Over recent decades, the field of telemedicine has been witness to periods of great promise, relative stasis as well as overstretch and false starts.
However, there is one telemedicine application which has seen steady, consistent growth. This is emergency telemedicine, where application development, especially teleconsultation and teleradiology, has synchronized with increasing demand for A&E as well as the forward march of telecoms technology.
From the outset, the benefits of telemedicine were self-evident in emergency care in settings such as ski resorts, highway or rail accidents, and after natural disasters. Telemedicine enabled trauma specialists to interact with overtaxed field personnel on site, to gauge the severity of injuries and provide clinical assessments on treatment or evacuation. This aspect of telemedicine was spun out off one of its first movers, the military.
Telemedicine and travel
The roots of ‘serious’ telemedicine practice can be considered to date to the 1990s. Nevertheless, medical practitioners were aware of the enormous possibilities it afforded well before this.
In the 1930s, luxury liners used marine radio-telephones to communicate with physicians about urgent cases on board. Travellers were again the core target market for the first teleradiology consultations, conducted in the 1960s by Dr. Kenneth Bird, who used a two-way/interactive television system that connected Massachusetts General Hospital to Boston’s Logan Airport to provide emergency medical care.
1994: A&E referrals fall at Belfast hospital
Among the earliest case studies on modern emergency telemedicine is a 12-month review of a 1994 link between the Royal Victoria Hospital in Belfast and a minor treatment centre (MTC) in South Westminster, London. Over the study period, the telemedicine link was actively used in only about 0.5% of cases. However, the number of patients referred to a GP fell dramatically as did those referred to A&E. Another interesting observation was an increase in confidence of the nursing staff at the Westminster MTC.
Wembley study compares outcomes, radiologists vs. teleradiologists
At the beginning of 1996, Wembley Community Hospital in London established a minor accident treatment service (MATS), supported by an advanced telemedical link to Central Middlesex Hospital. The system was run by emergency nurse practitioners based on a set of clinical protocols which consisted of prompts advising the use of telemedicine.
Two years later, a paper evaluated six months activity at the MATS, covering all patients seen – a total of 2,843, with 150 teleconsultations. After an interval of three months, 99 per cent of telemedical and 95 percent of non-telemedical cases were followed up. Interestingly, while no further problems had arisen with the telemedical group, 26 of the non-telemedicine group had consulted their GP for the same problem. Another interesting finding was that A&E teleconsultants interpreting radiographs performed better than the consultant radiologist who subsequently interpreted the original films.
Head CT scans
Similar efforts were also made in the US and continental Europe. Other than minor injuries support, another application area with near-universal acceptance in A&E practice consisted of the transmission of head CT scans to a tertiary neurosurgical centre, in order to obtain an immediate expert opinion.
Economic impact of emergency telemedicine
By the late 1990s, rather than convenience alone, the first arguments about the economic impact of emergency telemedicine had begun to appear. A 1997 paper from Hong Kong found a significant reduction in unnecessary transfers, alongside a decrease in adverse events occurring during transfer. Another study from Austria during the same year concluded that though teleradiology for CT scans was more expensive than transferring the physical scans by taxi, it was considerably quicker, and much less expensive than transferring the patient.
Growing ER costs drive US interest in telemedicine
The acceleration of growth in mobile telecoms quality onwards from the late 2000s, along with sharp falls in cost, has intensified the case for emergency telemedicine. Alongside, increased demographic pressure on emergency rooms due to an ageing population and ER staff shortfalls have strengthened this further.
ER figures have been used to make the case for emergency telemedicine in the US. 130 million people visit ERs each year, up 36 percent from 97 million in 1995. In spite of this, the number of ERs in the US dropped by 11 percent over the period.
One leading healthcare provider, Cardinal Health, estimates that the average costs of a telehealth visit at USD 40-50, compared to USD 922 for an emergency room visit and that telemedicine could eliminate nearly 1 in 5 ER visits, which corresponds in numbers to almost two-thirds of those discovered to be non-urgent. Cardinal Health also states that 20% of ER visits require follow-up care for similar conditions, while only 6% of telehealth visits do. This echoes the spirit of the findings of the Wembley Community Hospital MATS study in 1996, mentioned previously.
Waiting times and demographic pressures
The problems with emergency medical care are similar in Britain. A&E waiting times have increased substantially over recent years, with many National Health Service (NHS) units failing to meet a four-hour standard for admission and discharge at national level. The number of people going to A&E has also risen substantially. In 2016/17 there were 23.4 million attendances at A&E departments – the equivalent of 63,000 attendances each day on average, and since 2011/12, this has been growing by 1.7 per cent each year – or the equivalent of an extra 5,100 each day.
