A systematic review of prehospital telehealth utilization

Abstract

Objective

There has been moderate evidence of telehealth utilization in the field of emergency medicine, but less is known about telehealth in prehospital emergency medical services (EMS). The objective of this study is to explore the extent, focus, and utilization of telehealth for prehospital emergency care through the analysis of published research.

Methods

The authors conducted a systematic literature review by extracting data from multiple research databases (including MEDLINE/PubMed, CINAHL Complete, and Google Scholar) published since 2000. We used consistent key search terms to identify clinical interventions and feasibility studies involving telehealth and EMS, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

Results

We identified 68 articles focused specifically on telehealth interventions in prehospital care. The majority (54%) of the studies involved stroke and acute cardiovascular care, while only 7% of these (4) focused on telehealth for primary care. The two most common delivery methods were real-time video-conferencing capabilities (38%) and store and forward (25%); and this variation was based upon the clinical focus. There has been a significant and positive trend towards greater telehealth utilization. European telehealth programs were most common (51% of the studies), while 38% were from the United States.

Discussion and Conclusions

Despite positive trends, telehealth utilization in prehospital emergency care is fairly limited given the sheer number of EMS agencies worldwide. The results of this study suggest there are significant opportunities for wider diffusion in prehospital care. Future work should examine barriers and incentives for telehealth adoption in EMS.

Keywords

Emergency medical services EMS prehospital telehealth telemedicine

Introduction

There are nearly 20,000 reported emergency medical services (EMS) agencies providing care to over 37 million patients in the United States alone.¹ Innovations in delivery models that can minimize provider time to transport, improve productivity, and maximize quality of care are essential to improving our prehospital EMS system. Perhaps nowhere in healthcare is this challenge more evident than in the provision of emergency care to patients both in the emergency department (ED) and in the prehospital emergency environment encountered by EMS personnel. Every day, EMS providers face life-threating and time-sensitive encounters. Conversely, they are also met with many non-urgent situations where the utilization of their services may be more care than the patient requires, thereby overburdening the system. Telehealth applications show promise in aiding both of these challenges.

The American Telemedicine Association define telehealth as “the remote delivery of health care services and clinical information using telecommunications technology.”² In this study, the term telehealth refers to either “telemedicine” or “telehealth” interchangeably, and we do not distinguish between the two, in accordance with the World Health Organization guidelines.³ Telehealth is an alternative method of providing health and medical services to patients and other consumers.⁴

In the field of prehospital care, telehealth provides an opportunity for significant improvements in care, where time impacts patient outcomes. Assessment through advanced technology and workflows in this environment offer potential for improving critical decisions in a more rapid, cost-effective process. Moreover, EMS are often burdened by overcrowding, physician and nurse staff shortages, ambulance diversions, long-wait times, and non-urgent patients who utilize the ED as a medical home.⁵ Arguably, not all ambulance transports are acute. Many patients seen by EMS personnel present with treatment conditions that could be considered non-urgent and ideally do not need the robust services of an ED. Many of these situations encountered by EMS personnel ultimately prove cost-defective as patients burden an already overcrowded system with unwarranted use for their treatment. Consequently, telehealth in the field supports the delivery of non-emergency health care services at the point of need.

Objective

The objectives of this study are to examine the level of adoption, the format of delivery, and the clinical focus for telehealth in prehospital emergency care.

Methods

To address these objectives, a systematic literature review from the MEDLINE/PubMed, CINAHL, and Google Scholar research databases was conducted in December 2016 and updated in April 2017. We utilized the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology.⁶ Medical Subject Headings (MeSH) and keywords formed the basis of the search noting that “telehealth” and “telemedicine” are often used interchangeably in the literature. Keywords were identified by an experienced biomedical informatics researcher (J.L.) to produce the master list. This was independently reviewed and validated by a second clinical researcher (J.B.) and graduate student (A.W.), and was used to conduct the final search. The final search criteria were assembled using the terms: (“telemedicine” OR “telehealth”) AND (“emergency medical services” OR “ems” OR “ambulance” OR “prehospital”). We searched the date range from 2000 to 2016 and included only articles published in English, which were peer reviewed and had full-text availability. Google Scholar was utilized as an additional search engine for query into journal publications not recognized by the other databases but applicable to the search topic. Disagreements regarding articles to be included in the study were resolved by the fourth author (T.C.-L.).

During the first stage of the systematic review process, articles were examined by title and abstract to ensure they met the initial inclusion criteria. Articles were included if they: (a) centered around telehealth or telemedicine as the primary intervention; (b) were empirical studies carried out in an ambulance or EMS prehospital setting; (c) utilized a specific telehealth application or telehealth protocol in the management of patients in the prehospital setting; and (d) were peer-reviewed articles.

