EPM looks to the future of EM in 2020

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The Emergency Physicians Monthly board dusted off their respective crystal balls and traded their stethoscopes for prognosticator caps to predict potential trends and big events for 2020. Will their take on areas like technology, the 2020 elections, telemedicine and insurance industry prove correct, way off or will the truth be somewhere in the middle? Take a look and make sure to see how they did this time next year.

Mark Plaster, MD, JD

Election could hold the key


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I predict that in the run up to the 2020 national elections, health care costs will again be front and center in the national debate.  And with that emergency medicine, the poster child for expensive health care, with be in the bullseye.  The Right will be focusing on transparency of pricing and bringing down drug prices through fairer market competition.  President Trump has already started this ball rolling with initiatives in both areas.  EPs could get smeared if we are unable to make it clear to the public how little of that huge ER bill actually goes to us, the ones who actually provide that care.  And we need to be firmly on the side of open international competition for fair drug prices.

The Left on the other hand will be looking for either Medicare-for-all, national health service type system overhaul or a return to Obama-care in some form promising to hold down prices this time.  My money is that Trump and the Republicans will rule the day on this issue.  And it’s even possible that the Disrupter-in-Chief will succeed in shining a light on all the administrative bloat in health care costs.  I predict a win for patients without it coming out of our wallets in a big way.  The balance billing defeat that was recently experienced will affect the C-Suite types more than the rank and file care givers if we stay together and stand on the side of quality care for our patients.

On a different note, I predict there will be the beginning of a shift to wider application of lower tech solutions.  As an example, a bedside MRI costing a fraction of its higher end, higher resolution, outrageously expensive counterpart was introduced to the market at the last ACEP.  It was a sister product of a hand held ultrasound that has been priced within the range of every EP to purchase for themselves.  While both of these products are very, very early in their development and market adoption, they both represent a shift away from more complex and more expensive technologies that are, by necessity, less available to the majority of patients, particularly those located away from urban academic centers.  This is good news for EPs who are at the tip of the spear.


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Judith Tintinalli, MD, MS

Don’t expect perfect stability

EPs and residents were squashed in 2019.  The closure of residencies at Hahnemann University Hospital, including the EM residency, resulted in scrambles for spots for EPs and residents. Forty-five EM residents were placed in different programs, with costs of relocation left in the lurch. Not all faculty and staff received assurance of placement within the system.  Many of us felt heavy sadness at the closure, because as part of the original Medical College of Pennsylvania EM residency under David Wagner MD, one of our earliest and most respected programs just disappeared.

Sometimes disastrous change does eventually work out — for some. Summa Health in Akron, Ohio lost accreditation for its EM residency program in 2017 due to contractual EP issues, resulting in resident and faculty upheavals.  But by 2019, the Akron program (also one of the earliest in EM) was restructured and ACGME approved for 24 residents.  SummaHealth is now becoming part of the Michigan-based Beaumont Health System!

APPs and ED care


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EM needs to address the interaction between APP and EP care in EDs.  APPs should be well integrated into each EDs educational programs and safety and quality measurements.  Standards for direct and indirect supervision (where appropriate) need to be developed.  The specialty of emergency medicine developed on the premise that not just any MD can work in the ED, but it took specialized training, testing and recertification, to produce an emergency physician.  We have not yet followed those principles where APPs are concerned.  I would like to see movement toward clinical and educational integration, as physicians and APPs have much to learn from each other.

IT and the ED EHR

IT in its simplest forms will be increasingly incorporated into ED documentation, and will guide clinical care and quality management.  In EM, focused areas such as the HEART score, IPASS, order bundles for adult and pediatric sepsis, and drug interaction alerts, are already part of many EHR systems and are used for EP quality assessment. IT has great impact as an interactive learning tool in the ED.1 IT has already potentially impacted diagnostics in dermatology, pediatrics2, ophthalmology and radiology, but it will take time to integrate actively with EM.

Substance Abuse and ED Care

Look to relaxation of rules on physician suboxone prescriptions. Some EPs have obtained X numbers, but in states without enough clinics for continuing care, especially for Medicaid recipients and the indigent, it will take more time to get the ball rolling with EDs.  Negative physician bias about treating opioid disorders with another opioid persists.  There is some over-reaction for avoidance of opioid administration in EDs, for painful conditions like acute renal colic and cancer pain. Expect all this to smooth out.

(1) McNeely B, North Carolina State University, ‘Using Technology as a Learning Tool, Not Just the Cool New Thing’ educause.edu

(2) Kawamoto K et al Association of an EHR Add-on app for neonatal bilirubin management with physician efficiency and care quality JAMANetOpen 2019; 2(11):e1915343   doi 10.1001/jamanetworkopen.2019.15343

William Sullivan, DO, JD

Telemedicine
The demand for telemedicine will continue. Prescriptions for azithromycin and sildenafil will steadily increase. MICs for azithromycin will decrease from 25% to less than 10%. As a result, CDC will allow azithromycin to go over the counter, letting grocery stores put it right next to Mentos gum and LifeSavers in the checkout aisle. In states that do not allow independent practice of APPs, there will be a push toward telemedical and interstate collaborative agreements. New corporations will be formed to offer collaborating physicians for this purpose. Using this model, increasing numbers of emergency departments will be staffed solely by APPs. Emergency medicine organizations will invite this trend.

Troponins
There will be a push to return to low sensitivity troponins and CPK testing for patients with chest pain because high sensitivity troponins have been around for years and we still don’t know what to do with the values. Concepts of “demand ischemia,” “insufficient delta values” and requirements to “correlate values with EKG” will all slowly fade into oblivion.

