AAEM NEWS
Telehealth and Emergency Medicine: Our Virtual Practice Aditi U. Joshi, MD MSc FACEP
Despite the recent uptick in interest in virtual care, telehealth has actually existed for decades, used initially by the military and NASA to increase health access to those needing remote care. In general, telehealth is defined as using technology to have a remote medical encounter between two parties. It can refer to chat, store and forward, video, or telephone, the latter two generally being synchronous. Historically, there has been low engagement for various reasons; reimbursement, lack of understanding of use cases, lack of training, no implementation within health care systems and general slow uptake of technology.
In general, telehealth is defined as using technology to have a remote medical encounter between two parties.
THE CRUCIAL NEED TO DISTANCE, SCREEN, EVALUATE, AND PRESERVE PPE FOR THOSE NOT CRITICALLY ILL HAS ALLOWED USING REMOTE VIRTUAL CARE TO GROW IN BOTH ITS UTILITY AND ENGAGEMENT.
Nothing has changed the trajectory of using telehealth more than the recent COVID pandemic. The crucial need to distance, screen, evaluate, and preserve PPE for those not critically ill has allowed using remote virtual care to grow in both its utility and engagement. It is likely that while the stages of the pandemic ebb and flow, the use of telehealth will continue to expand within health care. For emergency medicine practitioners, who straddle prehospital and inpatient, there are three main ways telehealth has and is being used:
Provider to patient acute care: this is also called direct to consumer and is initially offered by large national companies to treat acute care complaints from wherever the patient is calling. Currently, much of the care is done without adjunct devices or apps unless a patient already has them; this has necessitated creative ways to do physical exam. It also has been limited by the patient’s accessible technology and connectivity leading to understandable concerns of increasing inequity in health care. In general, this allows convenience of care and future use in EM can allow for efficient triage and prehospital care. Tele-triage: is something unique to emergency medicine. Increased ED visits over the last few years has led to longer wait times, overcrowding, and increased left without being seen all of which lead to worse patient outcomes. A number of interventions have been trialed such as RN orders from triage, placing a physician, resident or advanced practice provider (APP) in triage for order placement or discharge, more provider engagement and transparent metrics. Much of this has not worked or required increased staffing. Tele-triage allows a physician or APP to perform a remote virtual triage visit with a nurse or tech, write a note and put in orders, allowing patients earlier entrance to the ED process. This can substantially decrease left without being seen and time to provider. It can potentially affect length of stay; however, studies have not yet supported this likely due to other factors affecting ED throughput such as boarding. Provider to provider or remote consults: Programs such as tele-stroke, allowing a hub hospital team to consult and advise treatment or transfer for ‘spoke’ hospitals are an example of this type of telehealth. There is a tendency to think of these in relation to their originating specialty, such as transplant, specialist, or stroke networks. However, many of these specialists are consulting in remote EDs or those without that particular specialist access. These consults allow for a specialist team to evaluate a patient and prepare for transfer. However, another benefit is decreasing transfers by advising on site care and allowing patients to be treated at their home hospital safely.
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COMMON SENSE SEPTEMBER/OCTOBER 2020
