key: cord-1023565-jdzmw27z authors: Hamm, Joel M.; Greene, Chris; Sweeney, Mike; Mohammadie, Setareh; Thompson, Linda B.; Wallace, Eric; Schrading, Walter title: Telemedicine in the emergency department in the era of COVID‐19: front‐line experiences from 2 institutions date: 2020-07-28 journal: J Am Coll Emerg Physicians Open DOI: 10.1002/emp2.12204 sha: d63c721a5aff917e86872bdfa4c5d8f009f5e347 doc_id: 1023565 cord_uid: jdzmw27z During the COVID‐19 pandemic, one of the major changes that has occurred in emergency medicine is the evolution of telemedicine. With relaxation of regulatory and administrative barriers, the use of this already available technology has rapidly expanded. Telemedicine provides opportunity to markedly decrease personal protective equipment (PPE) and reduce healthcare worker exposures. Moreover, with the convenience and availability of access to medical care via telemedicine, a more fundamental change in healthcare delivery in the United States is likely. The implementation of telemedicine in the emergency department (ED) in particular has great potential to prevent the iatrogenic spread of COVID‐19 and protect health care workers. Challenges to widespread adoption of telemedicine include privacy concerns, limitation of physical examination, and concerns of patient experience. In this clinical review, we discuss ED telemedicine applications, logistics, and challenges in the COVID‐19 era as well as recent regulatory and legal changes. In addition, examples of telemedicine use are described from 2 institutions. Examples of future applications of telemedicine within the realm of emergency medicine are also discussed. community to adapt to new technology, governmental regulation, and lack of financial incentive or reimbursement for use of telemedicine. 4 In the ED in particular, telemedicine has not been accepted for widespread use beyond a few specific applications. Telestroke, for example, has been used in EDs since the 1990s. 5 This modality is often used in critical access hospitals where neurology stroke specialists are lacking. The COVID-19 pandemic has significantly expanded the opportunity for EDs to use telemedicine because of need and has been aided by significant changes in regulations and billing. The COVID-19 pandemic has presented unique challenges to the healthcare system in the United States. Specifically, lack of personal protective equipment (PPE) has been an issue. On April 9, 2020, the US Food and Drug Administration confirmed that some distributors have placed certain types of PPE on allocation and has issued surgical mask and gown conservation strategies to healthcare organizations. 6 The Centers for Disease Control and Prevention (CDC) has even recommended the use of a home bandana or scarf as a last resort. 7 In addition, the risk to healthcare workers of contracting COVID-19 is real. Considering their close contact with the COVID-19 patients and repeated exposure, the "front-line" providers in the ED are at especially high risk. Twenty-nine percent of the initial patients in Wuhan, China were healthcare workers. 8 In addition, of the initial 77,262 patients infected with COVID-19 in China, 3387 were healthcare workers (4.4%), and of these, 23 died with median age of 55 years (range, 29-72). 9 In Italy, 20% of healthcare professionals were infected and some died. 10 The most recent estimates report at least 9282 COVID-19 cases in healthcare workers in the United States. 11 Telemedicine is an important tool that has been proposed to both protect healthcare workers and save PPE. 12 By limiting as many points of contact as possible, all professionals who interact with ED patients could benefit, including registration personnel, nurses, social workers, advanced practice providers (APP), and language translators. In addition, the extensive regulatory changes regarding telemedicine use in the United States present EDs with the opportunity to explore new adaptations of the technology. If changes are made permanent, emergency medicine healthcare delivery will need to rapidly adjust to the changing digital landscape and integrate telemedicine into routine care moving forward. Prior to the COVID-19 global pandemic, telemedicine in the United States had primarily been deployed to improve patients' access to specialist care and decrease time to decisionmaking in critical illness. Telecommunication for the provision of medical care has been evolving since its first implementation during an earthquake in Armenia in the late 1980s. 13 Many EDs have moved a physician or advanced practice provider to participate in the triage process to decrease wait times and leftwithout-being-seen rates. 19 In this capacity, they help to facilitate the rapid identification of patients needing immediate interventions and also to initiate imaging and laboratory testing. Frequently, they are able to evaluate, treat, and discharge many lower acuity patients from the waiting room. As the threat of a COVID-19 infection surge increased, it would be anticipated that patients would present along the entire spectrum of illness and that many would need minimal or no testing. 