Background
Telemedicine provides a unique opportunity for remote patient consultation and care. The implementation of video telemedicine into the ambulance for use by emergency medical service (EMS) providers has the potential to enhance the quality of care by decreasing time to definitive care, informing destination decisions and increasing diagnostic accuracy.1-6
As video communication and mobile technology improve, the opportunities to use telemedicine to enhance patient care continue to expand. Studies have demonstrated the capabilities of telemedicine in the emergency medicine settings, including military and rural trauma care.7,8 Recently, there has been a push for the implementation of telemedicine into the ambulance, primarily to assist with time-sensitive conditions such as acute stroke.3,4,9-12
The aims of these projects have often focused on connecting the patient to a remote specialist prior to hospital arrival, endeavoring to decrease the time from symptom onset to treatment — especially important when “time is brain.”13 A recent meta-analysis evaluating 6,605 patients treated with tissue plasminogen activator (tPA) demonstrated that ambulance telemedicine was significantly associated with decreased time from symptom onset to hospital arrival with no increase in adverse events.14
Telemedicine in the ambulance remains a relatively new concept, however, and concerns remain regarding its implementation. Concerns often cited in the literature include audio and video connection issues, interference with patient care, workflow disruptions and patient confidentiality.5,6,8,10,11,15 For successful implementation of telemedicine, paramedics’ perspectives on implementation strategies will be key.6,11
To better understand the benefits of and barriers to the implementation of EMS telemedicine, we reviewed the current state of EMS telemedicine and undertook a broad EMS survey to understand paramedics’ perspectives on EMS telemedicine. To our knowledge, there has been limited evaluation of EMS perspectives on prehospital telemedicine. Here, we will discuss what studies have already been conducted as well as the results of our survey study.
Methods
Setting
Marin County, California, is served by a fire-based EMS agency with three receiving hospitals, all of which are primary stroke centers. The EMS agency utilizes electronic patient care reporting using ImageTrend. The yearly volume of EMS transports was 15,000 per year. Marin County is a suburban area with some rural communities and most transports are within 15 minutes of a receiving center. At the time of this survey study, the county did not have any prehospital telemedicine capabilities.
Survey
The EMS telemedicine survey was administered to all 177 Marin County paramedics via an emailed online survey by SurveyMonkey. The survey captured respondent demographics, EMS experience, and perspectives on the perceived benefits, challenges, and situation-specific utility of prehospital telemedicine (Appendix 1).
EMS telemedicine was defined as video consultation with audio capabilities, either before and/or during transport with an offsite emergency physician or specialist. Questions were asked about the use of EMS telemedicine in general, as well as specific audio, video and equipment considerations.
The survey was first administered in February 2017, with a single re-send in December 2017. Due to the de-identified nature of the survey, it was re-sent to all paramedics, but providers were instructed not to complete a second time. The survey data collection period closed December 31, 2017. This study was approved by the Kaiser Permanente Northern California Institutional Review Board.
Data Analysis
Survey questions regarding the benefits, concerns and situation-specific utility of EMS telemedicine were answered using a five-point Likert Scale. To analyze the results of these questions, we stratified responses into three categories: agree, neutral and disagree. Open-ended questions were included throughout the survey and answers were reviewed by the study team. Comparisons regarding situation-specific utility of telemedicine were performed with review of 95% confidence intervals.
To assess the association between paramedic experience level and survey responses, we stratified by years as a practicing paramedic (<7 years vs. ≥7 years), comparing answer patterns with Whitney Mann U-tests. Seven years was chosen as the cut point post-hoc since it marked the lower tertile of paramedic years of experience.
Results
One hundred paramedics completed the survey for a response rate of 56%. Of the respondents, 95% were male, 97% were currently providing EMS care, 87% averaged over 15 patient contacts a month and the mean experience as a paramedic was 12 years (median 11 years; IQR 5-16 years)
Table 1
Only 44% of the respondents were aware of EMS telemedicine use in any context at the time of survey completion.
The majority of respondents agreed with or were neutral about statements asking whether telemedicine can improve pre-hospital diagnosis (35% agreed, 49% neutral), destination decisions (41%, 33%), and patient satisfaction (38%, 43%)
Figure 1
EMS, emergency medical services
The main practical telemedicine considerations raised by providers regarded difficulty hearing due to background noise (64%), connection issues (59%) and interference with normal care (64%) (Figure 2). Providers were less concerned about issues regarding the physical equipment such as loss or damage (39%) or the equipment being too challenging to use during patient transport (37%)
Figure 2
EMS, emergency medical services
Additionally, we assessed the different scenarios in which paramedics believed telemedicine would be most beneficial. For unclear acute stroke diagnoses, 56% (95% CI 46-66%) agreed that telemedicine would be useful, while only 20% (95% CI 13-29%) agreed it would be useful for a clear stroke diagnosis. Similar patterns were found for meeting trauma center criteria (33% vs 5%) and ST-segment elevation myocardial infarction (STEMI) criteria (50% vs 22%).
