Why Do We Continue Using the ER for Care?

Access to health care is one of the hottest topics in society today. As a nation, we have worked feverishly to find the perfect health system that ensures our citizens can get medical care whenever it's needed.

In a society that gets its news 140 characters at a time, we are now a generation of immediate information, training and activity. This extends to the health care system more than ever in our history. Finding ways to allow immediate, convenient access to medical care now includes an olio of options, from the doctor's office and urgent care centers to clinics in large retail chains. It also, of course, includes the old standby: the emergency room. With so many choices, it can be difficult to know how best to access medical care in the U.S. today.

According to the Centers for Disease Control and Prevention, ER visits increased by 20 percent in the first decade of the new millennium. That translates to about 136 million visits per year. One in 5 Americans will visit the ER at least once annually. Of those trips, only 12 percent will result in admission, meaning many of those visits, as many as 65 percent, are deemed unnecessary. The result is very costly in terms of both time and money.

ER visits are about four times as expensive as other ambulatory visits and take an average of four to five hours versus the usual one-hour visit in other venues. Billions of dollars in health care costs, along with 65 percent waste and endless hours of work and school time lost occur as a result.

So why do we continue using the ER for care? Convenience, mainly. For children, about 75 percent of their visits occur on nights and weekends, when the primary care physician is not open. Most of these visits are related to respiratory illnesses. Most adults show up for injuries, certainly unplanned and not likely to fit into a scheduled appointment.

Other more optimal options exist for care. The most important health care relationship remains the bond between the patient and primary care provider, or PCP. This type of medical home is critical to having a long-term health plan versus one based on crisis intervention. However, there are several limitations to this time-honored method of health care delivery: Inconvenient hours, lack of on-site diagnostics and off-site pharmacy requirements make one-stop shopping in this setting difficult, a departure from what we've come to expect in the supermart world of today.

Several alternatives exist to the PCP office and ER. Urgent care centers have become a staple across the country. While not open 24/7 like the ER, evening and weekend hours make them an attractive option. These venues usually have a 30- to 60-minute wait time and an average bill of $60. Limited diagnostics are often available, such as strep tests, urinalysis and plain X-rays. Generally staffed by physicians or nurse practitioners, these venues are great for common illnesses such as colds, flu, low-grade fever, earaches, sore throat and mild rashes, to name a few.

New to the market are the chain store clinics. Originally started as a way to entice customers into the store, these clinics are quickly becoming an alternative to the PCP and urgent care centers. Many of these clinics can diagnose and manage acute illnesses, and supply first-aid items, durable medical equipment and even fill prescriptions right in the store. In addition, significant efforts in detecting and preventing chronic illnesses (think: vaccines) can be done in this setting. These clinics definitely cater to the one-stop shopping lifestyle that a busy world desires and requires.

So, in the current world, where health care delivery systems are changing their focus to provide efficient, high-quality care at a reasonable price, is there ever a reason to use the ER? Of course.

The purpose of the ER was always to take care of true emergencies, not to be a convenient alternative to the primary medical home. Very young children, those under age 4, with significant fever and any extreme symptoms should be seen in the ER. Chest pain, broken bones, difficulty breathing, non-stop vomiting and diarrhea, acute loss of vision or speech, choking, burns or new-onset seizures that last several minutes all require immediate trips to the ER. These symptoms can signal a life-threatening situation or an evolving problem for which prompt intervention could yield better outcomes. However, if lines are long and the triage is slow, due to less-urgent issues clogging the ER, timely care could suffer and optimal outcomes might be lost.

As we continue to witness the vast changes occurring in the U.S. health care system, we need to think about new and innovative ways to supply appropriate care when it's needed, without sacrificing the important doctor-patient relationship. This may require abandoning some of our traditional expectations and incorporating the positive things about urgent care and chain clinics into mainstream care plans.

Fast-track options in ERs can mimic some of these other venues and assist in maintaining patient flow. However, to do this well, we need to think about resource deployment to ensure the quality and safety of these alternative delivery methods. We need to consider a single, national electronic medical record so that the medical history, which is so critical to inform the next phase of a patient's health, is readily accessible. We need to find ways to reward consumers for appropriate use of the various health care venues. We need to make sure that the Rockwellian version of the family doctor somehow endures in a fast-moving, complicated world, so that patients continue to find continuity and compassion in the care they receive.

For most of us, the day will come when we require the ER. It will be immediate and critical. As a society, we must ensure that ERs are functional and affordable when our time comes. Toward that end, we need to conserve our health care resources to fund these more expensive ventures by appropriately using the alternatives. This is our shared responsibility. Because the life depending on the ER could someday be your own.

Dr. Elaine Cox is the medical director of infection prevention at Riley Hospital for Children at Indiana University Health in Indianapolis. She is also the Riley clinical safety officer. Dr. Cox practices as a pediatric infectious disease specialist and also instructs students as a professor of clinical pediatrics at the Indiana University School of Medicine. The former director of the pediatric HIV and AIDS program, Ryan White Center for Pediatric Infectious Diseases at Riley, Dr. Cox helped lead the effort to change Indiana law to provide universal HIV testing for expectant mothers.