Emergency Medicine Telehealth: A Pandemic Becomes a Gateway for Virtual Care in Missouri

Abstract

Telehealth provides a novel bridge between patient needs and available resources. On-demand telehealth visits provide urgent medical services in a virtual setting. Telehealth can be used to provide care for patients despite geographical distance. Emergency Medicine quickly adapted in response to the COVID-19 pandemic through utilization of telehealth to solve various problems. Tele-triage was used to coordinate COVID-19 testing and treatment. Greater utilization of all current and emerging telehealth modalities could increase access and quality of care for all Missourians.

Introduction

In 1879, The Lancet published a case report of the first telehealth encounter of a physician evaluating a child for croup via the telephone, listening for the characteristic barking cough.¹ Despite extraordinary advances in telecommunication technology since then, the COVID-19 pandemic was the catalyst telehealth needed to become mainstream. Medicine as a whole (including emergency medicine) adapted quickly and dramatically in response to the pandemic, primarily via increased utilization of telehealth. Telehealth is the use of a variety of telecommunication technologies (commonly video, phone, or electronic health record) to provide a broad-range of health care services.^2,3 Telehealth communication can be synchronous (real-time) or asynchronous (delayed) in nature, and allows for information exchange between geographically separated providers, or between a provider and a patient.⁴ As COVID-19 created previously unforeseen obstacles to healthcare, telehealth provided a bridge between patient needs and available resources.

Since that first 19^th Century telehealth encounter, remote communication technology improved exponentially, further expanding the ways in which telehealth could be used to provide care and increase medical access. In particular, over the past few decades video conferencing tools and access to broadband networks built primarily for use unrelated to telehealth improved dramatically, but awaited mainstream adoption for medical applications. COVID-19 abruptly altered that equation. Pre-pandemic, telehealth was mostly still a novelty with limited uptake. Specific use cases, such as in Tele-Critical Care and Tele-Stroke, suggested improved outcomes (morbidity and mortality) utilizing telehealth in both single center trials and systematic reviews,^5,6 but adoption overall remained low. The reasons for low-adoption of telehealth was multifactorial, including start-up costs, billing and compliance regulatory hurdles, distrust and unfamiliarity with technology, cultural barriers related to practice change, provider preference, and patient expectations.⁷ Almost overnight, those barriers became less onerous across the world in March 2020. With abrupt mandatory global wide lockdowns, the inertia to change in healthcare was no longer acceptable, forcing providers and patients to use telehealth to continue essential healthcare related services.

COVID-19 in the Emergency Department

Novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) which causes coronavirus disease 2019 (COVID-19) rapidly spread across the world in 2020. Amidst initial uncertainty regarding COVID-19 contagiousness, symptomatology, and severity in the early months of the pandemic,⁸ the task of triage, diagnosis, treatment, and counseling fell primarily on physicians in emergency medicine (EM), intensive care, and hospitalist medicine, all while managing and treating other potentially critically ill patients.⁹ Personal protective equipment was suddenly a scarce resource. The unknowns of virus transmission, morbidity, and mortality were a massive psychological strain on providers.^10,11 Personnel on the front lines were more likely to get sick first or be exposed,¹² further straining staffing ratios.¹³ Furthermore, while collective cancellation of elective procedures and admissions resulted in an initial decrease in the volume of patients presenting to the emergency department (ED) during the pandemic, there was not a decrease in the number of medical emergencies.¹⁴ Delay in presentations for medical emergencies was a possible cause of increased ED mortality seen despite lower overall patient volumes.¹⁵