These pressures have been exacerbated by closures. One in six A&E departments are being closed or downgraded, which corresponds to 33 casualty departments in hospitals in 23 areas of the UK.
The scourge of unnecessary visits
Unnecessary visits to A&E account for 16% of the total in England, but go over 50% in areas such as Durham and Darlington. From time to time, the media has a field day, citing lists from health officials about people going to A&E with broken false nails, splinters in their fingers, emergency contraception, as well as shaving and paper cuts.
The situation is similar in the US, where over 30% of visitors discover their case is not urgent – after being attended to. Some studies have estimated that 14 to 27 percent of ER visits could be treated at facilities like retail clinics or urgent care centres, with potential savings of USD 4.4 billion.
Telehealth to ‘redesign’ emergency medicine ?
A 2017 study from the University of Warwick calls for using telehealth to “redesign” emergency medical services. It chooses best of breed cases from different continents to make three cases:
• Specialists in underserved communities
• Pre-ambulance triage
• Ambulance-based triage
Providing patient access to remote specialists in underserved communities
In its early stages, emergency telemedicine applications were motivated by the need to provide more timely diagnosis and care to patients in underserved communities, in other words those lacking hospitals with full-time emergency medicine teams.
The Warwick study cites the Western Australia Emergency Telehealth Service (ETS, which comprises over 70 regional and remote hospital EDs as a “prominent example of this type of telehealth initiative.” The WA ETS makes specialist emergency medicine physicians available via videoconferencing to support regional hospital-based clinicians with the diagnosis and treatment of acute emergency patients. Another example in the Warwick study is the Cumbria and Lancashire Telestroke Network in Britain. This remote teleconsultation service connects 15 stroke consultants to provide ‘out-of-hours’ advice from their homes to hospital sites.
More recently, conclusive evidence about some of the above advantages has been obtained from another study at the University of Iowa’s Carver School of Medicine. The study found that telemedicine-equipped rural emergency departments provided patients with access to a clinician six minutes sooner than those in hospitals without the technology, regardless of whether or not telemedicine was used to intermediate the interactions. However, when telemedicine was used, as happened in 42% of the interactions, the door-to-provider time was shortened by nearly 15 minutes. This, according to lead author Nicholas Mohr, MD, an emergency physician and associate professor at the University, could change outcomes for patients with conditions like “severe trauma, stroke, myocardial infarction.”
Pre-ambulance triage, via teleconsultation with probable primary care patients
The second application highlighted by the Warwick researchers consists of pre-ambulance triage, via a system called ETHAN (Emergency Telehealth and Navigation). This was developed by the Houston (Texas) Fire Department in 2014, and combines teleconsultation, social services and alternative transportation. Its aim is to reduce the numbers of primary-care related patients being transported directly to the ED via fire-engine (although it could apply equally to ambulance). Apart from reducing ED patient loading, ETHAN makes substantial cost savings by eliminating unnecessary fire engine/ambulance journeys – estimated at USD 2500 per trip.
ETHAN equips EMS units with a Tablet to respond to patient initiated calls. Patients are connected via secure videoconferencing software to a hospital-based emergency physician who makes a diagnosis based on vital signs measured on scene by the field crew. After outlining treatment options, the physician then makes a final decision on whether the patient should be brought to the ED by fire engine/ambulance or via taxi, or taken by the latter to a primary care facility, or instructed on home care.
There is, however, little homogeneity in pre-ambulance triage, either in the US or elsewhere. In 2013, a systematic review of 120 publications by The Norwegian Knowledge Centre for the Health Services found that there was “a lack of scientific evidence about the effects of validated pre-hospital triage systems,” and called for further research.
It has long been recognized that in-ambulance triage and care for an acute emergency patient during transportation to the ED, impact positively on patient outcomes, especially with time-critical conditions such as myocardial infarction and stroke. In several respects, Europe can be considered to be ahead of the US in this application. In Tucson (Arizona), a citywide ambulance telemedicine network, was shut down in 2011 due to budgetary problems and problems of reliability with the WiFi network.
On its part, the Warwick study reports on an ambulance-based telemedicine triage system with real-time bidirectional audio-video communication, carried out in Brussels. In 90 per cent of cases, preliminary pre-hospital diagnosis was formulated and was in agreement with in-hospital diagnoses. Failures, as had been the case in Arizona, resulted mainly from limited mobile connectivity.