New Innovation to Address System Overload by Systemizing the Field Triage and Treatment of Non-Emergent Patients

The Contra Costa County (CA) Fire Protection District is working with Tele911 to help make the system more efficient.
The Contra Costa County (CA) Fire Protection District is working with Tele911 to help make the system more efficient. (Photo/Dan Dineen)

Introductory Note from JEMS Editor Emeritus A.J. Heightman, MPA, EMT-P

JEMS has prided itself on introducing countless groundbreaking concepts and innovations to the EMS community since its inception in 1980. As an example, in May 1980, JEMS introduced Jack Stout’s Public Utility Model and System Status management which changed the way many EMS Systems operated. His concepts introduced new ways to maximize resources and revenue through changes in the deployment of crews and resources.

In Feb. of 1981, Dr. Jeff Clawson’s dispatch priority training and the Medical Priority Dispatch System (MPDS); the impact and designation of Trauma Centers in Oct. 1981; and the use of personal computers in medical data acquisition had major impact on the proper prioritization and deployment of field resources, distribution of trauma patients and computerization of EMS.

And, in Nov. 1982, Dr. Rick Hunt, Dr. Bob Bass and other EMS physician leaders announced in an article entitled “Standing Orders vs. Voice Control” that it was time to reduce the “Dr. May I Calls” and allow paramedics to follow established protocols to render care more expediently in the field.

It’s my belief that the following article will be viewed as another epic moment in EMS history when a regionalized system of treat, release and follow-up became possible throughout the United States, a system that allows providers to reduce the unnecessary transport of countless non-emergent patients; enables direct physician involvement in the assessment and release of many patients to places other than emergency departments that are often overcrowded; enables first responders and preciously needed ambulances to be released and available to respond to and care for emergent patients; and be paid for services provided whether they are transported or not.

Tele911 is a new company founded by three well known experts in EMS and emergency medicine that can be easily integrated into any EMS system. It allows the seamless interface between field responders and their patients with board-certified EMS physicians to dramatically reduce the strain on EMS resources and enable the safe and efficient field assessment, triage and distribution of non-emergent patients, which is a major strain on many EMS systems.

Marc Eckstein, MD, MPH, is a former New York City paramedic, a 25-year medical director and EMS bureau commander of the Los Angeles Fire Department, and professor of emergency medicine at the Keck School of Medicine of the University of Southern California.

Chris Maloney is the founder and former chairman of TriTech Software Systems, which grew to become the largest provider of public safety technology in the world.

Donald Jones is the former COO of MedTrans, and later an advisor to the CEO and board of American Medical Response (AMR) – now known as Global Medical Response – where he helped build EmCare, the largest medical group in the U.S.

This is your introduction to a new innovation that will address EMS system overload and add a new tool in an EMS system’s toolbox, the systematized treat and release of non-emergent patients.


“Medic 65 – Respond to the “sick patient.” 200 N. Elm Street.

Medic 65 responds with lights and sirens and arrives on scene to find a 35-year-old male complaining of fevers, fatigue and myalgias. He’s very concerned he has COVID-19 and is requesting to go to the hospital to get confirmatory testing and receive some of the newly approved therapies that will “cure” him.

Medic 65 transports the patient to the nearest Emergency Department (ED). Upon arrival, they are instructed by a triage nurse in full PPE to wait outside with their patient since this is a high likelihood of being a COVID patient.

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Medic 65 waits for 45 minutes to transfer care of their patient to the very busy ED staff, spends 15 minutes decontaminating the ambulance, and takes another 15 minutes to drive back to their station. They have spent a total of an hour and a half on this call.

The patient is assessed by a provider at ED triage and given a presumptive diagnosis of COVID-19. He is told that the hospital will not test him for COVID since he is young, has no comorbidities and at low risk for serious complications.

He is discharged home with no lab tests or x-rays, is told to quarantine at home for 10 days and take ibuprofen for fever and pain.

What makes this frustrating scenario even more vexing is that while waiting with the patient at the hospital, the medics hear a cardiac arrest call dispatched in their district. Since they are not available, they know that another unit from across town will have a delayed response to a truly critical patient.