Finally, we assessed differences in survey-reported perceived benefits, challenges, and utility of telemedicine based on years of provider experience. Providers with fewer years of experience were more likely to rate telemedicine as potentially useful for patients requesting release against medical advice (AMA) than paramedics with more experience (40% vs 32%, p<0.03). No other statistically significant differences were found to be associated with providers’ years of experience.
EMS Telemedicine. A Review of the Existing Literature.
The use of telemedicine has been rapidly expanding across various applications, from chronic disease management (diabetes, cancer, cardiovascular disease [CVD]) to postoperative care.16-23 In EMS, telemedicine is currently being implemented mostly in stroke care and CVD treatment, with noticeably fewer–but existent–trauma and primary care use cases.15
EMS telemedicine has been shown to decrease time to treatment for acute stroke patients and safely replace a neurologist on a mobile stroke unit, although the scalability of this model is in question.3,6,14,24-26 Technological advances have also made time-sensitive monitoring of patients with CVD possible with mobile electrocardiograms (ECGs).23,27,28
Currently, the most common forms of telemedical physician consultation delivery are real-time video conferencing and a “store and forward” method, where communication mostly consists of images, documents and video recordings sent to the receiving physician.15 There are ongoing efforts to improve the efficiency of the technology used for telemedicine, including the proposal of a 12-Lead/Holter device for mobile ECG applications and the usage of adaptive 4×4 multiple-input and multiple-output antenna configurations for a mobile telemedicine network.28,29
A recent study comparing technological parameters and decision-making between fourth-generation (4G) and third-generation (3G) networks found that, while 4G mobile communications provided higher video quality, coverage was still incomplete overall in both networks–thus revealing the need for further investigation and technological innovation in the field.5,15,30
To our knowledge, there has been little published on the use of mobile phones in EMS telemedicine specifically. However, there have been studies done on mobile phone usage in other telemedicine applications.31,32 For example, Smith et al. found smartphones are a viable option for training an inexperienced operator in ultrasound imaging amidst resource-limited conditions, and Garner et al. found that affordable and credible mobile applications are necessary to provide a platform for communication between key stakeholders in a limited resource setting.33,34
Various implementation studies have been done to evaluate the effectiveness of telemedicine and its potential role in emergency services. New York Presbyterian hospital has implemented a comprehensive enterprise wide program that includes a mobile stroke treatment unit and ED-based emergency care.35 In Germany, an observational study was done on a prehospital EMS teleconsultations program to evaluate utilization, safety and technical performance.36
In 2012, researchers had conducted a feasibility study in the same area that demonstrated limited improvement in stroke care using teleconsultation, but the technological advancements in the last few years have potentially changed this dynamic.37 These programs, in New York Presbyterian and Germany, were shown to be time-efficient and well-received by participants, though cost reduction for mobile stroke units in particular still needs to be addressed.35,36 Additionally, there are current prospective randomized controlled trials in both Germany and Scotland to further evaluate the safety and quality of the prehospital teleconsultation system.38,39
As highlighted by various studies, key stakeholders are crucial in the successful implementation of EMS telemedicine; as a result, survey studies evaluating the viewpoints of nurses, physicians, patients, and paramedics have been carried out.5,6,11,40 Multiple studies have found that patient attitudes toward video link technology in telemedicine are largely positive, and that the majority of physicians, nurses and ambulance personnel see the potential for telemedicine to be largest in situations where early diagnosis and intervention are key to a patient’s ultimate recovery.5,11
Alternatively, one study found that some nurses were cautious about telemedicine efficiency and ultimately thought the outcome of a given telemedicine intervention to be highly dependent on the skills of individual physicians providing consultatiion.40
What Does This Survey Mean for EMS Telemedicine Implementation?
Survey Learnings
While implementation of prehospital telemedicine is growing, to our knowledge, there are few published studies of paramedic attitudes to help inform telemedicine implementation. Paramedics are key stakeholders in prehospital telemedicine, and their experiences can provide valuable insights into potential challenges of telemedicine.11 Inclusion of paramedic knowledge and perspectives may improve telemedicine implementation programs. Additional input regarding paramedic user experience during and after implementation are also essential.
