The ER house call for the 21st century: Phil Mitchell at TEDxMileHigh (Transcript)

Walter is 72, has high blood pressure, high cholesterol, and mild dementia. He lives at home with his wife Betty. Walter’s been healthy in general, but has had a gradual decline and now needs some help with bathing and getting dressed. He picked up a GI illness and had pretty significant vomiting and diarrhea. When he couldn’t keep down any liquids, he became very dehydrated. He got up to go to the bathroom, felt weak and dizzy, and fell to the ground. Because the skin on his arms was so thin, he suffered from large skin tears on both of his forearms.

He was able to crawl back into bed, but Betty was concerned so she called 911, an ambulance arrived at their home, and Walter was taken to the ER where over the next six hours he had multiple blood tests, scans, and although they couldn’t find anything specifically wrong with him he was admitted to the hospital for observation.

Over the next two days, he started to improve but became more confused due to being in the new environment of the hospital, and he was still too weak to go home. Ultimately he was admitted to a skilled nursing facility for rehabilitation. So after a trip to the ER, a few days in the hospital ward, even more in a rehabilitation center, Walter finally made it back home ten days later. Ten days, and with several thousand dollars worth of hospital bills.

While your name may not be Walter, chances are one part of this story would be true for a lot of us. We feel that there’s something seriously wrong with our health, we call 911 and go to the ER. The ER is a place where patients have immediate access to life-saving care. From the moment 911 picks up your call, an elaborate system of care is set into motion. This hospital-based system uses robust emergency medical services to help patients that might be seriously injured or critically ill.

There are trained physicians, certified emergency nurses, critical care technicians, access to trauma surgeons, and other specialty physicians. It’s where you go when your throat closes from an allergic reaction and you can’t breathe, or when you fear that there may be internal bleeding from a bad accident, or a head injury. The ER offers expert care when it comes to these emergency situations.

Let’s face it: the ER saves lives. There’s a good chance that somebody sitting in this room has been a patient of mine in the ER, and if not me, someone just like me – someone who took care of you in one of your most vulnerable times; someone who was able to tell if your belly pain was appendicitis or if it was just Aunt Judy’s bad lasagna, or your heartburn and chest pain was related to reflux, or if it was actually a blocked artery in your heart; somebody who took care of you regardless of your circumstances; someone that’s caring for patients in one of more than 5,000 emergency departments throughout the United States.

Now the ER is set up for acute, unscheduled medical emergencies, like heart attacks, strokes, major traumas, or when you decide that getting drunk and breaking into an ostrich farm to “dance” with a 300-pound ostrich sounds like a good idea until he stomps on you, and you wake up in the hospital with your rib cage collapsed and just the vaguest recollection of the biggest chicken that you ever saw. True story.

But over my last 20 years working days and evenings, overnights, holidays, caring for patients with minor ailments to severe life-threatening conditions, I’ve seen the ER become a place of convenience for expedited care for those that have medical emergencies but not necessarily threats to life or limb. Today, approximately 37% of all ER visits are considered potentially unnecessary, and fewer than one in ten ER patients has an injury or condition that’s severe enough to have to stay in the hospital.

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Because the ER has to be fully prepared with specialists, training, medications, and equipment for the worst case scenarios, ER care can be some of the most expensive care out there. We’re talking nearly 46 million visits with a cost of four to six billion dollars for care that could potentially be done in another setting. And the cost for individuals is high as well.

In Colorado, the average ER plus ambulance cost is approximately $3,200, and nationwide, that range is between $1,400 and $3,600. And there are considerations besides cost. For elderly patients like Walter that go to a hospital, they can become weak and frail just from staying in the hospital for a few days. And for all of us, there’s a 5-10% chance of getting some type of infection just from staying in the hospital.

Now, most of us can think of a time when we felt too sick or too uncomfortable and felt that we only had a few options: stay at home, try and weather the storm; get dressed, get in the car, head to the hospital; or call an ambulance and go to the ER. But do we really need to go to the ER for nausea, vomiting, and dehydration? For a fever? Even for a big cut on your arm? Does everyone that goes to the ER really need that high of a level of care?