EMS providers, medical directors, fire chiefs, and administrators know that a high percentage of 911 calls are for non-emergency problems. Research shows that up to 85% of 911 system patients can be safely treated in alternative healthcare settings, including at home.1

EMS was originally developed to allow trained and skilled prehospital professionals to quickly respond to victims of time-critical emergencies, such as auto accidents and heart attacks, but have, over time, taken on the burden of managing a high volume of non-emergent cases.

In an effort to improve patient outcomes, we have spent decades figuring out how to minimize call processing, response, transport, and turnaround times, but very little about the fundamentals of EMS assessment and transport have changed for the better.

Over time, as we have successfully educated the population to call 911, a large majority of these calls are low acuity for chronic conditions, minor injuries, mental health crises, and substance abuse issues. Firefighters, EMTs and paramedics currently respond to these calls and then transport these individuals to the nearest ED by default, with no mechanism to triage out these unnecessary calls.

The turnaround time for an ambulance on each of these incidents averages an hour or more. It is estimated that the EMS system in the US costs over $30 billion annually, with almost two thirds of patients transported to the ED by ambulance, treated and released from the ED.2

In addition to the economic costs to support our EMS systems, lives are lost while paramedics are tied up on these low acuity calls and unavailable to respond to the calls where time truly does matter.

The Two Historical Options for EMS

Since the inception of EMS in the late 1960s, when someone has called 911 for a medical problem, field providers have only had two options: transport the patient by ambulance to the nearest ED or leave the patient at home with instructions to call 911 again if they get worse. This binary option is increasingly no longer financially sustainable or patient centric.

New Innovation in EMS Assessment, Treat & Release – with Follow-Up

A new company has been launched to address the challenges confronting today’s EMS systems. Tele911 is a technology company that integrates telemedicine and patient navigation through EMS systems to allow their personnel to safely treat and release (treatment in place) or transport to in-network alternate destinations. Tele911’s founders state that their model saves crew time, saves money, and saves lives.

The Contra Costa County (CA) Fire-EMS Alliance – a Tele911 Collaboration

The Contra Costa County (CA) Fire-EMS Alliance is a unique partnership between Contra Costa County Fire Protection District (CCCFPD) and American Medical Response (AMR) that serves a population of over 1.1 million people over 700 square miles in northern California. The Alliance responds to over 96,000 EMS incidents each year resulting in approximately 70,000 ambulance transports.

CCCFPD is working with Tele911 to help make the system more efficient and increase readiness for emergency calls. To accomplish this goal, Tele911 integrates telemedicine and patient navigation into the EMS system to better serve Contra Costa County patients and place much needed resources back into the system.

“CCCFPD prides itself on providing the highest quality emergency medical care for our community. Partnering with Tele911 will allow CCFPD to leverage innovation and technology to better serve our patients while keeping our highly trained paramedics available for those time-critical calls where every second counts”, says Peter Benson, MD, the CCCFPD Medical Director.

Fire Chief Lewis Broschard summed it up by saying, “As we look to the future of innovation within our EMS delivery model, we’re excited at the potential for telehealth to play a role in supporting comprehensive pre-hospital services to our community.”

How Tele911 Works

Photo provided by Tele911.

Using the Tele911 system, EMTs or paramedics arrive on scene of an EMS call, perform their systematic patient assessment, collect vital signs, and begin their usual documentation.

If their assessment reveals that the patient is stable as per the Tele911-provided EMS agency approved medical screening checklist, field providers establish a link to a Tele911 emergency physician using an app on an agency mobile device, such as a tablet, smart phone, or laptop.

Before the telehealth session is established, the Tele911 app determines whether the patient is covered by a Tele911 participating health plan. All regional health plans are invited to become participating health plans, including government programs, employer and union plans, and commercial health insurers.

The participating health plans add Tele911 as a benefit for their members, including reimbursement to the EMS agency for EMS 911 responses which result in a Tele911 telehealth visit, but no transport. Since EMS has traditionally not been paid for a response without transport, these agreements now present the potential to provide a vital source of continuing revenue while keeping ambulances and first response resources available.

The Tele911 system connects field providers with a board-certified Emergency Physician, who can see incident CAD data and the data input on the field ePCR on their computer screen before they engage with the patient.

