Thanks in part to a little-noticed policy shift by the Centers for Medicare & Medicaid Services (CMS), there is fresh evidence that telemedicine can offer rural hospitals a cost-effective solution to the serious challenges they face in trying to recruit and retain physicians to cover their EDs. Further, while efforts to build effective telemedicine networks in the emergency medicine arena have struggled, one network based in Sioux Falls, SD, is in expansion mode, with 185 hospitals in 13 states already hooked up to the network’s hub.

  • For years, CMS maintained that hospitals have to put in place a local physician who has to back up an advanced practice provider working in an emergency setting. But in 2013, CMS issued a memorandum stating that for critical access hospitals with tele-emergency services, that backup did not have to be local; it could be a physician operating virtually out of the tele-emergency hub.
  • After this policy change, several rural hospitals shifted some of their ED coverage to advanced practice providers, using an emergency physician from the tele-emergency hub as backup.
  • Investigators found that the savings achieved by making these adjustments amounted to an average of $117,000 per year at seven rural hospitals that took advantage of the new policy. Conversely, 12 hospitals that did not make any staffing changes continued to see their staffing costs rise by an average of $138,000 per year.

Although telemedicine has existed for years, its use in emergency medicine has been limited in most regions to specific specialty consults.

For instance, it is not uncommon for emergency clinicians to consult neurologists in this way when they see a stroke patient. A growing number of EDs have established telemedicine hookups with behavioral health specialists to help care for patients with psychological issues. Further, some EDs are using telemedicine for triage or in the care of patients with low-acuity conditions.

However, the idea of leveraging telemedicine to help address the chronic shortage of physicians staffing EDs in rural areas has been discussed often as a potent solution to a difficult problem. Critical access hospitals struggle to recruit and retain physicians, given the long work hours needed to cover an ED in these outlying areas and the lack of opportunities to interact with other professionals in the field.

Certainly, progress with using telemedicine for this purpose has been slow, given the regulatory hurdles and investment required to put such a system in place. But now there is fresh evidence that telemedicine can help not only to relieve the staffing burdens on critical access hospitals that are striving to maintain emergency care in their communities, it also can deliver financial benefits.

The Avera eCare network, affiliated with Avera Health in Sioux Falls, SD, has been providing emergency medicine consults via telemedicine to scores of hospitals in multiple states since 2009. Under the arrangement, hospitals pay a monthly fee for the ability to access an emergency physician via two-way hookup as needed with the push of a button. It took years and a generous supply of grant funding to establish the telemedicine network, but the approach offers rural hospitals a way around the dearth of physician expertise in their communities.

Documented financial savings from the approach have not necessarily been part of the package, at least not until the Centers for Medicare & Medicaid Services (CMS) instituted a little-known regulatory change.

For years, CMS maintained that under the Emergency Medical Treatment and Labor Act (EMTALA), hospitals have to ensure a local physician is in place to back up advanced practice providers working in an emergency setting. However, in 2013, CMS issued a memorandum stating that for critical access hospitals with tele-emergency services, that backup did not have to be local; it could be a physician operating virtually out of the tele-emergency hub. Marcia Ward, PhD, is the director of the Health Resources and Services Administration (HRSA)-funded Rural Telehealth Research Center at the University of Iowa. She and other colleagues set out to investigate the effect of this policy change by analyzing data from 19 hospitals that use the telemedicine network for emergency care in five states: Iowa, Minnesota, North Dakota, South Dakota, and Nebraska.

“We were able to get data from before and after they implemented [the tele-emergency system] and before and after the [CMS] policy change,” Ward explains. “We asked each of the hospitals to provide us with monthly calendars of their ED coverage ... so we could tell from these how many hours of coverage there were by physicians, by nurse practitioners, and by physician assistants.”

Additionally, the research team accessed CMS cost reports for the 19 hospitals, providing details on ED staffing for the study period. Further, Ward and colleagues conducted interviews with hospital leaders to gather more information about their staffing decisions before and after the CMS policy change.1

From all these data, investigators determined that of the 19 hospitals, 12 did not adjust their staffing decisions at all following the CMS policy change. However, the remaining seven hospitals did make changes, resulting in financial savings. In particular, the seven hospitals implemented a staffing approach whereby advanced practice providers backed up by a telemedicine physician covered their EDs for an average of 17.1 hours per day within three years of the policy change. In fact, the researchers reported that two hospitals adopted this model 24 hours a day during the study period.

The savings achieved by making these adjustments amounted to an average of $117,000 per year, primarily because of the lower compensation required for nurse practitioners or physician assistants vs. physicians. In addition to the financial savings, the seven hospitals reported they found it easier to recruit new physicians, primarily because the coverage requirements would not be so burdensome and the physicians would be afforded a better work-life balance, Ward reports. On the other hand, the 12 hospitals that did not make any adjustments to their staffing following the CMS policy change continued to staff their EDs with either onsite or local on-call physicians, and their staffing costs continued to rise. “They were continuing on the same trend line, which was upward in terms of increased costs over time,” Ward explains. Investigators report the average increase in annual compensation expenses for these hospitals was $138,000.

