WHITE PAPER INTEGRATION CHANGES EVERYTHING: COMMUNICATION, COLLABORATION, PATIENT FLOW, PATIENT PERCEPTION OF CARE AND THE BOTTOM LINE PRESENTED BY

WHITE PAPER INTEGRATION CHANGES EVERYTHING: COMMUNICATION, COLLABORATION, PATIENT FLOW, PATIENT PERCEPTION OF CARE AND THE BOTTOM LINE by: KIRK JENSEN, M.D., NATHAN GOLDFEIN, M.D. and MARK HAMM, MBA PRESENTED BY

Copyright 2014 EmCare, Inc. All rights reserved. This publication may not be reproduced, stored in a retrieval system or transmitted in any form or by any means electronic, mechanical, photocopying, recording or otherwise without prior permission of the copyright owner. This White Paper is an informational document. Readers should note that this document does not represent an endorsement by any entity. All page headers and custom graphics are service marks, trademarks and/or trade dress of Envision Healthcare, Inc. Emcare, Inc. is an Envision Healthcare company. All other trademarks, product names and company names or logos cited herein are the property of their respective owners. Any comments relating to the material contained in this document may be sent to: EmCare Marketing Department: Email: marketing@emcare.com Mail: EmCare, Inc. Marketing Director 13737 Noel Road Dallas, Texas 75240 PAGE 2 WHITEPAPER INTEGRATION CHANGES EVERYTHING

TABLE OF CONTENTS Executive Summary... 4 Introduction... 5 Evaluating the Major Flow Managers... 6 The Conflict that Causes Slow Flow... 6 Different Mindsets... 6 A Tale of Two Specialties... 8 Two Separate Groups Managing Two Crucial Departments... 9 How Integration Improves Collaboration... 9 Culture Impacts...10 The Fast Track to Patient Flow Improvement...10 Software that Powers Integration...10 Inventing RAP&GO... 12 Processes that Support Improved Patient Flow... 12 Using RAP&GO... 13 Case Study... 13 The Hospital CEO s Perspective...14 Rapid Results from D2D with RAP&GO...14 Calculating the Financial Impact of Integration...14 In Summary... 15 About EmCare...16 References...16 About the Authors... 17 WHITEPAPER INTEGRATION CHANGES EVERYTHING PAGE 3

Executive Summary If there was just one thing hospital leaders could do to move the metrics on quality, efficiency and cost-effectiveness, and ultimately improve revenue potential, many would focus on improving patient flow from the emergency department to the inpatient units. When patient flow is working well, the emergency department is always open for business. Patients are admitted more rapidly and spend less time boarding in the emergency department. The emergency department waiting room is not crowded and new visitors are seen more quickly. When the wait is short, potential patients don t leave the hospital without care. Beds are open for ambulances to bring more patients, often with more serious conditions. Word-of-mouth promotion and the hospital s reputation become more positive and marketing can tout messages about short wait times and outstanding performance. Changes in patient perception of care impact Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) bonuses or penalties, including those for the emergency department, and affect the hospital s bottom line. Key Takeaways Efficient patient flow is vital to the patient experience as well as hospital productivity. The impact of flow issues is nearly always exacerbated in the emergency department. Dysfunctional flow is often due to conflicts between emergency medicine physicians and hospitalists. Differing mindsets, incentive structures and group practices often result in decreased value to the patient and the hospital. Clinical, operational, technical, financial and leadership integration can help hospitals achieve significant improvements. Integration improves emergency and hospital medicine collaboration as well as patient flow. New software exists to power collaboration and automate communication, supporting an integrated model. Hospitals that have adopted an integrated model have experienced improved metrics. No doubt, the cost of allowing inefficiencies in hospital flow is exorbitant, but the intricacies of the relationships, motivations and influencing factors can make fixing the problem seem impossible. Most efforts to align emergency and hospital medicine physicians are ineffective. Insights gained while working with over 500 hospitals have helped identify how a shift in the processes, leadership and culture with an integrated solution can put hospitals on track for improved patient flow. This white paper details the root cause of the current dysfunction and how integrating emergency and hospital medicine on clinical, operational, technical, financial and leadership levels can help hospitals achieve significant improvements in patient flow related metrics. PAGE 4 WHITEPAPER INTEGRATION CHANGES EVERYTHING