When this survey was conducted, only 44% of the paramedics were aware of telemedicine ever being used in EMS. From the open-ended portion of this question, it appeared that most of the awareness involved telemedicine for stroke patients and for use within the emergency department (ED). The low percentage of telemedicine awareness is interesting and demonstrates that at the time of the survey, EMS telemedicine was still a fairly new concept.
In terms of the perceived benefits expressed by Marin County paramedics, their responses align with other studies that assessed providers’ perspectives of telemedicine. A study conducted by Gilligan et al. found that ambulance personnel believed video telemedicine would have a positive impact on care and the majority would be willing to use it in their practice.5
The concerns expressed in our survey also align with concerns often mentioned in the literature. The concerns most highly rated in our study included background noise, connection errors and interference with patient care. Other studies have found ED providers and paramedics are concerned about the workflow of telemedicine, that it may result in a delay of care, and the liability associated with its use.5,6 Some pilot studies have also referenced connection errors and issues with audio and video quality when initially tested in the ambulance.6,11,41 Consequently, it is important that these issues be addressed prior to implementation.
The perceived situation-specific utility of telemedicine is important in determining which telemedicine implementation programs to pursue. We found, as have others, that the perceived benefits of EMS telemedicine are especially germane for time-sensitive conditions.5 We found specifically that EMS providers are most interested in having telemedicine assistance in cases where it is challenging to diagnose time-sensitive conditions, such as stroke, trauma, and STEMI. This is not surprising, as telemedicine would provide a valuable second opinion that can decrease the time to treatment, improve the accuracy of alerts to hospitals, and influence destination decisions.
The ability to influence destination decisions can be especially important for stroke patients, as some may become ineligible for endovascular treatment if they are first directed to a hospital without treatment capabilities and then transferred to a comprehensive stroke center.41 Communication with a neurologist in the ambulance could allow for confirmation on which patients should be transported to comprehensive stroke centers directly, saving these patients time without overwhelming such centers with all stroke patients.
With regards to the provider experience-level comparisons, paramedics with fewer years of experience were more likely to agree that EMS telemedicine would be useful in situations where the patient is requesting release AMA. Possible explanations for this difference are that the less experienced paramedics may have less confidence in their decisions, may not have dealt with similar situations in the past, or may be more inclined to want a second opinion. Overall, our results regarding the perceived situation-specific utility of EMS telemedicine support the concept that telemedicine would be most useful when a physician’s opinion would significantly impact the treatment pathway of the patient, often the case in time-sensitive situations.
With specific regard to telestroke opportunities, one distinct advantage of telemedicine is that it can be implemented in all ambulances of an EMS service area. While prior studies have suggested the benefits of mobile stroke units for the treatment of possible stroke patients and have shown they can successfully decrease time to treatment, they tend to be resource intensive due to the presence of a CT scanner, and depend more heavily on the accuracy of the dispatcher.3,41
Recent literature has shown that dispatchers have a low positive predictive value for stroke diagnosis, with 55% of patients labeled as possible stroke victims having alternate diagnoses upon hospital discharge.42 Conversely, the implementation of telemedicine in the normal ambulance would allow for on-scene paramedics to initiate the stroke protocol which has been shown to be potentially cost effective and to decrease time to treatment.43,44
Survey Limitations
There are a few limitations to this survey study. First, it was done in a limited geographic area. Consequently, the results of this survey may not be generalizable to all locations. Second, this study was conducted prior to any EMS telemedicine implementation in Marin County. Therefore, these are perceptions of the benefits and barriers to telemedicine, not actual responses to a telemedicine program. Finally, the 56% response rate for this survey is a possible limitation as survey respondents may differ in their opinions from non-respondents.
Conclusion
Video telemedicine in the ambulance was a new concept to most paramedic survey respondents in this 2017 study, and most agreed or were neutral with the concept that telemedicine has the potential to improve the patient care experience, including prehospital diagnosis, destination decisions and patient satisfaction. Furthermore, providers were more likely to agree with the benefits of telemedicine in cases where the patient diagnosis or disposition was unclear.
Working with EMS personnel during the telemedicine implementation process is important and provides the opportunity to address provider concerns. In particular, it is essential to ensure audio and video quality are high, the equipment is unobtrusive and easy to use, and the use of telemedicine is easily integrated into the provider workflow.
References
1. Hansen M, Meckler G, Dickinson C, et al. Children’s safety initiative: a national assessment of pediatric educational needs among emergency medical services providers. Prehosp Emerg Care. 2015;19(2):287-291.
