Robert M. Bramante, MD FACEP CHCQM
Chairman, Emergency Medicine
Mercy Hospital
Progressive Emergency Physicians

Collaboration to Improve Asthma Care- ASMT Program Development 

The evaluation and management of acute asthma exacerbations is “bread and butter” for the Emergency Department. Over 25 million patients affected in the United States alone accounting for around 1.5 million of our ED patients. During a busy ED shift it is easy to overlook the true cost and societal impact of these exacerbations while evaluating and treating the acute issue. With increased mortality in the minority population, asthma management intersects clinical, environmental, and social issues. Asthma Self-Management Training (ASMT) programs have been presented, and the benefit has been established, in the literature. However, a key challenge existed which was funding these resources. Through a collaborative approach utilizing best practices, coordination between the ED and philanthropic support a valuable patient resource was developed at our site and demonstrated post support sustainability.  

While the acute management of emergent conditions is the obvious mission in the ED, throughout our specialty we have efforts and programs to address medical conditions and societal challenges to improve longitudinal patient care and help patients avoid acute exacerbations of controllable issues and in turn reduce their need for ED care, hospitalization, and missed life experiences. At our site the respiratory therapy department recognized the need for improving post hospital asthma care. The ASMT model was the goal and collaboration occurred with ED leadership. Using the population who presented to the ED put a focus on those individuals who had uncontrolled symptoms and often did not have adequate outside care, follow up, or resources.  

The program was initially developed and funded via a grant to support staffing, equipment, and to provide patients with management devices (peak flow, spacers). A discharge referral order was developed for medical staff to use and expanded beyond the ED and observation units to include inpatient discharges and on campus clinic visits. This order provided information for the patient regarding follow up on the after-visit summary document, but the order completed a more important role for patient engagement. The order drove a worklist for the ASMT staff to contact, and coordinate follow up with patients referred to increased engagement and follow through. Concurrently, while these background, initial funding, and IT tasks were being completed, the respiratory therapy team and ED leadership put on a staff education and engagement initiative. This included lunch and learn sessions, committee meeting presentations, staff huddle discussions, and email communications to socialize the program. The education and information initiatives focused on 2 key items, identification of patients (in this case any patient with an asthma diagnosis was eligible for referral) and the simplicity of placing a 4-letter discharge order for “ASMT.” While education, IT development, referral, and billing infrastructure were in development, the program, from the outset was done with a post grant sustainability mindset, which will allow for the continuation of the program post external funding. The processes put in place were tracked through the initial grant period to demonstrate the program could be financially sustained. 

Appointments were scheduled in a dedicated cadence calendar with two visit types. Intake visits were 60 minutes and follow up visits were 30 minutes. During visits asthma educators administered asthma knowledge assessments, education and teach back, development of written personalized asthma action plans (this utilized the traffic light symptom recognition model), and supply of and education on treatment devices including spacers and peak flow meters. On subsequent visits, an ongoing knowledge assessment was completed, action plans adjusted, and for those where control was poor, but technique was good, the educators flagged the case for provider review to coordinate care.  

These interventions led to improvements in asthma management for patients. Decreases in the following measures affecting healthcare quality of life were noted. Reduced urgent care visits, missed school/ workdays, ED visits (the decrease we experienced in ED visits in the ASMT population outpaced current published reviews), hospitalizations, refills on quick relief medications, and a reduction in episodes of systemic steroid use. A minimal number of patients in the program had a spacer and none had a peak flow device or written action plan. All patients enrolled had all three items post training. Perhaps most importantly was a nearly thirty-point increase in asthma knowledge scores for patients after intervention. This knowledge empowers patients to self-manage their disease process.  

While not an ED process, the development and success highlight a program that can be viable across facilities with collaboration and engagement between disciplines. Most importantly, the ED is where patients with poorly controlled or even controlled asthma with acute exacerbation interface with the healthcare system. This point of contact and engagement of the ED is instrumental in starting these referrals to empower patients and improve care. These collaborations allow for the scope of EM to extend beyond the acute events to improving life for patient populations.

