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Meet the ER doc who thinks like a designer –

A heart attack one minute. Mysterious stomach pain the next. A steady stream of fevers, headaches, and shortness of breath. As the safety net of the American health-care system, hospital emergency rooms are expected to be crowded, loud, and chaotic.




Bon Ku, an emergency physician at Thomas Jefferson University Hospital, thinks there has to be a better way.

For the last two summers, he has deployed teams of students with iPads inside Jeffersons busy emergency department, carefully mapping the movements of doctors, nurses, technicians, and patients. The goal of the project, a collaboration with the KieranTimberlake architecture firm, is to learn how emergency medicine could be improved through good design.

People ask me:Are you just trying to make the E.R. look prettier or polished, with the walls a more soothing color? he said. No. You can design spaces to change the behaviors of people.

Among the early results from the research: colorful heat maps suggesting that physicians spend too much time at computer keyboards at the expense of listening topatients, Ku said.


A heat map shows the locations of five categories of people in the Jefferson emergency department over a 48-hour period: patients (red), doctors (purple), nurses (blue), other staff (green), and family/friends (yellow).

That was no surprise, and certainly not unique to Jefferson, which typically gets at least 65,000 E.R. visits a year. Doctors and nursesnationwide have griped about the amount of time spent entering patient information into electronic medical records. But it has gotten Ku and his colleagues thinking about ways to alleviate the problem. Placing easy-to-use keyboard stations inside patient rooms, perhaps. Or better use of scribes employees who document the care while the physician focuses on providing it.

Ku, who majored in classical studies as a University of Pennsylvania undergraduate and later earned a masters degree in public policy at Princeton, has no formal training in design. But he is determined to get medical students thinking about it.

The E.R.-mapping study is one of 10design projects now underway in the Vault, the basement of a former Federal Reserve building in the 900 block of Chestnut Street that Jefferson owns.The lab is directed by pharmacist Robert Pugliese.

Oneeffort involves using a 3-D printer to make plastic models of patients jawbones, helping surgeons to prepare for difficult reconstructive surgery. In another, student researchers use electronic wristbands to monitor the movements of children in playgrounds, in hopes of determining which structures are most likely to encourage physical activity.

The emergency-department mapping project began when Ku saw a KieranTimberlake presentation of research it had conductedat JFK Plaza: how people use the park, where they sit, and where they stand. Billie Faircloth, a partner and research director at the architecture firm, recalled that Ku approached her afterward.

He said, I need this in my emergency department, she said.

Architects are used to interacting with people who have no formal design training. Listening to clients needs is a core part of the job, after all.But in Ku, Faircloth and her colleagues found someone who was unusually insightful about the potential for good design.

He talked very clearly about what he hoped to achieve, Faircloth said. He is basically looking at design from multiple perspectives.

Jefferson did not hire KieranTimberlaketo renovate the space. The firm offered its services purely for research purposes. Ku and his students are still sorting out what the results mean, and how they might lead to improvements.

The hospitals emergency department treats about 180 patients aday and at least seven every hour, though there is a lot of ebb and flow. Mondays are busiest, with a logjam of untreated ailments that has built up over the weekend. Regardless of the day, volumes tend to be highest from lunchtime until 2 a.m.

The spaceis divided into two wings, and, therefore, could serve as a living laboratory for testing different approaches for providing care. The larger A side has the more traditional E.R. configuration, with one central station for doctors and nurses, surrounded by patient rooms. The smaller B side is decentralized, with nurses separated into pods each surrounded by a cluster of four patient rooms.

Ku likes the B side because it tends to be quieter. But neither side has a good spot for providers to decompress. Kus solution?

I go to the bathroom, he said.

Ultimately, he would like to test which seating arrangements and other design elements might improve patient outcomes.

A recentstudy funded by the Robert Wood Johnson Foundation suggests that better design can, indeed, have an impact. Among the findings: Hospitals with shorter distances between delivery rooms were less likely to deliver babies bycesarean section. When rooms were arranged in a compact cluster rather than strung out along a long hallway, providers could work more efficiently, apparently reducing the pressure to move patients through the system more quickly by performing C-sections, the authors wrote.

