a serrated knife...

...can do a decent amount of damage very quickly. i slipped while cleaning one last night and sliced my finger. figured it was just a bad cut until i looked down and saw something white. while it turned out to be some kind of ligature and not bone, it hurt like hell and wouldn't stop bleeding.

so mrs. wintermute and i head over to the emory ER. i sign in at exactly 10:30.

almost six hours later we get home. all for a measly 3 stitches.

i didn't mind waiting. we brought books and i appreciate that a small laceration is a very, very low priority in the ER (a very agitated woman that took six cops to subdue was taking much of the staff's attention for the night). i received excellent clinical care from the RN who triaged me, the PA who irrigated the wound, and the MD who anesthesized and stitched up the wound. however, the sheer waste and redundancy in their administrative processes kills me:

• asked for my insurance card twice
• asked to fill out slightly different background forms twice
• asked verbally for my background info three times, including after being given a bracelet
• was "lost" to the nurse after being moved from a hallway bed to a room bed. for almost two hours after my procedure was finished, i waited for my discharge papers b/c they did not know where i was, despite the fact that i twice walked to the nurses station to tell them i was ready to leave. when she finally showed up, she said according to the paperwork i was still in bed # 5. so someone had forgotten to update the clipboard she was waving in her hand.
  
• heard my doctor paged three times. if UPS can tell me where my package is anywhere in the world and wal mart knows exactly where its inventory is, how can an ER not know where its doctors, the most precious asset they have, are located?
• on the way out, they commited the (financial) cardinal sin of not getting at least a co-payment from me. now i am in receivables hell (for them. i could care less). it will take 30 days to get to a bill to me. i can ignore it for 6 months before it goes to a collection agency. this is why ERs have an average uncollectable rate of 60%. in other words, for every $1.00 that they bill, they typically receive 40 cents.
  
• finally, to top it off, no one stamped my parking ticket. so i had to pay for parking, b/c the attendent didn't take my bandaged hand as proof that i had been in the ER (honestly, i'm sure he was just doing his job).
  

an ED (the proper term) sees 80K patients a year (a low figure, but the first # that came up on google). that's 220 per day. just repeating some of those redundant information requests to each patient could take up some time. let's say it adds five minutes (a conservative estimate) to each patient. that translates into 1,095 minutes of extra work, or about 18 hours. that's two full time employees!

here's how i would design an ED. btw, i worked for a company that manages EDs, so i know a little bit about this.

1. first, when a guest (that's right, they're a guest and should be treated as one) enters, he/she is greeted by a human. this person is trained or has experience in the hospitality industry. The greeter says hello, asks if they want to be in the ER. If so, she uses a handheld device (like what the rental car companies use when you check out) to get some quick info--name, ailment, allergies, etc. it's instantly entered into the system. the system assigns the case a priority, based on the current workload and staffing available.
2. the handheld prints out info on an adhesive sticker. the greeter sticks it to a bracelet, puts it on the patient, and explains what us happening, and that it may be awhile. the bracelet has a bar code on it, as well.
   
3. the greeter than hands the patient a pager. it will go off when the they are ready to call the patient.
4. the patient has a seat. it's very busy, so it takes 2 hours to be called. at any time, if the patient's condition changes or he feels short of breath or chest pains, he can press a help button. every thirty minutes, the pager asks him to put his palms on sensors. these sensors take and record vital signs. it also asks him to rate his pain level.
5. the RN is ready to triage the patient. as his pager buzzes, the RN comes out to get him. all of the patient's info is already captured, plus the RN can read how the patient's vital signs and pain have progressed since he got to the ER. the RN triages him and resets his pager to be called for further clinical attention. After explaining what is happening, the RN returns him to the waiting room. she enters what she did into the same system.
   
6. the patient returns to the waiting room. the greeter's system tells her that she needs payment info (this is not supposed to be asked until after triage). she uses the handheld to scan his card if he has one. if not, she assures him he will receive the same treatment.
7. some more time passes. the pager buzzes, and a RN or PA calls the patient back for treatment.
   
8. the clinicians use handhelds to scan the bracelet each time they move the patient, so he is never "lost" to them. the ask him to hold on to the pager, as he may have to wait in the room as well. they explain what is happening and what steps he can expect. the system may provide some guidance on how long he will have to wait until an MD can see him.
9. the MD arrives. her handheld is constantly in sync with the system, so she knows his ailments and how they have progressed. still, the MD asks how the guest is doing, as she is evaluated on her bedside manner, with a direct link to her compensation.
10. while treating the patient, the MD prescribes medicine. her system has his medical history and looks for any contra-indications.
    
11. as soon as the MD is done, she presses a setting on the patient's pager. her handheld is linked wirelessly to a printer in the room. she chooses from a drop-down menu of discharge instructions, wishes the patient well, and leaves. the pager alerts the charge nurse to begin the discharge process.
    
12. within minutes, a discharger arrives. b/c the patient is constantly scanned in via the bracelet, she knows where to find him. she explains the instructions and provides any materials (gauze, etc). she knows that whether the patient has medicare, insurance, or no coverage. trained in handling financial matters, she asks the patient if he can pay a little bit now. he offers his credit card. she swipes it on her handheld, hands him a receipt, takes his pager, and walks him to the door.
13. she then puts the pager in a docking station. it uploads all of the statistics and compiles them into a database that is name-blind. clinicians use it analyze outcomes. adminstrators use it to track turnaround time and procedures. the ER manager and her staff are evaluated and paid based on performance on key measures.
    

clearly, this an idealized version. but the technology is there. let clinicians practice medicine and adminstrators manage the process. identify and resolve bottlenecks. measure everything.