Kirby Black, MD FACEP
Director of Emergency Medicine
Oneida Health Hospital

Aron Goldfeld, JD
Vice President of Advocacy and Regulatory Affairs
TeamHealth

IDR Introduction for the Emergency Physician 

Governor Hochul’s budget recently included a provision to exempt managed Medicaid insurance from the IDR. This was one of the topics that NYACEP representatives spoke to during our lobby day in February 2026. In doing so, we as a group realized…we do not know very much about the IDR. This article is an attempt to start with the basics. In attempting to learn I contacted and collaborated for this article with Aron Goldfeld, JD – Vice President of Advocacy and Regulatory Affairs with TeamHealth.  

I felt like I had a handle on how the IDR worked. What I really learned was that I understood the basics of the Federal Program, whereas there is an entirely separate NY State program.  

Definition:  

• IDR – independent dispute resolution is the process of mediating a payment dispute between a healthcare entity and an insurer. The 2022 No Surprises Act created a federal mechanism, but New York State was already ahead of the curve with the IDRE (E for entity). 

The federal program, known as the No Surprises Act or “NSA” started in 2022 whereas NYS’ program started in 2014. Both programs prevent balance billing for out-of-network emergency services, and out of network bills rendered by out-of-network providers rendering services at in-network facilities. The intent and effect of the laws are to remove patients from payment disputes between insurers and providers. NYS has a specific element preventing surprise billing due to a referral from an in-network provider to an out-of-network provider. Several elements differ between NY and the Federal program.  

Payment methodology 

Under the NYS program, the 80th percentile of FairHealth is the benchmark value used as the “Usual and Customary Cost” for determining reimbursement. This year’s enacted state budget, however, adjusted the benchmark specifically for Empire Plans (New York State Health Insurance Plans provided to state employees), thus making NYS’s IDR framework fully applicable to the Empire Plans. Further, it modified the 2014 law by creating two benchmarks based on the FAIR Health Data: the 50th percentile (Allowed Benchmark and the 80th percentile (Maximum Fee) of all allowed amounts for the service by participating providers in the same or similar specialty and geographic area. The IDR entity under the NYS program involving Empire Plans must select whichever amount — the plan’s payment or provider’s fee — that is closest to the Allowed Benchmark. However, even if the IDR entity chooses the Provider’s fee, the plan is not required to pay above the Maximum Fee. (This was an advocacy loss for our contingency in Albany). 

The Federal arbitration process in accordance with the NSA is based on the QPA (Qualifying Payment Amount) which is based on the median contracted in-network rate anchored to 2019, with inflation adjustments based on the Consumer Price Index. Several of the regulations issued over the last several years by the federal agencies with jurisdiction over the NSA have been challenged extensively through litigation challenging several aspects of the rule-making that was inconsistent with the NSA’s statutory language. Provider groups have been highly successful in these lawsuits, known commonly as the “TMA Actions.” The rulings by the courts ensured that the NSA’s criterion by which the IDREs would deploy their evaluation of disputed claims would be balanced and fair, the administrative fees would be cost-effective and the QPA would be determined by health plans would be accurately calculated. The latter continues to remain in litigation pending a ruling by the 5th Circuit Court of Appeals.  

Arbitration 

• Both programs use “baseball” arbitration 

The insurer submits one payment amount; the healthcare provider submits one payment amount. The arbitrator must choose one of the two submitted amounts. In NY State, the case volume is much lower as it is restricted to fully insured health plans written, regulated and licensed in NY. Whereas federally the case volume is much higher resulting in far higher volumes than the regulators anticipated. 

Usage

Emergency Medicine and Radiology lead the way each with about 1/3 of the cases for IDR, whereas all other specialties combine for the last 1/3. There have been an estimated 3.3 million cases in the first 3 years of federal arbitration (Mid 2022-Mid 2025), with emergency medicine at an estimated 1.15 million disputes.  