Introduction Poor patient flow can have a significant negative impact on hospital performance, slowing throughput and effectively decreasing capacity. The 2012 Patient Flow Challenges Assessment (PFCA) report by AHA Solutions, an American Hospital Association company, reveals that, along with HCAHPS and readmissions, poor patient flow was one of the top three areas of concern for hospital leaders. The PFCA report breaks down each aspect of the patient care path in order to identify the key barriers throughout each of the eight stages of patient flow: (1) pre-admission, (2) admission, (3) diagnosis, (4) procedure, (5) recovery, (6) discharge, (7) post-discharge and (8) home (AHA Solutions, 2012, p. 5). Undoubtedly, both the causes and effects of poor patient flow can be found throughout a hospital system. While many factors contribute to overall inefficiencies, a primary culprit is physician communication and hand-offs at one of the key stages admission moving patients from the emergency department to the inpatient units. The negative impact of inefficient patient flow is often felt most in the emergency department the very department that requires faster movement, more flexibility and greater efficiency in order to effectively care for patients. Poor collaboration, strained communication, silo mentalities, differing incentives and other contributors to the highly fragmented relationship between the emergency medicine and hospital medicine physicians are common challenges. The constant demand to address these issues led to a deeper study of the conflict between the departments. Of note, hospitals with patient flow issues consistently demonstrated the following: The existing culture allowed physicians and staff to work in silos instead of focusing on a broader picture of patient-centered care. The divergent perspectives and priorities of the emergency medicine and hospital medicine physicians were causing inefficiencies, communication breakdowns and slow patient hand-offs. Inpatients who were ready to be discharged still filled hospital beds well into the late afternoon, blocking admissions from the emergency department. The average time to move the admitted patient from the emergency department to the inpatient unit was commonly 3½ hours or more (E.D. boarding time). Ultimately, the solution has been found in an integrated approach to emergency medicine and hospital medicine in order to improve communication, collaboration and performance. The Eight Stages of Patient Flow 1. Pre-admission 2. Admission 3. Diagnosis 4. Procedure 5. Recovery 6. Discharge 7. Post-discharge 8. Home (AHA Solutions, 2012, p. 5). WHITEPAPER INTEGRATION CHANGES EVERYTHING PAGE 5

Evaluating the Major Flow Managers The emergency department (E.D.) is the front door of the hospital addressing urgent and acute care needs of patients who are sick or injured. For many patients, the E.D. is only the first phase of their hospital experience. Nearly half of all inpatient admissions come from the E.D. In many hospitals, this percentage is far higher. In the E.D., efficiency and productivity are critical. Seconds count in an emergency and minutes count in E.D. metrics. Processes are carefully monitored for continuous improvement, and lean methodologies and rapid process redesign efforts focus on staffing, triage, registration and other factors that are critical to patient-centered care. Improving E.D. throughput has a distinct impact on value-based success. Centers for Medicare & Medicaid Services (CMS) goals for 2013 and 2014 include measures to record improvement in E.D. efficiency and throughput times. Efficiencies and Outcomes Significant service efficiencies as well as improved clinical outcomes can be achieved through the efforts of both specialties, including: Emergency Medicine Effective triage Professional, organized communication Lean thinking and patientcentered processes Continuous focus on improving flow and the patient experience Hospital Medicine Patient rounding throughout the day Observing and understanding a patient s needs Arranging appropriate services and assistance Managing the patient experience and creating a positive care environment While E.D. efficiency is important, it is not the only determinant of good patient flow. Patient flow controllers can exist throughout the hospital system including areas such as diagnostic radiology, laboratory, transport services, housekeeping and, most notably, inpatient services. Hospital medicine physicians, or hospitalists, direct the aspects of care for patients who may require admission to the hospital for inpatient services. Some consider the hospitalist to be the quarterback of the patient care team, teaming up with multiple players: E.D. physicians and personnel, primary care physicians, specialists, nursing staff, case managers, laboratory staff, radiology personnel, patients, family members, program coordinators, home care agencies and longterm acute care hospitals, rehab facilities and/or nursing homes. As many fullservice hospitals move to a model where laboratory services, radiology and other essential services are available 24 hours daily (and not just on a 7 a.m. to 5 p.m. basis as has traditionally been the case), the advantages of 24-hour hospitalist services will likely become even more dramatic. Because hospitalists provide the majority of clinical care for admitted patients, the impact of the hospital medicine group on HCAHPS scores is hefty. As a hospital-based practice, hospitalists are positioned to effectively manage hospital admissions and discharges. Therefore, from a patient flow perspective, hospitalists have come to play a major role in improving flow efficiency, satisfaction and cost (McHugh et al, 2011). The Conflict that Causes Slow Flow Ideally, hospitalists and emergency medicine physicians should have the best relationship in the hospital because the functions of the two groups are so intertwined. They are handing off patients from one specialty to another one physician to another collaborating on services, care and outcomes. Yet often this is not the case. At most hospitals, hospital medicine and emergency medicine physicians operate independently from one another and are concerned primarily with what is happening in their own areas, driven by overlapping but distinctly separate sets of priorities. There are conflicts due to the motivations of two different mindsets, two different pay structures and two different groups working in silos. Different Mindsets At the core of the conflict are the different mindsets and approaches of the two specialties which often lead to poor communication and strained relationships. PAGE 6 WHITEPAPER INTEGRATION CHANGES EVERYTHING