Using the National Public Safety Telecommunications Council framework, we categorized telehealth delivery for prehospital EMS in one of four different ways, with the addition of Audio.⁷

Audio. Real-time audio-only communication between patient and provider or provider to provider.

Store and forward. Asynchronous transmission of video, pictures, or other documentation about patients, scene environment (e.g. crashed vehicle, home setting), specific injuries, or other physical assessment signs.

Video conferencing. Two-way, real-time video conferencing among field providers, patients, and medical control or consulting staff, involving both audio and video.

Remote monitoring. Monitoring and adjusting, home or other remote patient diagnostic and treatment devices.

“Prehospital” was defined as relating to procedures administered or care provided prior to a patient’s arrival at a hospital and only met inclusion if the care was associated with any process included in the standard care pathway of community EMS activation. Utilization in this instance could include telehealth usage by 911 dispatch personnel, EMS personnel, or emergency medical control such as an emergency physician providing instruction through telemedicine applications to EMS personnel.

The second step of the review examined the full text of the remaining articles to determine the treatment characteristic and focus for which telehealth was discussed. Treatment characteristic is described as the primary attribute of treatment approach for which the telehealth application was utilized. For the review, this attribute was classified as either “acute” or “non-acute.” Acute represents those episodes requiring immediate or life-saving treatment, while non-acute represents non-urgent or primary care focused treatment. Articles were excluded if a clear delineation of treatment characteristic could not be identified through this examination. Conceptual articles, conference proceedings, non-peer-reviewed articles, and other systematic reviews were also excluded from the results during this stage.

Further specification of treatment approach was then described relative to the focus of the patient treatment condition in which the application was used. This could include conditions such as stroke or abdominal pain. Upon completion of this second level of the review, the results were compiled for final analysis based on treatment focus, treatment characteristics, and the primary telehealth delivery method. A flowchart depicting each step of the review process is noted in Figure 1.

Figure 1.

Systematic review flowchart.

Results

The initial literature search yielded a total of 407 studies, based on inclusion criteria, 339 were omitted from the analysis. The remaining 68 studies were selected for further examination. Sixty-four (94.1%) of the articles were deemed to exhibit treatment characteristics of acute care while the remaining four articles (5.9%) focused on non-acute treatment scenarios where a telehealth application was utilized to facilitate primary care treatment. Table 1 summarizes the primary data table, including the condition type, geographic region, and method for telehealth delivery.^8–75

Table 1.

Focus, region, and method by included study.

