Nestled in Parkland’s emergency department is a nondescript, cubicle-filled room. TVs displaying live video feed of the hospital entrances line the wall alongside what appears to be a giant spreadsheet of hospital names. Only the sight of an occasional medic grabbing Cheetos from a communal snack bowl hint the scene is in one of the country’s busiest hospital systems.

But then, a paramedic sitting at one of the cubicles is alerted by a sound from his headset, pulling him to his screen mid-sentence. The 20-year fire department veteran has just received the spiky mountain range of an EKG image, sent live from the back of an ambulance somewhere in Dallas County.

The image could indicate a heart attack, but he would need to pull in an emergency physician from across the hall to be sure. He murmurs a question to EMS over his headset before turning to the spreadsheet on one of the giant TVs to route the ambulance to a hospital listed in green, not the red or black fonts indicating an emergency room department is full.

On one end of that call, a patient in crisis and first responders struggling to save a life.

On the other, the full force of Parkland Memorial Hospital waiting to consult and coordinate.

Many of us are newly aware of Parkland for its gleaming (if boxy) new addition to Dallas’ skyline, but since its founding in 1872 the hospital has played a consistent supporting role in the community with a focus on providing care for indigent patients. "Parkland" actually refers to a network of its main memorial hospital and its many partners and subsidiaries, and its services are still primarily targeted toward the approximately 1 million people in Dallas County who are uninsured or qualify for Medicaid.

But even those Dallas residents who have more comfortable, private medical options are part of a health care system challenged by high uninsured rates and increasing utilization. Parkland’s sheer size, coupled with its inherent community focus, necessitate speed and efficiency in a way that is reshaping what all of us can expect from our health care system.

The hospital and its supporting health system have had challenges. Reports of patient abuse prompted regulatory scrutiny in 2011, and ongoing funding pressures continue to add levels of complexity to the already daunting task of providing quality care at low cost. But as patient safety improves and small funding respites offer space for limited growth, Parkland is continuing to turn its sights outward to serving its target population with evidence-based approaches.

Understanding the Parkland health system — and what makes it tick — is a crash course in health care's changing landscape and the importance of working on the scalpel’s edge of health delivery.

Scaling efficiency

Medical emergencies can be a great equalizer — rich or poor, you call 911 when you have a heart attack. And as Dallas County’s largest public, taxpayer-funded hospital, Parkland is the natural home for the paramedics behind millions of emergency response calls. In this way, our county hospital serves everyone, regardless of whether you ever step through the doors.

The BioTel office, with its TV monitors and Cheeto snack bowl, exemplifies Parkland’s leadership in meeting a community demand with the efficiencies of new technologies. When minutes matter, this pairing of scale and skill has immediate lifesaving implications.

Known as “the hidden heart of EMS,” BioTel is an emergency response group housed within Parkland, coordinating care for emergency patients. The work begins when paramedics somewhere in North Texas answer a 911 call, and ends when BioTel has found an available bed in one of the county’s more than a dozen hospital emergency rooms — a home for that patient’s care.

1 / 2Registered nurse Catherine Knapp, a BioTel emergency medical service specialist, works at Parkland Hospital in Dallas on Monday, July 2. (Jae S. Lee / Staff Photographer) 2 / 2Push pins mark locations of hospitals and fire stations in Dallas County inside a BioTel office at Parkland Hospital in Dallas, Monday, July 2. The office coordinates responses to medical emergencies all over the metro area.(Jae S. Lee / Staff Photographer)

The full-time nurse and paramedics who staff BioTel draw from their own experience and knowledge to offer counsel or else use the resources of Parkland’s bustling emergency room right outside the BioTel door. Because BioTel works with 14 departments within Dallas County, more than a dozen cities in North Texas directly benefit from Parkland’s expertise.

A gunshot victim can bleed out in less than three minutes, and a heart attack victim's chance of recovery ticks away with time, so this door-to-door coordination is a critical function. And if you find yourself in this situation, it's a team working at Parkland that will answer the call.

This mission has improved as health fields integrate more technology into their care. Good information has always been a focus of BioTel — the term itself is short for “biomedical telemetry,” referring to the transmission of data over radio. But in recent years, tech innovations have driven this value to new heights, such as with the ability to transmit EKG images from the back of an ambulance and keep a real-time inventory of available emergency beds throughout the county.

In business, the term “throughput” refers to the amount of product or data moving through a machine or system. Though perhaps not the terminology we normally associate with compassionate care, high throughput creates a positive domino effect in a hospital. When patient A’s path through the emergency room goes more quickly, patients B, C and D also benefit.

And Parkland's emergency room has historically had a throughput problem.

Emergency room wait times and inefficient use of limited public resources squeeze public hospitals. At one point, Parkland's wait times averaged eight to 13 hours. But while building the “New Parkland” in 2015, Parkland CEO Dr. Fred Cerise pulled in another community partner to address the emergency room’s throughput problem.