The patient suffers most, being caught in the middle of the conflict between the two physicians. And, boarding in the E.D. can delay necessary treatment for a patient who needs to be admitted as well as patients still waiting to see an E.D. physician, potentially leading to unnecessarily poor clinical outcomes. Emergency Medicine Mindset Emergency medicine physicians are driven by speed. E.D. lengths of stay are measured in minutes whereas inpatient lengths of stay are measured in days. So, E.D. physicians move fast and make critical decisions quickly. Since the E.D. is not intended as a setting for long-term care, the E.D. physician s goal is to quickly evaluate patients and make the determination to treat and release or present the patient to the hospitalist for admission. Rapidly moving patients through emergency care in order to see the next patient is a necessary part of the E.D. practice. E.D. physicians are concerned with how to triage, stabilize and determine the disposition of the patient whereas the hospitalist is more concerned with assessing the need to be admitted as well as where to admit the patient and what needs to be done before admission. Emergency medicine physicians must rely on every other function in the hospital organization to pave the way for the patients who enter the hospital under emergency circumstances. They know they have to get patients who meet the admission criteria moved to an inpatient unit. Yet, they are powerless to do so without the cooperation of hospitalists. The patient suffers most, being caught in the middle of the conflict between the two physicians. When the hospitalist doesn t immediately act on the emergency medicine physician s request, it can lead the E.D. physician to view the hospitalist as an opponent. Thus, E.D. physicians may begin to think that hospitalists: Procrastinate about seeing patients, taking their time to get to the E.D. for patient evaluations Want more information and more tests than are needed, even when the diagnosis is obvious Don t understand E.D. bed shortages that may exist Hospital Medicine Mindset Hospital medicine physicians tend to take more time and be more analytical and methodical. They are prone to research, discuss and collaborate on a decision. Hospitalists are tasked with treating the entire spectrum of patient issues instead of strictly focusing on the acute episode. Hospitalists have to address all the conditions of the patient. They must consider not only the patient s acute illness, but also chronic and secondary illnesses. They have to know the criteria for admission and the severity of the illness. Traditionally, when a poor relationship exists, the hospitalist may feel that E.D. physicians: Try to admit unnecessarily Don t fully evaluate patients Don t do a full work up in the E.D. Only uncover a single diagnosis Don t consider alternatives to admission Don t provide all the information needed for a hospitalist to make an admission decision WHITEPAPER INTEGRATION CHANGES EVERYTHING PAGE 7

Different Incentive Structures In some cases, the disconnect is due to measurements and incentives. Often, the hospitalist group is incentivized purely on the quality of the patient encounter and not at all on productivity. There may be little motivation for hospitalists to rush down to the E.D. to evaluate waiting patients. The hospital medicine group seldom has an inherent interest in key E.D. metrics, including the number of patients who left without treatment, hospital boarding time and patient satisfaction. Conversely, emergency physicians are incentivized based on efficiency and the number and acuity of patients seen. So it is critical for emergency physicians to see, diagnose and determine the disposition of the patient rapidly in order to free up the E.D. bed for the next patient. Increasing Value by Decreasing Disconnect The interests of the E.D. physician group varies widely from the interests of the Hospitalist group, resulting in lower satisfaction to the patients and caregivers. Different Groups The conflict in goals and performance standards can create a lack of trust, a strained relationship or even a competitive / adversarial relationship between E.D. and hospitalist groups. This is more likely to occur when two different management companies oversee the practices. The goals, reporting structure and productivity measures of the two are likely not the same, so the practices are more likely to work in silos. The Resulting Decrease in Value The result of poor interactions based on the differing mindsets and incentives of the E.D. and hospital medicine physicians manifests in time spent testing, reevaluating, negotiating, defending, even arguing when trying to move patients from the E.D. to the inpatient unit. When two different companies are managing emergency and hospital medicine groups, the process is even more challenging. The inefficiency leads to dissatisfaction of all parties, including the patients and their caregivers (Mayer, 2014). E.D. Interests Hospitalist Interests Value A Tale of Two Specialties The typical scenario is the E.D. physician calls the hospitalist trying to get the patient admitted and the hospitalist starts asking questions like what s the patient s PORT score? The E.D. doctor has only gone far enough to feel the patient should be admitted, but may not have had time to fully investigate and document what the hospitalist needs. This creates an instant barrier to efficient and productive communication. The situation is frustrating to both physicians at best and, at its worst, it can adversely affect the patient s care, experience and clinical outcomes. Here is an illustration of how the progression often goes: The E.D. physician makes a disposition decision and determines that the patient needs to be admitted. The E.D. physician pages the hospitalist to admit the patient. The hospitalist should respond in 30 minutes but, because s/he is often engaged in patient care, this can take much longer. The hospitalist requests additional tests, adding another 30-60 minutes to the process. Once tests are completed, the emergency physician calls the hospitalist again. Another 30-60 minutes passes. Upon arrival in the E.D., the hospitalist reviews test results and evaluates the patient in the E.D. to make sure that s/he agrees with the emergency physician s diagnosis. Another 30-60 minutes may pass. PAGE 8 WHITEPAPER INTEGRATION CHANGES EVERYTHING

