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Shortly after being re-elected, the Ontario government vowed that it was going to tackle wait times in emergency departments.

The announcement, largely overlooked, is an important one. The emergency room is not only the principal entry point to the health system (14 million visits annually in Canada), it is a microcosm of the health system.

Use the ER as a magnifying glass and you will shine a glaring light on all the big challenges in the system: the crying need for chronic-disease management; the dysfunction of primary care; the paucity of electronic health records; the shortage of health professionals, and nurses in particular; the gaping holes in community-based services (particularly for those with mental illness), and the lack of continuity of care.

If you eliminate unnecessary waits in the ER, you will solve myriad problems. Improvements in patient care will ripple through the system.

Make no mistake: The task is a difficult one that requires a political commitment, no small amount of cash and Sisyphean patience. But payoffs can be tremendous.

Wait times have been a sore point with consumers for generations, but dealing with them finally became a political priority in 2004, when Ottawa and the provinces signed the $41-billion health accord to "fix health care for a generation."

That sum included $5.5-billion to reduce wait times in five priority areas: cancer, cardiac care, joint replacement (hips and knees), cataracts and medical imaging.

No one ever believed these were the most medically urgent needs in the system.

Unquestionably, ER wait times should have been the number one priority, but politicians were scared off by the complexity of the problem.

The Big Five were chosen because they offered the most potential for political gain among the baby boomer demographic, and they could be dealt with expeditiously.

If you want more bypass surgery done, you increase the fee paid to heart surgeons, you open up more surgical time (and more surgical suites), and you impose penalties on hospitals that don't meet the wait-time benchmarks. Simple strategies that produce quick results. Not surprisingly, wait times for bypasses have evaporated.

The same formula, pay-for-performance, can be applied to virtually all surgical waits.

But how do you "incentivize" (to use one of those horrible bureaucratic words) improvements in the emergency room? That is the challenge Ontario now faces.

We do not need bigger emergency rooms. ERs do not need to treat more patients; if anything they have the opposite challenge, to divert patients with minor problems who don't need to be there (about 70 per cent of people who come to the ER walk out under their own steam), and to keep patients with chronic illnesses from being in a constant transition between home or nursing home and ER.

One possible approach is to penalize docs whose patients end up in the ER for treatment of minor problems or, conversely, to offer incentives for after-hours treatment in doctors' offices. This is possible because an increasing number of patients are rostered - meaning their doctors are not paid strictly by fee-for-service, and may receive bonuses for ensuring timely care.

But the so-called hangnail patients are largely a triviality in emergency departments. It's the minority needing hospital admission who are the challenge. Their wait times are appallingly bad.

According to a study released earlier this year by the Canadian Institute for Health Information, once there has been a decision to admit, one in 25 patients waits more than 24 hours for a bed, and one in 10 patients waits at least 15 hours.

Only one in 10 patients is admitted immediately. Yet they all should be in a hospital bed within a few hours. Having seriously ill patients - and all those needing admission are very sick, and often frail and elderly - left on gurneys in hallways without toilet facilities or food, and with a minimum of care, is a disgrace.

This is the wait time that desperately needs to be eliminated. And this is where the incentives and penalties need to kick in.

In Britain, the benchmark for admission from the ER is four hours: 96 per cent of patients are admitted within that time frame. If the number falls below 90 per cent, heads roll, often starting with the CEO of the hospital or health trust.

That's called accountability and our health-care institutions could use a healthy dose of it.

Backlogs in the ER are principally due to the lack of beds down the hall in hospitals. Beds are lacking, in large part, because of poor bed management, from lax discharge policies through to the shortage of home care and lack of space in long-term care facilities. The nursing shortage is a major contributing factor, too.

Whether more beds need to be opened and new wards built is debatable. The issue is largely patient flow.

A hallmark of good care is continuity. If we can't get it right in the emergency department, it's unlikely we can get it right in the rest of the health-care system.

We know what the problems are and we know how to fix them. It's time for some action, beginning in the ER.