EM-Telehealth During COVID-19

Emergency Medicine, a specialty constantly faced with changing conditions and pressure to adapt, quickly realized telehealth could be utilized in a variety of ways to solve pandemic related challenges. Notably, EM providers are available to provide telehealth services around-the-clock, and have been aptly described as the “availabilists,” a trait often overlooked, but critical to convenient and rapid care, both hallmark qualities of telemedicine.¹⁶ Many acted heroically and nimbly, expeditiously creating telehealth-based solutions to ensure reliable access to patient care despite overwhelming barriers amidst the shifting landscape of COVID-19 unknowns.¹⁷ In the prehospital setting, telehealth was used both for screening and evaluation prior to an ED visit for patients in facilities such as nursing homes or skilled nursing facilities, as well as for connecting first responders with emergency physicians to help with triage and system level loading.¹⁸ Within the ED, telehealth use grew to include remote attending supervision,^19,20 virtual evaluation to preserve personal protective equipment (i.e., ‘e-PPE’),²¹ and to connect patients with loved ones in the context of strict visitor policies.²² Tele-specialist consultations for ED patients such as tele-stroke continued, but grew in many other specialties as well,^23,24 in particular for behavioral health patient evaluations with extended disposition times due to bed capacity issues (Figure 1). Toxicologists, the majority of which are emergency physicians, increasingly utilized telehealth, beyond just treating patients with substance use disorder.²⁵ Traditionally, most toxicologists are only available for consultation at academic institutions. With telehealth, they could provide consults in real-time at other hospitals allowing patients access to their expertise and potentially preventing long and costly transfers.²⁶

Figure 1.

Compared with <1% telehealth use in 2019 across all categories, telehealth increased to 8.3% of all primary care visits and 2.6% of specialist visits in 2020. Visits to behavioral health specialists saw the largest increase in telehealth use during the pandemic, with 38.1% of all visits to these providers delivered by telehealth, compared with 1% in 2019.²⁷

Telehealth also was increasingly used in the post-ED discharge setting for ongoing monitoring of patients, particularly with COVID-19 oxygenation concerns.^28,29 This was a particularly effective strategy to allow for safe discharge and minimize exposures to others.

Telehealth Legislation

Emergency Medicine is a specialty defined, in part, by operational flexibility.³⁰ During the COVID-19 pandemic, EM leveraged this flexibility to adopt telehealth, allowing increased access to care for patients. However, up to this time federal regulation authorized billing only for telehealth services to rural areas. To allow reimbursement for healthcare services provided via telehealth to all geographies, new directives were warranted. Effective March 6, 2020, the Centers for Medicare & Medicaid (CMS) approved reimbursement for telehealth services in a broader set of circumstances than previously allowed. This allowed for telehealth visits to be considered the same as regular in-person visits, with reimbursement at the same rate.³¹ Furthermore, widespread use of telehealth during the COVID-19 pandemic required alterations to previous telehealth regulations regarding the Health Insurance Portability and Accountability Act (HIPAA).³² With the transmissibility of COVID-19, many patients did not want to engage with in-person care, and providers themselves were concerned with unnecessary exposures, changing the typical patient encounter dynamic.³³ These changes in Medicare and HIPAA, along with Missouri House Bill Number 1617 passed in 2018, allowed for telehealth to be utilized in most settings and by any licensed health care provider, as long as the same standards of care were met in both telehealth visits and in-person visits.³⁴ These new laws permitted by Missouri and the national government allowed rapid telehealth growth for continued patient care. Adoption quickly escalated (Figure 2) due to favorable legislation because of the pandemic, but these laws are not guaranteed in perpetuity when the pandemic subsides.

Figure 2.

Summary of the utilization of, provider perception of, and uptake of telehealth after the COVID-19 pandemic.³⁵

Telehealth Innovations In Missouri

Emergency Medicine organizations within the state of Missouri swiftly adapted to the pandemic utilizing telehealth. Examples include telehealth initiatives of Barnes Jewish Hospital/Washington University in St. Louis (BJH/WashU), University of Missouri - Columbia, and Mosaic Life Care in northwest Missouri. BJH/WashU developed an on-demand telehealth service that was integrated with the electronic medical record (EMR) for synchronous and asynchronous patient evaluations, triage, and COVID-19 testing guidance. This setup allowed patients to access urgent care services from a variety of personal telecommunication devices (including mobile). Through this platform, patients were able to be evaluated for a variety of chief complaints and could have outpatient tests ordered; prescriptions electronically sent; or if needed, referred to an ED, primary care doctor, or outpatient clinic for in-person evaluation. One advantage this setup facilitated was remote COVID-19 testing, allowing patients to be evaluated virtually, and if indicated, sent to a drive-thru COVID-19 testing site. Through the implementation of on-demand telehealth visits, the physicians at BJH/WashU were able to divert possibly contagious COVID-19 patients away from the ED waiting rooms and manage their care in a remote fashion when indicated.