Ultimately, it may take three to five hours before the patient is moved to the inpatient unit and every minute of wasted time chips away at value and patient perception of care. Two Separate Groups Managing Two Crucial Departments Emergency medicine physicians may feel: Goals not aligned with hospitalist group Compensation based on volume and productivity E.D. physicians want to increase visits and fast track admissions Believe hospitalists refuse patients Hospitalists may feel: Goals not aligned with E.D. goals Compensation is fixed and providers have average daily census limits Hospitalist-centered admission process Believe E.D. physicians are dumping patients on them How Integration Improves Collaboration There is a valuable synergy that naturally occurs when the goals, management reporting structure and productivity incentives of the two different specialties are the same. Alignment and cultural changes are more easily achieved when the emergency medicine and hospital medicine physicians are integrated and working together as ONE team. An integrated E.D. and hospitalist group overseen by a single management company has a distinct advantage in preparing, motivating and incentivizing physicians to work together. The groups are able to align on common interests and goals including patient focus, shared resources, reduced conflict, commitment to the team and increased value. The Foundation of Patient-Flow Improvements Improving patient flow often takes a complete refocus of the hospital organization on process, critical bottlenecks, teamwork, hand-offs and clinical leadership crucial elements that lead to culture change. Expert facilitation of changes to both processes and culture is a key element to bring about improved overall efficiency. Leadership Integration and Culture Change Behind virtually every successful, patient-centered E.D. is great leadership, a culture of service excellence and operational efficiency. When leadership can manage from a clinically and operationally integrated E.D. and hospitalist model, it can break down problematic silos, collaboratively addressing the availability of inpatient / ICU beds, spikes in arrival, diagnostic turnaround times and more. Emergency Medicine Goals not aligned with hospitalist group Compensation based on volume and productivity E.D. physicians want to increase visits and fast track admissions Believe hospitalists refuse patients Hospital Medicine Goals not aligned with E.D. goals Compensation is fixed and providers have average daily census limits Hospitalist-centered admission process Believe E.D. physicians are dumping patients on them Healthcare providers almost invariably support processes that improve patient care. After all, helping others is the reason so many physicians and nurses go into healthcare. The Benefits of Clinical, Operational and Technical Integration Integration includes behaviors, activities and tools that help organizations achieve, sustain and accelerate exceptional clinical, operational and financial outcomes. Even with the advantage of strong performing integrated groups, WHITEPAPER INTEGRATION CHANGES EVERYTHING PAGE 9

turning a historically disjointed system into a well-oiled machine will be easier if the right tools are used. Shared technology and structural improvements designed to enhance the process can improve communication and efficiency. Operational tools that are connected and shared can contribute to improving clarity, flow, hand-offs, communication and more. The benefits of integration and alignment include improving physician, staff and patient satisfaction and cost reduction, revenue enhancement and CMS-imposed penalty reduction. Culture Impacts The resources and services found to most boldly impact culture and throughput include: Patient-centered focus Effective departmental leadership with an on-site medical director The Key Ingredients of Value-based Success 1. Combining E.D. and hospitalist services to operate under shared goals 2. Optimizing throughput via system-wide collaboration 3. Focusing on providing quality patient-centered care Lean and rapid process redesign focused on internal processes that evaluate flow for value and non-value-added elements while keeping the spotlight on bed availability Interdepartmental collaboration Appropriate physician and nurse coverage Productivity-based compensation and physician engagement Providing each group with dashboards that include E.D. throughput metrics Comprehensive on-site practice resources, experienced leadership, quality management, extensive education and satisfaction programs can help hospitals change their cultures; improving system-wide efficiency, teamwork and patient flow and, thereby, positively affecting clinical quality, metrics, patient experience and financial impact. The Fast Track to Patient Flow Improvement Integration of the emergency and hospital medicine practices on all levels clinical, operational, technical, financial, etc. quickly and profoundly impacts the hospital by improving patient flow, optimizing care and efficiency, improving the patient experience and generating related value. For the hospital, improvements in efficiency, faster bed turns in the E.D., the opportunity for incremental admissions and decreases in patients leaving the E.D. without treatment allow opportunities for new revenue, with synergies that lead to a better bottom line. The key ingredients of a more efficient healthcare delivery system and valuebased success include: (1) combining E.D. and hospitalist services to operate under shared goals, (2) optimizing throughput via system-wide collaboration, and (3) focusing on providing quality patient-centered care. Here, EmCare Hospital Medicine introduces its recipe for success, an integrated emergency and hospital medicine solution called EmCare s Door-to-Discharge (D2D ) service. Software that Powers Integration EmCare s D2D service is supported by EmCare s proprietary Rapid Admission Process and Gap Orders (RAP&GO ) evidence-based software which leverages technology to improve clinical as well as administrative interactions between physicians and expedites patient flow. RAP&GO helps organize and PAGE 10 WHITEPAPER INTEGRATION CHANGES EVERYTHING

