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

The role of telehealth in sepsis care in rural emergency departments: A qualitative study of emergency department sepsis telehealth user perspectives

PURPOSE

Sepsis is a leading cause of hospitalization and death in the United States, and rural patients are at particularly high risk. Telehealth has been proposed as one strategy to narrow rural-urban disparities. The objective of this study was to understand why rural emergency department (ED) staff use provider-to-provider telehealth (tele-ED) and how tele-ED care changes the care for rural patients with sepsis.

METHODS

We conducted a qualitative interview study between February 15, 2022, and May 22, 2023, with participants from upper Midwest rural EDs and tele-ED hub physicians in a single tele-ED network that delivers provider-to-provider consultation for sepsis patients. One interviewer conducted individual telephone interviews, then we used standard qualitative methods based on modified grounded theory to identify themes and domains.

FINDINGS

We interviewed 27 participants, and from the interviews we identified nine themes within three domains. Participants largely felt tele-ED for sepsis was valuable in their practice. We identified that telehealth was consulted to facilitate interhospital transfer, provide surge capacity for small teams, to adhere with provider scope-of-practice policies, for inexperienced providers, and for patients with increased severity of illness or complex comorbidities. Barriers to tele-ED use and impact included increased sepsis care standardization, provider reluctance, and sepsis diagnostic uncertainty. Additionally, we identified that real-time education and training were important secondary benefits identified from tele-ED use.

CONCLUSIONS

Tele-ED care was used by rural providers for sepsis treatment, but many barriers existed that may have limited potential benefits to its use.

Implementation of rural provider-to-provider telehealth in country Western Australia: a retrospective observational analysis via the RE-AIM framework

BACKGROUND

Rural provider-to-provider telehealth is growing globally. It is used to both facilitate equitable access to specialist healthcare services for those living in rural and remote areas and provide support to place-based providers. There is limited research on the implementation of these services, especially in an emergency or inpatient hospital setting. The Western Australia Country Health Service (WACHS) Command Centre is one such example. First implemented in 2012, the Command Centre services a geographical area covering 2.55 million square kilometres, a population of approximately 550,000, and provides five clinical streams including Emergency, Mental Health Emergency, Midwifery and Obstetrics Emergency, Inpatient, and Palliative Care Afterhours Telehealth Services.

OBJECTIVES

This study aimed to evaluate the implementation and access of rural provider-to-provider telehealth in country Western Australia, for the years 2012 to 2023.

METHODS

A retrospective observational analysis was conducted of all patient contacts managed by clinical telehealth streams of the Command Centre, between 31 August 2012 and 31 December 2023. Utilising descriptive statistics, analyses was informed by the expanded Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) Framework and Implementation Outcomes Framework (IOF) definitions.

RESULTS

Over the near 12-year period, a total of 215,965 service contacts were analysed from the five Command Centre clinical streams. There was large variation in the reach and adoption of services across regions, sites, and health facility types, however service scope and activity has increased steadily over time (maintenance). 95 of the 103 WACHS-managed sites had utilised Command Centre clinical telehealth services. The Command Centre has seen an increase in the proportion of clinical telehealth services provided to the most disadvantaged populations, demonstrating improved equity of access (effectiveness) over time.

CONCLUSION

There is a steady expansion in the availability of provider-to-provider clinical telehealth services delivered by the WACHS Command Centre across country WA, but with wide variability of usage depending on region, site, and health facility type. The results of this study show there is a need to understand the contextual factors influencing the adoption, implementation, and sustainability of the service.

Lara J, Hollen A, Glenn M, Munn R, Hannan P, Arcaris B, Derksen D, Spaite DW, Gaither JB. Telemedical Direction to Optimize Resource Utilization in a Rural Emergency Medical Services System

Background

Telemedicine remains an underused tool in rural emergency medical servces (EMS) systems. Rural emergency medical technicians (EMT) and paramedics cite concerns that telemedicine could increase Advanced Life Support (ALS) transports, extend on-scene times, and face challenges related to connectivity as barriers to implementation. Our aim in this project was to implement a telemedicine system in a rural EMS setting and assess the impact of telemedicine on EMS management of patients with chest pain while evaluating some of the perceived barriers.

Methods

This study was a mixed-methods, retrospective review of quality assurance data collected prior to and after implementation of a telemedicine program targeting patients with chest pain. We compared quantitative data from the 12-month pre-implementation phase to data from 15 months post-implementation. Patients were included if they had a chief complaint of chest pain or a 12-lead electrocardiogram had been obtained. The primary outcome was the rate of ALS transport before and after program implementation. Secondary outcomes included EMS call response times and EMS agency performance on quality improvement benchmarks. Qualitative data were also collected after each telemedicine encounter to evaluate paramedic/EMT and EMS physician perception of call quality.