2. Seymour CW, Carlbom D, Engelberg RA, et al. Understanding of sepsis among emergency medical services: a survey study. J Emerg Med. 2012;42(6):666-677.
3. Taqui A, Cerejo R, Itrat A, et al. Reduction in time to treatment in prehospital telemedicine evaluation and thrombolysis. Neurology. 2017;88(14):1305-1312.
4. Bowry R, Parker S, Rajan SS, et al. Benefits of stroke treatment using a mobile stroke unit compared with standard management. Stroke. 2015;46(12):3370-3374.
5. Gilligan P, Bennett A, Houlihan A, et al. The doctor can see you now: a key stakeholder study into the acceptability of ambulance based telemedicine. Ir Med J. 2018;111(6):769.
6. Rogers H, Madathil KC, Agnisarman S, et al. A systematic review of the implementation challenges of telemedicine systems in ambulances. Telemed J Health. 2017;23(9):707-717.
7. Sailors RM, Duke JH, Wall JA, et al. DREAMSâ„¢(Disaster Relief and Emergency Medical Services) and Digital EMS. Proc AMIA Symp. 2000:1127.
8. Ricci MA, Caputo M, Amour J, et al. Telemedicine reduces discrepancies in rural trauma care. Telemed J Health. 2003;9(1):3-11.
9. Xiao Y, Gagliano D, LaMonte M, et al. Design and evaluation of a real”time mobile telemedicine system for ambulance transport [1] Work reported here was partially supported by National Library of Medicine. Journal of High Speed Networks. 2000;9(1):47-56.
10. LaMonte MP, Bahouth MN, Xiao Y, Hu P, Baquet CR, Mackenzie CF. Outcomes from a comprehensive stroke telemedicine program. Telemed J Health. 2008;14(4):339-344.
11. Smith SNC, Brown PC, Waits KH, et al. Development and evaluation of a user-centered mobile telestroke platform. Telemedicine journal and e-health : the official journal of the American Telemedicine Association. 2018.
12. Langabeer JR, II MG, 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.
13. Bourcier R, Goyal M, Liebeskind DS, et al. Association of time from stroke onset to groin puncture with quality of reperfusion after mechanical thrombectomy: a meta-analysis of individual patient data from 7 randomized clinical trials. JAMA Neurol. 2019.
14. Baratloo A, Rahimpour L, Abushouk AI, Safari S, Lee CW, Abdalvand AJPEC. Effects of telestroke on thrombolysis times and outcomes: a meta-analysis. Prehospital Emergency Care. 2018;22(4):472-484.
15. Winburn AS, Brixey JJ, Langabeer J, 2nd, Champagne-Langabeer T. A systematic review of prehospital telehealth utilization. J Telemed Telecare. 2018;24(7):473-481.
16. Baron JS, Hirani S, Newman SP. A randomised, controlled trial of the effects of a mobile telehealth intervention on clinical and patient-reported outcomes in people with poorly controlled diabetes. J Telemed Telecare. 2017;23(2):207-216.
17. Lee PA, Greenfield G, Pappas Y. The impact of telehealth remote patient monitoring on glycemic control in type 2 diabetes: a systematic review and meta-analysis of systematic reviews of randomised controlled trials. BMC Health Serv Res. 2018;18(1):495.
18. Garg SK, Parkin CG. The Emerging Role of Telemedicine and Mobile Health Technologies in Improving Diabetes Care. Diabetes Technol Ther. 2019;21(S2):S21-S23.
19. Sirintrapun SJ, Lopez AM. Telemedicine in Cancer Care. Am Soc Clin Oncol Educ Book. 2018;38:540-545.
20. Cannon C. Telehealth, Mobile Applications, and Wearable Devices are Expanding Cancer Care Beyond Walls. Semin Oncol Nurs. 2018;34(2):118-125.
21. Coldebella B, Armfield NR, Bambling M, Hansen J, Edirippulige S. The use of telemedicine for delivering healthcare to bariatric surgery patients: A literature review. J Telemed Telecare. 2018;24(10):651-660.
22. Williams AM, Bhatti UF, Alam HB, Nikolian VC. The role of telemedicine in postoperative care. Mhealth. 2018;4:11.
23. Bleda AL, Melgarejo-Meseguer FM, Gimeno-Blanes FJ, et al. Enabling Heart Self-Monitoring for All and for AAL-Portable Device within a Complete Telemedicine System. Sensors (Basel). 2019;19(18).