direct communication not only between physicians, but throughout all hospital departments involved in the patient flow process from E.D. to inpatient unit. All who are associated with coordinating a hospital admission and moving patients more rapidly through the admission process benefit from RAP&GO and so do patients. From the first day I used RAP&GO, I loved it! All the calls back and forth are eliminated. No more Let me call you back, where sometimes 30, 40 or 50 minutes would pass before you heard back. We can now stay ahead on beds as everyone who needs the message gets the message at the same time. ~ Quote from the House Supervisor of a hospital using RAP&GO RAP&GO software includes evidence-based criteria for the top 12 conditions that commonly cause about 80 to 85 percent of all inpatient admissions coming from the hospital s E.D. Using the software, with just a few quick clicks, an E.D. physician can determine if a patient meets the hospitalist-approved admission criteria. The RAP&GO software quickly and easily provides information about a patient s condition that is relevant to the admission in a format that is useful to both the hospitalist and the emergency physician. So, the two physicians have the exact details they need to quickly render a decision. If the patient meets the agreed-upon criteria for admission, the emergency physician creates a gap order and the patient can be sent straight to the inpatient unit, thereby reducing the time the patient spends boarding in the E.D. and decreasing the likelihood of an E.D. bottleneck. Using this model, the hospitalist does not examine the patient in the E.D. unless the process indicates the patient may need to go to an ICU. Once a gap order is created and the patient arrives on the inpatient floor, the hospitalist then sees and evaluates the patient. Assuming the hospitalist is still in agreement that the patient should be admitted, the hospitalist will then write admission orders. D2D is an Integrated Services Solution The solution introduced by EmCare is a combined E.D. and hospitalist service called EmCare s Door-to- Discharge service. This structurallyintegrated physician model is revolutionizing the industry by changing the preconceived notions about how emergency medicine and hospital medicine practices interact. D2D encourages E.D. physicians and hospitalists to align goals and work together to reduce hospital LPT / LPMSE rates; reduce E.D. boarding time; improve patient flow, clinical quality and patient satisfaction; and open up needed E.D. beds. RAP&GO also uses telephonic technology to page, text or call each person in the chain of events (emergency physician, hospitalist, bed supervisor, E.D. clerk, etc.) and gives them an automated message about what needs to occur when they need to take an action (i.e. call the E.D., assign a bed, move the patient to the inpatient floor, etc.). If someone in that chain fails to respond in the predetermined time (tracked by the RAP&GO software), the software will escalate the activity by paging, texting or calling that person s supervisor until the patient is properly moved through all steps of the admission process. Everyone in the communication chain is held accountable to quickly respond and move the patient to the inpatient floor as appropriate. The RAP&GO software also includes standard reports which can signal areas or people that need improvement. The integration of the departments through D2D with RAP&GO quickly and efficiently puts the emergency physician and the hospitalist on the same page. Further, it eliminates the need for time consuming back-and-forth conversations, arguments and debates that might otherwise occur. And, it allows for tangible process improvements. WHITEPAPER INTEGRATION CHANGES EVERYTHING PAGE 11

Inventing RAP&GO EmCare s RAP&GO software was developed by a hospitalist, Nathan Goldfein, M.D., who had the vision to see the communication and flow challenges that existed in hospitals and figured out a way to improve decision-making, communication and flow. Dr. Goldfein was a mechanical engineer specializing in industrial engineering and an inventor for 20 years before he decided to go into medicine. Starting Off Right Discharge planning typically begins the moment the patient is admitted. Hospitalists who collaborate with case managers can be instrumental in helping to successfully transition the patient to the next stage of appropriate care. I thought medicine was going to be the epitome of efficiency. But, let s just say it was not. Right out of residency, I realized parts of the system were broken; some processes were a mess. Neither the E.D. physicians nor the hospitalists had adequate knowledge of the challenges of the other specialty. Unfortunately, this caused a situation where both specialties were so busy arguing and pointing the finger at each other that no one was looking at how to fix the system. I knew there had to be a better way. ~ Nathan Goldfein, M.D. Hospitalist He designed RAP&GO to organize and enhance the vital clinical exchange between emergency and hospital medicine physicians by using software and communications technology to manage the information and process. Consequently, using the software reduces errors, delays and distractions that are natural to humans working in a complex, interruption-driven environment. Some of the mundane yet time consuming and frustrating tasks of calling, tracking and following up are much more effectively managed by the software. Processes that Support Improved Patient Flow It s one thing to have processes in place that improve efficiency. But, flow is equally thwarted if there are no inpatient beds available when needed. There are countless variables that impact bed availability often beyond the control of either the emergency physician or hospitalist. Still, it helps to be aware of initiatives and programs that are available to a hospital for addressing areas that can be managed. EmCare offers valuable support to the hospital for a number of strategies to improve both patient flow and the patient experience, such as: Accommodating discharge strategy planning within the first 24 hours. Supporting the hospital s 11 a.m. Discharge program or other focus on timely discharge. PAGE 12 WHITEPAPER INTEGRATION CHANGES EVERYTHING

