Many hospitals already are leveraging telemedicine to quickly connect patients with needed consults for things such as stroke and mental healthcare. However, there is growing interest in applying this same type of technology to the problem of crowding in the ED.
For instance, as part of a larger effort to incorporate digital health solutions throughout its healthcare system, New York-Presbyterian (NYP) is piloting the use of virtual visits for patients who present to the Lisa Perry Emergency Center at NYP’s Weill Cornell Medical Center in New York. Administrators say it is a level of service patients have long been requesting.
“When patients go to the ED, one of their complaints and concerns has always been that they wait forever, which for some of the simple things shouldn’t take that long,” says Rahul Sharma, MD, MBA, CPE, FACEP, the emergency physician-in-chief for the Division of Emergency Medicine, an associate professor at Weill Cornell Medicine, and the medical director of strategic initiatives and the “Making Care Better Program” for NYP Weill Cornell Medical Center. “We just wanted to give our patients another option at the way they receive healthcare.”
Ensure Safety, Compliance
Sharma acknowledges the idea of providing virtual visits to patients who go to the trouble to travel to the ED for care did not seem like a winning idea to some of the staff initially. They assumed these patients would demand to see a provider in person. However, Sharma compares this new offering in emergency care to what already has happened in banking.
“Several years ago, banks were going up everywhere in New York City. On every single street corner there was a bank,” Sharma notes. “When they built up all these banks, people would ask why would anyone go to an ATM when you have a bank and you can just go to the teller.”
Now, people rarely go inside a bank just to get cash from the teller, says Sharma, and he thinks patients are yearning for the same kind of convenience when they require medical care, although he stresses that this approach is suitable only for patients with lower acuity conditions — at least at this stage.
People with chest or abdominal pain, or people who require long workups or CT scans are not ideal for the virtual approach, Sharma explains. However, he notes that a significant chunk of patients who present to the ED have colds, small wounds they need to get checked out, or other minor conditions that can be managed safely by a provider who is seeing them via telemedicine hookup, especially when other aspects of care are in place to ensure safety.
“While the patient is being seen virtually, they have already been seen by a physician assistant [PA] or a nurse practitioner [NP] in the triage area,” Sharma explains. “They have had vital signs taken, they have already had a formal triage and all the other requirements have been done, so these people aren’t just getting whisked into a room and whisked out. We still have to follow our requirements, and we want to make sure we are doing this in a safe way.”
Target Wait Times
While the process is still quite new, initial results are promising.
“We initially offered the service for four hours a day. We then expanded it to six hours, and now we have expanded it to eight hours a day Monday through Friday,” Sharma explains. “We plan to expand this to 16 hours a day.”
On average, over a period of four to six hours, three or four patients are seen via telemedicine, and that should double when the service expands to 16 hours, Sharma notes.
“These are patients who would otherwise spend a couple of hours in the ED, and they are in and out within half an hour, which is just unheard of,” according to Sharma, and he notes there are benefits for emergency providers as well.
“What it does is allow our [on-site] physicians and providers to focus on other patients,” Sharma says. “What we are essentially doing is decanting the ED [of] these simple, lower-acuity patients so [providers] can spend more time with, and get other patients out, sooner.”
This is becoming more important, Sharma says, because despite some predictions that passage of the Affordable Care Act would reduce ED volume, the opposite has occurred.
“If you look at the numbers nationally, the number of visits to the ED actually has gone up,” he says. “More patients are coming to EDs, making it more challenging for providers, so if we can offer services that take a chunk of these patients away from our [on-site] providers and have someone else take care of them, that results in improved overall operational efficiency for our ED.”
Interacting with patients is the easy part of offering care via telemedicine in the ED, Sharma notes. Integrating the offering into the workflow of the ED presents more challenges.
“As with any initiative, we had to make sure we had buy-in from our nurses and staff members as well as our physicians because there is no point of doing something unless you have buy-in from your staff,” he says.
Also critical is getting everyone educated and comfortable with the new process.
“From the time a patient comes in, if your front-end intake process, your triage process, is not well-designed and it is not robust, then this won’t be a success,” Sharma explains. “Everyone from patient services to the registrar to the greeter nurse and the [PA] or [NP] who is examining the patient has to be on the same page and well informed.”
Sharma notes that in NYP’s program, the PAs and NPs in the triage area are equipped with scripting on how to introduce the program, which is voluntary, to appropriate patients.
“They have to explain that we are trying a new program where the patient can be seen by one of our same doctors, but by telehealth monitor in a private room with convenient chairs,” he says. “These are board-certified, Weill Cornell faculty attending physicians. They are sitting in a room that is essentially an old office that is equipped with monitors. It is not in the ED.”
Patients also have the option of visiting the “fast track” area of the ED in which they likely will wait between two to three hours to see a provider, Sharma explains.