The University of Missouri’s ED began utilizing telehealth for on-demand visits in early 2019. However, the potential benefits of those efforts in telehealth were not apparent until March of 2020 when the role of on-demand care during the COVID-19 pandemic became a necessity. As the ED leadership learned more about COVID-19 and CDC guidelines for testing were released, it became clear that an on-demand screening process in a controlled environment tied to a high-volume testing center was critical to the function of the healthcare system. Leaders from across the health system in information technology, EM, laboratory services, and ambulatory care collaborated to develop a workflow in which symptomatic or at-risk patients could be screened for COVID-19 24/7 by an advanced practice provider (APP). This collaboration, paired with an algorithm based upon CDC guidelines, allowed healthcare providers to increase visit capacity from about ten per day to over five hundred patient encounters per day.

Mosaic Life Care developed a system of tele-triage that utilized the flexibility of its emergency physicians. Emergency physicians at Mosaic established themselves as regional experts on COVID-19, becoming early adopters of monoclonal antibodies. However, as they began prescribing this therapy, they realized the complexities regarding eligibility-criteria caused confusion, leaving many eligible patients untreated. To address this problem, a few EM physicians became “COVID Physicians On-Call” for both their network of hospitals and the surrounding region. The physician on-call performed tele-triage, speaking directly to physicians and practitioners, assessing for onset of COVID-19 symptoms, comorbidities, and severity of illness. They then scheduled eligible patients for outpatient infusions or referred for ED evaluation. As of December 2021, they treated over 3,355 patients with monoclonal antibodies within the Mosaic hospital system.

Future State of EM-Telehealth

The future of EM telehealth is bright as medicine enters the digital era alongside the rest of the world, transforming how we deliver care by utilizing technology to improve efficiency, quality, and safety. EM has the opportunity to be a leader in this space and grow exponentially with it, as almost no other specialist is armed with such a vast array of skills to catalyze patient-centered telehealth services. First, EM providers are “available” 24/7/365, a defining feature of the specialty.³⁶ Furthermore, local Tele-EM providers, as opposed to national and international telehealth companies, have access to “insider” information in their community to help arrange timely acute and follow-up care as needed. EM providers are also experts in triage, thriving on rapid decision making of the undifferentiated patient with limited information and benefiting from a broad knowledge base to allow for accurate triage.³⁷ Finally, EM providers are experienced in quickly establishing trust with new patients who are suffering, a skill that could be even more challenging in a virtual format.³⁸

Within the ED, telehealth use for triage decisions both for new patient arrivals and inter-hospital transfers is a plausible role. This will likely become more essential over time as the COVID-19 pandemic highlighted system-wide bed capacity logistical issues that might not fade,³⁹ even if the pandemic wanes, given an ever-increasing geriatric population and a persistent healthcare labor shortage.⁴⁰ Especially in rural areas where local hospitals depend on a physician workforce that might not uniformly include physicians with extensive training and certification in EM, telehealth can offer a bridge to high quality care with triage, treatment, and disposition assistance.⁴¹ A Tele-ED model allows high-quality emergency care simultaneously at multiple sites for critically ill patients in locations that do not see a high volume of these patients. Utilizing a Tele-ED hub-and-spoke model, rural EDs are capable of handling clinical scenarios that would otherwise be difficult to train, staff, and plan for in resource-limited locations. This will allow some patients to receive care in local, smaller hospitals as opposed to being transferred to a larger medical center further away.⁴²

