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 medi cal 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.

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 prehospi tal and inpatient, there are three main ways telehealth has and is being used:

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.

Provider to patient acute care: this is also called direct to consumer and is initially offered by large national com panies to treat acute care complaints from wherever the patient is calling. Currently, much of the care is done with out 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 trans fers by advising on site care and allowing patients to be treated at their home hospital safely.

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It is both an exciting and uncomfortable time in medicine as we imagine the far-reaching consequences.

For those wanting to setup a program, the high level is knowing the needs of the practice, hos pital, and community. The details are outside the scope of this article, however, keep the fol lowing in mind:

Use case: Be clear the problem you are trying to solve whether decreasing transfer, improving throughput measures etc. as that will dictate the type of program to create.

Create a team: this includes administrative, tech, compliance, legal, and billing

Choose platform: Again, this will be based on the use case. It should be secure, easy to use for both patients and clinicians, and easy to troubleshoot. Many do not automatically inte grate into the electronic medical record (EMR) so keep that in mind when thinking through workflows. Understand billing/reimbursement: Working with the billing department to understand what types of services you can and will bill for.

Credentialing and regulatory: Ensuring all pro viders have proper licensing based on state and federal laws.

Training: Ensuring all know not only how to use the platform but understand workflows, processes, and how to have effective virtual encounters (webside manner, physical exam, clinical guides).

Quality Assurance: Reassessment of clinical outcomes, whether the program is fulfilling its intended purpose and changing as needed. The ability to see patients at a distance and expand our area of care will create some inter esting questions for ourselves as emergency medicine: how far does our specialty expand? How will we ensure safe practices and quality visits for patients in and outside the emergency department? How will this impact our education and need to train our undergraduate and gradu ate medical students for this future? It is both an exciting and uncomfortable time in medicine as we imagine the far-reaching consequences. However, it’s important to remember that telehealth is simply a modality to help us under stand our patients home environments, improve access within our communities and neighbor hoods, and be able to advocate for our patients in a much larger way.  

Why AAEM?

AAEM is the leader within our field in preserving the integrity of the physician-patient relationship by fighting for a future in which all patients have access to board certified emergency physicians and physician rights are protected.

It’s a challenging time for emergency physicians - AAEM recognizes that and were doing something about it.

We’ve continued to fight for your due process rights — AAEM worked closely with the sponsors of newly introduced legislation. We’ve had your back during COVID-19 — Read our position statements and letters to government officials advocating for you during this pandemic. We protect your practice rights — We’re actively working to address APP independent practice to create a balanced workforce through both position and policy statements. We’re advocating for a solid future for our specialty - we’re working with the newly formed EM Workforce Committee for a future with a balanced work force. We’re committed to diversity, equity, and inclusion – The AAEM Diversity, Equity, and Inclusion Committee is working hard to bring members resources and awareness, including statement on the Death of George Floyd and the Statement Against Federal Regulation. We joined the clear message being sent that #ThisIsOurLane. We are the front line providers, and we will be at the forefront of the solution, which is why we signed on to support AFFIRM.