $62M savings as the diverted patients still need to see a doc.
    – Also, you seem to assume telemedicine as a similar scope of practice as an in-person encounter which has been proven wrong by the literature. Not to mention it is clearly stated by the CMPA, CSPO and other colleges across the country. 30% of patients “diverted” from the ER will not all necessarily eligible for telemedicine consults.
    Finally, in your proposed solution, patients still need to go to the ER, wait for triage and then a doctor (are we not in shortage in Canada?). If you have 100 docs in ERs across the province, whether they see the patient in-person or virtually, the overall capacity remains the same so not sure how this reduces wait times.

    The John Hopkins school of medicine has conducted a similar experience in a ER departement (n=>3,000 patients) and found not only that telemedicine could not screen as many patients as in-person but also that there were fewer patients who left without being seen during in-person screening than during telescreening. Food for thoughts.

    • Grant says:

      Chris – judging by your response, I am questioning if you even read the article?

    • Peter F. says:

      Thanks for reading and for the thoughtful comments.

      The $62M comes from the following:
      – Current average ED visit cost = $207
      – Current low-acuity ED costs = $414M ($207 x 2M visits)
      – Potential virtual ED diversion visit cost = $176 (15% per visit efficiency saving applied to $207)
      – Potential future state low-acuity ED costs = $352M ($176 x 2M visits)
      – Potential cost savings = $62M ($414M – $352M)

      It is worth noting that virtual ED diversion should never be implemented with the primary objective of saving money; this is merely a potential added benefit that could be achieved with a program like this that is launched on a provincial scale (in addition to the physician capacity, wait time, and patient experience problems that it could help solve). However, until these programs become more commonplace, we cannot evaluate their effectiveness from a financial perspective – so until then, all these savings are purely hypothetical and are thus worthy of skepticism.

      To your second point around scope, although virtual care definitely has its limitations when compared to an in-person encounter, from a low-acuity perspective, it can actually be used to handle a large proportion of the main conditions that are typically included in this classification. Coupled with the fact that these emergency rooms would still have nurses physically present to potentially assist with certain physical examinations, the list of presenting conditions that can be handled via virtual care in an emergency setting is long and increasingly growing. So while I totally agree that not all 30% of the diverted patients will be eligible, I don’t think the number will be much below that.

      To your third point around physician capacity, there is actually a lot of physician capacity in the system – there is just no easy to tap into it. The average ED physician works 15-16 shifts per month, and a major reason why they don’t work more is because their only option would be to pick up another full shift, which understandably no one wants to do. Many Canadian ED physicians – as evidenced by the hundreds that practice on the Maple platform – are both willing and wanting to work more, but just not in the form of a whole extra 8-12 hour in-person shift. Allowing ED physicians to practice virtually with more of an “Uber” style (when they want, where they want) is a way to create and take advantage of a network approach to provide that extra capacity for virtual ED diversion programs.

  • Kim Moran says:

    Why would we build more virtual hallways rather than fix the root cause of the issue? We don’t need to better match demand and supply but we do need to better match patient needs to the appropriate service provider. We know that many mental health patients come to hospital to be stabilized and sent to long waiting lists for community treatment. We also know that they are re-admitted 3x more than any other patient group. Investment in community treatment solves the root cause which is how we end hallway healthcare rather than build more virtual hallways.

    • Peter F. says:

      I totally agree that community investment gets at the root cause and needs to be the backbone of any hallway healthcare strategy moving forward, but at the same time, that doesn’t mean we can’t still make improvements elsewhere. Every type of organization has a role to play and hospitals (as well as other healthcare organizations) should always be looking to modernize how they deliver care. Although virtual ED diversion will not end hallway healthcare, it is a low-cost way for hospitals to improve wait times and the patient experience for those that present with suitable low-acuity conditions.


Peter Forte


Peter Forte is a former consultant and director of public sector business development at Maple

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