20 Telemedicine provides a medium for evaluating, educating, and reassuring these patients with mild illness, and reduces the expenditure of PPE. Discharge instructions, referral to outpatient testing facilities, and return precautions could be communicated. Patients requiring interventions or more extensive evaluations (laboratory or imaging studies) also require the presence of healthcare workers to perform these studies. Although the initial evaluation, exam, laboratory draws, and imaging studies can often be "batched" together to avoid the risk of donning/doffing PPE, these patients often require reassessments, vital sign measurements, and communication of results and disposition planning. These interventions also presented an opportunity to employ telemedicine mobile carts for communication, observation of respiratory status, performing "walk tests" and other forms of reassessment. Similarly, discussions with patients either regarding discharge planning or admission rationale could be discussed virtually. These devices can also be used for specialty consultation; for instance, the evaluation of a patient by psychiatric personnel in the ED. Because of the increased risk of morbidity and mortality for older physicians and the immunocompromised, 21 several emergency physician groups have taken measures to decrease the risk of COVID-19 exposure for these healthcare professionals. Anecdotal reports exist of departmental policies aimed at protecting high-risk personnel including those older than 60-65, immunocompromised, or pregnant from contact with suspected COVID-19 patients. Some kept physicians older than 50 out of higher risk aerosolizing procedures, such as endotracheal intubation. 22 Telemedicine offers a potential option for emergency physician groups that have at least double coverage and are interested in decreasing the exposure of this at-risk group of physicians. This strategy uses a dedicated telemedicine cart. Many institutions are familiar with these devices as they are often used to provide telestroke capabilities. However, instead of providing a remote neurologist, a physically present emergency physician is replaced by a virtual remote physician. The requirement for this process to be successful is that the remote emergency physicians duties are predominantly supervisory. Remote access to the institutions electronic medical record allows the emergency physician the ability to chart and place orders. This could be useful in academic institutions with emergency or other residents staffing the ED. In support of this, the Accreditation Council for Graduate Medical Education (ACGME) released a position statement that states "effective immediately, the ACGME will permit residents/fellows to participate in the use of telemedicine to care for patients affected by the pandemic." 23 Included in the position is the allowance of direct supervision via telemedicine. Primary care by APPs could also be supervised by this modality. There must be at least double coverage in the ED so that a physically present emergency physician is always available to perform procedures, intubations, and resuscitations. The virtual remote use of telemedicine could also be used by an emergency physician infected with COVID-19 who is well enough to work a shift from home, but not yet beyond the recovery period allowing him/her to return to physical work. 24 As preparations for the surge of COVID-19 illness increased, plans to cohort patients under investigation for COVID-19 within the ED led many institutions to develop COVID-19 pods. Some hospitals' plan was to incorporate other medical specialties (internal medicine, anesthesia, trauma surgery, pulmonary and critical care medicine) into the ED workforce with a board-certified emergency medicine attending available for consultation via telemedicine. Additionally, within the COVID-19 persons under investigation (PUI) cohorted unit, those testing positive for SARS-CoV-2 who manifest mild symptoms may be able to continue to provide care via telemedicine. Telemedicine becomes part of an innovative and integrated strategy to expand critical ED operations despite a temporarily unavailable workforce. As stated above, multiple challenges existed prior to COVID-19 with 1 of the largest being the rural/urban billing restrictions instituted by Medicare. However, other challenges exist with the majority of these surrounding operations and technology. One of the first operational hurdles that must be overcome is that of platform choice. Although many video conferencing platforms exist and are able to be used currently, it is unlikely that the grace we have been given with the relax- Training of staff is one of the biggest logistical hurdles that must be undertaken and typically requires multiple training sessions. Once trained, the acceptance into general use of the technology is best achieved by establishing a telemedicine