Track ‘impending badness’ to minimize clinical and financial risk


Track ‘impending badness’ to minimize clinical and financial risk

Elmhurst Emergency Medical Services

Good post-discharge follow-up and personalized care will both help to increase satisfaction and reduce damaging lawsuits, says Kathleen Schmelka of Elmhurst Emergency Medical Services.

For physicians, the most challenging patients aren’t those who are obviously sick or obviously well. Rather, they are the ones in the middle—those who appear well but discreetly harbor the early stages of less common, yet more catastrophic, disease.

Think about the patient who comes into the emergency department (ED) with what appears to be a simple case of constipation, but who actually is experiencing diverticulitis. Or the patient with what appear to be flu-like respiratory symptoms but are actually pulmonary emboli. What happens to these patients when they are discharged from the doctor’s office or the ED and later experience a poor outcome?

Their overall satisfaction with the care they received is likely to play an important role in their actions. This may be truer now than ever before, given that television ads advise the public today that almost any poor outcome can be resolved favorably with litigation whether or not poor care or misdiagnosis actually occurred.

Limited interaction presents challenge

Physicians want patients to go home satisfied with their care and knowledgeable about their post-discharge instructions. After all, these factors greatly affect clinical outcomes. Yet for emergency medicine physicians in particular, time constraints can pose a challenge.

Unlike family physicians who get to know their patients over many visits, emergency medicine physicians typically are afforded a single interaction, with one opportunity to establish rapport and create a satisfying patient experience. Furthermore, they have minimal time to spend with patients as ED volumes grow and the pressure to see more patients per shift intensifies. Given these constraints it is not surprising to find that the most common claim in emergency medicine is diagnosis-related: 57 percent of emergency medicine claims allege either misdiagnosis, failure to diagnose or a delay in diagnosis.

“Programs that automate patient follow-up and engagement can act as a safety net to catch patients who experience clinical deterioration—‘impending badness’—after discharge.”

Within this unique environment, it’s also difficult to ensure that patients have a clear understanding of their instructions at discharge. If they are unable to follow the physician’s plan of care as a result, they may be at increased risk of clinical decompensation.

In the highly competitive and litigious area of emergency medicine, such scenarios can result in multimillion dollar lawsuits that take years to resolve. Take the example of the patient who presented with apparent constipation. In an actual legal case, a patient who failed to follow post-discharge care plans experienced worsening symptoms and eventually was diagnosed with diverticulitis and a perforated colon. The lawsuit, which went to settlement, nevertheless cost the ED practice the time, cost, stress and aggravation of lengthy litigation.

Follow-up to improve satisfaction and outcomes

As consumerism grows in healthcare, patients increasingly expect to be treated as ‘clients’. They want to feel validated and valued, just as in any other environment where they pay for a service. Because most patients appreciate follow-up from their physicians, touching base with a patient after discharge can strengthen both the patient/physician relationship and provider loyalty—while also contributing to higher patient satisfaction.

Cases such as the non-compliant diverticulitis patient illustrate the opportunity to reduce medical liability by using a comprehensive follow-up program to check on patients the day after discharge. In that case, the patient likely would have been advised to return to the ED when she indicated she was feeling worse.

From a clinical aspect, programs that automate patient follow-up and engagement can act as a safety net to catch patients who experience clinical deterioration—‘impending badness’—after discharge and bring them back for reassessment. Using a text message or email the day after discharge, this timely follow-up can include questions about how a patient is feeling, medication concerns or any other concerns about the overall ED experience.

When a patient indicates he or she is not feeling any better, or is feeling worse, the response triggers a chain of events that starts by directing him or her to call the physician or return to the ED. Simultaneously, the tool sends a message to the ED charge nurse about the patient’s feedback. The nurse can immediately consult with a physician and call the patient within minutes, if necessary. Family members can respond for those who are not technologically-savvy, and a call-back system can be used when there is no response to the digital contact.

No matter which technology creates the outreach, patients generally appreciate the follow-up. Higher satisfaction comes from the chance to address any concerns, and better outcomes become more likely. Physicians, too, receive satisfaction from knowing that patient care won’t end up at the ED doors.

Mitigate potential legal claims

Not too long ago, if an elderly woman died after a decade on a feeding tube, her family was likely to say, “It was her time”. Today, however, healthcare providers face a highly litigious society that is less accepting of undesirable outcomes—even in the face of natural progression or unavoidable circumstances.

Digital patient engagement can play a significant role in lessening the desire to assign blame. By providing timely patient follow-up and possibly improving outcomes, it could mitigate the impact of legal claims. In addition, this level of follow-up provides evidence of a provider’s efforts to contact patients to check on their well-being and understanding of discharge instructions.

For example, the ‘evidence’ provided by a patient who reports that he/she is feeling better, understands the discharge instructions and is on-schedule for an appointment with his/her primary care physician, may afford some level of protection in the event of litigation.

At the same time, follow-up can help alert providers to remaining clinical issues in order to avoid potential untoward events in the future. It also can help reconcile any patient satisfaction concerns that, without the follow-up, could result in the patient giving a less-than-positive Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) rating.

More than just risk reduction

ED physicians must balance the need for quick patient throughput with the need to do all they can to send patients home satisfied with their experiences and knowledgeable about their discharge care. If patients don’t fully understand the services provided in the ED or what they need to do at home, the risk of post-discharge clinical decompensation and patient dissatisfaction increases.

No physician wants to see that. Emergency medicine physicians average an 8.7 percent annual liability claims rate—the fifth highest of all medical specialties. Those physicians and their healthcare organizations want to employ every possible strategy to minimize the risk of lawsuits that claim negligent care. Using digital patient follow-up to track and thwart any potential for poor outcomes does more than mitigate the impact of a possible legal claim. It’s about doing the right thing for patient care; it’s about helping people get well, and stay well.

Kathleen Schmelka MD has been in practice as a board certified Emergency Physician on the East Coast and in the Midwest for 16 years. In addition to her clinical work, she owns a consulting company that works with healthcare-related innovation development in Chicago, Illinois. She can be reached at


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