Study	Clinical focus	Year	Delivery	Region
Tanguay et al.⁸	Cardiovascular	2015	Store and forward	Canada
Brunetti et al.⁹	Cardiovascular	2014	Store and forward	Italy
Brunetti et al¹⁰	Cardiovascular	2014	Store and forward	Italy
Papai et al.¹¹	Cardiovascular	2014	Store and forward	Hungary
Rasmussen et al.¹²	Cardiovascular	2014	Store and forward	Denmark
Clemmensen et al.¹³	Cardiovascular	2013	Store and forward	Europe
Ducas et al.¹⁴	Cardiovascular	2012	Store and forward	Canada
Schoos et al.¹⁵	Cardiovascular	2012	Store and forward	Denmark
Brunetti et al.¹⁶	Cardiovascular	2011	Store and forward	Italy
Gonzalez et al.¹⁷	Cardiovascular	2011	Combination	USA
Correa et al.¹⁸	Cardiovascular	2011	Store and forward	Brazil
Sardi et al.¹⁹	Cardiovascular	2011	Video conferencing	USA
Brunetti et al.²⁰	Cardiovascular	2010	Remote monitoring	Italy
Hsieh et al.²¹	Cardiovascular	2010	Store and forward	Taiwan
Otsuka et al.²²	Cardiovascular	2009	Remote monitoring	Japan
Sejersten et al.²³	Cardiovascular	2008	Store and forward	Denmark
Strauss et al.²⁴	Cardiovascular	2007	Store and forward	USA
Drew et al.²⁵	Cardiovascular	2006	Store and forward	USA
Abrashkin et al.²⁶	General/acute	2016	Video conferencing	USA
Felzen, et al.²⁷	General/acute	2016	Combination	Germany
Cho et al.²⁸	General/acute	2015	Combination	Korea
Buscher et al.²⁹	General/acute	2014	Combination	Germany
Czaplik et al.³⁰	General/acute	2014	Video conferencing	Germany
Yperzeele et al.³¹	General/acute	2014	Combination	Brussels
Widmer et al.³²	General/acute	2014	Video conferencing	Switzerland
Bergrath et al.³³	General/acute	2014	Combination	Germany
Bergrath et al.³⁴	General/acute	2014	Combination	Germany
Rortgen et al.³⁵	General/acute	2013	Combination	Germany
Skorning et al.³⁶	General/acute	2012	Video conferencing	Germany
Bergrath et al.³⁷	General/acute	2011	Combination	Germany
Kwak et al.³⁸	General/acute	2009	Video conferencing	Korea
Sibert et al.³⁹	General/acute	2008	Video conferencing	USA
Takeuchi et al.⁴⁰	General/acute	2008	Video conferencing	Japan
Kang et al.⁴¹	General/acute	2006	Store and forward	Korea
Tachakra et al.⁴²	General/acute	2006	Video conferencing	UK
Ellis et al.⁴³	General/acute	2006	Video conferencing	USA
Haskins et al.⁴⁴	General/acute	2002	Video conferencing	USA
Langabeer et al.⁴⁵	Primary care	2016	Combination	USA
Krumperman et al.⁴⁶	Primary care	2015	Audio	USA
Morimura et al.⁴⁷	Primary care	2011	Audio	Japan
Gillen⁴⁸	Primary care	2010	Audio	UK
Barrett et al.⁴⁹	Stroke	2016	Video conferencing	USA
Belt et al.⁵⁰	Stroke	2016	Video conferencing	USA
Chapman Smith et al.⁵¹	Stroke	2016	Video conferencing	USA
Itrat et al.⁵²	Stroke	2016	Store and forward	USA
Lippman et al.⁵³	Stroke	2016	Video conferencing	USA
Torres Zenteno et al.⁵⁴	Stroke	2016	Combination	Spain
Valenzuela Espinoza et al.⁵⁵	Stroke	2016	Video conferencing	Belgium
Bowry et al.⁵⁶	Stroke	2015	Video conferencing	USA
Eadie et al.⁵⁷	Stroke	2015	Video conferencing	UK
Ebinger et al.⁵⁸	Stroke	2015	Combination	Germany
Wu et al.⁵⁹	Stroke	2014	Video conferencing	USA
Van Hooff et al.⁶⁰	Stroke	2013	Video conferencing	Belgium
Bergrath et al.⁶¹	Stroke	2012	Combination	Germany
Liman et al.⁶²	Stroke	2012	Video conferencing	Germany
Walter et al.⁶³	Stroke	2010	Combination	Germany
Gonzalez et al.⁶⁴	Stroke	2011	Combination	USA
Kim et al.⁶⁵	Stroke	2009	Video conferencing	USA
LaMonte et al.⁶⁶	Stroke	2004	Video conferencing	USA
Handschu et al.⁶⁷	Stroke	2003	Combination	USA
Cicero et al.⁶⁸	Trauma	2015	Video conferencing	USA
Ito et al.⁶⁹	Trauma	2013	Remote monitoring	Japan
Song et al.⁷⁰	Trauma	2013	Remote monitoring	Korea
Hasler et al.⁷¹	Trauma	2012	Video conferencing	Europe
Ogedegbe et al.⁷²	Trauma	2012	Store and forward	USA
Boniface et al.⁷³	Trauma	2011	Remote monitoring	USA
Charash et al.⁷⁴	Trauma	2011	Video conferencing	USA
Nelson et al.⁷⁵	Trauma	2011	Combination	USA

Treatment focus

Telehealth treatment focus centered on five different categories of treatment conditions. Nineteen (28%) concentrated on the use of telehealth applications in the treatment of acute neurological emergencies or stroke. The majority (68%) of these stroke studies were feasibility studies, examining the potential use of telehealth to validate stroke diagnosis, more accurately measure stroke scales, or speed up disposition to definitive care. While most studies were observational in nature, a departure were two large randomized controlled trials (RCTs) for stroke that focused on improving clinical outcomes, through faster delivery of tissue-type plasminogen activator (tPA).^59,63

Eighteen articles (26%) focused on applying telehealth to cardiovascular conditions. Nineteen articles addressed telehealth applications in a more general approach, to be used as an adjunct in the treatment of a variety of generalized acute treatment conditions. Eight articles (12%) addressed telehealth utilization in the treatment of trauma patients. Four articles utilized telehealth to manage the primary care or non-acute patient demographic. These primary care studies focused on reducing ambulance transports to the emergency department, and better utilization of paramedic resources.^45–49 Figure 2 summarizes telehealth treatment focus.

Figure 2.

Treatment focus for telehealth in EMS.

Study designs

The quality of the study design was variable, the largest majority were descriptive or observational in nature (39 studies, 58%). Most were focused on very small sample sizes, and attempted to prove feasibility for the use of telehealth. Only 8 studies (12%) involved randomized clinical trials, and all but two of those were for prehospital stroke management. Seventeen studies involved case-controls and four utilized cohorts.

Primary results

We analyzed the primary outcomes and results for each of the studies, and found that the use of telehealth to drive improvements in clinical outcomes represented just over 26% of the studies. Most studies were feasibility assessments (36, 53%). User acceptance of technologies represented four (6%) and cost-effectiveness was the primary outcome in 10 studies (15%).