KieranTimberlake developed the iPad tool that was used to map the Jefferson E.R., and it was customized for a health-care setting with input from Ku and his colleagues.

Ku, the assistant dean for health and design at Jeffersons Sidney Kimmel Medical College, wants to eventually make the tool available to hospitals anywhere. From what he can tell, there is far too little study of hospital spaces once they are built.

The science of how we build new health-care facilities, he said, should be as rigorous as the science of how we develop new drugs or therapy.


Bon Ku (center) and medical student Allison David (far left) are studying how to improve emergency medicine with better design.

Published: September 7, 2017 3:01 AM EDT

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Meet the ER doc who thinks like a designer –


Video Shows Utah Nurse Handcuffed After Refusing to Draw Patient’s Blood – New York Times

She took a few steps back and screamed, Somebody help me! as Officer Payne pushed her through two sets of doors out of the emergency room and outdoors, twisted her so she was partly facing a wall and placed her in handcuffs.

Excerpts from the video, which came to light at a news conference by Ms. Wubbels and her lawyer on Thursday, gained widespread attention.

The video led to apologies from the mayor of Salt Lake City, Jackie Biskupski, and the police chief, Mike Brown, on Friday and an outpouring of support for Ms. Wubbels, 41. Investigations by the Police Departments Internal Affairs unit and the citys Civilian Review Board are also underway, the mayor said in a statement.

These are officers of the peace, Ms. Wubbels said in an interview on Friday. There was nothing peaceful about this incident.

The episode unfolded on July 26 as the Salt Lake City police were helping another police department in an investigation of a driver who had crashed into another vehicle while fleeing the police. The fleeing driver was killed, according to a report filed by Officer Payne, and the other driver was flown to Utah Hospital.

Officer Payne wrote that he was seeking to draw blood from the patient to check if he had any chemical substances in his system at the time of the crash, though it was not clear why.

He wrote that he spoke with Ms. Wubbels, who was the nurse in charge in the burn unit, and tried to explain the exigent circumstances of the request.

The confrontation intensified as they headed to the emergency room from the burn unit upstairs.

Im just being told what to do by my entire hospital, she said, referring to her administrators.

Officer Payne responded, And Im being told what to do by my boss, and Im going to do what my boss says.

Officer Payne could not be reached on Friday. Chief Brown said in a statement on Friday that he was alarmed by the video.

I want to be clear, we take this very seriously, he said, adding, Within 24 hours of this incident, Salt Lake City Police Department took steps to ensure this will never happen again.

The chief said that Officer Payne had been suspended from the blood draw program, in which officers are trained as phlebotomists to take blood samples, and that a new policy had been put in place. The Salt Lake Tribune reported that Officer Payne remained on duty with the Police Department.

Ms. Wubbels, a nurse at the hospital since 2009, said she was adhering to hospital policies and the law. The United States Supreme Court has ruled that the police do not have the right to draw blood in drunken-driving investigations without a warrant.

It wasnt like she decided she was a constitutional scholar, her lawyer, Karra J. Porter, said in an interview on Friday.

No charges were filed against Ms. Wubbels, who was in handcuffs for about 20 minutes before being released. Ms. Wubbels said she wanted to use the episode to educate medical professionals and the police and to open a civic dialogue.

University of Utah Health, which runs the hospital, supports Ms. Wubbels and is proud of her decision to focus first and foremost on the care and well-being of her patient, Kathy Wilets, a spokeswoman, said in an email. She followed procedures and protocols in this matter and was acting in her patients best interest.

Ms. Biskupski said that efforts to get the police to increase the use of de-escalation techniques have been successful but that this incident is a troubling setback.

Robert J. Louden, a retired chief hostage negotiator with the New York Police Department and a professor emeritus of criminal justice and homeland security at Georgian Court University in New Jersey, watched the video and said in an interview on Friday that Ms. Wubbels was an absolute professional.

