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POSTED: December 31st, 2022
POSTED IN: EM Pulse - The Official Newsletter of MOCEP, November/December 2022,

Written by Christopher Palmer, MD, FACEP, FCCM, Associate Professor of Anesthesiology and Emergency Medicine, Department of Anesthesiology, Division of Critical Care, Department of Emergency Medicine, Washington University School of Medicine, St. Louis

This article is reprinted in part with permission from Missouri Medicine 119:5:2022.

There was a time when Emergency Medicine (EM) physicians were confined to the walls of the Emergency Department (ED).  As a newly recognized specialty by the American Medical Association in 1979, this was exhilarating for those who fought for the recognition of EM physicians and their skillset, and rightfully so.¹  Today, due to those pioneers, EM is now an indispensable pillar of the healthcare system and remains a safety net for all.  As the US healthcare system continues to buckle under the tremendous strains imposed by financial, legal, governmental, and demographic challenges, EM is being asked to do more with less.²  Fortunately, the specialty of EM has an unstoppable growth mindset with a trailblazing attitude rooted in deeply held core values to treat anyone at any time, regardless of circumstance.  Just as EM physicians branched outside the ED walls into EMS, ultrasound, toxicology, critical care, education, global health, and administrative roles, telehealth is the next frontier.  A metamorphosis into a hybrid physical-digital care model will transform EM and its capabilities yet again, while helping to address today’s most pressing healthcare challenges. 

EM enters the digital era alongside the rest of the world, transforming how we deliver care by utilizing telehealth technology to improve efficiency, quality, and safety. Secular forces such as a tsunami of geriatric patients with extensive comorbidities, a shortage of healthcare workers and beds, shrinking operating margins, and increasingly burdensome regulatory requirements make telehealth an attractive strategy to tackle these challenges head on. EM has a prime opportunity to be a leader in this space and grow exponentially with it, as almost no other specialty is armed with such a vast array of skills to provide patient-centered telehealth services in a plethora of ways. Importantly, EM providers are “available” 24/7/365, a defining feature of the specialty that fills a healthcare need and a telehealth demand.³  Furthermore, local Tele-EM providers, as opposed to national and international telehealth companies, have access to “insider” information in their community to help arrange both timely acute and follow-up care (with specialists and PCPs) as needed, which is critical to quality outcomes and patient satisfaction. Not only in the ED, but in the pre-hospital realm as well, telehealth expands the scope of EM providers and their impact. 

Within the ED, telehealth use for triage decisions (tele-triage) both for new patient arrivals and inter-hospital transfers (to tertiary hospitals) is an intriguing use case.  Starting well before the COVID-19 pandemic and continuing up to today, nationwide bed capacity issues for most healthcare institutions are worsening due to multifactorial reasons mentioned prior.   Improving the triage process with tele-triage providers to decrease door-to-doctor-time might subsequently improve left-without-being-seen rates and department flow with early order placement.⁴   Remote providers in geographically agnostic locations and time zones can expand the EM labor pool to assist with this role (state licensing dependent).  Lower acuity patients can be quickly discharged by tele-triage providers freeing up time for in-person providers to see higher acuity patients.  Time critical diagnosis recognition (stroke, STEMI, sepsis) for ED patients will also be an opportunity for EM-telehealth providers to aid and improve the quality of care that patients receive despite challenges with limited bedside staffing.⁵  These life-threatening conditions can be recognized by a telemedicine provider (ideally with access to an electronic health record), and with earlier treatment initiated, historically outcomes are improved.⁶  

To maximize efficiency and quality within the ED, EM telehealth will likely trend towards a hub-and-spoke model (one central telehealth command center coordinating care for many different hospitals).  This lends itself to improved standards of care with focused and trained core telehealth providers performing triage and advising/assisting best practice protocols (sepsis, lung protective ventilation, sedation, geriatric care, infection prevention, trauma, cardiac arrest, disaster management).⁷ This model could also decrease new knowledge translation time to the bedside for complex diseases with constantly evolving treatment guidelines.  Especially in rural areas where local hospitals depend on a physician workforce that might not uniformly include physicians with extensive training and certification in EM, telehealth can offer a bridge to high quality care with triage, treatment, and disposition assistance.⁸ A hub and spoke model also allows for triage and high-quality emergency care simultaneously at multiple sites for critically ill patients in locations that do not see a high volume of these patients. Utilizing EM telehealth, rural EDs will be more capable of handling clinical scenarios that would otherwise be difficult to train, staff, and plan for in resource-limited locations. This will allow some patients to receive care in local, smaller hospitals as opposed to being transferred to a larger medical center further away, easing bed pressures on tertiary hospitals and improving patient satisfaction.⁹