The ER has become this safety net for all that are injured or ill and according to the CDC, 2015, 46% of patients that went to the ER stated they did so because they had no other place to go for care. Unfortunately, this puts a big burden on our medical professionals and we know that patients aren’t getting the best care for their needs. We need to reimagine the ER to provide better, faster, less expensive care that focuses on bringing care into our communities by literally bringing emergency care into our homes.

We need an ER house call for the 21st century. Many of the non-life-threatening conditions that usually wind up in the ERs can easily and safely be treated in the comforts of your own home. A well-trained physician assistant can stitch that cut you got from mishandling your paring knife and they can do that in your kitchen. An EMT can provide IV fluids for nausea and dehydration and they can do that from your couch. A skilled nurse practitioner can replace a feeding tube that came out or stopped working and you wouldn’t even have to get out of your bed until they got there.

Imagine being thoroughly cared for in the comfort of your own home. Think about the last time that you were sick. Not stuffy nose sick, really sick. Coughing, hacking, wheezing, short-of-breath sick. Wouldn’t it have been nice to know that you could call someone, have them send someone to you? You could use your phone, website, mobile app, contact a medical team, and instead of sitting in a waiting room, they’d begin asking about your symptoms and your illness immediately.

They’d let you know if you did in fact need to go to the ER or if they could send someone to you instead. If it wasn’t a life-threatening condition, they’d get a team, send them to your home, and in the meantime, they could begin giving you advice about how to treat some of your symptoms of your badly sprained ankle, your sore throat, your flu-like symptoms.

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And then, in about an hour, fully stocked, fully loaded, Toyota Prius, with a lab for blood tests, and strep tests, and a pharmacy, and splinting materials, suture materials, and even an EKG would arrive to your door. This ER house call could help so many patients, but especially elderly, frail, and memory-care patients. Taking these individuals out of their day-to-day routine with a disruptive trip to the ER can cause days or weeks of behavioral problems for the patients and their loved ones.

Replacing high cost, hospital-based care with convenient, patient-centered, low-cost care is what patients want. It allows medical professionals to provide better and faster care. Quality providers in the home can gain insights into a patient’s lifestyle that you couldn’t get in a doctor’s office or even a trip to the ER. Office-based providers could work for months, up to a year, to try and figure out why Mary’s breathing problems aren’t getting better, even despite changes in therapies; yet a mobile team that enters her home and sees the clutter and the three cats would have that “Aha!” moment much sooner. In-home providers would have access to the community-wide electronic health record, where they could obtain and learn about the patient’s recent hospitalizations, their laboratory studies, their x-rays, their CT scans.

They’d be able to offer immediate care with things like breathing treatments and IV antibiotics for pneumonia, steroids for asthma, tetanus vaccines for wounds. They’d be able to communicate with the patient’s doctor to come up with a plan that works. ER house call for the 21st century allows patients to get more convenient care, it allows medical professionals to provide better care, and it also saves money 2013, my colleagues and I began bringing the ER house call to patients all over Denver. We saw, with a very conservative calculation, savings of over $4 million in 2016 alone.

We’re also able to bring that ER plus ambulance price tag down from $3,200 to less than $300. We’ve made ER care faster and less expensive, while getting patient satisfaction scores three times higher than the national healthcare averages. If we can take this new model, expand it to just ten cities over the next two years, we could save more than $50 million in healthcare costs while providing a better experience for everyone. Patients deserve to be treated in the right place, at the right time, and at the right cost. And we should do it in a way that’s centered on them and where they are the most comfortable.

With the reimagined ER house call for the 21st century, Walter and Betty wouldn’t have had to call 911, or spend over a week in the hospital. And they didn’t Luckily for Walter, Betty had the ER come to him. Walter was treated with IV fluids from the comfort of his own bed. He had his skin tears cleansed and meticulously repaired with Betty at his side.

And when the care team arrived, they communicated with Walter’s doctor, and together, they all came up with the best plan of care. Once Walter was feeling better, home health nurses were scheduled to come out regularly and help with wound care and his recovery. Therapists helped him rebuild his strength. Walter never had to leave his home. We can’t settle for the status quo when it comes to emergency care, and the time for this dynamic change in healthcare is now.

Thank you.

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