Officer Payne was 100 percent not correct, he said, adding, It seems to me hes in need of an attitude adjustment.

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Video Shows Utah Nurse Handcuffed After Refusing to Draw Patient’s Blood – New York Times


Only 3.3% of emergency room visits are ‘avoidable,’ study says – Healthcare Finance News

Only 3.3 percent of emergency room visits are avoidable, according to a study published Thursday in the International Journal for Quality in Health Care.

This is because those visits deemed ‘avoidable’ involve mental health or dental care, issues with which the ER is generally not equipped to deal, according to the study published in the peer-reviewed journal.

[Also: Medicaid expansion results in more emergency room trips; fewer patients uninsured]

The study shows that despite the health insurance industry’s campaign about avoidable ER visits, most patients in the emergency room belong there, said American College of Emergency Physicians President Becky Parker, MD.

The ‘avoidable’ emergency department visits are defined as visits in which patients did not require any diagnostic or screening services, procedures, or medications, and were discharged home.

“Most patients who are in the emergency department belong there and insurers should cover those visits,” Parker said. “The myths about ‘unnecessary’ ER visits are just that myths.”

The study analyzed data from the National Hospital Ambulatory Medical Care Survey from 2005 to 2011.

The most common ‘avoidable’ ER visits in the study included cases in which patients were discharged with alcohol- and mood-related disorders, or with dental conditions.

The study showed that 10.4 percent of visits by patients diagnosed with alcohol-related disorders, 16.9 percent for mood-related disorders and 4.9 percent for dental-related conditions, were ‘avoidable.’

While these visits were deemed avoidable, the majority of patients with these conditions still required some form of diagnostic or treatment service, said the study’s authors.

“We found that many of the common conditions of ‘avoidable’ emergency department visits involved mental health and dental problems, which ERs are generally ill-equipped to treat,” said lead study author Renee Hsia, MD, of the Department of Emergency Medicine at the University of California, San Francisco. “This suggests a lack of access to healthcare rather than intentional inappropriate use is driving many of these ‘avoidable’ visits. These patients come to the ER because they need help and literally have no place else to go.”

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How Four Master’s Students Used Design to Help One Haiti Emergency Room – The Bentley University Newsroom

Imagine walking into a crowded emergency room and having your symptoms recorded electronically, in order to minimize wait time and maximize care. That efficient scenario a dream of hospitals everywhere is newly underway at a hospital in Haiti.

In 2015, Boston, Mass.-based Partners in Health (PIH), which runs University Hospital in Mirebalais, Haiti, set out to develop an electronic triage system to replace its paper-based process.Their strategy was to expand on OpenMRS, the open-source medical record system implemented there. But this being relatively new territory for the PIH team, they sought additional experts to get the job done.

Tapping into a Learning Community

Enter Bill Gribbons, a leading authority on user experience who directs the Masters in Human Factors in Information Design (HFID) at Bentley University. PIH contacted Gribbons, who then reached out to his extensive network he calls it a learning community and received a flood of interest. He recruited another faculty expert, Roland Hubscher, to help advise a team, and four part-time graduate students eager for hands-on experience and excited to make a difference. All were willing to work on the project remotely, for no pay and no course credit.

I firmly believe some of the most meaningful learning happens outside the confines of a traditional classroom, said Gribbons. This type of project, one that requires in-depth involvement and makes an immediate impact on a product, is invaluable for students particularly for graduate students, who are looking to grow their careers and stand out in a crowded marketplace.

The HFID students were located in different cities and time zones and came from different professional backgrounds. Kim Forthofer, the team lead, was in Southwest Harbor, Maine, Mary Gribbons in Cambridge, Mass.; Truc Tokarz in San Jose, Calif.; and Dan Lopes in Toronto, Ontario. Though they were not able to work on site in Haiti, they used Google Hangouts to meet as a group on Wednesday evenings to stay on track.