“If you tell patients that, they will say, ‘Why not try the new program,’” he says. “We were actually a little surprised at how many patients agreed to this program. I do want to emphasize, though, that this is not for all patients. This is for patients with minor issues — not for complicated workups where physicians really need to physically touch the patient.”
Sharma adds that a critical element to successfully offering virtual visits in the ED is making sure facilities provide the same high level of care to a patient regardless of whether that patient receives in-person treatment or virtual telehealth services.
“You have to follow all the rules and regulations to make sure that you do this in a safe manner,” he says. “That’s why we make sure that all these patients have gone through triage, have gotten vital signs taken, and are appropriate candidates. What we don’t want to do is open this up for all patients.”
Payment for virtual visits is just the same as if the patients were treated in person. There is no additional charge for telehealth, Sharma notes, and thus far, patients seem very pleased with the approach.
“We have had patients from the ages of 21 to 91, and we called back many of them to see how they liked the experience,” he says. “I would say most of them loved the experience and wouldn’t want it any other way.”
Buoyed by these early results, NYP plans to expand the telehealth option to a second hospital soon, and to closely monitor the effect on ED throughput as well as the overall patient experience.
“If this all goes well, we could see this expanding to other NYP sites as well,” Sharma adds.
Address Hurdles Early On
While NYP is one of the first health systems to pilot virtual visits in the ED, there have been earlier efforts. For instance, back in 2013, the University of California San Diego Health System launched a pilot to determine if telemedicine could help ease crowding by leveraging on-call physicians remotely when the ED gets busy. Hillcrest Medical Center, a Level I trauma facility that was treating about 60,000 patients a year in the ED at the time, implemented the approach.
The pilot consisted of an on-site telemedicine module that included a video screen, a camera that could be controlled by the remote physician, and tools to enable the physician to evaluate a patient during the telemedicine encounter. A dedicated, on-site nurse would handle the peripherals — placing a stethoscope where instructed by the remote physician, for example.
The most critically ill patients were not treated remotely, but there were no set criteria limiting what types of patients could be seen via telemedicine, although the approach was designed primarily for patients who were deemed safe at triage to be sitting in the waiting room while the ED was full. During the pilot, investigators noted that while most of the patients treated via telemedicine were on the lower acuity side, some patients required hospital admission.
Investigators had high hopes for the approach. The thinking was that eventually one off-site physician potentially could examine patients from several different EDs, improving efficiency and throughput at multiple sites in the health system. However, the approach never got beyond the pilot phase. Benjamin Guss, RN, the nurse champion of the telemedicine project, dubbed the Emergency Department Telemedicine Initiative to Rapidly Accommodate in Times of Emergency (EDTITRATE), explains that part of the problem was that the model required the involvement of both a remote physician and an on-site physician.1
“A telemedicine physician would be seeing the patient primarily, but then at the end of the visit the telemedicine doc would have to discuss the case with an on-site doc, and then that emergency physician would basically give the blessing to whatever the diagnosis was or the discharge or admission [decision], so it [required] taking two physicians to see one patient, which really bogged down the whole system,” Guss explains. “It took the [on-site] ED physician away from seeing other patients, and it ended up just taking a lot longer to get through one patient.”
The involvement of the on-site physician was necessary because, at the time, some insurance companies required this step for reimbursement, and some clinician leaders at the hospital wanted the on-site physician involved out of liability concerns, Guss explains.
Despite these administrative hurdles, patients were receptive to receiving care via telemedicine.
“It went really well. We saw about 85 patients, and there were no bad outcomes with any of them,” Guss recalls. “Some patients would even come back and ask for [a telemedicine visit] again when they presented to the ED. Unfortunately, though, we weren’t doing it every day; it was only used when the ED was busy.”
The pilot lasted for about six months, never moving beyond the pilot stage, but Guss notes there is still interest in restarting a telemedicine approach in the emergency setting if the insurance and liability concerns can be addressed.
“I really enjoyed doing it and think it can be a big success and work well in the ED,” he says. “We are just waiting for a good time to start it up again.”
Guss’s advice to emergency medicine colleagues interested in developing a telemedicine approach is to have a clear plan in place, get everyone involved to agree to the plan, and make sure that insurance companies are on board with the approach as well.
Sharma from NYP echoes these sentiments, noting that getting the workflows right is the biggest challenge. He also notes that providers and staff have to understand fully how the process will work before launch.
“While it is a new service, some people may not be comfortable doing this, and some patients may not want to do this,” he says.
- Toila V, Castillo E, Guss D. EDTITRATE (Emergency Department Telemedicine Initiative to Rapidly Accommodate in Times of Emergency). J Telemed Telecare 2016; doi: 10.1177/1357633X16648535.