Participating in programs such as early rounding on inpatients or rounding with a multidisciplinary team. Assisting with initiatives such as day of discharge conferences or, preferably, next day discharge conferences to identify patients who may be ready to go home. Providing expertise in setting up a discharge lounge. Supporting the use of nurse practitioners and physician assistants in accordance with the hospital s bylaws and state laws. Investigating new concepts in hospital medicine such as ways to overcome inefficient routines, for example, rounding on discharges first and taking more time with sicker patients later as medically prudent. Providing educational programs customized and facilitated by clinical services experts. Designing and implementing an effective hospitalist orientation process (Quinn, 2011). Using RAP&GO RAP&GO software relies on shared ownership of the process. Through agreedupon protocols, shared knowledge bases and safety features, both emergency and hospital medicine physicians have a better understanding of the process and requirements of each specialty. In addition, by automating the steps that are unrelated to patient care, the physicians can focus on what matters most physician-to-physician communication, high-quality patient care and patient satisfaction. The benefits of RAP&GO in an integrated model include: D2D Dashboards After implementing D2D, E.D. volume grew while LWBS declined. 850,000 820,000 790,000 E.D. VOLUME Assisting emergency physicians in providing the information needed by the hospitalists which expedites decision-making and improves confidence. Decreasing the administrative, non-value-added tasks for physicians and nurses. Having a shared tool to measure and manage time intervals in order to identify opportunities for improvement. Assisting case management with timely notifications that keep patient flow on track. Case Study Reducing the minutes between disposition and the time the patient is moved to the inpatient unit in essence provides more capacity to serve additional patients. In this case study, reducing E.D. boarding time showed a positive impact on revenue without expanding the facilities. 760,000 730,000 700,000 2.0% 1.6% 1.2% 0.8% 0.4% 0.0% % LWBS 250 MIN. 200 MIN. RAP&GO DISPOSITION TO FLOOR TIME 650 patients x 125 minutes (reduction in time patient spends in E.D.) 2011 2012 2013 150 MIN. 1,354 Freed E.D. Bed Hours 100 MIN. 50 MIN. 0 MIN. BEFORE RAP&GO AFTER RAP&GO Combined data for four facilities, achieved in a 30-day time period. WHITEPAPER INTEGRATION CHANGES EVERYTHING PAGE 13

The Hospital CEO s Perspective In addition to being better for patients and physicians, hospital administration also experiences benefits from integration of emergency and hospital medicine practices, one of which is less need to play referee between the two practices. Hospital administration also experiences benefits from integration of emergency and hospital medicine practices. What RAP&GO does is get us out of a professorial debate between the emergency medicine and hospital medicine physician.... It s easy to put in place. It s a very effective way to communicate. People respond quicker to it. They trust the process. It reduces everybody s frustrations.... Patients are not languishing in the E.D. waiting for a bed. In the long run, it s better for the patient better for the staff. ~ Quote from RAP&GO client CEO Rapid Results from D2D with RAP&GO In addition to the very valuable patient care and patient experience benefits, the D2D model has also been proven to deliver significant financial benefits to hospitals that had previously been experiencing even minor challenges with LWBS, LPT and LPMSE rates. The hospitals where EmCare s D2D with RAP&GO are currently in place are experiencing a nearly 12 percent improvement in E.D. volume resulting from the improved efficiencies described earlier and the reduction in patients leaving without being treated.* Faster admission Less E.D. boarding time More E.D. capacity Less wait time in the E.D. Less ambulance diversion * Potential new hospital revenue is representative of a decrease in LWOT / LPMSE rates and / or improved bed availability which, in turn, contributes to an increase in E.D. volume. An increase in E.D. volume may result in improved revenue for the hospital through charges for the additional patients in the E.D. Historical data suggests that admission rates under the D2D program remain essentially flat compared to the time period immediately prior to implementation of the D2D program. Thus, the additional E.D. volume would result in additional admissions and potential increased revenue for the hospital. Calculating the Financial Impact of Integration Calculating the financial impact of integration can be done the same way for any hospital using its own unique values. Following is an illustration of the potential financial benefit that can be realized based upon the results of D2D with RAP&GO. PAGE 14 WHITEPAPER INTEGRATION CHANGES EVERYTHING