champion in the department. As the evolving COVID-19 pandemic imposes unprecedented pressures on EDs across the nation, the CMS has revised federal regulations governing the use of telemedicine, enabling dramatically expanded use in the ED setting (Table 2) . These modifications, granted in part due to advocacy from the American College of Emergency Physicians (ACEP) and other national physician organizations, 25 provide the legal and billing framework for broad and creative application of telemedicine New guidance allows the use of any 2-way real-time audio-visual interface between physician and patient. The requirement under EMTALA for all patients presenting for evaluation to the ED to receive a medical screening exam has not changed. The University of Alabama at Birmingham Hospital is a level 1 trauma Our experience has been positive; although we understand that it is not as optimal as in-person supervision, it has proven to be a viable method to provide resident supervision in an academic emergency medicine residency program during this difficult time. Although there are some drawbacks, we have also found advantages in this mode of supervision. We feel we can provide appropriate resident supervision, teaching, and feedback. 22 We have also used telemedicine carts in our triage area to perform no-touch physician evaluations in isolation rooms and to provide access for patient evaluations by specialists in the ED. The patient is then brought back to the respiratory ED. The respiratory ED is separate from the main ED and consists of 24 discrete rooms. To assess the patient in these rooms, telemedicine has been implemented. Each room is outfitted with a tablet on a stand with an adjustable clamp and that can be moved for ease of communication with the patient. The physician is able to "enter" the room along with the APP or resident, scribe, and nurse. During this interview, a determination is made as to whether an "in-person" or "no-touch" exam will be needed. If an "inperson" exam is required, they will enter the room in full PPE and conduct the examination. They also has the option to do a "no-touch" examination and document the medical screening examination completed using the telemedicine encounter. In addition, there is the option to do reassessments and discharge planning over telemedicine. The portable system is easily cleaned after each use with cleansing wipes. There has been a marked decrease in all healthcare worker contacts with potentially infected patients. Registration, social work, language interpretation, and reassessments may all be completed by telemedicine. Along with this has come a significant decrease in PPE use given fewer healthcare worker contacts. To date, only a few healthcare workers who work in the University of Kentucky Chandler Medical Center ED have tested positive for COVID-19. Many mistake telemedicine as just the installation of a videoconferencing solution. However, the challenges, implementation, and scaling are akin to starting a new service line or clinic. How to provide appropriate care should be the number 1 goal of any telemedicine program. Auscultatory exams can be performed using any number of tele-stethoscopes. Incorporation of point-of-care ultrasound and imaging seems like a very logical next step but largely due to cost of the devices and time Patient experience must also be taken into account when evaluating telemedicine. The best planned programs benefit the patients, the physician, and are atleast cost neutral. Those only benefiting one party are unlikely to be sustainable. The patient experience will change over time as technology literacy changes and acceptance increases. The ability to do a physical examination over telemedicine will likely increase patient acceptance. Specifically, the auscultatory examination not only improves the ability to address medical problems, but also lends validity to the idea that many older patients have who associate the stethoscope with receiving care. In the era of COVID-19 with both physician and patients wearing masks, telemedicine allows the patient to see the face of at least 1 physician. Our experience with telemedicine and the unprecedented changes that our patients experience when seeking care in our EDs seem to indicate that patients are accepting of interacting with a physician in this fashion. Largely, the challenge has been with the economic model. The economic model has improved greatly for telemedicine given the changes in reimbursement, but should we see a regression of reimbursement, then much of the progress that has been made may unfortunately stall. Another challenge may be the initial cost of hardware and software; however, the efficiency gained from department patient flow and throughput should cover this cost over time. Finally, if there is no concern for exposure, some of the applications may be unnecessary. [27] [28] [29] but little innovation has been made in the field since that time. Using telemedicine to expand access to specialists has