Editors’ Note: This article was accepted on April 26, 2020, and was accurate at that time. Because information about SARS-CoV-2 and COVID-19 is evolving rapidly, please verify these recommendations and information.

Telemedicine has long been suggested as a viable technological solution for improving access to care. But because of barriers around reimbursement, technological limitations, and scalability, health care institutions have been slow to adopt it. Physician and patient preference for in-person care has been another impediment to adoption.

The COVID-19 pandemic shifted this paradigm; telemedicine use has become widespread. Its potential for decreasing emergency department volume, mitigating transmission of SARS-CoV-2, and saving precious resources such as personal protective equipment (PPE) is now apparent. 

Case Use in Chicago

Rush University Medical Center in Chicago created its on-demand virtual care platform in 2019 primarily for patients with low-acuity complaints, much like a virtual urgent care. The online platform was expanded in March 2020 in anticipation of increased patient volumes due to the COVID-19 pandemic. The aim was to “flatten the curve” of COVID-19 by facilitating video visits in place of in-person hospital visits when possible. The pandemic created a large demand from patients with concerns about the coronavirus. Video visits were a channel through which health care workers could provide medical advice regarding testing, quarantine and isolation, supportive care, and whether patients should present for in-person care.

Patients with the chief complaint of “concern for novel coronavirus” were provided a free video visit by a physician or advanced practice provider. In anticipation of high volumes, Rush recruited quarantined emergency physicians, primary care physicians whose clinics had closed, residents, and advanced practice providers.

Prior to the pandemic, the platform saw about two patients daily. Within days of expanding operations of the COVID-19 module, use rapidly grew to 100 patients daily.

Resident Participation

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This new demand for telemedicine visits spurred rapid institutional change that facilitated the opportunity for residents to deliver health care in novel ways. Emergency medicine residents in particular played an integral role in scaling telemedicine visits, specifically by creating training modules, recruiting practitioners, pilot testing, and conducting visits for patients.

On March 18, 2020, the Accreditation Council for Graduate Medical Education recognized the national demand for telemedicine visits and accelerated giving permission to residents and fellows to participate in telemedicine care.1 Additionally, the federal government began relaxing regulations for telemedicine, notably with regard to restrictions for reimbursements.2 In response to this need, Rush increased its training of health care workers for video visits. We also utilized residents on the telemedicine platform as demand continued to outstrip capacity.

To start conducting video visits, residents had to fulfill several requirements, including completing an online training module, registering their devices to be added to the practitioner pool, and attending an in-person or online tutorial conducted by an information technology specialist or health care worker. The entire training process took about an hour.

Rush achieved emergency medicine resident coverage by reassigning two full-time residents to the program after the cancelation of nonessential rotations. Additional emergency medicine resident coverage was provided by residents on nonclinical rotations on a part-time basis. By co-scheduling attendings and residents, Rush essentially doubled capacity for evaluating patients. Residents presented cases to attendings via the Epic electronic medical records system chat function, and faculty were immediately available by phone and video to troubleshoot difficult cases. Patients were dispositioned to outpatient testing centers, home isolation, or the emergency department. Patients directed to the emergency department for in-person care had their visits streamlined through the emergency physician’s direct communication with the receiving charge nurse.

At Rush, emergency residents demonstrated the clinical acumen, adaptability, and technological savvy that allowed for the rapid expansion of the hospital’s telemedicine platform. Although the residents only met with patients confirmed under investigation for having the novel coronavirus, the success of this venture suggests that residents can be assigned to a more diverse set of complaints and gain necessary skills that will become more valuable as telemedicine becomes commonplace.

Impact

The video visit platform proved so popular that the volume of patients seen online since its launch was comparable to or even exceeded the volume of patients seen in the emergency department. The large majority of patients using this platform were appropriate for outpatient supportive care.

The aim of expanding video visits was to provide an alternative to in-person care, with the secondary benefits of conserving PPE resources and reducing unnecessary exposure to COVID-positive individuals who did not require hospitalization. Theoretically, patients seen via virtual visit may have instead presented to the emergency department if the telemedicine service were not available. In fact, more than 40 percent of adult patients who completed post-visit surveys reported they would have sought in-person care had they not used this virtual service. Although this theory cannot be formally tested now because of decreased ED volumes resulting from Illinois shelter-in-place orders, it is reasonable to hypothesize that the telemedicine platform led to decreased ED visits.