Results

The telemedicine pilot project was implemented in September 2020. Overall, there were 58 successful encounters. For this analysis, we included 38 patients in both the pre-implementation period (September 9, 2019-September 10, 2020) and the post-implementation period (September 11, 2020-December 5, 2021). Among this population, the ALS transport rate was 42% before and 45% after implementation (odds ratio 1.11; 95% confidence interval 0.45-2.76). The EMS median out-of-service times were 47 minutes before, and 33 minutes after (P = 0.07). Overall, 64% of paramedics/EMTs and 89% of EMS physicians rated the telemedicine call quality as "good."

Conclusion

In this rural EMS system, a telehealth platform was successfully used to connect paramedics/EMTs to board-certified EMS physicians over a 15-month period. Telemedicine use did not alter rates of ALS transports and did not increase on-scene time. The majority of paramedics/EMTs and EMS physicians rated the quality of the telemedicine connection as "good."

Rural Patients' Experiences with Synchronous Video Telehealth in the United States: A Scoping Review

Background: Telehealth can help increase rural health care access. To ensure this modality is accessible for rural patients, it is necessary to understand rural patients' experiences with telehealth. Objectives of this scoping review were to explore how rural patients' telehealth experiences have been measured, assess relevant research, and describe rural telehealth patient experiences. Methods: We searched five databases for articles published from 2016 through 2022. Primary research reports assessing rural adult patient experiences with synchronous video telehealth in the United States in any clinical area were included. Data collected pertained to study characteristics and patient experience assessment characteristics and outcomes. Quality of included studies was assessed using the Quality Assessment with Diverse Studies tool. Review findings were presented in a narrative synthesis. Results: There were 740 articles identified for screening, and 24 met review inclusion criteria. Most studies (70%, n = 16) assessed rural telehealth patient experience using questionnaires; studies employed interviews (n = 11) alone or in combination with surveys. The majority of surveys were study developed and not validated. Quantitative patient experience outcomes fell under categories of patient satisfaction, telehealth care characteristics, patient-provider rapport, technology elements, and access. Qualitative themes were most often presented as telehealth benefits or facilitators, and drawbacks or barriers. Conclusions: Available research indicates positive patient experiences with rural telehealth services. However, study weaknesses limit generalizability of findings. Future research should apply established definitions for participant rurality and clearly group samples by rurality. Efforts should be made to use validated telehealth patient experience measures.

Development of an Implementation Science Telehealth Toolkit to Promote Research Capacity in Evaluation of Telehealth Programs

Background

The field of telehealth is rapidly growing and expanding access to quality health care, although there have been varied implementation outcomes in telehealth modalities. Dissemination and implementation (D&I) research can provide a systematic approach to identifying barriers and facilitators to telehealth implementation processes and outcomes.

Methods

An interdisciplinary research and clinical team developed an implementation science telehealth toolkit to guide D&I evaluations of new and existing telehealth innovations.

Results

The toolkit includes a separate section to correspond to each step in the D&I evaluation process. Each section includes resources to guide evaluation steps, telehealth specific considerations, and case study examples based on three completed telehealth evaluations.

Discussion

The field of telehealth is forecasted to continue to expand, with potential to increase health care access to populations in need. This toolkit can help guide health care stakeholders to develop and carry out evaluations to improve understanding of telehealth processes and outcomes to maximize implementation and sustainability of these valuable innovations.

Characteristics and Effectiveness of Mobile- and Web-Based Tele-Emergency Consultation System between Rural and Urban Hospitals in South Korea: A National-Wide Observation Study

(1) Background: The government of South Korea has established a nationwide web- and mobile-based emergency teleconsultation network by designating urban and rural hospitals. The purpose of this study is to analyze the characteristics and effectiveness of the tele-emergency system in South Korea. (2) Methods: Tele-emergency consultation cases from May 2015 to December 2018 were analyzed in the present study. The definition of a tele-emergency in the present study is an emergency consultation between doctors in rural and urban hospitals via a web- and mobile-based remote emergency consultation system (RECS). Consultations through an RECS are grouped into three categories: medical procedure or treatment guidance, image interpretation, and transportation requests. The present study analyzed the characteristics of the tele-emergency system and the reduction in unnecessary transportation (RUT). (3) Results: A total of 2604 cases were analyzed in the present study from 2985 tele-emergency consultation cases. A total of 381 cases were excluded for missing data. Consultations for image interpretation were the most common in trauma cases (71.3%), while transfer requests were the most common in non-trauma cases (50.3%). Trauma patients were more frequently admitted to rural hospitals or discharged and followed up with at rural hospitals (20.3% vs. 40.5%) after consultations. In terms of disease severity, non-severe cases were statistically higher in trauma cases (80.6% vs. 59.4%; p < 0.001). The RUT was statistically highly associated with trauma cases (60.8% vs. 42.8%; p < 0.001). In an analysis that categorized cases by region, a statistically higher proportion of transportation was used in island regions (69.9% vs. 49.5%; p < 0.003). More RUT was associated with non-island regions (30.1% vs. 50.5%; p = 0.001). (4) Conclusions: The tele-emergency system had a great role in reducing unnecessary patient transportation in non-severe trauma cases and non-island rural area emergency cases. Further research is needed for a cost/benefit analysis and clinical outcomes.