key: cord-0907418-c6s823ev authors: Uscher-Pines, Lori; Sousa, Jessica; Mehrotra, Ateev; Schwamm, Lee H; Zachrison, Kori S title: Rising to the Challenges of the Pandemic: Telehealth Innovations in U.S. Emergency Departments date: 2021-05-22 journal: J Am Med Inform Assoc DOI: 10.1093/jamia/ocab092 sha: 8e16f09518fc0b68a14bf6373ae6da7bc6d8b6ea doc_id: 907418 cord_uid: c6s823ev OBJECTIVE: During the first nine months COVID-19 pandemic, many emergency departments (EDs) experimented with telehealth applications to reduce virus exposure, decrease visit volume, and conserve personal protective equipment. We interviewed ED leaders who implemented telehealth programs to inform responses to the ongoing COVID-19 pandemic and future emergencies. MATERIALS AND METHODS: From September-November 2020, we conducted semi-structured interviews with ED leaders across the United States. We identified EDs with pandemic-related telehealth programs through literature review and snowball sampling. Maximum variation sampling was used to capture a range of experiences. We used standard qualitative analysis techniques, consisting of both inductive and deductive approaches to identify and characterize themes. RESULTS: We completed 15 interviews with EDs leaders in 10 states. From March-November 2020, participants experimented with more than a dozen different types of telehealth applications including tele-isolation, tele-triage, tele-consultation, virtual post-discharge assessment, acute care in the home, and tele-palliative care. Prior experience with telehealth was key for implementation of new applications. Most new telehealth applications turned out to be temporary because they were no longer needed to support the response. The leading barriers to telehealth implementation during the pandemic included technology challenges and the need for “hands-on” implementation support in the ED. CONCLUSIONS: In response to the COVID-19 pandemic, EDs rapidly implemented many telehealth innovations. Their experiences can inform future responses. During disasters, emergency departments (EDs) must triage, stabilize, and care for large numbers 64 of patients. Further, disasters require EDs to rapidly shift from directing maximal resources to a we reached thematic saturation, defined as the point at which new interviews did not uncover 124 new types of telehealth applications that met our inclusion criteria. Interviews were conducted via videoconference using Microsoft Teams and followed a semi-127 structured protocol. Topics included 1) basic information about the ED (e.g., location, patient 128 volume); 2) impact of COVID-19 on the ED; 3) prior experience with telehealth and the role of 129 prior experience in informing the response to COVID-19; 4) new telehealth applications piloted 130 in response to the pandemic and duration of use; 4) changes to existing telehealth programs in 131 response to the pandemic; 5) telehealth applications that were considered but never implemented; Analysis 140 We coded interview transcripts using qualitative research software (Dedoose, LLC). We 141 developed a hierarchically organized codebook to summarize themes and identify patterns. We 142 used standard qualitative analysis techniques, consisting of both inductive and deductive 143 approaches to identify and characterize instances of themes arising from the domains covered in 144 the interview guide (e.g., prior use of telehealth), as well as unanticipated themes that emerged 145 (e.g., decision to de-adopt/terminate certain telehealth programs). The lead author (LUP) 146 conducted ongoing coding of all transcripts, refining the codebook as she worked and adding 147 relevant probes to interviews in progress. We defined a theme as a concept noted by at least 25% of participants. When identifying themes, 150 we considered cohesiveness and prevalence across participant responses, but also incorporated 151 perspectives that were inconsistent (i.e., negative case analysis). We achieved consensus 152 regarding the characterization of themes through interactive discussions among the research 153 team. 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 Results 155 We conducted 15 interviews with ED leaders from 14 institutions in 10 states. To obtain our 156 final sample, we invited a total of 35 individuals (26 identified in published literature and 9 157 through snowball sampling) giving us a response rate of 43%. ED leaders who did not participate 158 did not differ substantially from participants with respect to U.S. region or hospital type. All 159 participants were ED physicians; however, most also held leadership positions such as ED 160 medical director or ED telehealth director (Table 1) . Interviews uncovered 8 distinct themes 161 about the implementation of different telehealth applications (Table 2) . 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 we had this program in place prior to COVID-19] we already had the infrastructure, the IT team, 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 adds logistical challenges. Participant 4 operating a tele-isolation program explained, "When you 263 do telemedicine, there's inefficiencies…When providers are right next to each other, in-person, 264 communication is very easy. When we were trying to do things by telephone or by tablet, it's just 265 a little bit harder." Participant 9 who implemented a different tele-isolation program added, "If 266 you have a generally healthy staff at a relatively low patient volume, and feel like you have the 267 protective equipment, I think almost universally, people aren't going to find the hassle worth the 268 time." It follows that there must be an acute need for telehealth that outweighs its disadvantages. However, participants noted that many telehealth applications that were implemented for the Regardless of the reason for discontinuation, participants universally acknowledged that the 292 experience implementing new telehealth programs was important for emergency preparedness, and they were pleased to have the improved infrastructure and capability in case of a future 294 disaster. Participant 1 operating several discontinued programs explained, "I think we were 295 pretty happy with the way the program turned out, and we'd probably be able to pretty quickly 296 jump back into the program if the needs changed…All the telehealth carts are still in the ED. They're all working and could be used at any time." One threat to long-term sustainability was that several new and expanded programs did not have 300 long-term staffing plans. Most leveraged staff that had excess capacity for a limited time, such as 301 outpatient providers who had very few patients in March and April 2020 and temporarily 302 assumed new responsibilities. The problem with this model is that when these staff resumed their 303 prior duties, there was no obvious supply of alternative staff. As participant 11 operating a tele-304 urgent care service explained, "We had the pediatric providers see adults because they were 305 really twiddling their thumbs. They were just sitting there with no kids to be seen. So, they said, The leading barriers to telehealth implementation during the pandemic included 326 technology challenges and the need for "hands-on" implementation support in the ED. 327 Despite improvements in the quality and availability of low-cost technologies in recent years, 328 participants often mentioned how equipment failure, equipment shortages, connection issues, 329 device incompatibility with available software, lack of EHR integration, and limited 330 functionality undermined their telehealth programs. Participants also noted that these problems One ED actually reported discontinuing a tele-medication reconciliation program that had been 363 in place prior to the pandemic to reduce the number of people in the ED and shorten ED length 364 of stay. Participant 11 explained, "We couldn't rationalize having someone else on the ground to 365 move that cart around, because we were trying to get everybody out of the ED." It should be noted that several tele-isolation programs experimented with having patients answer 368 telehealth video calls from clinicians in the ED so that staff would not be required to enter the 369 room and assist with this task. However, these programs faced their own challenges because 370 patients were not always prepared or comfortable doing this. Remote supervision of ED providers. One program was able to use physician assistants overseen 379 by remote ED physicians via telehealth to conduct urgent care visits . 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 centers, and our findings may be most applicable in these settings. We hypothesize that the larger 462 academic medical centers were more likely to implement multiple telehealth programs at once, 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 The data underlying this article will be shared on reasonable request and application to the 488 corresponding author. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 Role of Emergency Medicine in Disaster Management Ciottone's Disaster Medicine Western washington state COVID-19 Defining and operationalizing disaster preparedness in (COVID-19) in the emergency department Responding to COVID-19: Healthcare Surge 516 Capacity Design for High-Consequence Infectious Disease. 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The American 619 Authors have no conflicts to disclose