Integration Changes Everything: Communication, Collaboration, Patient Flow, Patient Perception of Care and the Bottom Line

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

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Page 2 | WHITEPAPER | integration Changes Everything

TABLE OF CONTENTS
WHITEPAPER | integration Changes Everything | Page 3
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
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.
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.
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.

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).

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.
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 long-
term acute care hospitals, rehab facilities and/or nursing homes. As many full-
service 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.
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 patient-
centered 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

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.
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
The patient suffers most,
being caught in the middle
of the conflict between the
two physicians.

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.
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, re-
evaluating, 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).
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.
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.
E.D. Interests
Hospitalist Interests
Value

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.
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,
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

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
• 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 value-
based 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
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

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.
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.
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 structurally-
integrated 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.

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.
“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.
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.

WhitePaPer | inteGration ChanGes everythinG | Page 13
• 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 agreed-
upon 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:
• 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.
650 patients
x 125 minutes (reduction in time patient spends in e.D.)
1,354 Freed E.D. Bed Hours
Combined data for four facilities, achieved in a
30-day time period.
D2D Dashboards
after implementing D2D, e.D. volume
grew while lWBs declined.
E.D. VOLUME
700,000
730,000
760,000
790,000
820,000
850,000
% LWBS
0.0%
0.4%
0.8%
1.2%
1.6%
2.0%
2011 2012 2013RAP&GO DISPOSITION
TO FLOOR TIME
0 MIN.
50 MIN.
100 MIN.
150 MIN.
200 MIN.
BEFORE
RAP&GO
AFTER
RAP&GO
250 MIN.

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.
“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.
Hospital administration
also experiences benefits
from integration of
emergency and hospital
medicine practices.

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
* 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 patient-
centered 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
Integration changes
everything: communication,
collaboration, patient flow,
patient perception of care
and the bottom line.

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.
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.
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

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.

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
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.
WHITEPAPER | INTEGRATION CHANGES EVERYTHING © 02/2014 EmCare, Inc. – All rights reserved.

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