The Future of Emergency Medicine?

Telemedicine granted emergency medicine physicians the ability to perform house calls, albeit virtual ones. This was a unique opportunity to be present in a patient’s home, understand their living situation, and speak to members of their family. Physicians gained a more holistic view of their patients, which allowed them to identify specific challenges that patients face and determine their ability to remain under self-quarantine. In the time of a pandemic, this was one of the few opportunities for patients to interact with their physicians without the barriers imposed by face masks. Perhaps this was a more personal and fulfilling experience for both patients and health care workers than what could be offered by the sterility of a gowned, gloved, and masked physician in an austere ED room.

Emergency physicians on the front lines will face tremendous adversity in the coming months. And although video visits have been suggested as a means of reducing burnout during a pandemic, perhaps this brief segue into telemedicine foreshadows a grander future for the technology even after the pandemic subsides.3 The application of telemedicine in emergency medicine may allow us to identify nonemergent complaints prior to their presentation in the emergency department and increase overall efficiency while simultaneously increasing patient satisfaction.^4–7

Reimbursement

In an effort to ensure continued access to health care during the pandemic, the Centers for Medicare & Medicaid Services has allowed for payment parity for telehealth visits. We believe that our specialty should advocate for continuing this parity post-pandemic. To be a truly effective intervention that complies with EMTALA regulations, telemedicine programs should focus on outlining credentialing, expectations, and privileges for its workers and specifying protocols for triaging patients and transferring patients for in-person care.8 Ultimately, we believe that if executed with care and due diligence to hospital bylaws and governing regulations, telemedicine could serve as an impactful release valve for the exponential growth in ED volumes and waiting rooms that was seen prior to the COVID-19 pandemic.

Emergency physicians should be the driving force behind telemedicine efforts because we are arguably the most qualified specialty to determine when a patient requires emergency services and inpatient care. With this in mind, emergency medicine residency programs should incorporate telemedicine as a core component of training. 

Sometimes it takes a crisis to sow seeds of innovation. Telemedicine has favorably disrupted medicine and paved the way to new approaches to health care delivery systems. Our response to the pandemic has accelerated the proof of concept that telemedicine can be successfully implemented to advance emergency medicine and, ultimately, better serve our patients.

Dr. Adams is an emergency medicine resident at Rush University Medical Center in Chicago. Dr. Shah is assistant professor of emergency medicine at Rush. Dr. Hexom is residency program director at Rush.

References

1. Nasca T. ACGME response to the coronavirus (COVID-19). Accreditation Council for Graduate Medical Education website.
2. Bashshur R, Doarn CR, Frenk JM, et al Telemedicine and the COVID-19 pandemic, lessons for the future. Telemed J E Health. 2020;26(5):571-573.
3. Moazzami B, Razavi-Khorasani N, Moghadam AD, et al. COVID-19 and telemedicine: immediate action required for maintaining healthcare providers well-being. J Clin Virol. 2020;126(4):104345.
4. Sharma R, Clark S, Torres-Lavoro J, et al. Telemedicine in the emergency department: a novel, academic approach to optimizing operational metrics and patient experience. Ann Emerg Med. 2017;70(4):S128.
5. Watson J, Bhat R, Izzo J, et al. Telemedicine model of physician intake decreases door-to-provider time. Ann Emerg Med. 2017;70(4):S128-S129.
6. Greenwald PW, Clark S, Hsu H, et al. A path to telemedicine: an academic institution’s implementation of a novel telemedicine practice for emergency department patients to telemedicine. Ann Emerg Med. 2017;70(4):S130.
7. Greenwald PW, Stern M, Clark S, et al. A novel emergency department–based telemedicine program: how do older patients fare? Telemed J E Health. 2019;25(10):966-972.
8. Rockwell KL, Gilroy A. Emergency telemedicine: achieving and maintaining compliance with the Emergency Medical Treatment and Labor Act. Telemed J E Health. 2018;24(11):934-937.