For a hospital with 30,000 annual E.D. visits, an admission rate of 15 percent, averaging $1,000 of revenue per E.D. patient and $8,500 for patients who are admitted, a reduction of boarding time from a typical 3.5 hours (210 minutes) down to one hour (60 minutes) may result in potential increased hospital billing for new patients being seen and treated or admitted by over $8.5 million per year.* Assumptions: The minutes of E.D. bed time freed up by appropriate and timely admissions can be fully utilized for evaluation of E.D. patients, treatment including labs and radiology, and no change to the hospital s current percentage of E.D. patients admitted to an inpatient unit. EmCare s D2D process with RAP&GO software is designed to expedite admissions, but does not increase the overall admission rate. The impact results from greater efficiency and capacity which may lead to reduced LWOT, LPT and LPMSE rates and ultimately resulting in increased E.D. volume.* Entered by hospital: E.D. Volume E.D. Admission Rate Average Hospital E.D. Revenue Per Patient Average Hospital Revenue Per Admit Average E.D. Patient LOS Current E.D. Boarding Time (Disposition to Floor) for Admitted Patients Integration changes everything: communication, collaboration, patient flow, patient perception of care and the bottom line. * Potential new hospital revenue is representative of a decrease in LWOT / LPMSE rates and / or improved bed availability which, in turn, contributes to an increase in E.D. volume. An increase in E.D. volume may result in improved revenue for the hospital through charges for the additional patients in the E.D. Historical data suggests that admission rates under the D2D program remain essentially flat compared to the time period immediately prior to implementation of the D2D program. Thus, the additional E.D. volume would result in additional admissions and potential increased revenue for the hospital. In Summary Integration changes everything: communication, collaboration, patient flow, patient perception of care and the bottom line. With this insight, EmCare has developed the industry blueprint for success. EmCare s Door-to-Discharge program with RAP&GO evidence-based software tackles the outdated silos and the rigidities of complex and cumbersome systems, and delivers improved quality, safety and service: Addresses throughput and efficiency with lean and rapid process redesign Provides leadership to bring all departments together on a patientcentered mission Integrates the emergency medicine and hospital medicine physician team Creates efficiencies in length of stay and implements an inpatient early rounding and discharge program Supports the process with software to improve communication, accuracy, confidence and efficiency Supports growth in E.D. volume / performance and the potential for new revenue generated by decreasing boarding time and opening up E.D. beds WHITEPAPER INTEGRATION CHANGES EVERYTHING PAGE 15

EmCare s Door-To-Discharge service streamlines numerous steps in a patient s journey through the hospital from entering the E.D. to triage, from admission to a treatment area to diagnostic testing / results. EmCare processes are designed to drive greater: Efficiency and cost savings Potential new hospital revenue Satisfaction and positive perception of care Improved quality of care About EmCare EmCare is a leading national physician practice management company and provider of clinical department outsourcing services, including physician recruiting, credentialing, scheduling, leadership, training and education and billing, for hundreds of hospitals nationwide. The company services more than 750 contracts with nearly 600 hospitals and healthcare systems nationwide. Authors and Contributors Authors: Kirk Jensen, M.D. Nathan Goldfein, M.D. Mark Hamm, MBA Contributors: Donna Biehl, RN, BS Jason Crampton Sabrina Griffin, RN, BSN, CEN Roxie Jackson, RN, BA, MSHL Francisco Loya, M.D. Kim Mills Steve Schaumburg Integrated services include: Emergency Medicine Hospital Medicine Acute Care Surgery Anesthesiology Radiology / Teleradiology EmCare clinicians participate in more than 12 million patient encounters annually. The company focuses on helping each client with efficiency, quality of care and creating outstanding patient experiences. In short, EmCare is making healthcare work better. For more information about EmCare and its services, call 877.416.8079 or visit www.emcare.com. References AHA Solutions, Inc., a subsidiary of the American Hospital Association, jointly published with Hospitals in Pursuit of Excellence (HPOE). (2012). The patient flow challenges assessment. Retrieved from http://www.aha-solutions.org/content/pfca/ahasolutions-report-pfca-012412.pdf. Mayer, T., Jensen, K., & Hamm, M. (2014). Hardwiring hospital-wide flow. Gulf Breeze, Florida: Fire Starter Publishing (forthcoming). McHugh, M., Van Dyke, K., McClelland, M., & Moss, D. (October 2011). Improving patient flow and reducing emergency department crowding: A guide for hospitals. Retrieved from http://www.ahrq.gov/research/findings/final-reports/ptflow/ptflowguide.pdf. Quinn, R. (October 2011). The earlier, the better. The Hospitalist. Retrieved from http://www.the-hospitalist.org/details/article/1354283/the_earlier_the_better.html. PAGE 16 WHITEPAPER INTEGRATION CHANGES EVERYTHING

