Over the last 50 years, emergency departments (EDs) have become the hub of acute care, with relentless increases in patient volumes and unprecedented access to high level diagnostic technology and hospital resources, with the majority of patient visits paid by public funds. EDs have evolved in a relatively short time to become the de facto site for acute, unscheduled care. The development of data sources and record-keeping has struggled to keep pace, with a resulting gap in the ability of policymakers and payors to structure surveillance methods, measure quality, and determine fiscal effectiveness.

There are two sources of national data on ED visits. The Nationwide Emergency Department Sample (NEDS), performed by the Agency for Healthcare Research and Quality (AHRQ), is a portion of the Healthcare Cost and Utilization Project (HCUP). NEDS data is available from 2006 through 2020. The 2020 NEDS database year includes discharge data for ED visits from 995 hospitals located in 40 states and the District of Columbia, approximating a 20-percent stratified sample of U.S. hospital-owned EDs.

The other source is the Center for Disease Control and Prevention’s (CDC’s) National Center for Health Statistics (NCHS), which has conducted and released data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) since 1992. The ED component of the National Ambulatory Medical Care Survey (NHAMCS) has been a nationally representative survey of nonfederal, general, and short-stay hospitals that is conducted annually. NHAMCS uses a multistage probability design with samples of geographic primary sampling units (PSUs), hospitals within PSUs, and patient visits within EDs. The latest NHAMCS ED survey report is from 2020 and consists of 26 data tables that were constructed from NAHMCS data. The survey is based on a sampling of 14,860 ED patient case reports from 294 emergency departments.

Major Changes to Come: ACEP Working for You

The CDC’s NCHS announced plans to update their ED data collection in coming years with the expansion of its NHCS, which collects ED data from a national sample of hospitals through the submission of UB-04 claims and EHR encounters for the entire calendar year. This is a change which reflects the importance of ED data. It has become even more important in following pandemic effects on ED visits, and creating dashboards that continue to track troubling impacts of infectious diseases, mental health care gaps, and increasing health care implications of substance use.

ACEP has been a driver of this change. ACEP has strongly supported the efforts of the CDC for the timely collection, analysis, and reporting of NHAMCS data, which supports emergency physicians and the changing practice of emergency medicine. The ACEP Qualified Clinical Data Registry—Clinical Emergency Data Registry (CEDR)—was launched in 2015 and has built secure data pipelines to a large nationwide network of EDs. The network has compiled structured and blinded data on more than 100 million ED visits and has become the primary submission source of standardized ED patient care data to the NCHS. The CDC has realized the efficiency and quality of this data source, and has begun to use this as a supplemental data source for their NHCS.

The NHAMCS ED component has been the national source of data on ED visit demographics, reason for visit, diagnostic or screening services, procedures, medication therapy, type of clinicians seen, diagnoses, and expected sources of payment. These data support trend analyses and are used to support national health care strategies, track gaps in health care delivery, and drive policies developed by the Centers for Medicare & Medicaid Services (CMS). For over 28 years, the survey clearly has tracked increasing use by vulnerable populations and socioeconomic barriers to the use of other sources of health care. Groups that have had significant increase in the use of emergency services include persons of color, Medicare and Medicaid beneficiaries, residents of the South and West, and women.

Despite incredible work in adapting to increased volumes and acuities, payers have exploited opportunities to discredit emergency physicians and other health care practitioners and reduce reimbursement for emergency care. This year alone, emergency medicine and emergency physicians are facing major practice challenges related to decreasing reimbursement, with the implementation of the No Surprises Act (NSA). Emergency physicians are working to develop models for value-based purchasing, including the Merit-based Incentive Payment System (MIPS) and MIPS Value Pathways (MVP). There are also major coding and documentation guideline changes to ED evaluation and management services. Further, emergency physicians have had very inconsistent guidance on the application and reimbursement of telehealth in emergency care.

There must be a timely, reliable, and effective source of data for researchers, planners, and policymakers for the critical issues facing emergency medicine. NCHS has recognized that data in CEDR and other data collected by ACEP can be used as an important supplementary data source for their NHCS. ACEP members will recognize this as a huge testimonial to the College and will find value in how it ultimately supports bedside practice. As patients become older, sicker, and burdened by more chronic diseases, emergency physicians have been adaptable in using a broader range of diagnostics and treatments to deliver quality care. As mental health patients and those suffering ill effects of substance use have crowded into EDs, new strategies have evolved to guide care and increase the community application of out-of-hospital resources. And, emergency physicians have been extraordinarily resourceful in finding and sharing best practice information as COVID abruptly impacted communities.

The amalgamation of CDC and ACEP resources reflects the exciting transformation of CEDR into the Emergency Medicine Data Institute (EMDI). The Institute will offer insights for clinicians, researchers, and the administrators who oversee ED resources.

What are the early impact areas of the Institute collaboration?

Practice Trends: Aging ED population and other demographic drifts
Surveillance: Only possible with NCHS and state/regional data source collaboration
Quality Improvement: Adherence to quality measures, clinical protocols, and best practices across sites and over time
Clinical Decision Support: For use of diagnostics, and treatment modalities, with bedside development and application
Linkages to other Datasets: Including data registries for time-sensitive conditions

This is a dramatic opportunity for improving the future of emergency medicine by the application of digital tools, and the 160 million ED patients who are served each year.

Dr. Augustine is national director of prehospital strategy for US Acute Care Solutions based in Canton, Ohio; clinical professor of emergency medicine at Wright State University in Dayton, Ohio; and vice president of the Emergency Department Benchmarking Alliance.