EMS providers often feel helpless when they arrive on scene and discover the patient’s need is more primary care than emergent in nature. In Houston, the fourth largest city in the United States, this happens frequently. In fact, a recent study by a local university estimated that 40% of all ED visits are primary care related.1
Since there’s an average of more than 800 9-1-1 EMS calls every day in Houston, that results in a lot of unnecessary transports to the ED for primary care-related complaints such as minor headache, chronic joint pain or insomnia. Other than transporting the patient to the ED, there’s typically little EMS providers can do to address these kinds of medical concerns.
Unnecessary ED transports compound Houston’s problem of ED overcrowding—local hospitals experienced a 33% growth rate in visits during a 10-year period, with wait times in the largest facilities in excess of six hours or more.2 Providing primary medical care through the ED is inefficient from a healthcare system perspective and often suboptimal from a patient experience and medical care perspective.
To combat the growing problems, Houston Fire Department (HFD) EMS developed an innovative mobile integrated healthcare project called ETHAN—Emergency Telehealth and Navigation. ETHAN is a community-wide collaboration led by the HFD that uses mobile technologies, community-based paramedicine, and local and regional partnerships with other agencies and organizations to triage and connect low-acuity 9-1-1 callers with primary care resources in the community.
HFD Medical Director David Persse, MD, FACEP, points out, “The EMS Agenda for the Future spoke of EMS as being fully integrated with the overall healthcare system. If successful, ETHAN will be a major step in that direction.”
ETHAN is fundamentally a community-based paramedicine approach that integrates extensive use of health information technology with traditional medical care. Spearheaded by HFD Associate Medical Director Michael Gonzalez, MD, ETHAN is based on five key interrelated concepts:
- Patient-centered navigation to appropriate levels of care;
- Population-based tools and needs assessments;
- Leveraging community resources, partnerships and collaborations;
- Long-term financial sustainability through improved outcomes; and
- Extensive integration of mobile health and other technologies.
Table 1: Local, regional and national ETHAN program partners
The last component—technology—is extremely important, as it enables physicians in Houston’s 9-1-1 call center to communicate directly with patients via tablets with integrated telehealth capabilities. Other embedded information systems include clinic scheduling systems, health information exchange (HIE) access and transportation scheduling.
Also critical is HFD EMS’ partnerships with local, regional and national organizations to improve the spectrum of care and augment agency resources. (See Table 1.) Without community-based partnerships, EMS agencies would find obtaining resources for mobile integrated healthcare programs nearly impossible.
The program was in planning stages during 2014, and officially kicked off in December. An evaluation of clinical and economic outcomes from the program is being conducted prospectively by the University of Texas Health Science Center. In the first five months, over 700 patients have been successfully evaluated and over 80% have resulted in outcomes not requiring the use of the ambulance. Navigation toward more appropriate levels of care should produce a significant impact on efficiency, appropriate utilization and a reduction in overcrowding at local EDs.
ETHAN is being funded during the initial multiyear period through the Texas 1115 Healthcare Transformation Waiver program. Through the Delivery System Reform Incentive Payment, the 1115 Waiver seeks to incentivize hospitals and other providers to transform their service delivery practices to improve quality, health status, patient experience, coordination and cost-effectiveness. Eligibility for this program requires participation in a regional healthcare partnership. Within a partnership, participants include governmental entities providing public funds known as intergovernmental transfers (IGT). The city of Houston provided the necessary IGT funds.
The ETHAN project reached its current design after over six years of shaping and development. This evolution began in 2009 with a nurse triage phone line that was accessed by call takers at the 9-1-1 emergency communications center, where they connected patients with nurses who used a computer-based algorithm to triage patients and determine the most appropriate disposition. This project failed because callers expecting an ambulance to be immediately dispatched instead experienced a prolonged Q&A interrogation by a nurse and weren’t cooperative with the program. In addition, it was recognized that the nurses were very conservative in making dispositions, resulting in very few diversions from dispatching of an ambulance.
The nurse triage phone line was discontinued and a similar algorithm was used by HFD paramedics located at the paramedic-staffed base station used by the HFD for all field-to-hospital medical communications. Field crews connected the patients in the field with the paramedics over the phone. Paramedics could schedule the patient a clinic appointment and a taxi ride when appropriate.
Due to the conservative design of the algorithm, however, it too often determined the disposition to be immediate transport to the ED when it didn’t seem medically necessary. As a result, a large percentage of patients still ended up being transported to the ED and first responders grew frustrated with the project.
Although significantly more costly, replacing the algorithm with emergency physicians allows for much quicker determination of the patient’s medical acuity and dramatically improves the accuracy of triage results to ensure the most appropriate disposition. The interactions using the nurse triage line algorithm typically took up to 20 minutes or more, whereas physicians can assess the patient and make a disposition decision in around seven minutes. This is a more satisfactory experience for both the patient and the EMT or paramedic.
HOW ETHAN WORKS
After the first responding HFD apparatus arrives on scene, the crew assesses the patient and makes an initial determination as to whether the patient needs emergency care. If the patient does indeed require emergency care, the crew then activates the ETHAN program. To do that, they use the tablet that’s available on every fire/EMS vehicle—both ambulances and traditional fire apparatus alike—to connect the patient with an emergency physician via HIPAA-compliant and secure video conferencing software.
