Another Side to CT, MRI Data?

Your chart on page 50 in the "Datadig" of your November 2010 issue [see below] points out that the number of CT and MRI scans ordered by the emergency department has climbed nearly threefold in a decade, without producing a corresponding increase in diagnoses of life-threatening conditions.

I think there are any number of really good "take aways" from this fine chart, including the preliminary conclusions that: (a) ED personnel are really pretty good at making accurate diagnoses (which they are); (b) life-threatening conditions presenting at the ED are often obvious (Why else does a person often present to the ED?); (c) CT and MRIs are more available than they were in 1998 and their use now is often included in some "standards of care;" (d) this is another example of "defensive medicine;" and (e) this great increase in the number of these tests ordered certainly adds greatly to the overall cost of medical care.

While fully realizing that no chart or research study can cover all areas (that's why dissertations and most academic studies end with the recommendation for more study), we wonder if the value of this chart would have increased significantly by adding a third line showing how many "not-yet-diagnosed important but NOT life-threatening conditions" were found. If these additional ED-ordered CT and MRI tests are finding other significant conditions that can be addressed and managed earlier, it might change the conclusions of the chart to indicate an overall national cost savings and increased client lifetime well-being and satisfaction. (So I guess the "comment" here is simply: Is this additional data available and, if it is, could it be included in one of your future charts?)

The monthly "Datadig" may be the single most important part of your publication and we congratulate you on it, in spite of the above comment.

Carolyn Westin, BSN, MA, CLNC
Westin Associates
Belleville, Kan.

The Center of Our Dilemma

RE: "But They Said This Key Would Work: Coverage, Access and the Meaning of Insurance, Part 2," H&HN Weekly, Dec. 7

Once again Emily Friedman, in her make-sensical style, brings us closer to the center of our health care dilemma(s).

Our legislators already are passing the risk of taking care of the population's health care needs to the industry. … something called bundled payments and ACOs. Our legislators are going to postpone fixing the physician reimbursement issue, leaving it up to someone else.

Our legislators underpay providers for the cost of taking care of Medicare and Medicaid patients, taxing the remainder of those that can pay for care (cost shifting).

The center of our universal problem(s) lies not with the very tough issues we have to face as a country—a crumbling economy, underemployment, crumbling infrastructure, those who go untreated, those who require behavioral health intervention and can't get it, and on and on. The center resides with the very nature of our current political system, i.e., our fellow Americans who have made holding office a career.

Our founding fathers did not design our system, nor did they intend or contemplate the federal system to provide a vocation for those who serve us in Washington. They envisioned our best and brightest leaving their homes and businesses for a period of time to serve their country, and thereafter return to their vocation.

In [the movie] "The American President," starring Michael Douglas and Annette Bening, the president as portrayed by Mr. Douglas has a line, during the press conference at the end of the film, that sums up the center of our problem (i.e., a Congress that will not address the tough issues). "I was so busy trying to keep my job, I forgot to do my job."

These are difficult times requiring extraordinary leadership to make difficult decisions. If the decisions being made are focused on the self-interests of those trying to keep their jobs rather than on what is best for our country and society, our society surely will crumble as others have before it.

Martin L. Gutkin, MBA
Vice President of Finance and CFO
Kennestone Hospital
Marietta, Ga.

Hamstrung by EMTALA

RE: "EMTALA and the Acute Care Setting" by Joyce W. Pompey, H&HN Weekly, Nov. 15, 2010

EMTALA is not new nor are its interpretations. With more than 50 percent ofED visits for nonemergent conditions, hospitals are caught between a rock and a hard place over what constitutes medical screening.

A patient with an earache comes in, is triaged by a nurse as nonemergent, and then sits and waits for hours to see a doctor. A [patient with a] cut finger comes in, is triaged by the nurse as nonemergent, and then sits for hours to see a doctor.

The patients get billed at ED rates. The care could have been provided by a primary provider. And the ED gets backed up.

So you can advise all you want about how to comply with EMTALA, but those of us who live it every day are hamstrung as long as a "medical screening" is required. The point is that hospitals are loathe to substitute nurse triage for "medical screening." And to have a physician do the triage is cost-prohibitive.

I have been in hospitals that try to address the issue of emergency department capacity and nonemergents by advising patients that since they are nonemergent they will have to wait until the more acute-need patients are seen first—or they can go next door (an area contiguous with the ED) where, for a minimum charge (or no charge depending on funding), they can be seen by a primary provider.

Stefani Daniels, MSNA, RN, ACM, CMAC
Managing Partner
Phoenix: The Hospital Case
Management Company
Pompano Beach, Fla.