This is due to the nature of the No Surprises Act applying to Emergency Care (and by extension emergent Radiology imaging), generally reflective of the fact that health plans are averse to offering emergency providers fair, market-based rates, choosing instead to leverage the EMTALA obligation imposed on emergency providers that we must see the patient regardless.  

For NYS, the estimate is that less than 8% of emergency department visits by a commercially insured patient are out of network, which represents ~2-4% of total encounters.  

How this affects Emergency Physicians

Advocacy for fair and sustained reimbursement remains a pivotal priority for ACEP, NYACEP and all provider groups participating in Emergency Medicine. Unfortunately, the budget provision this year has potentially weakened NYS’s IDR program. If any member feels that their practice has seen negative effects, we urge you to report this to us so we can continue to advocate. 

Laura Melville, MD MS
Assistant Professor of Emergency Medicine, Weill Cornell Medical College
Associate Research Director and SAFE Medical Director
Department of Emergency Medicine
NewYork-Presbyterian Brooklyn Methodist Hospital
Chair, New York ACEP Research Committee

Amanda Schorr, MD 
Emergency Medicine PGY-1 
Department of Emergency Medicine 
NewYork-Presbyterian Brooklyn Methodist Hospital 

For many emergency physicians, the evaluation of early pregnancy loss (EPL) once followed a familiar pathway: confirm an intrauterine pregnancy, exclude ectopic pregnancy or another emergent condition, provide symptomatic treatment, and arrange obstetric consultation or outpatient follow-up. Definitive management was often deferred to obstetric or family medicine colleagues. Yet early pregnancy loss accounts for approximately 900,000 emergency department visits annually in the United States, and continued reductions in access to obstetric care have increased the likelihood that patients will rely on emergency physicians not only for diagnosis, but also for counseling and treatment.¹ 

This evolution has been driven by important advances in the evidence and by patients’ need for more timely access to care. Contemporary management of stable patients includes three evidence-supported options: expectant management, medication management, and uterine aspiration. Rather than identifying a single preferred treatment, current care emphasizes shared decision-making, allowing patients to choose among these approaches based on their clinical circumstances, preferences, and goals.^2-5 

As emergency physicians have assumed a broader role in EPL management, the education of residents and practicing physicians must keep pace. Formal training in medication management, manual uterine aspiration (MUA), and patient counseling has varied considerably across residency programs and practice settings. Recognizing this need, ACEP developed its Medical Focus section on Early Pregnancy Loss, centered on the Miscarriage Management Toolkit—a curated collection of clinical protocols, medication guidance, procedural instruction, videos, patient education materials, implementation resources, and key references developed specifically for emergency physicians. Throughout this article, we refer to these educational resources collectively as the Toolkit. Readers can access the Toolkit through the ACEP Medical Focus section on Early Pregnancy Loss. 

The Toolkit reflects more than two decades of advances in clinical research, education, and multidisciplinary collaboration. Studies of expectant management demonstrated that many patients with uncomplicated EPL can be managed safely without immediate intervention.³ The National Institute of Child Health and Human Development Management of Early Pregnancy Failure Trial established vaginal misoprostol as an effective alternative to uterine aspiration for many patients.⁴ More recently, Schreiber and colleagues demonstrated that pretreatment with mifepristone significantly improves treatment success while reducing the need for subsequent uterine aspiration compared with misoprostol alone.⁵ Together, these studies shifted miscarriage care away from a single treatment pathway and toward individualized, patient-centered management. 

Scientific evidence alone rarely changes clinical practice. Clinicians also need practical educational resources, opportunities to develop new skills, and institutional support. Interprofessional educational interventions have been shown to change clinical practice in emergency departments, highlighting the importance of implementation alongside scientific discovery.⁶ The advances reflected in the Toolkit are the product of collaboration among emergency physicians, obstetrician-gynecologists, family physicians, educators, and patients whose experiences have shaped modern miscarriage care. Organizations including TEAMM, Access Bridge, the Reproductive Health Access Project, TEACH, FeminEM, and Innovating Education at the University of California, San Francisco have all contributed educational materials that have advanced education in this field. Rather than recreating these efforts, the Toolkit curates them into a single emergency medicine-focused resource for bedside care, residency education, and departmental implementation. 