We looked to Bentley because we knew that their graduate students would be accountable for their work and thoughtfully execute this project, said David DeSimone, business analyst at PIH. The students did not disappoint. They asked all the right questions and delivered a product that was immediately well received.

Designing a Product that Makes a Difference

Designing an electronic emergency intake form, from a remote location, is no easy task. The requirements were that the form permit easy scanning by a nurse and visually signal the urgency of a patients medical needs. To begin, University Hospital sent its typical paper intake forms to the Bentley team for analysis. This system, which ranked patients with a numerical score and a color based on severity, left plenty of room for mathematical error.

In addition to the technical parameters, cultural considerations were also essential. One of the biggest challenges for the team was coming up with a user-friendly design for a population that has limited access to computers, said DeSimone. Their initial designs used a keyboard only, with no mouse. But by the time we implemented the technology, we were able to train the nurses on Google Chromebooks.

A significant part of the design process involved user surveys and user testing. Due to the distance and lack of readily available technology, the Bentley team designed static mockups and used a cognitive walkthrough exercise where they asked nurses to role-play a patient-intake scenario.

This helped us better understand the human thought process behind the products use, said Forthofer. We knew it was possible that lives could depend on nurses understanding the new app as quickly as possible.

Life-Changing Experience

Despite the lack of credit or pay, the experience of acting as consultants had enormous value for the team. They improved the hospital experience for patients in Haiti, while also building their own skills and putting them into practice.

The project was much more like a real consulting gig instead of a realistic project done over a semester and graded by a professor. This provided us with real-world pressure as well as real-world confidence and experience, said Forthofer, who also gained reinforcement that she is in the right career, for the right reasons. I began my professional life as an environmental engineer and user experience is a second career for me, so challenges related to technical and scientific areas are the ones I continue to be drawn to.

This venture is a first for Partners in Health, in terms of developing a product that triages patients electronically in real time. They hope the intake form will be replicated at other facilities in Haiti and elsewhere. Anecdotally, they know that emergency room waiting times are lower and, more important, that prioritization has improved so the most critical patients are seen first. PIH has plans to gather data on the products effectiveness, but in the meantime, patients are getting better care and nurses and doctors are better able to do their jobs – a winning prescription all around.

Dedicatedto Preparing a New Kind of Business Leader

Bentley Universityis one of the nations leading business schools, dedicated to preparing a new kind of business leader with the technical skills, global perspective and ethical standards required to make a difference in an ever-changing world. Bentleys diverse arts and sciences program combined with an advanced business curriculum prepares graduates to make an impact in their chosen fields. The university enrolls approximately 4,000 undergraduate and 1,000 graduate students. ThePrinceton Reviewranked Bentley #1 in the United States in both career services and internships andBloomberg BusinessWeekranked Bentley a top 10 undergraduate business school.

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How Four Master’s Students Used Design to Help One Haiti Emergency Room – The Bentley University Newsroom


ER bills questioned – Calaveras Enterprise

Dignity Healths Mark Twain Medical Center is one of many hospitals that partner with EmCare.

EmCare, a company responsible for staffing emergency rooms in hospitals across the country, including Mark Twain Medical Center, is linked to a spike in surprise medical bills, according to health policy and economics researchers at Yale University.

The study examined close to 9 million emergency room visits run by a variety of companies between 2011 and 2015. It found that when EmCare partnered with a hospital, not only did out-of-network bills increase, but the number and rate of tests ordered and patient admissions also rose.

EmCare is a subsidiary of Colorado-based Envision Healthcare. Since April 2017, Mark Twain Medical Center in San Andreas has partnered with EmCare to provide emergency room staffing.

In a prepared statement, Mark Twain Medical Center officials said their rates and services offered have remained consistent since partnering with EmCare.

Mark Twain Medical Center and its more than 300 physicians, nurses and support staff are committed to providing, high-quality care to the residents of Calaveras County. In a continually changing health care landscape, were proud that for nearly 30 years we have been able to offer the community 24/7access, 365 days a year, consistent, highly skilled emergency medical services, the medical center said in a statement.

