Metrics in the ER: Impact on Healthcare Delivery and the Law

Metrics. What are they? And, in the world of litigation, are they good, bad, or ugly?

For my fellow Gen-X’ers, the word “metric” calls to mind an ambitious, but unsuccessful, national effort that included cartoons and frazzled teachers trying to get America on board with a 10-based system like most of the globe.

However, metrics in this context, while still measurements (no cartoons, unfortunately), are utilized to track aspects of healthcare delivery with the goal, ostensibly, of improving patient outcomes. Let’s not be fooled, though, there is a business component at play. Healthcare is a business, after all. And when business metrics take precedence over patient care, emergency departments and individual practitioners can be unintentionally opening themselves up to liability.

The Risk Associated with Emergency Department Metrics

In emergency departments, metrics typically include patient arrival-to-provider times, length of stay times, patient acuity, and return visits. This data is used to demonstrate, and improve upon, the performance of the emergency department.

Do these numbers really say anything about quality of the care being provided though? The answer is unclear.

Take for example this scenario:

Some hospital emergency departments have altered their staffing model to improve the patient arrival-to-provider time by having a patient seen by an APC (Advanced Practice Clinician, who is either a nurse practitioner or physician assistant) in the waiting room within minutes of arrival. The APC conducts a limited examination and puts in an “order set” for a presumed diagnosis. This improves the arrival-to-timing metric but disrupts continuity of care as, more than likely, that patient will still be in the waiting room for a while and assigned another provider once taken back to a room.

Two problems occur in the medical-legal world with this model, although a metric may have improved:

1. The patient is in a non-private location (the waiting room) having labs drawn and discussing personal information within earshot of other patients. The patient satisfaction metric is already potentially going down and the likelihood of Board complaints are starting to go up.
2. With the change in providers, one provider may not agree with the other, and “discontinue” orders may be issued as to the orders placed by the APC initially. This results in confusion or questions when the records are examined in a legal context. To avoid this, at minimum, these providers must discuss with one another their rationale for changing the initial orders, or it looks like there are too many cooks in the kitchen.

When actual medical care is delivered, providers should not have their medical knowledge and decision-making disrupted or constrained by metrics. Better stated, good medicine should not be limited by time.

Moreover, if a provider believes certain diagnostic studies are indicated but they are reluctant to order too many things to avoid a hand-slap, this creates a push-and-pull for the ultimate decision making. Is their decision financial or medical?

In the litigation context, everything not done by the provider will undoubtedly be questioned if that omission potentially led to an adverse outcome and was required by the standard of care. Nobody wants to hear about metrics and the “overall value” toward healthcare delivery when, for example, their parent is in the ER and an MRI could’ve detected a dissection, but one wasn’t ordered.

The Right Way to Develop Metrics

Metrics certainly can improve patient flow, provide for more efficient staffing, prevent bottlenecks in the hospital generally, and enhance healthcare delivery and patient satisfaction as a result.

However, to maximize the positives and reduce the potential for litigation and reports to regulatory bodies, emergency room physicians/providers should work in collaboration with experienced healthcare attorneys to establish standards and guidelines for metrics. In doing so, they can achieve value, in every sense of the word, in emergency department healthcare delivery.