The Toolkit illustrates an important principle in emergency medicine: advances in patient care depend not only on new evidence, but also on making that evidence practical, accessible, and teachable. The Toolkit also reflects years of engagement within ACEP. In 2022, the ACEP Council adopted Resolution 26, Promoting Safe Reproductive Health Care for Patients, encouraging expanded education and evidence-based resources for clinicians caring for patients with miscarriage and other reproductive health emergencies. Subsequent Council actions continued to reinforce reproductive healthcare education within emergency medicine. Together, these efforts demonstrate how member advocacy, collaboration, and professional leadership can translate emerging evidence into practical educational resources. 

Beyond its educational content, the Toolkit reinforces that comprehensive management of uncomplicated early pregnancy loss falls within the evolving scope of emergency medicine practice. Whether used as a point-of-care reference by an individual clinician, as a curriculum for residency education, or as the foundation for departmental protocols, these resources lower barriers to incorporating contemporary miscarriage management into routine emergency care. For physicians practicing in settings without immediate obstetric consultation, the Toolkit provides practical guidance for delivering timely, evidence-informed, patient-centered care while working within local policies, credentialing processes, and available resources. 

The history of early pregnancy loss management illustrates that improving patient care requires more than scientific discovery. It requires education, collaboration, implementation, and continued evaluation of both clinician practice and patient experience. The ACEP Miscarriage Management Toolkit represents an important step in translating evidence into emergency medicine practice, but its greatest impact will depend on thoughtful implementation across diverse practice environments. Future research should evaluate how these resources influence care in community hospitals, academic centers, and emergency departments without immediate obstetric support. Equally important is continued investigation of patients’ experiences with emergency department miscarriage care, including communication, shared decision-making, timely access to treatment, and overall experience of care.⁷ As emergency physicians continue to expand their role in managing early pregnancy loss, these patient-centered outcomes should remain the ultimate measure of success. 

Further Resources 

ACEP Medical Focus: Early Pregnancy Loss
https://www.acep.org/by-medical-focus/early-pregnancy-loss 

FeminEM
https://feminem.org 

Access Bridge
https://www.accessbridge.org 

Sophia Lin, MD FPD-AEMUS FACEP
Assistant Professor of Clinical Emergency Medicine and Clinical Pediatrics
Director of Emergency Ultrasound
Department of Emergency Medicine
Weill Cornell Medicine

Courtney Chiu, MD 
New York ACEP 2026 ACE 
Medical Education Fellow 
Department of Emergency Medicine 
Maimonides Medical Center 
 

The Art of Observation in Emergency Medicine  

Imagine standing in an art museum, pausing in front of a painting that catches your eye. Your gaze moves across the canvas, and you observe the way the controlled brush strokes mingle amongst each other. You admire the way the composition draws your eyes to the central characters, elevating them with subtle authority. You notice the rich details of the sumptuous clothing and you begin getting a sense of who these figures are. This act of observation is not unique to art. This exercise in visual thinking is very similar to what emergency medicine physicians do with every patient encounter. Before we say a single word to a patient, we observe. We notice their work of breathing and if they appear lethargic or in distress. We draw conclusions based on this visual information, which informs our practice. Diagnostic accuracy often depends on a clinician’s ability to see, not just look.  