The emergency physician is able to access the patient’s medical record that’s created on scene, including the patient’s demographics, vital signs, medical history, allergies, medications and the chief complaint. The physician consults with the patient by video conference in a way very similar to what’s normally done at the ED. All physicians hired for this project are board-certified emergency physicians who practice at local hospital EDs and have multiple years of experience.
Table 2: ETHAN patient disposition after eligibility screening
While the video conference takes place, the field crew remains on scene to assist the physician with any additional information needed, such as taking a new set of vital signs or palpating the patient’s pain site. The physician then makes the final determination regarding the patient disposition, which could be one of six alternatives, as shown in Table 2, and briefly described below.
Referral to a community primary care clinic and taxi ride: This is the ideal disposition and is currently applied to about 10% of initial ETHAN patients. When the emergency physician determines the patient could be better cared for at a primary care setting, the physician will schedule an appointment at one of the local partner clinics using a Web-based scheduling system that uses the patient’s ZIP code to identify the closest clinic location and next available appointment time. All clinic visits are scheduled for the same day or the next day at the latest. The clinic receives an appointment confirmation with the patient’s demographics and chief complaint. The clinic’s providers are also able to access the local HIE to view additional information on the patient. If the patients need transportation assistance to get from their residence to the clinic, the physician uses a Web-based application to schedule a taxi ride. The clinic visits and taxi ride billing is handled through a third party administrator. For uninsured patients, the program covers the cost of the clinic visit and taxi ride. For insured patients, clinics bill the patient’s insurance directly for the visit and the program covers the taxi ride only.
Referral to an ED and taxi ride—patient declined referral to clinic: The emergency physician may determine that the patient needs to go to the ED, but ambulance transportation isn’t necessary. This disposition category accounts for over 50% of initial ETHAN encounters. In this case, the physician instructs the patient to go to the ED and schedules the patient a taxi ride. The physician can also schedule a taxi ride to an ED if the patient refuses to be seen at the clinic and insists on going to an ED for a low-acuity complaint.
Referral to an ED with ambulance transportation: In only about 19% of cases thus far, the ETHAN physician has determined that a patient needs immediate emergency care and instructs the field crew to transport the patient to an ED. As explained previously, the ETHAN program is only activated after the field crew determines a patient doesn’t need emergency care, so these instances are an important teaching opportunity for the physician to educate the field personnel why emergency transportation is needed.
Referral to patient’s primary care provider (PCP) or home care: When a patient has their own PCP, the patient might choose to see their PCP instead of going to a partner clinic—this disposition makes up approximately 7% of cases. When possible, the ETHAN physician encourages this option as the patient’s own PCP is often the best provider to coordinate the patient’s care and ensure continuity and integration of care. Also, based on the ETHAN physician and patient’s discussion, they might decide that no additional care is needed and the physician might only provide the patient with home care instructions.
Patient declined referral to clinic and receives ambulance transport to ED: The patient might choose to decline the ETHAN physician’s advice and insist on going to an ED. The ETHAN physician and responding crew communicate to the patient that seeing a PCP at one of our clinics will provide them with better care and convenience than going to an ED. They also explain that ambulance transport isn’t necessary and doesn’t add any value to the care the patient will receive. Nevertheless, some patients still insist on going to an ED via an ambulance, although at 5% this disposition is rare. The physician is empowered to decline the use of the ambulance, but in some situations the physician and EMS crew decide to abide by the patient’s insistence.
Patient refusal to participate: The patient might refuse to participate in the ETHAN program and refuse to speak with the ETHAN physician over the tablet. Although this disposition is possible, it accounts for less than 1% of encounters.
PATIENT FOLLOW-UP & OUTCOMES EVALUATION
Following the ETHAN encounter, the patient’s information is automatically forwarded to Care Houston Links, a city of Houston Health Department program that provides care navigation services. Through this program, social workers and healthcare navigators follow up with the patient to ensure the patient’s needs were met and to identify any additional human/social services needs and identify ways to address them. A patient satisfaction survey is also administered.
Follow-up may include things like insurance coverage, transportation, food assistance, health literacy, counseling, etc. The goal is to deploy a holistic approach to healthcare and connect patients with resources they can access for their future health needs, thus reducing their reliance on the emergency system.
In addition, all program data on patient disposition, participation, volumes, clinical outcomes, and costs are being measured and evaluated by an independent third-party university researcher at the University of Texas Health Science Center. This outcomes research will hopefully show significant reduction in costs and unnecessary transports, with (at least) no reduction in care and higher patient satisfaction survey scores. If annual evaluations confirm this hypothesis, the ETHAN program will be financially sustainable for the long-term.
ETHAN is a developing mobile integrated healthcare EMS program committed to being an integral component to address Houston’s healthcare delivery system through more coordinated out-of-hospital care. To survive long-term, it must be financially sustainable, producing a return on investment of sorts, where outcome benefits are greater than their costs. By focusing on technology-enabled patient navigation to more appropriate levels of care and leveraging community collaborations and partnerships, we expect this program to grow significantly in years to come.
1. Begley C, Courtney C, Abbass I, et al. (2013.) Houston hospitals emergency department use study: January 1, 2011 through December 31, 2011. Health Services Research Collaborative, University of Texas School of Public Health. Retrieved Sept. 9, 2015, from https://sph.uth.edu/research/centers/chsr/hsrc/.
2. Wolf R. (June 19, 2007.) What does a health crisis look like? See Houston. USA Today. Retrieved Sept. 9, 2015, from www.usatoday.com/news/nation/2007-06-18-texas-healthcare_N.htm.