Improving the triage process with tele-triage providers to decrease door-to-doctor-time might subsequently improve left-without-being-seen rates and department flow with early order placement. ⁴⁴ Time critical diagnosis recognition (stroke activation, ECG interpretation, sepsis) will also be an opportunity for EM-telehealth providers to provide assistance and improve the quality of care that patients receive despite limited bedside staffing. The hub-and-spoke telehealth model lends itself to improved standards of care with core telehealth providers advising best practice protocols⁴⁵ (sepsis, lung protective ventilation, sedation, pulmonary embolism management, geriatric care, infection prevention). This model could decrease new knowledge translation time to the bedside for complex diseases with constantly evolving treatment guidelines. These effects are not just theoretical, they are resulting in increased quality of care presently. Telehealth use in remote and rural EDs demonstrated improved or equivalent clinical effectiveness, appropriate care processes, and—in certain contexts—improvement in speed of care.⁴³

The future of EM-telehealth in the pre-hospital realm with emergency medical services is a prime opportunity and likely where most of the reach and growth of EM-telehealth will occur. Use cases abound primarily around the concept of “forward triage”⁴⁶ to help level load hospital systems, and direct patient care to the right place at the right time with an expert in triage—an EM provider (Table 1). Some of these opportunities are already live. In 2019, the emergency triage, treat, and transport (ET3) program was developed for EMS to treat patients at the scene of a call with the help of telehealth, or transport the patient to an alternative site like an urgent care or a doctor’s office.⁴⁷ Although still in proof of concept/pilot stage, the ability to triage a patient at the point of contact to avoid an unnecessary ED visit or help guide the patient to the proper place of treatment could potentially be monumental in a value based health care system.⁴⁸ This concept should ultimately have positive financial impacts for hospital systems looking to avoid penalties on readmissions, insurance companies looking to avoid paying for high healthcare costs, medics for getting paid when not transporting patients, and patients themselves for lower healthcare spending. Forward triage by EM providers using on-demand telehealth evaluations to decrease unnecessary ED visits but still allow for expert evaluation is the future. Whether this is the “walking well” with minor care symptoms, EMS assisted such as with ET3, in skilled nursing facilities/assisted living/rehabilitation centers, tele-consults to other outpatient centers (urgent cares, primary care offices), private company partnerships, or community centers with “tele-booths” (shelters), EM-telehealth staffed by 24/7/365 experts in triage offers a solution. Finally, outside of critical triage roles, EM providers often wear many hats, more so than other specialties. Whether this is expertise in ultrasound, critical care, education, medical toxicology/substance use, global health, or EMS, it can be implemented and monetized in ways never before possible without telemedicine. Partnerships and contracts can be established near and far (state license depending) for best-in-class care in these domains without classic geographical, or even time zone restrictions.⁴⁹

Table 1.

Potential approaches and examples of patients who may qualify for telehealth based on input-throughput-output model of emergency care.36

Emergency Care Phase	Potential Approaches	Examples of Potential Patient Presenting Concerns
Input
Unlikely to Need ED	Asynchronous text-based messaging (or email) Telephone visits Synchronous audio-video visits Referral to primary care practices, retail clinics, or urgent care Virtual ED with outpatient coordination of diagnostic testing, if needed	Asymptomatic hypertension in outpatient setting Patients being sent for test to avoid preauthorization Patients being sent for convenience of rapid specialty consultation Upper respiratory tract–type symptoms Potential Covid-19 testing without cardiovascular or neurological symptoms Sexually transmitted diseases Rashes Fever in healthy hosts Most extremity injuries Back pain
Reasonable to evaluate before deciding if they need to go to the ED	Asynchronous text-based messaging (or email) Telephone visits Synchronous audio-video visits Referral to primary care practices, retail clinics, or urgent care Virtual ED with outpatient coordination of testing, if needed Community paramedicine Scheduled visits in the ED for patients who need ED but not emergently	Abdominal pain Lacerations Asthma Infectious and pulmonary symptoms
Highly likely to need in-person evaluation in ED	Community paramedicine Mobile stroke units Traditional 911 prehospital system	Chest pain or new syncope in at-risk patient population (age or comorbidities) Stroke symptoms New difficulty breathing in patient without known asthma GI bleeding Significant trauma
Throughput
	Tele-intake (tele-triage) Facial recognition software for registration Test ordering prior to or upon arrival Virtual rounds and family engagement Specialist consults by synchronous audio-video visits Interprofessional collaboration	Most patients
Output
Moderately likely to be eligible for discharge from the ED rather than be admitted	Digital discharge planning Text-based messaging Digital technology for home remote patient monitoring Community paramedicine Specialist consults by synchronous audio-video visits Hospital-at-home	Most patients who would be placed in observation status Patients requiring antibiotic infusions Patients within 1–2 days of being ready for discharge (i.e., heart failure, chronic obstructive pulmonary disease, pneumonia, dehydration)