The statement did not provide additional information about billing rates or the number of out-of-network verses in-network bills, as requested.

Television shows paint the emergency room as a place of drama, but for patients, one minor medical emergency can turn into a monetary burden.

A trip through the emergency room doors is followed by a brief talk with the triage nurse and, depending on the status of the emergency, youll wait before seeing an emergency room physician.

Many patients do not know that the physician is an out-of-network doctor until it is too late.

Zack Cooper, assistant professor of public health and economics at Yale University, was one the studys three authors. He said that companies might bank on patients failing to look too closely into their plan and their hospital of choice.

If patients were aware, they may not go to these hospitals, Cooper said. The challenge has been in an emergency, they may not have enough choice.

In 2015, the Consumers Union published a survey that showed that 1 in 4 Californians who underwent surgery or received other treatment at a hospital believed their services were in network but were billed at out-of-network rates.

The New York Times interviewed a woman who received a $500 surprise bill in the mail following a stint at Sutter Coast Hospital in Crescent City. After slipping outside her Crescent City home, she was a taken to Sutter Coast Hospital, where she was treated for a broken ankle. While working on paying off her deductible, she was stunned to receive the bill.

The physician did not identify himself, and only briefly touched her ankle. The physician worked with EmCare.

Network: A network is a group of health care providers, including doctors, specialists, dentists, hospitals and surgical centers.

Out-of-Network Care: Going out of network means youll have to pay a larger chunk of the cost or the total cost of services depending on the plan.

Hospitals typically negotiate rates with major health insurers, but EmCare has traditionally negotiated its rates independent of hospitals. Physicians can bill at higher rates when they are out-of-network providers.

Using insurance claims data, the study found that 22 percent of emergency room visits were treated by out-of-network physicians, with an average surprise bill of $622.55.

Over 1 in 5 visits nationwide to in-network emergency rooms results in bills from out-of-network physicians, according to a previous study. But the most recent study found that 80 percent of those out-of-network bills were issued by about 15 percent of the hospitals studied. Many of those hospital emergency rooms were staffed by EmCare personnel.

That really looked like a light switch had been flipped, said Cooper. It had changed so rapidly.

Gregory J. Duncan is the chief of surgery at Sutter Coast Hospital and sits on his countys health board. He has 25 years of experience dealing with hospital services and billing. He began to notice an issue with billing and coding following an abrupt change from a prior staffing company to EmCare in 2015.

Colleagues working within the hospital began to float horror stories of past experiences with EmCare. He also began to receive complaints from patients who received the surprise bills.

Ive spoken with individuals at two other hospitals and they also had concerns, said Duncan. One doctor worked with a patient and agreed to lower the bill. One of my concerns is if you are someone who understands the billing, you can do that, but most dont have that and to me, that is not fair.

The billing became so bad in Crescent City that on April 25, the Del Norte County Board of Supervisors passed a resolution severing ties between the hospital and EmCare. The resolution specifically mentions EmCare, but was extended to include any out-of-network health care provider.

When the bill arrives, that is when you have your heart attack, Duncan said.

Envision Healthcare provided a prepared statement that dismissed the study as fundamentally flawed. The statement also said that out-of-network billing was not an issue specific to any one company.

The study appropriately identifies out-of-network reimbursement as a source of dissatisfaction for all payers, providers and patients in our current health care system. While the source and methodology of the study is fundamentally flawed and dated, we agree with the implied recommendation which is to advance a shared goal to re-engineer the current system in a positive way.

Cooper agreed that out-of-network billing was not inherently indicative of EmCare, but that firms like EmCare might be taking advantage of the situation.

The research compared EmCare to its top competitor TeamHealth, which took over mostly nonprofit emergency room departments. The research found a smaller increase in out-of-network billing and almost no change in admissions, coding or testing.

When the bill arrives, thats when you have your heart attack.

Its not necessarily that it is good or bad; it just turns out that in this case, EmCare is engaging in behavior that I think we can describe as not being in the patients best interest, Cooper said.

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ER bills questioned – Calaveras Enterprise