An urgent revolution

Urgent-care clinics are keeping many patients out of hospital emergency rooms.

Nahariya Hospital 224.88 (photo credit: Ariel Jerozolimski)
Nahariya Hospital 224.88
(photo credit: Ariel Jerozolimski)
Although the country's hospital system gets the lion's share of health budgets, the most important mission in public health is trying to prevent as many people as possible from ever reaching a hospital. One way is preventing chronic disease with healthful lifestyles such as avoiding tobacco, eating nutritious food and exercising regularly, while another is preventing injuries at home, outdoors and on the road. The third way of minimizing visits to emergency rooms is to take care of everything from fevers and infections to broken bones at walk-in urgent-care facilities in the community. The Israeli pioneer of this concept was the late Dr. David Applebaum, who after working as medical director of Magen David Adom's intensive-care ambulance service, opened his first TEREM (Tipul Refu'i Miyadi or immediate medical care) clinic in February 1990 at the rundown and money-losing MDA station at the western entrance to Jerusalem. I was there to report on the innovation, which replaced MDA's meager first-aid service, promising greater efficiency at no extra cost and modelled after the US model of urgent, private care centers. Staffed by specialists in urgent care, TEREM ( was committed to taking no more than an hour between arrival and release. Applebaum's motto was: No patient should go to hospital who can be managed outside. Little did I know when interviewing him that 13-and-a-half years later, the charismatic and energetic physician would be killed along with his daughter Na'ava in the suicide bombing at Cafe Hillel on the eve of her wedding. "Staff at hospital emergency rooms are always complaining that the majority of patients they see don't belong there," Applebaum told me at the opening. "[They say] that patients should have gone to their health fund clinics or family doctors' offices, but these were closed or the queue was too long. We can treat 85 percent of the patients who come to emergency rooms, and the hospitals can treat those who really need hospitalization." SINCE THEN, TEREM has grown to have urgent-care branches in Beit Shemesh, Ma'aleh Adumim, Modi'in and Jerusalem's Arnona quarter (Tayelet center), plus a family medicine clinic in the capital's Katamon district. The company is not ready yet to expand further, preferring to improve its existing facilities, which currently treat 170,000 customers a year. TEREM's chief executive officer is Beirut-born, Bangkok-raised, London-trained family medicine specialist Dr. Joseph (Joe) Djemal, who came on aliya in 1988 and got to know Applebaum at Shaare Zedek. The assistant medical director is Dr. Nahum Kovalski, who came from Canada, where he graduated from McGill University's medical school before doing a residency in surgery and urology and moving to Jerusalem, where he continued at Hadassah University Medical Center but then joined TEREM to return to his first love - acute-care medicine. The company organized its first conference for community physicians in Jerusalem (including Arabs from the eastern part) earlier this month. Held at the Regency Hotel on Mount Scopus, the all-day event was dedicated to "Urgent Care - A New Specialty Solves Old Problems" and attracted some 250 participants. DR. MICHAEL DOR, acting head of Health Ministry's medical branch, opened the event by denouncing the penny-pinching Treasury for attempting to freeze the discussion of constructing infrastructure for additional hospital beds until at least 2010 at a time when Israel's number of general hospital beds per 1,000 residents is among the lowest in the Western world. Dor noted that with the health system helpless in the face of severe budget restrictions, it can only encourage private entrepreneurs to try to prevent hospitalization. "High-quality centers like TEREM's should continue to grow in the community," said Dor. Dr. Brendon Stewart-Freedman, a Hebrew University Medical Faculty family physician and director of the Tayelet branch, said the "doctor in the box" concept in the US in the 1980s - of any available physician giving treatment to the next patient in an urgent care clinic - was a failure. It was replaced by having free-standing, walk-in urgent-care centers with specialists trained to perform minor surgery, diagnose and rule out heart attacks and strokes, cope with unwell babies and pregnant women set broken limbs in casts and deal with acute infections. This is the TEREM model. "The conditions are usually not life threatening, but patients feel it can't wait for the health-fund clinic. "Hospital emergency rooms are places of stress and crowding, and they give priority to mild-to-moderately-sick patients. Somebody who has a broken leg waits on the side while doctors try to save the life of a heart-attack victim. Family medicine practices are usually packed, have limited hours and technology and rarely offer house calls." Today, said Brendon-Stewart, there are between 12,000 and 15,000 urgent-care clinics in the US alone, and private health insurance companies subsidize the costs. He noted that more Americans go to urgent-care clinics than to hospital emergency rooms, which have to have a gamut of specialists on duty at once. Urgent-care physicians need special skills "because they get different patients from those in emergency rooms." Only seven percent