Overutilization of healthcare resources often has negative implications. The Choosing Wisely campaign, an initiative of the American Board of Internal Medicine, was proposed to help patients and caregivers engage in shared conversations to reduce overuse of potentially harmful tests and procedures. However, the Choosing Wisely campaign’s lack of linkage to medical liability considerations has substantially reduced its impact. For instance, excessive medical imaging and its associated radiation exposure inflicts a measurably real and significant risk of carcinogenesis, drives costs, and therefore is a significant Choosing Wisely target. This is a particularly important consideration in the emergency care setting, frequently cited as an extremely utilization rich environment due to the higher inherent risk of missed pathology and the isolation of clinical care. We hypothesize a special type of predetermined standard of care (a “safe harbor”) can be defined based upon medical evidence, and upon consultation among multiple experts and advisors, for a selected number of clinical conditions within the specialty of emergency medicine (EM). Furthermore, a state-based, federally- contracted and legally-recognized Quality Improvement Organization (QIO) could adopt the “safe harbor” and, in doing so, establish the standard of care in the context of a legal liability claim. Practitioners who meet such a standard and implement it appropriately satisfy their obligation under the law of medical malpractice. Ultimately, defining provider liability through this predetermined, or ex ante, standard of care, may result in a significant reduction in healthcare resource utilization within EM. Through this reduction, the quality of care would not decrease, adverse event reporting would improve, and a measurable reduction in radiation exposure would occur. Moreover, these predefined standards of care would improve communication between patient and provider during the clinical transaction. A diverse and experienced team of Vanderbilt University medicine, law, economics, and clinical faculty will undertake this. Phase one will summon a broad group of technical experts and advisors to define safe harbors for a narrow set of distinct clinical conditions within EM. These safe harbors would be presented for review and approval by the appropriate QIO. Phase two will advance the safe harbor demonstration to EM practitioners within Vanderbilt University Medical Center. Phase three will evaluate the demonstration and determine the effects of the safe harbor on clinical decision making, adverse reporting, utilization, radiation exposure, patient satisfaction and clinical outcomes.

Many patients who present to the emergency department (ED) receive a vast array of diagnostic tests, some of which might not be useful. Providers often feel obligated to order so many tests to protect themselves against the risk of being sued. We believe if a standard of care providing legal protection for certain clinical conditions were agreed upon and followed, unnecessary testing would significantly decrease in the ED, which, in turn, would improve patient safety, augment the quality of care delivered, and increase patient satisfaction.