To compensate for a severe shortage of experienced emergency physicians, small, rural hospitals in the Great Plains are taking advantage of a Sioux Falls, SD-based emergency telemedicine network to connect local EDs, which often are staffed by mid-level providers or primary care physicians, with experienced, board-certified emergency medicine physicians whenever they need added expertise. This approach has grown from eight participating hospitals in 2009 to 150 hospitals today, with more expected to sign on soon.

  • The Avera eCARE telemedicine network operates out of Avera McKennan Hospital, a tertiary care facility in Sioux Falls, SD, providing emergency medicine consultations to rural hospitals in multiple states. Hospitals pay a monthly fee for access to the tele-emergency services.
  • Barriers to the approach include the high cost of implementing two-way, audiovisual communications that are private and reliable to all participating hospitals, and properly licensing all the emergency medicine physicians operating out of the hub.
  • Studies show that while the tele-emergency service offers financial benefits to patients and the local economy, rural hospitals typically do not share in these financial dividends. The prime motivation for offering the service is to facilitate access to emergency medicine expertise and to improve care quality, although some experts observe that there also may be benefits in terms of the effects on physician retention.

For years, there has been a shortage of emergency physicians, straining rural hospitals, many of which use family practice physicians or advanced practice providers to cover shifts in the ED. Although many of these providers are highly experienced, there can be instances in which especially newly minted providers are overwhelmed by cases requiring a high level of emergency care expertise. Transferring patients to a larger, tertiary care facility may be an option in some cases, but there are times when recovery or even survival depends on swift treatment.

In such cases, it would help if providers at these small, rural facilities had 24/7 access to experienced, board-certified emergency physicians at a moment’s notice through a telemedicine hookup. This arrangement exists in the Great Plains where designated emergency physicians at Avera McKennan Hospital, a tertiary care facility in Sioux Falls, SD, have been available to consult on cases at small, rural hospitals in multiple states through the Avera eCARE telemedicine network.

Beginning with just eight participating hospitals in 2009, the tele-emergency network now includes 150 hospitals, with more scheduled to sign on soon. Further, while the small hospitals that use the service do not necessarily reap direct financial benefits from the approach, studies show that patients and local economies benefit through savings related to avoided transfers and other expenses.

Developers note that the main benefit from the approach (and the primary the reason why rural hospitals pay for this service) is better patient care. They also suggest that the success of the network offers ample evidence that telemedicine could provide answers to other regions struggling to maintain ready access to emergency care expertise. (See story about pediatric emergency medicine in this issue.)

Surmount Regulatory Hurdles

Although the telemedicine network operates well now, developers acknowledge they had to surmount multiple barriers to make the approach feasible. Obtaining the funds to nurture the effort has been an ongoing challenge, but grants have arrived from multiple sources. Of particular importance was $6.2 million in funding from the Helmsley Charitable Trust in 2009.

“That money was critical to the success of our network,” observes Mandy Bell, MHA, eCARE quality and innovation officer at Avera eCARE in Sioux Falls, SD. “We were able to hire board-certified emergency physicians to be available around the clock pretty much instantly so that they weren’t also working other jobs in the hospital’s main ED where they would have to be pulled away from the bedside,” she explains.

The money also went toward putting the robust information technology and wireless networks in place so that two-way video communications between the tertiary care hub and participating rural hospitals would be high quality and private. However, in the early days of the project, developers were unsure whether the approach would catch on and expand.

“It was a brand new concept, and it took a lot of conversations with providers and nurses about whether this was something that they would feel comfortable having in their rural EDs, whether this was something they would actually use in the case of an emergency, and whether their administrations would eventually be willing to pay for the service,” Bell notes. “From day one, we did have the participating facilities start to pay what we call a monthly service fee for access to the network, but early on, grant funding was taking care of most of that cost.”

Another barrier was related to the fact that the telemedicine hub provides service to hospitals in multiple states; therefore, the providers delivering the service must be licensed in all those states.

Take Note of Emerging Needs

With eight years of experience and an expanding market, network administrators have a good understanding of how and when the emergency telemedicine network is used most often, and they have come to understand the emerging needs of many of the small, rural hospitals that use the service.

“The trend that we have picked up on as we work with hospitals in the Great Plains area is that they have these very seasoned physicians with 30 or 40 years of experience who are retiring ... and it is hard to recruit and retain a practice in a rural environment with someone who did not actually grow up in a rural environment,” Bell says.

Many communities increasingly rely on mid-level providers to fill the staffing needs in the community, but that leaves fewer physicians available to take calls in the ED.

“We have some hospitals where the physicians used to be on call every other night, and that was burning them out, especially the new physicians with young families,” Bell shares. “They were really struggling to maintain a work-life balance with that onerous call schedule.” Such demands make it difficult to recruit physicians into rural settings, so many hospitals in these regions staff their EDs with advanced practice providers. In these arrangements, an experienced, board-certified emergency physician who is accessible via telemedicine makes everyone involved more comfortable, Bell explains.

