Should an emergency department act as an entryway to the hospital or a roadblock? An island or part of one continuous pathway?

As health care leaders strive to integrate all the disparate pieces of their systems, some are starting to rethink the purpose of the ED and how it plays into the care continuum. EDs treat nearly 136 million patients a year, only 70 million of which are urgent care visits, says David Seaberg, M.D., dean of the University of Tennessee College of Medicine and a practicing emergency physician.

Patients are using the ED out of convenience, rather than urgency, and Seaberg wonders why more health systems can't just give the customer what he or she wants.

"I call the emergency department almost the front porch of the medical neighborhood," Seaberg says. "We could be an entry point or a portal into more value-based systems of care like ACOs or the medical home or episodes of care. They come in through the emergency department, and we can help coordinate their care either to a primary care home or specialty care or even to a skilled nursing facility."

Faced with long wait times and low satisfaction scores, Good Shepherd Medical Center, in Longview, Texas, has moved to reinvent its ED in recent years. As part of a program called Care Direct, established in 2010, it has pursued a three-pronged approach to nonurgent patients in the ED, says Ron Short, vice president of operations. Clinicians perform a medical screening on the patient, figure out a transition path and try to connect patients with a primary care physician when they don't have one.

In the first year, the Care Direct coordinator consulted with 2,000 patients, and connected 386 with a PCP or specialist. For those without insurance — about 35 percent were classified as self-pay — Good Shepherd made payment arrangements with the clinic and didn't burden the patient with a sizable ED bill. Key to the approach, Short says, is sitting down with patients, showing them empathy and explaining why they're better suited to a different setting in the hospital.

"When done right with sensitivity and compassion — explaining that 'It isn't that we don't want to see you here, it's really just that your problem is best taken care of with a family practice physician, with someone who can help you be healthier by seeing you longitudinally' — it can be effective," Short says.

There are some barriers that inhibit integration with the ED. The approach requires an integrated informatics system so emergency physicians are on the same page as clinics or other providers along the continuum. Some EDs are so inundated with patients today that it can be hard to think about tomorrow. And some emergency physicians are forced to spend too much time and money doing unnecessary tests to shield themselves from medical malpractice lawsuits, says Andrew Sama, M.D., president of the American College of Emergency Physicians and senior vice president of emergency services at North Shore-Long Island Jewish Health System, Manhasset, N.Y.

Regardless of the roadblocks, emergency medicine is poised to become a larger and more integrated part of the value equation, he says.

"We're strategically placed to make a big difference, and that's what our push is from the emergency medicine perspective," Sama says. "We know that if we work closely with our hospital executive partners, we can make significant changes in this system."