That partner was Toyota. The automaker has a philanthropic arm that offers free expertise to nonprofits to improve efficiency in the model of "kaizen," or continuous improvement. It's a succinct motto for both an automaker and a hospital system. Parkland asked the local automaker famous for its logistics efficiency for help cutting down the time between a patient receiving discharge orders and actually leaving the hospital. Remember, if patient A is clogging the pipeline, B, C and D might be barred from lifesaving care.

Today, small purple, red and green lights outside a patient’s door helped communicate logistics, such as whether the patient needs to be seen, the room cleaned, a discharge order given. And it works. Typical discharge time dropped from 52 to 31 minutes.

1 / 4Nurse Quiante Minnifee, right, checks patient Cynthia Reighard at Hatcher Station Health Center in Dallas on Monday, July 2.(Jae S. Lee / Staff Photographer) 2 / 4A sign of Hatcher Station Health Center in Dallas on Monday, July 2. (Jae S. Lee / Staff Photographer) 3 / 4Becky Flores, a phlebotomy technician, right, draws blood for patient Cynthia Reighard at Hatcher Station Health Center in Dallas on Monday, July 2.(Jae S. Lee / Staff Photographer) 4 / 4Becky Flores, a phlebotomy technician, right, draws blood for patient Cynthia Reighard at Hatcher Station Health Center in Dallas, Monday, July 2. (Jae S. Lee / Staff Photographer)

Community care and community costs

Of course, Toyota was willing to help Parkland out precisely because it isn’t one of the private, luxury hospitals growing in prominence in the health landscape. Rapid hospital consolidation and a movement toward more profitable "concierge" care make public hospitals like Parkland an increasingly rare breed.

Parkland's community-first ethos is more than a noble declaration — it's a legal and funding reality. Parkland is a safety-net hospital, meaning it follows a legal mandate to accept all patients no matter their insurance status. Texas has the highest uninsured rate in the nation, almost twice the national average. It makes sense that an entire subsidiary of the hospital, Parkland Community Health Plan, focuses solely on linking communities to coverage.

Getting people insured puts Parkland on better financial footing and increases access to the preventative services that keep all of Dallas County happier and healthier.

Parkland faces pressures from within county lines as well, especially when it comes to mental health. When Timberlawn, formerly Dallas's largest psychiatric hospital, closed earlier this year, Parkland wound up taking on a significant share of the acute cases that were previously diffused throughout the county, with the caseload almost doubling. You can see the need in the psychiatric emergency room, where cots sit ready to transform waiting areas to overflow rooms.

Ultimately, funding ties the Parkland system to every citizen of Dallas County, or at least their wallets. About a third of Parkland’s funding comes from Dallas County property taxes. This fact allows Parkland to experiment with innovative models of population health delivery and prevention for those who need it most, but it can also create an inherent conflict.

Uninsured and Medicaid patients are drawn not just from the tax-paying Dallas County, but also from the suburbs. It’s a problem as old as the hospital itself. Surrounding counties’ lower property taxes and bare-minimum health coverage combine to push indigent patients toward Dallas, at the expense of Dallas residents. It’s not fair — to Dallas residents or to Parkland’s ER — but Parkland must still prepare to meet the needs of all patients.

Prevention is the best medicine

Of course, the ultimate goal of a health care system is to keep people out of hospitals in the first place. This may seem obvious, but it's important to begin with this guiding principle to build systems that prevent illness, not just react to it. It's also an efficient goal. Keeping one patient out of the hospital means you can treat another, and simultaneously lessens the burden on the taxpayers and government programs that fund care.

A hospital is a health care hub, but even one as big as Parkland cannot possibly oversee the vaccination schedules and yearly checkups of more than a million Dallas residents. So since 1989, Parkland has founded more than a dozen community clinics, responsible for broadening Parkland’s physical reach into communities and moving the most common primary care needs closer to patients.

As health care systems shift to prioritize prevention, community clinics are physically changing the county’s health care landscape, benefiting from Parkland’s scale and resources.

Plugged in takes a more literal meaning where Parkland uses technology. Virtual visits and e-consultations can get patients in quick contact with specialists, who in turn can see more patients. Electronic consultations, telehealth, predictive analytics: Technology and innovation give patients more choices while simultaneously eliminating pressures on Parkland.

For many Dallas residents, Parkland may come to mind only as an abstract public service paid for and forgotten. But its unique historical (and legal) obligation to the county’s medically indigent incentivize the kind of efficiency desperately needed in health care today. From an emergency response center to exams-by-phone, Dallas is setting the standards for how micro efficiencies can improve access to care on a macro scale.

As goes health care, so goes Parkland. And Dallas, all of Dallas, should pay attention.

Laura Hallas is an editorial intern with The Dallas Morning News.

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