Emergency department telemedicine consults decrease time to interpret computed tomography of the head in a multi-network cohort

Estimating the Proportion of Telehealth-Able United States Emergency Department Visits

STUDY OBJECTIVE

We use national emergency department (ED) data to identify the proportion of "telehealth-able" ED visits, defined as potentially conductible by Video Only or Video Plus (with limited outpatient testing).

METHODS

We used ED visits by patients 4 years of age and older from the 2019 National Hospital Ambulatory Medical Care Survey and applied survey weighting for national representativeness. Two raters categorized patient-described Reasons for Visit (RFV) as telehealth-able (yes, no, uncertain) for both Video Only and Video Plus visits. This categorization was stratified by age (4 to 17 years old, 18 to 35, 36 to 64, and 65 and older). Visit characteristics that were used to remove further nontelehealth-able visits included admission, procedures, diagnostic testing, acuity level, and pain score.

RESULTS

Our sample included 133.6 million United States ED visits in 2019 for patients aged 4 years or older. Of those, between 3.4% and 8.8% of visits were telehealth-able by Video Only and between 5.0% and 9.7% by Video Plus, considering only the first RFV. Visits by younger patients were more often telehealth-able, with the proportion of telehealth-able visits decreasing with advancing age. Considering all RFVs, between 0% to 6.6% of ED visits were telehealth-able with Video Only and 0.02% to 7.6% with Video Plus.

CONCLUSION

Between 3% and 10% of United States ED visits may be potentially telehealth-able for patients aged 4 years and older, considering the first listed RFV and ED visit characteristics. Fewer visits may be telehealth-able when all reasons for visits are considered.

The Effect of Sepsis Recognition on Telemedicine Use in Rural Emergency Department Sepsis Treatment

Background: Provider-to-provider emergency department telehealth (tele-ED) has been proposed to improve rural sepsis care. The objective of this study was to measure the association between sepsis documentation and tele-ED use, treatment guideline adherence, and mortality. Methods: This analysis was a multicenter (n = 23) cohort study of sepsis patients treated in rural emergency departments (EDs) that participated in a tele-ED network between August 2016 and June 2019. The primary outcome was whether sepsis was documented explicitly in the clinical note impression in the local ED, and the primary exposure was rural tele-ED use, with secondary outcomes of time to tele-ED use, 3-h guideline adherence, and in-hospital mortality. Results: Data from 1,146 rural sepsis patients were included, 315 (27%) had tele-ED used and 415 (36%) had sepsis recognized in the rural ED. Tele-ED use was not independently associated with sepsis recognition (adjusted odds ratio [aOR]: 1.23, 95% confidence interval [CI]: 0.90-1.67). Sepsis recognition was associated with earlier tele-ED activation (adjusted hazard ratio 1.66, 95% CI: 1.28-2.15) and greater 3-h guideline adherence (aOR 1.37, 95% CI 1.03-1.83) Sepsis recognition was not independently associated with mortality (aOR 1.32, 95% CI 0.97-1.80). Conclusions: Although tele-ED care is a promising strategy to improve sepsis outcomes, its use was limited by under-recognition of sepsis in rural EDs.

Telehealth-guided provider-to-provider communication to improve rural health: A systematic review

INTRODUCTION

Telehealth may address healthcare disparities for rural populations. This systematic review assesses the use, effectiveness, and implementation of telehealth-supported provider-to-provider collaboration to improve rural healthcare.

METHODS

We searched Ovid MEDLINE®, CINAHL®, EMBASE, and Cochrane CENTRAL from 1 January 2010 to 12 October 2021 for trials and observational studies of rural provider-to-provider telehealth. Abstracts and full text were dual-reviewed. We assessed the risk of bias for individual studies and strength of evidence for studies with similar outcomes.

RESULTS

Seven studies of rural uptake of provider-to-provider telehealth documented increases over time but variability across geographic regions. In 97 effectiveness studies, outcomes were similar with rural provider-to-provider telehealth versus without for inpatient consultations, neonatal care, outpatient depression and diabetes, and emergency care. Better or similar results were reported for changes in rural clinician behavior, knowledge, confidence, and self-efficacy. Evidence was insufficient for other clinical uses and outcomes. Sixty-seven (67) evaluation and qualitative studies identified barriers and facilitators to implementing rural provider-to-provider telehealth. Success was linked to well-functioning technology, sufficient resources, and adequate payment. Barriers included lack of understanding of rural context and resources. Methodologic weaknesses of studies included less rigorous study designs and small samples.

DISCUSSION

Rural provider-to-provider telehealth produces similar or better results versus care without telehealth. Barriers to rural provider-to-provider telehealth implementation are common to practice change but include some specific to rural adaptation and adoption. Evidence gaps are partially due to studies that do not address differences in the groups compared or do not include sufficient sample sizes.