24. Wu TC, Parker SA, Jagolino A, et al. Telemedicine Can Replace the Neurologist on a Mobile Stroke Unit. Stroke. 2017;48(2):493-496.
25. Geisler F, Kunz A, Winter B, et al. Telemedicine in Prehospital Acute Stroke Care. J Am Heart Assoc. 2019;8(6):e011729.
26. Bowry R, Parker SA, Yamal JM, et al. Time to Decision and Treatment With tPA (Tissue-Type Plasminogen Activator) Using Telemedicine Versus an Onboard Neurologist on a Mobile Stroke Unit. Stroke. 2018;49(6):1528-1530.
27. Seetharam K, Kagiyama N, Sengupta PP. Application of mobile health, telemedicine and artificial intelligence to echocardiography. Echo Res Pract. 2019;6(2):R41-R52.
28. Pineda-Lopez F, Martinez-Fernandez A, Rojo-Alvarez JL, Garcia-Alberola A, Blanco-Velasco M. A Flexible 12-Lead/Holter Device with Compression Capabilities for Low-Bandwidth Mobile-ECG Telemedicine Applications. Sensors (Basel). 2018;18(11).
29. Tchao ET, Diawuo K, Ofosu WK. Mobile Telemedicine Implementation with WiMAX Technology: A Case Study of Ghana. J Med Syst. 2017;41(1):17.
30. Winter B, Wendt M, Waldschmidt C, et al. 4G versus 3G-enabled telemedicine in prehospital acute stroke care. Int J Stroke. 2019;14(6):620-629.
31. Greenwood DA, Gee PM, Fatkin KJ, Peeples M. A Systematic Review of Reviews Evaluating Technology-Enabled Diabetes Self-Management Education and Support. J Diabetes Sci Technol. 2017;11(5):1015-1027.
32. Garabedian LF, Ross-Degnan D, Wharam JF. Mobile Phone and Smartphone Technologies for Diabetes Care and Self-Management. Curr Diab Rep. 2015;15(12):109.
33. Smith A, Addison R, Rogers P, et al. Remote Mentoring of Point-of-Care Ultrasound Skills to Inexperienced Operators Using Multiple Telemedicine Platforms: Is a Cell Phone Good Enough? J Ultrasound Med. 2018;37(11):2517-2525.
34. Garner SL, Sudia T, Rachaprolu S. Smart phone accessibility and mHealth use in a limited resource setting. Int J Nurs Pract. 2018;24(1).
35. Sharma R, Fleischut P, Barchi D. Telemedicine and its transformation of emergency care: a case study of one of the largest US integrated healthcare delivery systems. Int J Emerg Med. 2017;10(1):21.
36. Felzen M, Beckers SK, Kork F, et al. Utilization, Safety, and Technical Performance of a Telemedicine System for Prehospital Emergency Care: Observational Study. J Med Internet Res. 2019;21(10):e14907.
37. Bergrath S, Reich A, Rossaint R, et al. Feasibility of prehospital teleconsultation in acute stroke–a pilot study in clinical routine. PLoS One. 2012;7(5):e36796.
38. SatCare: Remote Support for Ambulance Clinicians in Medical Emergencies. https://ClinicalTrials.gov/show/NCT03323229. Accessed 13 January 2020.
39. Telemedical Support for Prehospital Emergency Medical Service. https://ClinicalTrials.gov/show/NCT02617875. Accessed 13 January 2020.
40. Johansson A, Esbjornsson M, Nordqvist P, et al. Technical feasibility and ambulance nurses’ view of a digital telemedicine system in pre-hospital stroke care – A pilot study. Int Emerg Nurs. 2019;44:35-40.
41. Fassbender K, Grotta JC, Walter S, Grunwald IQ, Ragoschke-Schumm A, Saver JLJTLN. Mobile stroke units for prehospital thrombolysis, triage, and beyond: benefits and challenges. Lancet Neurol. 2017;16(3):227-237.
42. Oostema JA, Chassee T, Reeves MJPEC. Emergency dispatcher stroke recognition: associations with downstream care. Prehosp Emerg Care. 2018;22(4):466-471.
43. Espinoza AV, Devos S, van Hooff R-J, et al. Time gain needed for in-ambulance telemedicine: cost-utility model. JMR Mhealth Uhealth. 2017;5(11):e175.
44. Langabeer JR, Champagne-Langabeer T, Gleisberg GR, Persse D, Gonzalez M. Tele-EMS Improves Productivity and Reduces Overall Costs. JEMS. 2019.
This study was supported by a grant from the Kaiser Permanente Northern California Community Benefit Program.