of TEREM's patients have to be referred to a hospital, and half of those are placed in a ward. Because primary-care general practitioners have usually been kept in the dark when their patients go to an urgent-care clinic, TEREM introduced "Rofeh Amit" (ROAM), in which its computers automatically inform practitioners by e-mail when their patient has been treated. "We have 100 GPs and family doctors registered so far," said Stewart-Freedman, "and we send 350 files (containing medical reports, lab results, diagnoses and X-rays) by e-mail overnight each month. ROAM doctors can go into TEREM's Web site at any time and see the status of their patients. It's a very inexpensive and efficient system that turns primary physicians into members of a medical management team. There have been excellent reactions to it in the community." TEREM's digital X-rays also make it possible to send images of a complicated condition to an outside radiologist or orthopedist for consultation. Kovalski discussed the issue of uniform digital medical files, which would greatly simplify the treatment of patients in both urgent-care centers and hospitals and provide urgent medical information such as allergies to antibiotics or previous X-rays and medical charts. "Medical systems in the UK and Canada are investing a fortune in these, but there is much resistance among some doctors and patients, and there is still a way to go before we get it here, as there are technical and privacy issues." The need for GPs and specialists to enter data into computer files annoys many of them, because they have less time for actually speaking to patients, he said. And he cited the case of St. Mary's Hospital in Leonardtown, Maryland, from which a laptop computer with personal information on 130,0000 patients was stolen. Johns Hopkins University Hospital lost tens of thousands of patient and employee records. When US actor George Clooney (who played in ER), was injured in a motorcycle accident, more than 40 hospital employees who accessed his digital medical record leaked data to the press. The technique that offers the most privacy, said Kovalski, is patient-centered records, such as the Israeli LifeOnKey system, in which individuals have control over their data and can grant access to medical workers when and in the amount they wish. "We at TEREM endorse LifeOnKey. It will reduce pressure on emergency rooms and save many millions of shekels a year for health funds by forgoing tests and treatments already performed." Dr. Efy Halperin, head of the infectious disease unit at Jerusalem's Bikur Holim Hospital, warned about the growing resistance of bacteria to commonly used antibiotics. Broader-spectrum antibiotics can also kill harmless bacteria and lead to more resistance. "There are antibiotics that were effective against tuberculosis 50 years ago, but today, South Africans are dying of it because of the resistant strains, and the best oral drug against gonorrhea is losing its effectiveness. We expect the Health Ministry to educate the public better and lower expectations for antibiotics and lower their usage." Halperin noted that half of all antimicrobials go to animals to make them fatter, needlessly exposing those who eat them to antibiotics. TEREM pediatrician Dr. Deena Zimmerman reported that since many primary physicians are unprepared to treat emergencies in children and lack the necessary equipment, she has run pediatric advanced life support courses to promote quick diagnosis and appropriate treatment. Dr. Itai Shavit, head of the pediatric emergency department at Haifa's Rambam Medical Center, discussed the fascinating subject of pain in infants and children. "There have been giant changes in this field during the past decade. There are three myths: That babies don't feel pain, that they don't remember pain, and that pain builds character and is a natural part of life." Shavit said that neonates, including premature babies, feel pain; circumcision - for example - hurts. By 29 weeks of gestation, pain pathways are well developed in fetuses, as are neurological systems for the transmission and modulation of pain, he added. The amount of pain felt by babies can now be quantified by noting the power and frequency of crying, arm and leg movements, blinking of the eyes and skin folds on the face. A study published in The Lancet a decade ago which included an Israeli author had a major impact on changing minds about pain in babies. They studied the reaction of 87 children to the pain of vaccination four and six months after birth; half of them had been circumcised as neonates, and the others had not. The double-blind study showed that those who had experienced the pain of circumcision reacted more strongly to the shot. Even premature babies' heartbeats speed up when subjected to pain. They feel it. "The body has a pain memory," said Shavit. "The pain itself may not be consciously remembered, but the painful experience is. Anxiety increases the pain threshold, and fear makes pain greater. Pain is not character building; it is a negative experience, and all babies have the right to pain relief or sedation." Shavit showed a video of a young child undergoing a painful procedure but not even wincing while the doctor was working on her; she was being shown a cartoon that completely captured her attention. "Some of the medical care we gave in the past makes you ashamed. Today, minimizing pain doesn't take longer, but it's more humane and an ethical requirement."