Langabeer R, Gonzalez M, Alqusairi D, et al. Telehealth-enabled emergency medical services program reduces ambulance transport to urban emergency departments. West J Emerg Med. 2016;17(6):713-720.
Researchers in Houston wanted to measure the ability of using a combination of telemedicine, social service pathways and alternative means of patient transportation for patients who didn’t require an ED visit by ambulance. It was conducted by the Houston Fire Department and termed the Emergency Telehealth and Navigation (ETHAN) program.
Eligible patients included those with primary care-related complaints. The most common categories were “abdominal pain,” “sick,” “injury/wound” and “other pain.” Inclusion criteria included the following: Able to have full history and physical exam by paramedics (non-emergent conditions); age > 3 months; ability to communicate in English; normal vital signs; absence of fever in chronically ill patients or those over 65; ability to care for self; access to private transportation; and access to pediatrician for pediatric patients.
Patients with chest pain, acute neurological changes, altered mental status or difficulty breathing, syncopal episode, suspected non-accidental injury or neglect in pediatric patients and minors with no legal guardian on site were excluded.
Once identified, the patient was interviewed via video by an emergency medicine physician working in the Houston Emergency Center that provides regional telecommunication and dispatch for EMS. If the physician and patient agreed that their condition was non-emergent, the physician would pursue one of three pathways.
The first was to provide a prepaid taxi ride to the ED for conditions difficult to address in a primary care office; the second was a referral with taxi ride to a primary care physician appointment made by the emergency physician. The third pathway was non-transport and delivery of aftercare instructions.
Over 12 months, EMS providers enrolled 5,570 patients to participate and compared that to a control group of patients with similar conditions who were not offered participation in ETHAN. Eighteen percent of ETHAN patients were transported to the ED vs. 74% in the control group. Additionally, EMS crews returned to service 44 minutes faster for the ETHAN patients (39 vs. 84 minutes).
There was no difference in clinical outcomes or patient satisfaction.
Doc Wesley Comments
The concept of mobile integrated healthcare or community paramedicine (MIH-CP) has been around for a few years. However, little has been done to measure its impact on resource utilization. A key concern many have regarding MIH-CP is the ability of EMS providers to recognize and properly triage patients who don’t require ambulance transport. ETHAN addressed this by providing physician consultation using telemedicine to facilitate a reliable patient interview and assessment.
This isn’t an expensive program, costing $179 per ETHAN patient. When you consider that the average ED visit for primary care-type complaints costs around $1,500, it’s saving money. The authors note that a report of the fiscal impact of this program is in the works and I can’t wait to see it.
Unfortunately, these types of programs are difficult to implement. This is particularly true where private agencies provide services without subsidies from their local municipality. EMS is only compensated by insurers when patients are transported.
Although this compensation may be low, it’s better than nothing. For programs like ETHAN to succeed, insurers need to pay for the telehealth services that EMS provides and share some of the money they’re saving by not transporting patients to the ED.
Medic Wesley Comments
Telehealth-enabled programs will succeed. Although they’re costly to start up and annual costs are high, EDs around the country are overwhelmed with patients who don’t need to be there.
The cynical side of me found this fact interesting: One-third of patients who met the determination of non-emergent and had scheduled appointments for the next day in a clinic failed to show. We see this often in the ED.
Why can’t the same ED physician assess via telehealth to the ED triage desk, and then make referrals to the appropriate care? Being ruled by patient satisfaction scores and Emergency Medical Treatment and Labor Act (EMTALA) laws, hospitals have to take these patients. The cost of healthcare rises when patients demand services that could easily wait until clinic hours.
Programs like ETHAN are necessary and need to be funded. Having the chance to be evaluated by a physician and potentially being treated without transport, is optimal for many patients, especially the elderly or parents with multiple children.
Although there are some no-brainers when it comes to transport, the ED often sees people who just don’t know what else to do. Why tie up an ED when these patients just want to know if it’s ok to wait until tomorrow?
Time for a change. Uber Care. I like it.