Outside the walls of the ED, the future of EM-telehealth in the pre-hospital realm is a massive opportunity waiting to be unlocked.  EM telehealth could play a prominent role in “forward triage” where health systems use an expert in triage (an EM physician) to direct patient care to the right place at the right time before they arrive to an ED (often in conjunction with EMS).¹⁰  It is theoretical that some of the ED overcrowding/high left without being seen rates could be mitigated if lower acuity patients did not require or were directed away from the ED by an EM telehealth provider, when appropriate. This concept is already being actively tested in a pilot stage. In 2019, the emergency triage, treat, and transport (ET3) program was developed for EMS to treat patients at the scene of a call with the help of a telehealth provider, or transport the patient to an alternative site like an urgent care or a doctor’s office.¹¹ Although still in proof of concept/pilot stage, the ability to triage a patient at the point of contact to avoid an unnecessary ED visit or help guide the patient to the proper place of treatment based on the patient’s acuity, the ED’s current capacity, and their known capabilities could potentially be monumental in a value based health care system.  This concept may ultimately have positive financial impacts for hospital systems looking to avoid penalties on readmissions, insurance companies looking to avoid paying for high healthcare costs, medics for getting paid when not transporting patients, and patients themselves for lower healthcare spending. Forward triage by EM providers using on-demand telehealth evaluations to decrease unnecessary ED visits but still allow for expert evaluation has a promising future. This may be the “walking well” with minor care symptoms utilizing a tele-urgent care offering staffed by ED physicians, EMS-assisted evaluations such as with ET3, telemedicine visits in skilled nursing facilities/assisted living/rehabilitation centers, or even in community centers (shelters).  No matter the location or time, EM-telehealth staffed by 24/7/365 experts in triage offers a solution. This also offers a new opportunity for EM physicians young and old to capitalize on geographical freedom, focus on wellness, avoid burnout, and extend their careers.¹²    

Finally, outside the traditional EM paradigm, EM expertise in a broad array of domains is an asset to be monetized, and telehealth could allow that at scale. This should appeal to EM programs looking for new/increased revenue models, and hospitals seeking to contain costs but enhance quality metrics.  Whether this expertise is in ultrasound, critical care, education, medical toxicology/substance use, global health, EMS, or others, the value of EM physicians can be monetized in ways never before possible utilizing telemedicine. Partnerships and contracts can be established near and far for best-in-class care in these domains without classic geographical, or even time zone restrictions.¹³ 

Conclusion

Society is transforming, and as Marc Andreessen stated, “software is eating the world.”¹⁴  This digital transformation and evolution of our world will not exclude the field of medicine.  In fact, COVID-19 just expedited it. Although there are challenges with telehealth and unknowns, society quickly embraced its benefits and is unlikely to retreat to yesterday’s expectation of in-person visits for everything. Patients from this point forward will expect access to telehealth as an option when outcomes are equal,¹⁵ and will shift their consumer preferences to those who provide it, like preferences for web-based and mobile applications compared to their physical counterparts (ex. online banking). EM must start planning for this future now as the shift to telehealth is still in its infancy. Younger generations will continue to be more facile with technology and expect its incorporation in their care as they grow older and acquire health issues. Telehealth is the next frontier for EM to innovate, lead, and grow. Important questions remain unanswered (patient satisfaction, cost savings, patient centered outcomes, health equity using telehealth, clinician wellness, etc.) as the gaps in knowledge around telehealth continue to be illuminated.  The opportunity is now, and some EM programs have already seized the moment, embraced technology and change, and are boldly seeking ways to expand EM’s reach and delivery of exemplary care to all patients in need, now in a more modern format. That is the ethos of EM, evolving virtually in front of our eyes in hopes of a brighter future, and will propel our specialty to new heights.   

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