Telehealth in Emergency Medicine

Authors:

Brandon Allen, MD; Marsha Lewis, MD; and Juan Rondon, MD, on behalf of the SAEM ED Admin and Clinical Operations Committee.

Overview

Telehealth refers to the use of digital information and communication technologies to access health care services remotely. This innovative concept was developed over 40 years ago with one of the earliest recorded uses being remote transmission of electrocardiogram telemetry.¹ The modalities currently used for telecommunication include video, phone, and electric health records. Telehealth transmissions primarily fall into two categories: synchronous and asynchronous. Synchronous telehealth, the most prevalent program, involves live interactions between the patient and the healthcare provider.² Asynchronous programs entail the transfer of clinical information, such as images and videos, often termed "store and forward."²

In March 2020, the declaration of the COVID-19 public health emergency (PHE) initiated the expansion of telehealth coverage by the Centers for Medicaid & Medicare Services (CMS) and private insurers.³ For the duration of the PHE, telehealth visits are billed using standard evaluation and management (E/M) codes, with CMS reimbursing outpatient services provided via telehealth at the same rate as in-person visits.^3,1 While the COVID-19 pandemic accelerated the adoption and application of telehealth, its pre-pandemic uses include stroke, critical care, trauma, radiology, burn management, and behavioral health.^3,4

One of the first applications of telehealth in the emergency department (ED) is tele-stroke, initiated in the 1990's to improve access to care and outcomes for patients experiencing an acute stroke.³ Tele-stroke is now widely used by critical access hospitals and has been shown to improve thrombolytic utilization rates and reduce disparities in acute stroke care.⁵

Another notable application, tele-triage, became popularized during the pandemic and was widely implemented in EDs. It involves remotely screening patients to assess their condition and determine necessary care, thereby mitigating issues of ED crowding by reducing left-without-being-seen rates and door-to-provider times while enhancing overall operational efficiency.^6,7 Tele-triage also generates increased revenue and offers short-term savings from reduced staffing costs.⁶

Interested Parties

The successful implementation of a telehealth program requires buy-in from several key interested stakeholders, including health care providers, hospital administrators, information technology specialists, private insurers, and government agencies. These stakeholders play a crucial role in identifying both opportunities and barriers to providing telehealth services. Common barriers to adopting telehealth applications include infrastructure costs, reimbursement considerations, equipment usability, and provider preferences.¹ Ensuring alignment of concerns and interests among all parties is imperative for a successful telehealth program.

With the PHE expiring on May 11, 2023, the federal government's flexibility in delivering telehealth also ceased. In addition, as of December 31, 2023, the availability of ED E/M and critical telehealth services is limited.⁸ During the PHE, health care providers using telehealth were exempt from penalties for violations of the HIPPA Privacy, Security, and Breach Notification rules. This Notification of Enforcement Discretion expired May 11, 2023 , and applications such as Skype and Facetime are no longer approved platforms for telehealth services. Beginning January 1, 2025, only Medicare beneficiaries residing in designated rural areas will be eligible to receive telehealth services.⁸

Telehealth is revolutionizing health care, especially in the ED where its numerous benefits include expanding access to high-quality care and improving patient satisfaction.⁶ The exploration of emerging innovative applications, such as direct-to-consumer telehealth, virtual EDs, virtual rounding, and post-discharge management, underscores its potential.² For long-term sustainability, legislators must develop evidence-based federal policies for the post-PHE use of telehealth.