In-hospital telehealth consultation from EM providers may be a concept more challenging to envision as EM has historically stayed within the walls of the ED or in the pre-hospital setting. Of course, at one time, pre-hospital care disrupted the established order and took time to fully envision its scope. However, the skills of EM providers should not be limited to these areas as emergencies occur and need to be managed, regardless of location. Thus, a future use case where EM-telehealth leverages their skillset of expertise in resuscitation, management of the undifferentiated decompensating patient, triage, and procedural knowledge (troubleshooting, oversight via telehealth) could easily be imagined in the inpatient realm. Having access to an on-demand provider with these capabilities could improve patient outcomes, standardize treatments, leverage a smaller workforce, and decrease bedside provider stress/anxiety/burnout. EM expertise in a broad array of domains is an asset to be monetized and telehealth allows that at scale. This should appeal to EM programs looking for new/increased revenue models, and hospitals seeking to cut costs but maintain quality metrics. Telehealth also offers opportunities for EM physicians young and old to capitalize on geographical freedom, focus on wellness and avoid burnout, or less physically demanding work.⁵⁰

Challenges Ahead

Emergency Medicine, like all other specialties, is facing massive challenges to remain a competitive and profitable business. There will always be a need for EDs, without question, but how they are staffed (more APPs), the volumes they see, and the reimbursements they get could drastically change in the coming decade putting downward pressure on provider salaries and ED margins. As technology improves with Artificial Intelligence⁵¹ and Machine Learning, organizations (both for-profit and nonprofit) will likely seek to utilize these tools to supplement a cheaper/less experienced workforce to maintain quality while increasing profits. In addition, current big tech companies (Amazon, Google, etc.) are actively trying to disrupt the healthcare industry via on-demand telehealth services they offer for low acuity complaints.⁵² This could decrease ED volumes and revenue, and although at times frustrating, these lower acuity patients provide revenue to EDs that are essential. Finally, EM advocacy groups are constantly battling CMS for adequate reimbursement. Despite valiant efforts, the bureaucracy in medicine is overwhelming and unrelenting, making it challenging to maintain a financially sustainable business and be paid appropriately for services rendered. Emerging telehealth opportunities may help to alleviate some of these pragmatic challenges, while providing a patient-centered approach to 21^st Century EM.

Conclusion

Society is transforming, and as Marc Andreessen stated, “software is eating the world.”⁵³ This digital transformation and evolution of our world will not exclude the field of medicine. In fact, COVID-19 just expedited it. Although there are challenges with telehealth and unknowns, society quickly embraced its benefits and is unlikely to retreat to yesterday’s medicine. Patients from this point forward will expect access to telehealth as an option when outcomes are equal,⁵⁴ and will shift their consumer preferences to those who provide it, similar to preferences for web-based and mobile applications compared to their physical counterparts. EM must start planning for this future now as the shift to telehealth is still in its infancy. Younger generations will continue to be more facile with technology and expect its incorporation in their care as they grow older and acquire health issues. Telehealth is the next frontier for EM to innovate, lead, and grow. Important questions remain unanswered (patient satisfaction, cost savings, patient centered outcomes, health equity using telehealth, clinician wellness, etc.) as the gaps in knowledge around telehealth continue to be illuminated. The opportunity is now, and many Missouri EM programs have already seized the moment, embraced technology, and are boldly seeking ways to expand EM’s reach and delivery of exemplary care to all patients in need, now in a more modern format. That is the ethos of EM, evolving virtually in front of our eyes.