Visual thinking and observation are important skills in clinical practice, yet they are not taught formally within the medical curriculum. ^1,2 Encouraging medical trainees to apply skills developed in the art gallery to the clinical setting provides them with perspectives they would not otherwise have with traditional medical training alone.³ Observation in turn plays a key role in developing communication skills. The ability to precisely and accurately articulate visual observations is a critical skill for learners.⁴ When art-based programs are incorporated into medical training, they positively influence development of professionalism and interpersonal/communication skills, which are ACGME core competencies.⁵ Additionally, arts-based pedagogical methods are important in supporting medical trainees in their development of empathy and tolerance of ambiguity, as well as observation and communication skills.⁶  

Employing visual thinking strategies (VTS) is more than simply asking viewers of a painting, “What’s going on?” VTS is a structured, systematic way of guiding learners through their cognitive thought processes when examining visual art.⁶ The questioning is almost Socratic, and learners are prompted to reason through their thoughts with unbiased observation. Learners are asked questions including “What do you see?” and “What do you see that makes you say that?”⁶ When faced with these questions, learners are prompted to support their statements with visual evidence and see perspectives different from their own. 

VTS also encourages learners to build their metacognitive awareness. When asked “What do you see that makes you say that?” learners are guided to better understand their own initial biases and interpretations.⁶ They gain a deeper understanding of how they examine the world and develop conclusions. Jumping to conclusions and having preconceived biases are common human cognitive errors that can manifest in clinical practice.⁷ Arts-based educational methods help learners understand their metacognitions. With this understanding, learners are then able to improve their clinical reasoning skills and mitigate their biases. 

In a busy emergency department, careful observation can be overshadowed by cognitive shortcuts and time constraints, impeding development of metacognitive awareness and other skills important to clinical practice. In contrast, art museums provide a unique space to slow down, observe, reflect, and practice visual thinking in a low-stakes, psychologically safe environment. By fostering observation, curiosity, and reflection, this approach not only supports acquisition of clinical skills but also offers a meaningful counterbalance to the cognitive and emotional demands of emergency medicine. As emergency medicine is consistently ranked among the highest-risk specialties for burnout, art-based programs may fill an important need for innovative approaches that support both clinical and reflective practice.  

As the value of arts-based education has become increasingly appreciated, the number of institutions offering art-based interventions to its medical trainees has grown. These interventions include tracks, workshops, and electives. The learning goals and objectives differ depending on the institution’s needs. Some programs focus on observation skills, while others aim to support empathy development and wellbeing. An example of an art-based intervention is The University of Texas Southwestern Medical School’s Art of Observation course, an optional elective taught primarily at the Dallas Museum of Art. After participation in this course, students reported enhanced observation skills, improved physician socialization, and reduced burnout symptoms.⁸ Another example of an art observation course is Harvard Medical School’s Training the Eye: Improving the Art of Physical Diagnosis course, a preclinical elective teaching visual literacy at the Boston Museum of Fine Arts. After the course, students’ mean number of observations on a visual skills exam increased and the sophistication of their descriptions of artistic and clinical imagery improved.² 

At the emergency medicine residency program at Maimonides Medical Center in Brooklyn, we created a curriculum for an optional VTS workshop for our residents, utilizing Kern’s six steps for curriculum development. On our needs assessment, we found that there was a need for structured training in visual thinking and observation skills, as well as a humanities-based learning experience outside of the hospital. We hosted our first session in 2024 at the Brooklyn Museum where we dedicated one hour to analyzing a Kehinde Wiley painting (Figures 1). I was trained in VTS as an Art History major in college and through art gallery work and co-led this workshop with the residency’s humanities scholarly track leader. Feedback for the workshop was very positive. One participant wrote, “Thank you for broadening our minds and turning our attention inward and slowing us down to see the more important and subtle things in art and medicine.” Given the importance of arts-based education in medical training and the need for this in our residency, we plan to iterate our initial effort and continue to offer this workshop to our residents. 

Figure 1: Maimonides Emergency Medicine residents participate in a VTS workshop analyzing a Kehinde Wiley painting.

Maria Tama, MD
Assistant Professor of Pediatrics in Emergency Medicine
Zucker School of Medicine at Hofstra/Northwell
Director, Division of Emergency Ultrasound
Staten Island University Hospital- Northwell Health

Michael P Johnson, MD
Senior Instructor of Pediatric Emergency Medicine
University of Rochester Medical Center