The emergency room at White Memorial Medical Center on Los Angeles' Eastside was buzzing when paramedics arrived on a Friday night with an elderly man slurring his words and complaining of aching bones.
The nurse in the receiving bay immediately ran through standard triage questions: "Are you diabetic? Do you have high blood pressure? Are you allergic to any medications?" Each drew the same response: "I don't know."
The hospital and doctors had no record of the man or his medical history. And with their only guide a piece of crumpled paper they found tucked into the man's pants that seemed to indicate he might have had cancer, doctors had to order a full diagnostic work-up, including blood tests and an EKG to check his heart.
It was another night of high-priced detective work at one of America's urban hospitals.
"We're mostly flying blind here," said Dr. Brian Johnston, the senior emergency room physician at White Memorial, shaking his head at the high costs generated by the lack of records and unnecessary testing.
Waste bedevils much of America's fragmented healthcare system, driving up already skyrocketing costs. As health spending overwhelms government budgets, the stakes are especially high for safety-net institutions like White Memorial that serve the country's poorest patients, largely at taxpayer expense.
The best safety-net systems — in Denver, Dallas, New York and elsewhere — have found ways to practice medicine more efficiently, using electronic records and integrated systems to manage care for low-income patients and cut costly hospitalizations.
In Los Angeles, Chicago and many other cities, local healthcare officials are now scrambling to catch up.
"There is really no system of care here," said Allen Miller, a Los Angeles consultant who is working with private hospitals, clinics and physicians on a potentially trailblazing initiative to link together medical providers that care for some of Los Angeles County's neediest patients.
"We think by working together, there are ways to provide the right care and spend less money," he said.
White Memorial, a nonprofit hospital founded in 1913 by the Seventh-day Adventist Church, is on the front lines of that campaign.
The sprawling medical center rises out of the heart of Latino Los Angeles, almost literally in the shadow of the county's mammoth public hospital just east of downtown.
For nearly a century, the two institutions have served the same communities of immigrants and other Angelenos without private insurance or without access to the upscale hospitals on the city's Westside.
They often serve the same patients. On a recent Tuesday, 38 of the 270 people seen at White Memorial had also received care at L.A. County/USC Medical Center in the last year, according to hospital data.
But doctors and nurses at the two hospitals have no way of knowing which tests were run or what treatment was provided because they cannot access each other's computer systems.
Nor can they see what care patients might have received at the 70 other acute-care hospitals or at any of the thousands of doctors' offices and clinics around the county.
Patients, many of whom don't speak English, often have difficulty providing guidance.
In the White Memorial emergency room, doctors and nurses tell stories of people who can't explain big scars on their chests, or even drug allergies or recent blood tests.
"We end up repeating an unbelievable amount of medical tests and other things that probably have been done somewhere else," said Dr. Juan Barrio, who directs White Memorial's internal medicine internship program.
Nationally, most emergency doctors reported in a recent survey by the American College of Emergency Physicians that at least a quarter of their patients had gotten tests that could have been avoided with better access to medical records.
Adding to the inefficiency, White Memorial and many other hospitals that care for low-income patients have few resources to ensure that their patients are getting needed care once they leave the hospital.
That can lead to complications at home and costly trips back to the emergency room. Studies show that poor patients are much more likely to end up back in the hospital.
At a place like White Memorial, where about 85% of the patients are on Medicaid, Medicare or some other government health insurance program, the cost of that waste is borne directly by taxpayers.
A thousand miles away, Denver Health, which every year provides care to a third of that city's 600,000 residents, has shown there are ways to reduce the waste.
The nationally acclaimed safety-net system has developed a network of neighborhood and school-based clinics where patients go for checkups, vaccinations and other routine care, a critical tool in reducing expensive hospitalizations.
And Denver Health's extensive electronic data system allows doctors and nurses to access patients' medical records anywhere in the system, reducing costly errors and duplication.
The initiatives have helped Denver Health hold costs for many medical procedures far below those at other Denver hospitals, according to Colorado Hospital Assn. data. And last year, Denver Health bested more than 100 other leading academic medical centers in a measure of how many patients survived under hospital care.
There are immense challenges to replicating those results in Los Angeles County, where dozens of independent private hospitals work alongside the massive county health system to provide care to about 5 million people who either lack insurance or rely on the publicly funded Medicaid program.
But in an unusual partnership sparked by the healthcare law President Obama signed last year, White Memorial is now working with two other major safety-net hospitals and the county's largest chain of nonprofit health clinics to try to create the kind of integrated system that is cutting costs and improving quality in Denver.
Clinic operator AltaMed; Hollywood Presbyterian Medical Center; Citrus Valley Health Partners, a hospital in the San Gabriel Valley east of Los Angeles; and White Memorial plan to begin sharing medical records in a year.
And by 2013, they hope to be able to begin managing care for thousands of patients by using AltaMed's clinics and a network of independent private physicians, instead of expensive emergency rooms and hospital wards.
At the same time, the new partnership is talking with the county health system, which is working on its own streamlining efforts, about sharing more records to cut down on duplicative services.
The cooperative venture is still in its early stages. But health officials in the nation's most populous county say they have no choice.
"There aren't enough beds here. There aren't enough doctors.... And there isn't enough money," said Elvia Foulke, Citrus Valley's chief operating officer. "We have to figure out a way to care for these people more rationally. We just have to."