HRSA's evidence-based tele-emergency network grant program: Multi-site prospective cohort analysis across six rural emergency department telemedicine networks

Background

The Health Resources and Services Administration (HRSA), Federal Office of Rural Health Policy (FORHP) funded the Evidence-Based Tele-Emergency Network Grant Program (EB TNGP) to serve the dual purpose of providing telehealth services in rural emergency departments (teleED) and systematically collecting data to inform the telehealth evidence base. This provided a unique opportunity to examine trends across multiple teleED networks and examine heterogeneity in processes and outcomes.

Method and findings

Six health systems received funding from HRSA under the EB TNGP to implement teleED services and they did so to 65 hospitals (91% rural) in 11 states. Three of the grantees provided teleED services to a general patient population while the remaining three grantees provided teleED services to specialized patient populations (i.e., stroke, behavioral health, critically ill children). Over a 26-month period (November 1, 2015 –December 31, 2017), each grantee submitted patient-level data for all their teleED encounters on a uniform set of measures to the data coordinating center. The six grantees reported a total of 4,324 teleED visits and 99.86% were technically successful. The teleED patients were predominantly adult, White, not Latinx, and covered by Medicare or private insurance. Across grantees, 7% of teleED patients needed resuscitation services, 58% were rated as emergent, and 30% were rated as urgent. Across grantees, 44.2% of teleED patients were transferred to another inpatient facility, 26.0% had a routine discharge, and 24.5% were admitted to the local inpatient facility. For the three grantees who served a general patient population, the most frequent presenting complaints for which teleED was activated were chest pain (25.7%), injury or trauma (17.1%), stroke symptoms (9.9%), mental/behavioral health (9.8%), and cardiac arrest (9.5%). The teleED consultation began before the local clinician exam in 37.8% of patients for the grantees who served a general patient population, but in only 1.9% of patients for the grantees who provided specialized services.

Conclusions

Grantees used teleED services for a representative rural population with urgent or emergent symptoms largely resulting in transfer to a distant hospital or inpatient admission locally. TeleED was often available as the first point of contact before a local provider examination. This finding points to the important role of teleED in improving access for rural ED patients.

Do Hospitals Providing Telehealth in Emergency Departments Have Lower Emergency Department Costs?

Background: Since 2003, the University of Mississippi Medical Center has operated a robust telehealth emergency department (ED) network, TelEmergency, which enhances access to emergency medicine-trained physicians at participating rural hospitals. TelEmergency was developed as a cost-control measure for financially constrained rural hospitals to improve access to quality, emergency care. However, the literature remains unclear as to whether ED telehealth services can be provided at lower costs compared with traditional in-person ED services. Introduction: Our objective was to empirically determine whether TelEmergency was associated with lower ED costs at rural hospitals when compared with similar hospitals without TelEmergency between 2010 and 2017. Materials and Methods: A panel of data for 2010-2017 was constructed at the hospital level. Hospitals with TelEmergency (n = 14 hospitals; 112 hospital-years) were compared with similar hospitals that did not use TelEmergency from Arkansas, Georgia, Mississippi, and South Carolina (n = 102; 766 hospital-years), matched using Coarsened Exact Matching. The relationship between total ED costs and treatment (e.g., participation in TelEmergency) was predicted using generalized estimating equations with a Poisson distribution, a log link, an exchangeable error term, and robust standard errors. Results: After controlling for ownership type, critical access hospital status, year, and size, TelEmergency was associated with an estimated 31.4% lower total annual ED costs compared with similar matched hospitals that did not provide TelEmergency. Conclusions: TelEmergency utilization was associated with significantly lower total annual ED costs compared with similarly matched hospitals that did not utilize TelEmergency. These findings suggest that access to quality ED care in rural communities can occur at lower costs.

Telemedicine as the New Outpatient Clinic Gone Digital: Position Paper From the Pandemic Health System REsilience PROGRAM (REPROGRAM) International Consortium (Part 2)

Technology has acted as a great enabler of patient continuity through remote consultation, ongoing monitoring, and patient education using telephone and videoconferencing in the coronavirus disease 2019 (COVID-19) era. The devastating impact of COVID-19 is bound to prevail beyond its current reign. The vulnerable sections of our community, including the elderly, those from lower socioeconomic backgrounds, those with multiple comorbidities, and immunocompromised patients, endure a relatively higher burden of a pandemic such as COVID-19. The rapid adoption of different technologies across countries, driven by the need to provide continued medical care in the era of social distancing, has catalyzed the penetration of telemedicine. Limiting the exposure of patients, healthcare workers, and systems is critical in controlling the viral spread. Telemedicine offers an opportunity to improve health systems delivery, access, and efficiency. This article critically examines the current telemedicine landscape and challenges in its adoption, toward remote/tele-delivery of care, across various medical specialties. The current consortium provides a roadmap and/or framework, along with recommendations, for telemedicine uptake and implementation in clinical practice during and beyond COVID-19.