Telemedicine can be defined as “the remote delivery of health care services and clinical information using telecommunications technology.”¹ While telemedicine has been gaining traction in other medical specialties, namely stroke care and psychiatry, several emergency departments have developed tele-emergency medicine programs and several more have been exploring telemedicine options. A systematic review of the tele-emergency medicine literature in 2015 demonstrated three main categories of applied tele-emergency medicine: telemedicine for general emergency medicine care (eg, a rural hospital would use a tele-emergency medicine program for consultations on their patients), direct-to-patient urgent care offerings, and telemedicine for special patient populations (eg, stroke or trauma care).² While many in emergency medicine are familiar with telemedicine use with stroke care, this article highlights three current tele-emergency medicine offerings in the United States that focus on direct-to-patient care or direct-to-provider consultation.

Direct to Patient

New York-Presbyterian/Weill Cornell Medicine in New York City has implemented the Emergency Department Telehealth Express Care Service, a direct-to-patient care telemedicine offering. This program aims to quickly see emergency department patients who would typically be seen in low-acuity areas, thus reducing wait times for all ED patients. The length of stay for patients treated via the Express Care offering is 35–40 minutes as opposed 2.5 hours in the emergency department. The program is currently offered at two emergency departments, Weill Cornell Medical Center and Lower Manhattan Hospital.

The encounter starts with an in-person triage by an ED nurse, followed by a medical screening examination performed by an ED physician assistant or nurse practitioner. The patient is then brought into an examination room with a telehealth video cart that is linked to an attending ED physician in an office geographically remote from the emergency department. The patient’s visit finishes with a video consultation and discharge by the attending. The Express Care program is staffed by emergency physicians and is available 16 hours per day, seven days a week. These patients are billed as ED visits because they receive a full triage and an in-person medical screening examination. Since July 2016, the program has had more than 2,000 visits. Patient experience-of-care scores have been in the 99th percentile, and the patients’ ages have ranged from 18 to 99 years old, with approximately 20 percent of these visits from patients older than 60.

Judd Hollander, MD, professor of emergency medicine and associate dean for strategic health initiatives at Sidney Kimmel Medical College of Thomas Jefferson University in Philadelphia, leads his institution’s telehealth offerings. The overall program has had more than 25,000 visits, including on-demand video visits for patients, scheduled video visits, remote second opinions, virtual rounds, and Jefferson Neuroscience Network and remote consults. JeffConnect, its direct-to-patient video-visit program, is currently the only direct-to-patient on-demand video-visit program from an academic center that has 24-7 staffing from physicians in a brick-and-mortar urgent care and emergency department. As for telemedicine education, not only does Jefferson have a telehealth leadership fellowship, it also incorporates telemedicine into its emergency medicine residency training. Its residents work with the telehealth physicians to see ED patients in follow-up using video visits, focusing on both clinical reasoning and communication skills.

Direct to Provider

In 2009, Avera eCARE implemented an emergency care telemedicine program with its service line eEmergency. The eEmergency program serves rural clinicians in the upper Midwest and nationally. With a touch of a button, an ED clinician has access to a board-certified emergency physician and an emergency nurse. This program allows peer-to-peer support and consultation, including help with difficult cases such as pediatric trauma, strokes, and cardiac arrest. The cameras enable the eEmergency providers to see and hear the patient at the remote site, and with their peripherals, the eEmergency providers can view an intubation, including the view from the video laryngoscope. Avera eEmergency covers 150 hospitals in 10 states and has consulted on more than 40,000 patients. The eEmergency program has resulted in an estimated cost savings of $29 million and avoidance of more than 4,000 patient transfers.

The Future of Telemedicine

As Rahul Sharma, MD, MBA, CPE, FACEP, the emergency medicine physician-in-chief at Weill Cornell Medicine, states, “Patients want high-quality, efficient health care, and most emergency departments and health care systems will have no choice but to incorporate telemedicine in some aspect of emergency care.”

Barriers, including state licensure, reimbursement, and credentialing requirements, are actively being reconsidered at the state and federal levels. Research is ongoing regarding the outcomes of telehealth programs in emergency medicine. A telehealth program will most likely be coming soon to an emergency department near you.

Dr. Hayden is director of telemedicine in the Department of Emergency Medicine at Massachusetts General Hospital in Boston.

References

1. About telemedicine. American Telemedicine Association website. Accessed May 8, 2017.
2. 2. Ward MM, Jaana M, Natafgi N. Systematic review of telemedicine applications in emergency rooms. Int J Med Inform. 2015;84(9):601-616.