Address Staffing Challenges

What was the reasoning behind not taking advantage of the CMS policy change? In interviews with hospital leaders in the 12 hospitals that did not make any changes, investigators learned that some of them simply did not know about the policy shift or they were waiting for more clarification from state regulators as to whether they could adjust staffing. Others said they were fine with their staffing approach for now, Ward says.

Among the seven hospitals that took advantage of the policy clarification, staffing solutions varied.

“Some talked to the nurses at their hospital and asked who wants to go back to school,” Ward says. “They grew from within, taking local nurses and helping them go back to school to become nurse practitioners so that they could staff the ED.”

Often, the hospitals simply relied on the telemedicine emergency physicians during the weekends so they did not have to pay for locum tenens physicians during this period, a relatively simple adjustment that nonetheless trimmed compensation costs considerably.

“The seven hospitals employed individual solutions based on their challenges with recruiting physicians,” Ward says. For example, in some cases, the hospitals lost physicians due to retirements or relocations. In others, physicians were burned out and said they needed fewer coverage hours in the ED.

Additionally, in facilities that adjusted staffing, Ward reports that physician candidates liked the access to specialists and a team approach because it was what those candidates were used to at other jobs. This access also enticed prospective advanced practice providers.

“To know they would have somebody with them if they got a case that involved something they hadn’t seen in a long time that presented a diagnostic or treatment plan challenge [was appealing],” Ward shares.

Be Patient

While most clinicians have expressed satisfaction with this tele-emergency approach, that view is not universal, according to Ward.

“There are definitely providers who will say they have practiced in the ED ... for 30 years and don’t see the need to change,” she says.

Further, she notes there is a lot of variability in how often providers actually use the service.

“Some are only using it for the highest-need cases such as stroke and AMI [acute myocardial infarction] where time is of the essence. They are using it when they know they have to transfer a patient because [the tele-ED service] is very helpful with arranging either placements or the actual transportation [logistics],” Ward explains. “It takes some time. If you throw out a new technology, clinicians are not going to immediately adopt it if they have a choice in the matter.”

Instead, most of the time, physicians or advanced practice providers will give the new solution a try. If they see particular benefits for their patients, then they will gradually begin to use it with more cases, Ward shares. Regardless, it is clear that hospitals are warming to the concept, particularly in light of the documented benefits that telemedicine can bring to EDs and communities.

Brian Skow, MD, FACEP, chief medical officer at Avera eCare, notes that since the time of Ward’s study, the number of EDs in rural areas participating in Avera’s tele-emergency network has increased from 150 to 185. The network’s reach has grown, too.

“Our footprint has extended to now providing tele-emergency services within 13 states, reaching well beyond the Midwest [to states] such as New Hampshire, Maine, and Texas,” he explains.

Although the tele-emergency network did not become a reality until 2009, Avera Health has been involved in telemedicine since 1993, developing several related hospital services through its virtual health center, Skow notes. There are telemedicine offerings directed toward ICU care, behavioral health, pharmacy, hospitalists, and senior care, to name a few.

“We have been fortunate to have leadership that believed in telemedicine and allowed us to defy traditional healthcare delivery models,” Skow says.

Even within the tele-emergency offering, the services evolve continuously based on feedback from clinicians in the hospitals who rely on the telemedicine hub for guidance and advice. Consider that through “tele-intubation,” emergency physicians operating out of the hub can offer assistance with emergency endotracheal intubations.

“This support includes guidance on medications, intubation methods, and recommendations toward devices and cable technology,” Skow explains. “[Similarly], ‘emergency behavioral health’ provides admission support in determining the condition of a patient, peer-to-peer consults for behavioral health-related questions, and assistance with patient management, such as patient education and [help in] locating an admission facility.”

Confront Barriers

While Avera’s eCare network is thriving, most other telemedicine approaches in the emergency medicine arena have struggled so far, Ward acknowledges.

“We have looked at six grantees that HRSA funded specifically for tele-ED,” she explains. Some of the approaches have failed to get much uptake from rural hospitals. Others have run into push-back from local providers who are more accustomed to going it alone. “If those relationships are not built or worked on ... local providers don’t see the benefit,” Ward adds.

Further, reimbursement issues have plagued endeavors in telemedicine for years. But the landscape on that front is beginning to change, as evidenced by CMS’ 2013 rule change. Still, building such a network is a tall order.

“It is hard to get to that tipping point where there is enough volume to where you can have dedicated people 24/7,” Ward says. “For telemedicine and tele-ED in particular, that is the challenge.”

Despite the economic barriers, Ward expects to see more tele-emergency solutions in the coming years. The regulatory and reimbursement challenges have begun to ease while the workplace shortages in rural health continue to mount, she observes.

“As for credentialing and licensing, people seem to be figuring out how to do those [in telemedicine],” she says. “I think [tele-emergency services] are going to keep growing.”


  1. Ward MM, Merchant KAS, Carter KD, et al. Use of telemedicine for ED physician coverage in critical access hospitals increased after CMS policy clarification. Health Aff (Millwood) 2018;37:2037-2044.