• Studies in Innovation: Redirecting High-Cost Care

    Sidebar: Karen Wagner Apr 27, 2016

    Healthcare organizations around the country are working on new ways of delivering better-quality care more cost efficiently. At the crux of many of these innovative efforts is technology, as the following case study illustrates.

    A major contributor to high healthcare costs is the unnecessary use of emergency department (ED) services when urgent or even primary care would be appropriate. In December 2014, the Houston Fire Department’s (HFD’s) Emergency Medical Services (EMS) division initiated a program designed to redirect non-emergent cases to more appropriate care settings, such as community primary care clinics.

    Called ETHAN (Emergency Telehealth and Navigation), the program incorporates mobile technologies to triage EMS 911 cases. When responding to a 911 call, EMS providers assess whether the case is emergent. If it is deemed not to be, the EMS provider and the person requiring care can opt for a real-time clinical assessment via video teleconferencing software on a computer tablet. The assessment is provided by an emergency physician located at HFD’s dispatch center. The physician assesses whether the patient requires transport to an ED or referral to a clinic or primary care physician. Patients who do not consent to the telehealth assessment are transported to an ED.

    The Houston Fire Department’s Emergency Telehealth and Navigation (ETHAN) program in action.

    This staged photo shows the Houston Fire Department’s ETHAN program in action. The patient (holding the tablet) is receiving a remote consultation from a physician while an HFD paramedic watches. (Photo: Houston Fire Department)

    The goal is to reduce the number of unnecessary ED transports and reduce overcrowding in Houston’s busy EDs, where, according to a study by researchers at the University of Texas School of Public Health, 40 percent of cases are primary care-related.

    According to calculations by Diaa Alqusairi, PhD, a senior staff analyst for the HFD and the ETHAN program’s initiator, the average cost to transport a patient by ambulance in Houston is $1,600. The cost to treat primary care-related cases in the ED is $600 to $1,200, about four times the cost of treating the same case in an outpatient clinic.

    Of the 6,047 patients agreeing to mobile clinical assessment between the program’s inception in December 2014 and February 2016, only 18 percent were transported to an ED. A majority of the remaining patients were referred to an ED by non-ambulance transport, such as a cab or self-transport, or referred to primary care.

    Because of infrastructure and budget limitations, Alqusairi says the program has a maximum capacity of 250 video clinical assessments per week. Although the program has almost reached capacity at times, a more typical number of calls is 100 per week. Alqusairi says the city receives about 300,000 EMS calls each year, so he sees room for growth with ETHAN, but for the foreseeable future the program is not able to handle mobile assessments for every qualifying patient.

    Alqusairi says the program is adaptable to other large urban areas, but there are challenges. One of the greatest is up-front technology costs, which totaled $0.7 million for expenses such as IT infrastructure, video-conferencing equipment, and system integration and interfaces.

    Another challenge is the cultural change. Current HFD protocol calls for all ambulances sent out in 911 cases to transport patients to an ED. Longtime EMS personnel are accustomed to transporting patients to EDs, no matter the severity of the case.

    “It’s a really big cultural change from the way fire departments work,” Alqusairi says. “We’re having better results as more members from the field try the program and adopt it as an essential tool.”

    Currently, ETHAN is funded through a federal waiver program totaling $12 million over a five-year period and a city ordinance that penalizes businesses that have contracts with the city but do not offer health plans to their employees. Because of the way the program is structured, Alqusairi says, the state’s telemedicine laws prohibit the services from being reimbursed by Medicare and commercial payers. Estimated operating costs are $1 million annually, or about $300 per patient served. Using estimated savings of $1,300 per patient not transferred to an ED (the $1,600 cost of transport minus $300), the program has saved HFD $6.4 million so far.

    HFD officials are in discussions with area hospitals and health plans about cost sharing, especially for the cost of cab transport to an ED. Although the fire department realizes the bulk of the savings, healthcare organizations also save by avoiding costly ED treatments. The eventual goal is to provide a reduction in the number of EMS transports to a specific hospital and then estimate the cost savings, which would be shared between the hospital and the fire department. “We want to demonstrate the savings for the healthcare system in Houston and take that to the hospitals,” Alqusairi says.


    Karen Wagner is a freelance healthcare writer based in Forest Lake, Ill., and a member of HFMA’s First Illinois Chapter.

    Interviewed for this article: Diaa Alqusairi, PhD, senior staff analyst, Houston Fire Department.

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