“It makes the [nurse practitioner] more comfortable with the scenario, and it makes the rest of the medical team more comfortable because while they know that [the on-site practitioner] can handle almost anything, there are going to be those few things that they are really going to want help for, and now they can get that through telemedicine,” she says.

Other rural hospitals staff their EDs with family practice physicians who primarily work in primary care, and they too can encounter patients in the ED requiring procedures or care that they may not feel well-equipped to provide. “Sometimes, we will come to facilities where the physicians have not had the chance or even the need to do an advanced airway procedure for many years,” Bell explains. In these cases, an emergency physician who routinely performs that procedure who can help coach others through the process can make a huge difference in the patient’s care, she says.

In addition to using two-way audiovisual communications during such patient encounters, the emergency physicians operating out of the hub also have access to imaging from the local hospital as well as electronic medical records, if needed. They may also use a video laryngoscope. “We can tie our video unit into that video feed so that our remote physicians can also view the airway when [the on-site provider] is trying to place an airway tube in the right location,” Bell explains. “Those are really intense situations, especially if you are dealing with a difficult airway because of trauma or other factors with the patient.”

Develop Protocols

Clinton MacKinney, MD, MS, an emergency physician practicing in Little Falls, MN, and deputy director of the Rural Telehealth Research Center in the Department of Health Management and Policy at the University of Iowa in Iowa City, IA, explains that the most common calls into the emergency telemedicine network involve heart attacks, strokes, multiple trauma, and behavioral health concerns. This largely aligns with a 2016 analysis conducted by MacKinney and colleagues, who examined what clinical situations typically trigger tele-emergency consultations.1

MacKinney notes that family practice physicians or nurse practitioners on duty in the ED may not be comfortable handling these types of complex or time-sensitive cases. “In those situations, it is really nice to have those emergency physicians from the hub looking over your shoulder, offering help when you want it, and also getting out of the way when you don’t want it,” he says. “That is critically important to a successful tele-emergency program, how the folks at the hub treat the professionals out in the rural area.”

MacKinney adds that very little training or preparation is needed on the part of the on-site clinician to use the service. They can simply press a button, and an emergency physician from the hub will be available to consult, generally in a matter of seconds.

“Typically, there is a flat screen monitor that is 50 inches or so diagonal, a camera that can be manually controlled, and a surround-sound-type microphone that is usually hung right over the bed where the patient would be,” MacKinney shares.

Once the equipment is set up and two-way communications capability is established in a rural hospital setting, it is helpful for the local staff to devise some protocols around who will use the system and when it will be activated. How the system is used varies quite a bit depending on the characteristics of the facility and the experience level of the staff, MacKinney relates.

“In some rural EDs, they have very low volumes, but periodically they will have a severe or serious case,” he says. “But the person who is staffing the ED may not be as experienced in emergency medicine as the clinicians on staff in a larger hospital,” he says. Also, some hospitals have more than one room set up for telemedicine encounters, he adds.

Employ Communications Training

Even experienced emergency clinicians find value in using the telemedicine service on occasion. For instance, MacKinney has called into the hub on two occasions. “In one situation, we had a young man who had a cardiac arrest, and it was complicated because he was coming in and out of cardiac arrest frequently,” he explains. MacKinney consulted with the emergency medicine physician at the hub to get his take on whether there was something he missed or anything else he could do. The hub physician reassured MacKinney that he was doing all the right things.

The second case involved a man who overdosed on blood pressure (BP) medication, and MacKinney was having a tough time getting his BP up. “We had the [ED physician] from Sioux Falls, SD, engaged, and we had a pharmacist from our hospital down there with us, and it was just very complex,” MacKinney recalls.

In these atypical situations, it can be helpful to have the telemedicine physicians available to discuss treatment approaches, MacKinney observes. “They know how to be consultative, professional, and helpful, not questioning or judgmental,” he says.

In addition to their experience and board certifications, the physicians providing the telemedicine consultations from the hub receive added training on how to work effectively with their remote practitioners, Bell explains. “That is really about communication strategies and dealing with the fact that you keep your hands in your pockets. You can’t reach through the TV and do any of these procedures yourself, so how do you personally handle that feeling of stress,” she says. “The local provider is remaining in control of the patient. It is their patient, and we are there to help them as they are asking for help so they are never feeling like we are there to judge them or disagree with them in front of the patient.”

When the telemedicine physician disagrees with the on-site practitioner, he or she will ask to speak with the practitioner on a private phone line, Bell explains.

The emergency care telemedicine hub tends to be busy when regular EDs are busy, with the peak time generally between noon and 2 a.m. most days, Bell explains. Interestingly, the weekends tend to be less busy, perhaps because during this period many rural hospitals staff their EDs with locum tenens providers who are less familiar with the telemedicine network or how it works, she says. One critical aspect of the telemedicine service is that the emergency physicians are not dividing their time between local emergency patients and telemedicine calls. They are devoted only to handling the calls that come in from participating hospitals within the network.