Appropriate Use Criteria
Appropriate Use Criteria (AUC) requiring that physicians receive approval prior to ordering screening tests will be challenged as an EMTALA violation. CMS will then make an exclusion for AUC within EMTALA statute. Doctors will quickly learn what AUC indications are necessary to justify the tests they want to order, causing the entire concept of “appropriate use” to increase overall spending in the emergency department and increase costs of care.

Sepsis Criteria
Since the definitions used and treatment recommended in the CMS Sepsis Core Measures are not evidence-based (Kalantari WJEM 2017), encourage overutilization of testing and antibiotics (Esposito JEM 2018), and mortalities from septicemia have increased after their implementation (CDC WONDER Database, http://wonder.cdc.gov/mcd.html). CMS will rescind its Sepsis Core Measures. Nah, what am I thinking? There’s too much money to be made by refusing payment to providers because a patient got unnecessary antibiotics 10 minutes later than what some arbitrary Core Measure dictated.

Insurance
Insurance companies will continue increasing premiums and deductibles to patients while at the same time denying coverage and underpaying providers. “Surprise billing” legislation will be instituted forcing providers to treat patients at whatever paltry rates the insurance companies feel like paying. Hospitals will then, through necessity, begin refusing nonemergent care to patients who have insurance through certain carriers. Insurance companies will then create social media campaigns accusing medical establishment of refusing care to patients and will lobby Congress to create laws requiring all medical providers to care for all patients from all insurance. Assuming that it notices the events, the medical establishment will participate in crafting the mandatory care legislation, kick dirt and complain about some other totally unrelated issue.

Patient satisfaction
The lawsuit alleging that Kaiser Permanente used patient satisfaction scores to fire a physician for refusing to prescribe inappropriate opiates (https://www-1.thenewstribune.com/news/local/article235764152.html) will be settled before discovery takes place so that Kaiser can prevent public disclosure of statistics showing correlation between high patient satisfaction, higher death rates, less appropriate medical care and/or higher numbers of opioid prescriptions.

Esposito, et al, Sepsis Core Measures – Are They Worth The Cost? Journal of Emergency Medicine, 2018; 55(6): 751–757.
Kalantari et al, Sepsis Definitions: The Search for Gold and What CMS Got Wrong, West J Emerg Med. 2017 Aug; 18(5): 951–956.

Nick Genes, MD, PhD

Bupe goes big / prescribing controlled substances via telemedicine

X-waivers are a little like Butterfly ultrasound devices — they seem useful and cutting-edge, and everyone knows that rare colleague who has one (too bad they never seem to be working when you need them). I do think 2020 will be a big year for X-waivers and buprenorphine prescribing, though. Our department is starting to offer training sessions and protocols for prescribing and referrals and based on my social media feeds, a lot of us across the nation are signing up. I bet by the end of 2020 it’ll be a lot easier to find ED docs who can prescribe buprenorphine.

And let’s not forget — the DEA is expected to create a “special registration” process to allow docs to prescribe controlled substances via telemedicine (actually, they missed their October 2019 deadline). This will have implications for remote pain management, tele-psychiatry and for many of us who are balancing “in person” ED shifts with virtual care. But the DEA holdup is said to be related to the Improving Access to Remote Behavioral Treatment Act of 2019 — the prospect of treating mental illness and addiction via telemedicine is looking promising for 2020.

Helplessness before the Insurance Industry

I share Bill’s pessimism that any medical society or patient advocacy group can successfully win concessions from the insurance industry in 2020. Even the fact that we call it “Surprise billing” instead of “Arbitrary and opaque lack of coverage” is playing into the insurance industry’s hands. They’re too big, too rich and have too much influence in Washington. Perhaps a new US President can help rein in some excesses but even that seems like a long shot.

EHR Burden Reduction

Our colleagues in ambulatory clinics will spend 2020 prepping their EHRs for lessened, more flexible E/M documentation requirements for coding office visits (set to go live Jan 1, 2021). I expect ACEP to join with the AMA and other organizations and lobby for similar reduction of documentation burden, for ED visits and inpatient hospitalizations. It’s a small step toward reducing mindless clicking, note bloat and returning the medical record to a means of communicating the story of the patient, and not a vehicle for charge capture.

AI in the ED

We’re already confronting “machine” interpretations of complex patient data — every time we’re handed an EKG. But in 2020 I suspect many of us will start to see broad predictions about patient outcomes, from their EHR. My hospital is currently testing predictions like “likelihood of admission” “likelihood to decompensate” and even “estimated survival at six-months” — based on a variety of sources like demographics, comorbidities, labs and vitals, and validated on similar cohorts from our data warehouse. What thresholds for certainty should be set, before sharing predictions with clinicians (and patients!)? How are we ED docs going to incorporate these predictions into our assessments and plans? What happens when we disagree with the computer — how can we even figure out, on shift, the data the computer used to make these predictions? This is going to be a major topic in medicine, especially Emergency Medicine, in 2020 and beyond.

Salim R. Rezaie, MD

Every year we see medicine advance more and more and it is always interesting to think about what the future of medicine is going to be.  Instead of writing a 500 word essay on my predictions, I will list what I see happening in 2020:

  1. Wearable Heart Rate & Rhythm Monitors From Wrist Watches Being Used More Readily
  2. Artificial Intelligence Develops More Use
  3. Telehealth Will Gain Mainstream Adoption
  4. More Uses for Virtual Reality
  5. Drone Delivered Medical Devices to Remote Areas

 

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