Telehealth delivery and growth

Telehealth was delivered in a variety of ways. The use of real-time video conferencing (integrated audio and video) is the predominate method of delivery (26 studies, 38%). Seventeen (25%) utilized the store and forward method, an asynchronous method of communicating primarily images, documents, and recorded videos. A further 17 (25%) used a combination of both store and forward and real-time audio and video. Three articles utilized audio only as the single mode of communication. A summary of these findings is shown in Figure 3.

Figure 3.

Telehealth delivery method and treatment focus.

A small majority (51%) of all studies were conducted in Europe, with Germany having the highest frequency in that region (12 studies). Thirty-eight per cent of the studies were conducted in the USA. Seven (10%) of the programs were conducted in Asia (largely Japan, Korean, or Taiwan), and the remainder were conducted in other areas.

We observed moderate growth in the number of publications per year. In the years from 2000 to 2010, the average number of studies published was less than two per year, with a major shift between 2011 and 2016 to around 9 per year. There is a positive trend towards greater utilization of telehealth in EMS. Figure 4 shows the trend in publications by year.

Figure 4.

Growth in telemedicine publications by year.

Discussion

This study has evaluated the trends, scope, and type of telehealth usage in prehospital emergency medicine. This review is the first comprehensive review of telehealth application in prehospital emergency medicine. Findings from this study suggest that over the last decade, prehospital telehealth application-based research has grown steadily with a significant positive trend. However, given the sheer number of organizations providing prehospital care, with nearly 20,000 EMS agencies in the US alone, and probably hundreds of thousands elsewhere across the globe, the amount of published research on telehealth interventions is limited. This suggests significant potential for expanded utilization across prehospital care.

The focus has largely been on urgent, life-saving treatments such as providing prehospital stroke, cardiovascular, and trauma consultation. Together these three conditions represent over 80% of all publications studied. This area appears to be understudied; however, the use of telehealth for primary care related conditions appears to offer some potential. The continued overcrowding of hospital emergency departments and ambulances is just one factor leading to higher potential for telehealth. In addition, at least in the US, there is a problem of inappropriate use of emergency medicine for non-urgent issues. Many patients report higher use of emergency departments and ambulance transport due to inadequate access to primary care, as well as, lack of both transportation and insurance.⁷⁶

We observed that telehealth delivery patterns varied by clinical focus. Cardiovascular programs tended to use a higher proportion of store and forward methods, while prehospital stroke relied more on real-time video conferencing. It was observed that general acute care used more combination approaches. Telephone triage was found to be the predominant method of intervention for primary care. Efforts in primary care telehealth have centered on triaging the patient at the source with the initial 911 call. Only one study utilized real-time video conferencing to facilitate triage and navigation to a primary care community clinic.

Interestingly, directing patients away from ambulance transport in this manner requires access to a robust network of community referral resources to allow direction of the patient to a more appropriate care location. Community EMS systems may play a role through telehealth applications in directing patients to appropriate care facilities by serving as a touch point of communication with the larger healthcare network.

As we observed from the published studies, telehealth has the potential for greater utilization in many regions of the globe, and in both metropolitan and rural areas. The research assessed here has shown the potential for paramedic involvement in telehealth to improve care through a variety of mechanisms, whether asynchronous or synchronous. There was a fairly even distribution between real-time video conferencing and store and forward delivery mechanisms. It would appear that remote monitoring is the least explored tool investigated in previous research, making it an interesting subject for future studies.

Limitations

This study has limitations. When selecting articles for a systematic review, there is at least some reviewer bias as judgement is involved in screening and selection. We attempted to mitigate the effects of this bias by involving multiple reviewers, both for selection and subsequent analyses. There are undoubtedly some articles that we might have omitted which were relevant, or included which were less relevant. A further limitation is that the timeframe of this study is around 16 years. While that is considerable, there are likely several articles that were published prior to 2000 that were not included. However, the purpose of the study was to identify modern evidence about telehealth. Finally, we included a narrow definition of search terms, to ensure that we only included true telehealth studies implemented by EMS agencies. The search could have been expanded, however, we feel the review findings here best represent the state of the current research implementation in prehospital ambulance utilization of telehealth.

Recommendations for future research

Findings from this study are significant in that they point to current practices in telehealth adoption for EMS. There is significant potential for additional research, both around barriers that limit current growth as well as incentives that could catalyze broader utilization. There is some indication for future, policy-oriented change in EMS roles and reimbursements.⁷⁷ This review provides direction for future research towards identifying strategies for mitigating prehospital telehealth barriers and expanding utilization globally.

Conclusion

We have found evidence of a positive trend in the frequency of publication of telehealth studies in the field of prehospital emergency care. Given the sheer number of EMS agencies worldwide, and the continued growth trend in publications noted here, we believe there will be continued interest and adoption of telehealth.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to this research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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