“If [a practitioner] has a multi-victim accident coming in, they are not going to want to wait 12 minutes for our provider to wrap up whatever he or she is doing at the bedside,” Bell says. “In an emergency, you need somebody right now, and if we are going to provide that level of support, we’ve got to be there right away.”

For instance, Bell recalls two incidents during which immediate assistance from the telemedicine physicians was critical. The first case occurred several years ago, when the telemedicine network was still in its infancy.

“A woman had been bitten by a rattlesnake and was taken to the ED where [clinicians] gave her antivenom. She went into anaphylaxis, so her throat swelled and she couldn’t breathe on her own,” Bell notes. “It was a life-threatening situation, especially given that a flight team was so far away.”

The telemedicine physician helped the on-site provider with an airway-clearing procedure so that the patient could be transported safely to a bigger facility to handle the situation.

In the second case, a young girl was in critical condition following an all-terrain vehicle accident. “She was in critical condition when she came into the ED,” Bell explains. “Our providers were able to walk [the local practitioners] through how to place a chest tube to help the patient’s lungs inflate.” The girl still had to be transported to a larger facility, but the telemedicine physicians provided critical expertise in a life-threatening situation, Bell adds. As the program has grown and progressed, administrators have figured out new ways to offer value to participating hospitals and to be a more integrated part of the local healthcare teams. For instance, hub providers will participate in debriefings after significant events in a community.

“If the hospital has had a community member who has had a really bad outcome, we can bring in a chaplain to help walk through the event,” Bell explains. “We will help [the local team] get through some of those challenging first days.”

Determining how to be a part of the local rural healthcare team even though one may not be there physically has enabled the program to thrive, Bell offers.

“In many places, we are on a first-name basis with the local care team,” she says. “We feel like we are alongside them in the trenches when the worst happens.”

Consider Effect on Care Quality

The telemedicine service is still funded through monthly service fees paid by the participating rural hospitals. One new study shows that the approach offers financial dividends to patients, primarily by enabling them to avoid the costs associated with transfer to a larger facility. Researchers note that staying in a local hospital saves patients about $5,600 in a given year, considering the costs associated with transfers, missed work, lodging, and other expenses.2

However, with the high cost of operating the service, local hospitals do not necessarily enjoy any direct financial benefits, although there is a boost to the local economy, according to investigators. But some note that anecdotal evidence suggests there is an educational benefit to the local providers who take advantage of the telemedicine service.

“Telemedicine may be helping them stay up to date with information,” observes Nabil Natafgi, PhD, MPH, CPH, a research associate and adjunct assistant professor in the Department of Health Management and Policy at the University of Iowa College of Public Health in Iowa City, IA, and a co-author of several studies on the effects of the telemedicine network. “For instance, if [a provider] connects for a specific case regarding cardiac arrest, and they receive recommendations ... they would know the next time they see this presentation or a similar diagnosis what kind of physical exams and treatment they should provide to the patient.”

MacKinney suggests there are some indirect ways that rural hospitals benefit financially from using the emergency telemedicine service. In particular, he points to savings in recruitment and retention costs.

“We have anecdotes that rural hospitals have been more successful in recruiting providers to their areas because of the availability of tele-emergency medicine,” he says. “When something really bad is going on, you may feel alone, so it is very nice to have the collegial support available to you.”

A second benefit is a lesser-known rule in critical access hospitals that enables the tele-emergency hub to be the backup physician for a physician assistant or a nurse practitioner working in a rural ED, MacKinney explains.

“Therefore, a hospital would not have to pay for a backup physician to be on call in the ED. They could simply use the tele-emergency hub as the backup,” he says. However, while there are some financial advantages, MacKinney stresses the main reason to use tele-emergency services is not financial.

“It is to improve the quality of care, and to help those providers who are working in resource-poor areas and don’t have staff or backup,” he says. “Not every rural ED can have available an emergency medicine-trained physician and all the support systems he or she is accustomed to,” he says. “The compromise, I think, is tele-emergency care.”


  1. Ward MM, Ullrich F, MacKinney AC, et al. Tele-emergency utilization: In what clinical situations is tele-emergency activated? J Telemed Telecare 2016;22:25-31.
  2. Natafgi N, Shane D, Ullrich F, et al. Using tele-emergency to avoid patient transfers in rural emergency departments: An assessment of costs and benefits. J Telemed Telecare 2017; doi: https://doi.org/10.1177/1357633X17696585.


  • Mandy Bell, MHA, eCARE Quality and Innovation Officer, Avera eCARE, Sioux Falls, SD. Email: mandy.bell@avera.org.
  • Clinton MacKinney, MD, MS, Emergency Physician and Deputy Director, Rural Telehealth Research Center, Department of Health Management and Policy, University of Iowa, Iowa City, IA. Email: clintmack@cloudnet.com.
  • Nabil Natafgi, PhD, MPH, CPH, Research Associate and Adjunct Assistant Professor, Department of Health Management and Policy, University of Iowa College of Public Health, Iowa City, IA. Email: nabil-natafgi@uiowa.edu.