Nationwide, ten percent of emergency room visits are non-urgent. People call 911 or go to the hospital for ailments that could be cured at a doctor’s office or clinic. A majority of these patients are on Medicaid or are uninsured, and their ER visits drive up healthcare costs.
That makes them the target audience for a computer program used by Louisville Metro EMS, which could save both the health care system and patients money, while providing more appropriate care.
911 calls in Louisville are route to Metro Safe. Inside it’s quiet and calm by design because on the other line it’s likely not.
Calls may require any combination of police, fire and EMS; others require none of the above and that population is the focus of the Priority Solutions Integrated Access Management program, or PSIAM, and Louisville Metro is the only EMS agency in the country that uses it.
PSIAM is basically a digital triage. The program, which was created from software company Priority Solutions, uses an algorithm to identify low-priority calls based on patient information.
“We got a call the other night, two or three in the morning, for a lady who had stubbed her toe and cracked her toenail,” said Jeremy Urekew, a paramedic for Anchorage Fire and EMS.
“And she wanted an ambulance to come take a look at that. And though the system is here to take care of people when they feel they have an emergency, and it’s a good system to have, there is a lot of gross abuse to it–a lot of people that call over and over again,” he said.
911 operators put data from these calls into PSIAM. If the program says the call isn’t an emergency, it goes to Michelle Figeruoa. She’s a registered nurse and works a few feet from the 911 operators in Metro Safe.
Figeruoa is responsible for asking the callers more questions and for finding clinics or doctor’s offices that are willing to take a non-emergency call.
“For instance, Norton Immediate Care, they have a website with all their immediate care centers, the addresses, the phone numbers. So we try to match based on the time of the call, if it’s later in the evening, the closest immediate care center if that’s appropriate for the level of care that’s needed,” she said.
When the program began over a year ago, LMEMS was cautious only to let absolute non-emergency calls through the system, rather than risk mis-classifying a serious call, said Kristin Miller, LMEMS chief of staff.
“The key to this and the reason why we have nurses on the phone line is that it’s really about a combination of the algorithm and their clinical judgment. They just don’t go word for word though what the screens tell them on the computer they have to use their intuition and their experience to determine what the next best step is for the patient,” Miller said.
But there are a couple issues. To use the system, EMS must form partnerships with clinics and doctors willing to take patients on the fly, which is why PSIAM was canceled in Richmond, Virginia.
“As the economy went down, our resources went down,” said Lee Ann Baker, Richmond Ambulance Authority’s Chief Administrative Officer. “When I look back at some of the paperwork at the beginning we had a lot of involvement from the free clinics and more free clinics open and you could just see they started cutting back on their hours or just closing down,” she said.
The patients that went through the PSIAM system responded well to program, said Baker. But others want what they think they need and requested an emergency response for a non-emergency, she said. Around 75 percent of PSIAM calls in Richmond were redirected back to the 911 system to dispatch an ambulance, she said. PSIAM operations manager Mark Rector said that’s not surprising.
“Traditionally, when someone calls 911 the expectation is that the cavalry will respond, meaning police, fire, medical or a variation of that because that’s sort of the public’s expectation from the tradition,” said Rector.
But PSIAM has the potential to save both EMS agencies and patients money, while providing more appropriate care to the patient.
A study by Washington State Hospital Association gives some context, reporting average ER costs. For a headache, an ER bill could be over $2,000 dollars, not counting a pricey ambulance ride. The report further shows headaches are the top three diagnoses for ER visits and headaches are an example of something PSIAM may pick up, said Miller.
But that still doesn’t convince Urekew, who said patients aren’t always the best historians and a headache could lead to something more.
“Seventy-year-old lady that’s dizzy. Ok, whatever, I get dizzy too. It happens,” he said. “Show up on scene, lady’s have an active stroke–an active stroke–one of the most time sensitive emergencies in the pre-hospital world. Heart attack, strokes and trauma–the three things that every minute counts.”
Miller, Baker and Rector said there have been zero reported incidences where using PSIAM resulted in a negative outcome. Part of the reason is the agencies have been very careful with triaging only the most obvious non-urgent calls.
Rector said more cities are interested in the program. And with costs and ER use rising, it may be programs like PSIAM that the healthcare industry is looking for, if patients can adapt.