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 spend on average 3.9 and 2.4 hours in EDs for more serious and less serious issues, respectively.
This time spent is 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 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 cut 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 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 about 15% more efficient through virtual ED diversion, the potential savings to the system might be 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 a 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 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.
The technology exists to make virtual ED visits a reality. There is a clinical and financial case to justify 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.
Potential Conflict: Maple is a private virtual care platform and has a product for hospitals looking to launch an ED diversion program.
The comments section is closed.
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.
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.
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
Really maple? The company that prescribes opioids by text message giving lessons to fix public healthcare?
Not really sure where you’re getting your information from – this Global New report suggests otherwise:
https://globalnews.ca/news/3694224/canadian-company-maple-offers-doctors-visits-online-for-a-price/
“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.”
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…
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.
Chris – judging by your response, I am questioning if you even read the article?
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.
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.
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.