We posted recently about a New America event on health care quality, but we wanted to highlight in more detail some of the points made by one of our speakers, Brent Asplin, MD, MPH. Dr. Asplin is the head of emergency medicine at Regions Hospital in St Paul. Minn, and he talked about what the quality challenges look like from the ER. He called the ER, "a room with a view," and noted, "If there's a problem with quality or access in your community, you will see it first in the ER." US ERs get about 115 million visits a year, he said. Behind that number are 115 million individual patient stories.

There's a common perception that the ER crisis is largely due to the uninsured who have no place else to go. There's an element of truth in that; the uninsured are a burden on the ER. But that's just one of many problems—lack of access to primary care, poor management of chronic disease, shrinking numbers of ER beds, and inefficient "flow," meaning if that beds aren't freed up efficiently in the rest of the hospital, patients needing admission pile up in the ER.

Some of this should be familiar to our readers by now. But one point Dr. Asplin stressed that was new to us was the shortage of psychiatric beds. I had seen this first hand when I visited hospitals in New Orleans after Katrina, but I hadn't realized it was reaching crisis proportions even in states like Minnesota, where health care overall is pretty good. After hearing Dr. Asplin discuss this, I tracked down a report by the American College of Emergency Physicians last June that found that psychiatric patients waiting twice as long as other patients. Often they are getting little or no psychiatric care while they wait. Our mental health infracture is too weak, and our ERs are too overwhelmed to fill in the gaps.

Dr. Asplin told us about a depressed, suicidal 72-year-old patient with multiple medical problems who was at the ER when Dr. Asplin arrived at 8:30 a.m. on a Saturday. He was still waiting for a bed at 4:30 that afternoon, when Dr. Aplin left. And he was still waiting when Dr. Asplin returned to work on Sunday. And on Tuesday. He ultimately spent 75 hours in the emergency department waiting for a psych bed. (Asplin remembers too that this occurred precisely as some Institute for Healthcare Improvement experts were at Regions that very day helping them address their patient flow problem...)

Dr. Asplin maintains that we can and should be able to improve emergency departments through some internal changes in hospitals—his own hospitals is already working on patient flow and related problems that lead to the crowding that concerns him every time he looks up at the board and sees how many patients are waiting for a hospital bed and how long they have been waiting. But the big fix for ERs nationally needs a big fix for the health care system as a whole—how we cover people, how we pay for care, how we treat patients. Dr. Asplin wishes we had health care counterpart to the NIH—a National Institute on Health Care Delivery. And he supports health reform proposals that change the payment and delivery systems, so that we pay for good care, not just lots of care, and can reward doctors who effectively manage high-cost patients. He's happy to see them in his ER when they belong there. But he'd rather that we have a health care system that keeps them healthy outside of the hospital, outside the ER, when they don't.