the potential to improve patient outcomes, and in the scenario that our regional healthcare system becomes overwhelmed during this pandemic, sets a framework to effectively triage which patients will need to be transferred to a tertiary care center emergently. The application to critical access hospitals in the United States can be extrapolated 1 step further to international EDs in resource-limited settings. The technology has fostered an ease of collaboration never before seen that gives us the power to begin addressing health disparities. In many African countries that have upward of 1 million citizens for each ventilator access to emergency medicine, critical care, and infectious disease specialists may be instrumental in stemming the flow of infection and managing critical COVID-19 patients. 30 If the regulatory changes remain permanent after the global pandemic, telemedicine would necessarily be integrated into ED operations. One potential application would be patients using telemedicine to consult an emergency physician from home. Another possibility would be scheduling a 24-48 hour follow-up telemedicine visit after an in-person ED visit. As healthcare has been slow to adapt to the digital revolution, the many abrupt changes since the onset of the pandemic have the potential to lead to more permanent changes in how patients access emergency medical care. As we continue to explore this technology and its use in the medical field becomes more facile, we will undoubtedly uncover more applications for telemedicine that enable us to better serve our patients and collaborate with our colleagues. The widespread application of telemedicine in EDs is novel and requires careful scrutiny. A national work group is needed to conduct research and track outcomes for COVID-19 patients seen by in-person The COVID-19 global pandemic has significantly strained the emergency care delivery system in the United States. EDs across the States are creating novel approaches of telemedicine implementation to support this stressed system. The strengths of telemedicine help us meet the needs of our patients and have proven to be one important tool in our toolbox to help us navigate the most significant public health crisis of this century. Joel M. Hamm MD, MPH https://orcid.org/0000-0001-7191-3403 Building a regulatory and payment framework flexible enough to withstand technological progress Telemedicine Opportunities and Developments in Member States. World Health Organization American Telemedicine Association Medicare Telemedicine Health Care Provider Fact Sheet American Telemedicine Assoication: telestroke guidelines Surgical Mask and Gown Conservation Strategies-Letter to Healthcare Providers. Food and Drug Administration Centers for Disease Control and Prevention Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China Death from COVID-19 of 23 health care workers in China COVID-19 and Italy: what next? MMWR characteristics of health care personnel with COVID-19 -United States Virtually perfect? Telemedicine for Covid-19 Spacebridge to Armenia: a look back at its impact on telemedicine in disaster response A cohort study of acute plastic surgery trauma and burn referrals using telemedicine The use of telemedicine for realtime video consultation between trauma center and community hospital in a rural setting improves early trauma care: preliminary results Telecardiology improves quality of diagnosis and reduces delay to treatment in elderly patients with acute myocardial infarction and atypical presentation Thrombolysis delivery by a regional telestroke network-experience from the U.K. National Health Service Teleultrasound in resource-limited settings: a systematic review. Front Public Health Impact of rapid entry and accelerated care at triage on reducing emergency department patient wait times, lengths of stay, and rate of left without being seen Centers for Disease Control and Prevention Severe outcomes among patients with coronavirus disease 2019 (COVID-19) -United States Virtual remote attending supervision in an academic emergency department during the COVID-19 pandemic. Accepted for publication AEM Educ Train Accreditation Council for Graduate Medical Education. ACGME Response to COVID-19: Clarification regarding Telemedicine and ACGME Surveys. Date released Medicare Telehealth Coverage Expansion During the COVID-19 Public Health Emergency Notification of Enforcement Discretion for Telehealth Remote Communications During the COVID-19 Nationwide Public Health Emergency. Health and Human Service/Office of Civil Rights Memorandum Telestroke-the promise and the challenge. Part one: growth and current practice Telestroke: rapid treatment of acute ischemic stroke patients using telemedicine in a Singapore emergency department Telemedicine for safe and extended use of thrombolysis in stroke: the Telemedic Pilot Project for Integrative Stroke Care (TEMPiS) in Bavaria Telemedicine in the emergency department in the era of COVID-19: front-line experiences from 2 institutions