The Tele911 physician then performs a focused visual/audible evaluation of the patient via a Tele911 telehealth visit and quickly determines the safe disposition of the patient, usually in under five minutes.

Tele911 only has board-certified Emergency Physicians to work as telemedicine providers. These physicians are carefully vetted and are also trained in local EMS protocols and EMT/paramedic scope of practice.

Field providers perform their usual patient assessment and enter the patient’s demographic and contact information, medical insurance, medical history, medications, allergies, and vital signs on their ePCR in the usual fashion. If the patient meets the clinical criteria on the Medical Screening Checklist, the field provider on scene requests a telemedicine consult by simply using the free Tele911 mobile app. If the patient is a member of a participating health plan, the app notifies the field provider that a Tele911 physician will be with them momentarily. If the patient is not a member of a participating health plan, then the field providers are notified that the patient is not eligible for a telemedicine consult and should be treated as per existing policies.

The Tele911 physicians are located remotely.  The user interface for these physicians allows them to see the ePCR information entered by the field providers. This integration allows the physician to risk stratify the patient, review any diagnostic information uploaded into the ePCR (including a 12 lead ECG, if acquired), even before the Tele911 virtual visit begins. This leveraging of technology and innovation is vastly superior to the current model of on-line medical control, which requires field providers to provide all patient information verbally and does not allow the medical control physician to see the patient.

The virtual assessment by a physician opens several new, safe options for patient disposition. If treatment-in-place is appropriate, field resources are quickly released and go available on scene. This saves an average of 45 to 60 minutes per incident, which decreases response times to calls, decreases patient off-load times (aka “wall time”) at the ED, ambulance decontamination and cleaning time, and ensures EMS resources are more available to save the lives of high priority patients.3

It also protects the revenue for EMS provider agencies since they will get paid for  responses that do not result in patient transport.

Is There a Risk to Leave Some Patients on Scene?

In the traditional EMS model, non-transports are extremely high risk and constitute a major source of litigation.4 However, with this new model, the decision not to transport is made by a board-certified Emergency Physician, and that physician, in addition to patient assessment and transport/no-transport decision-making, helps coordinate follow-up appointments for patients through their participating health plan.

The Tele911 physician also sends the patient appropriate aftercare instructions electronically and sends in any necessary prescriptions to the patient’s pharmacy.

Finally, a Tele911 physician will contact patients who are treated in place within 24 hours of their initial 911 call to make sure they are doing well, have received their prescriptions, and answer any questions they may have. If the physician determines the patient requires further treatment, the doctor will arrange for transportation to the appropriate medical setting.

Alternate Destination Transport

If the EMS patient does require transport but does not require the services of an ED, the physician may recommend the patient be transported to an alternate destination, which may include an in-network urgent care clinic, a mental health facility or a sobering center. The patient will be transported by ambulance, family member, or ride share provider, as recommended by the physician.

If the Tele911 physician determines the EMS patient requires ED care but does not need to go to the closest hospital, the patient may be transported to the closest in-network ED reachable within an estimated transport time under 30 minutes.

The benefit of transporting to an in-network ED is that the patient avoids potentially significant bills resulting from an out-of-network ED visit including high co-pays, insurance deductibles and surprise billings, which can amount to thousands of dollars out of pocket.

In addition, the in-network ED usually has access to the patient’s medical records which help physicians provide directed care and avoid expensive and unnecessary testing, expanded clinical workups and even hospital admissions.

Tele911 is working to get as many health plans to sign up to include as many patients as possible. If a patient is not a member of a participating health plan, they will be treated and transported in accordance with current local protocols.

Financial Implications for EMS Provider Agencies

Historically, EMS provider agencies have only been able to bill for ambulance transports to an ED. This provides an unnecessary incentive to transport ALL patients to the ED, regardless of whether they need ED care.

Changing this paradigm is the premise behind a pilot program by the Centers for Medicare and Medicaid Services (CMS) called ET3 (the Emergency Triage, Treat, and Transport Program) which began January 1, 2021.5   

The CMS ET3 program only covers Medicare fee-for-service patients, who typically comprise a very small percentage of all EMS patients. It also does not cover the one-third of Medicare patients who are covered by commercial health plans under Medicare Advantage plans.