About the Authors Kirk B. Jensen, M.D., MBA, FACEP, Chief Medical Officer for BestPractices, Inc., is a leader in practice management, patient flow and clinical care. Author of numerous articles and three books, Leadership for Smooth Patient Flow (2007 ACHE Hamilton Award winner), Hardwiring Flow, and The Hospital Executive s Guide to Emergency Department Management, coach and mentor for E.D. s across the country, and acclaimed speaker, Dr. Jensen has twice been honored as the American College of Emergency Physicians (ACEP) Speaker of the Year. Dr. Jensen served on the expert panel and site examination team of Urgent Matters, a Robert Wood Johnson Foundation initiative focusing on elimination of E.D. crowding and preservation of the healthcare safety net. Faculty member of the ACEP management academy and The Studer Group, chair and faculty member for the Institute for Healthcare Improvement (IHI), writer and presenter for HealthLeaders Media, Dr. Jensen shares expertise on patient safety, patient flow, operational strategies, error reduction, and change management. Dr. Jensen holds a Bachelor s Degree in biology from the University of Illinois (Champaign) and a Medical Degree from the University of Illinois (Chicago). He completed a residency in Emergency Medicine at the University of Chicago and an MBA at the University of Tennessee. Nathan Goldfein, M.D., is Vice President of Operations with EmCare Hospital Medicine and the director of the Hospital Medicine program at Gerald Champion Regional Medical Center in Alamogordo, N.M. Dr. Goldfein graduated from the University of Arizona College of Medicine in 2005 and finished his residency in internal / hospital medicine at the University of New Mexico in 2008. His undergraduate degree is in mechanical engineering and manufacturing. Prior to pursuing medical school, Dr. Goldfein worked in manufacturing, experience which provides him an exceptional understanding of how to mix business, technology and medicine to create the best experiences and outcomes for patients while improving process efficiency and physician satisfaction. He holds more than eight patents and is the inventor of more than 100 additional products and programs. Additionally, he is the architect of EmCare s revolutionary Rapid Admission Process and Gap Orders, or RAP&GO, evidence-based software. RAP&GO is designed to improve communication between E.D. physicians and hospitalists, expedite inpatient admissions and reduce E.D. boarding time and lengths of stay. Mark Hamm, MBA was appointed EmCare Hospital Medicine s Chief Executive Officer in 2010. He has expertise in emergency medicine as well as an extensive background in the management of hospitalist programs, including developing and executing strategic plans, day-to-day operations and practice growth. He is the creator and architect behind EmCare s pioneering Door-To-Discharge integrated E.D. and hospitalist service which is reinventing the way hospital medicine is delivered in the United States by improving physician-to-physician communication, helping hospitals improve hospital-wide patient flow and decrease E.D. boarding times and lengths of stay for patients in both E.D. and inpatient settings, and improving physician, staff and patient satisfaction. Mr. Hamm has contributed to a number of articles on the subjects of decreasing boarding time and improving the patient care path from the E.D. to the inpatient floor. He is quoted in numerous journals on the topic of blending the objectives of the two hospital-based specialties, and he has presented the concept at many lectures and meetings, including presenting to over 2,000 participants at the Studer Group s annual event, What s Right In Healthcare. Prior to joining EmCare, Mr. Hamm served as Chief Operating Officer / Vice President of Hospital Medicine and Emergency Physician Operations at HCA Physician Services. He has also served as a Senior Vice President of Operations over TeamHealth s Hospital Medicine and Emergency Medicine Divisions. Mr. Hamm earned a bachelor s degree in Finance from the University of Memphis, and an MBA in Healthcare Management and Strategic Marketing from the University of Tennessee. To schedule an interview or appearance of any of the authors, contact: Jennifer Whitus, Marketing Communications Manager jennifer.whitus@emcare.com 214.712.2793 To learn more about Door-To-Discharge and other EmCare services visit us at www.emcare.com or call 877.416.8079. WHITEPAPER INTEGRATION CHANGES EVERYTHING PAGE 17

877.416.8079 www.emcare.com Local Practice. Divisional Support. National Resources. Integrated Services: Emergency Medicine Hospital Medicine Acute Care Surgery Anesthesiology Radiology / Teleradiology EmCare is an Envision Healthcare company. Mission Statement: EmCare exists to serve and support physicians, hospitals, health systems and other health care clients in providing high quality patient care efficiently and affordably. Mission Statement: EmCare exists to serve and support physicians, hospitals, health systems and other health care clients in providing high quality patient care efficiently and affordably. Vision Statement: EmCare s vision is to create a new, integrated model of physician services through: The Science of Clinical Excellence The Art of Customer Service The Business of Execution This requires several strategic imperatives: Medical Leadership Service Excellence Hardwiring Flow Evidence-Based Patient Safety Protocols Teamwork WHITEPAPER INTEGRATION CHANGES EVERYTHING 02/2014 EmCare, Inc. All rights reserved.