Tele911 expands on the ET3 model by adding as many health plans as possible, including managed Medicaid plans, Medicare Advantage, self-insured employer plans, union health plans and commercial health insurance. State Medicaid fee-for-service plans can also choose to become participating health plans.

Tele911 establishes agreements with participating health plans that allow EMS provider agencies to get paid for their response for treatment in place or their transport fee when bringing the patient to an alternate destination.

Image provided by Tele911.

The Financial Impact of Moving to This New Model

Under the Tele911 model there is no cost to integrate Tele911 into an EMS system. The field App is free and Tele911 fully integrates data transmission between the CAD, the ePCR system, and the Tele911 physicians.

CEO Marc Eckstein, MD points out that Tele911 is not another telemedicine company providing urgent medical care. He states that “Tele911 is changing the paradigm of EMS, which has not fundamentally changed in 50 years. Transporting all patients to the ED or leaving them at home with no physician interface or follow-up, and EMS Provider Agencies not receiving any reimbursement, is not patient-centered and not financially sustainable.”

Dr. Eckstein established a nationally recognized telemedicine program in the EMS system in Los Angeles. He said the impetus for changing that system was to ensure highly trained first responders were available to respond quickly to patients with time-critical conditions and decreasing the time spent on low acuity incidents.

“Tele911 allows paramedics and EMTs to focus on the “E” in EMS – the true emergencies, while providing appropriate services to those who do not need ED care”, Eckstein says.

Summary

These are challenging times for everyone – especially health care providers. Tele911 allows EMS Agencies to accomplish their mission despite budget cuts, increasing call loads, a disproportionate number of low acuity patients, and dwindling resources.

Most EMS Provider Agencies are also struggling right now with surging call loads, a paramedic shortage, and prolonged ambulance patient off load times since EDs and hospitals remain at or near capacity.6

Additionally, municipal budgets have been decimated due to the pandemic.7 EMS provider agencies are facing potential layoffs and are having to do “more with less”.8

The status quo, i.e. “You call, we haul”, is no longer sustainable and is no longer in our patients’ best interests.

Integrating the Tele911 program paves the way to a better future to allow EMS provider agencies to accomplish their mission, which is to save lives while providing the best services to the citizens they serve.

You can learn more about Tele911 at www.tele911.com.

References

  1. Innovation Opportunities for Emergency Medical Services. July 2013. https://www.ems.gov/pdf/2013/EMS_Innovation_White_Paper-draft.pdf. Accessed Dec 13, 2020.
  2. Augustine JJ. Emergency Medical Services Arrivals, Admission Rates to the Emergency Department Analyzed. Dec 17, 2014. ACEP Now. https://www.acepnow.com/article/emergency-medical-services-arrivals-admission-rates-emergency-department-analyzed. Accessed Dec 13, 2020.
  3. Langabeer JR, et al. Telehealth-Enabled Emergency Medical Services Program Reduces Ambulance Transport to Urban Emergency Departments. West J Emerg Med 2016;17: 713–720.
  4. Morgan DL, et al. Emergency medical services liability litigation in the United States: 1987 to 1992. Prehosp Disaster Med. 1994;9:214-220.
  5. Emergency triage treat and transport (ET3) model. Centers for Medicaid and Medicare Services. https://innovation.cms.gov/innovation-models/et3. Accessed Dec 13, 2020.
  6. Wan W. Pandemic is pushing America’s 911 system to ‘breaking point,’ ambulance operators say. The Washington Post. Dec 3, 2020. https://www.washingtonpost.com/health/2020/12/03/911-ambulance-services-breaking-point/. Accessed Dec 13, 2020.
  7. Harrison D. State, local governments slashed spending after COVID. Next year could be worse. Wall Street Journal. Nov 29, 2020. https://www.wsj.com/articles/state-local-governments-slashed-spending-after-covid-next-year-could-be-worse-11606669200. Accessed Dec 13, 2020.
  8. Cassidy D. NYC EMS Workers Brace for Layoffs as City Grapples with Budget Crisis. Forbes. Aug 20, 2020. https://www.forbes.com/sites/danielcassady/2020/08/19/nyc-ems-workers-brace-for-layoffs-as-city-grapples-with-budget-crisis/?sh=66ddf3307d2f. Accessed Dec 13, 2020.

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