Defining emergency telehealth

Introduction

In 2016, the American College of Emergency Physicians (ACEP) Emergency Telehealth Section was awarded an ACEP Section Grant to develop a telehealth-focused practice guideline document with a number of specific goals. Our primary goal is to develop a working definition of emergency telehealth that appropriately aligns with the ACEP definition of emergency medicine.

ACEP promotes high-quality emergency care and advocates for emergency physicians and their roles in patient care and public health. ¹ , ² In a statement of values, ACEP encourages emergency physicians to take responsibility and leadership in improving the quality of emergency care. ¹ , ² Emerging technologies, and specifically telehealth, are rapidly impacting emergency physicians and their patients, providing access, empowering health literacy and improving convenience.

Telehealth – the use of telecommunications technologies to communicate and facilitate health-related services between two remote parties – is typically used in health care between provider and patient or between two health-care providers. ³ This modality can serve as a vehicle to enable the delivery of high-quality, cost-effective, convenient and efficient health care to patients while providing access to health services from nearly any location. ⁴ Telehealth can improve the quality of care delivered by supplementing available services or providing care that may otherwise be unavailable due to time, distance or resource limitations.

The words ‘telemedicine’ and ‘telehealth’ are traditionally used interchangeably and are linked to terms such as tele-emergency medicine, tele-psychiatry, tele-dermatology, telestroke and so on to refer to specific telehealth services. ⁵ While these terms indicate a clinical specialty or discipline, they all fall under the umbrella of telemedicine or telehealth. The term ‘telemedicine’ implies remotely providing a health-care service when there is a sick or injured patient. ⁶ The term ‘telehealth’ is broader and more inclusive, encompassing screening, prevention, maintenance, follow-up services, health-related education, public health and health administration. ³ , ⁵ We use telehealth broadly to describe all specialties and services related to health care delivered via telecommunications technologies.

Caring for patients remotely is valuable in a variety of settings, including acute unscheduled and emergency care, inpatient settings and disaster response. Telehealth has been used for decades, facilitating care for millions of patient encounters. Common examples include teleradiology, telestroke, tele-psychiatry and teletrauma. The advent of low-cost, high-bandwidth data transmission has introduced a host of new applications and democratised access to care. New applications such as direct to consumer services show promise but lack rigorous studies of outcome and cost-effectiveness. Although telehealth offers many opportunities and much potential, patients, providers and payers demand evidence to facilitate further development of the field.

ACEP defines emergency medicine as a medical specialty with a focus on the diagnosis and treatment of acute, undifferentiated illness or injury and all components required to provide that care. The ACEP definition clearly states ‘Emergency medicine is not defined by location but may be practiced in a variety of clinical settings … [including] telemedicine’. ⁷

According to a survey conducted by the Telehealth Section in 2012, emergency physicians work in telehealth providing direct clinical services, remote supervision, remote monitoring, remote diagnostic testing, care coordination and teaching and education. Given this broad adoption of telehealth among emergency physicians, the ACEP Emergency Telehealth Section determined that there was importance and urgency to define emergency telehealth better.

Developing a definition for emergency telehealth

We conducted a modified Delphi process in six rounds consistent with the method described by Hsu and Sandford. ⁸ Participants were asked to volunteer from the membership of the ACEP Emergency Telehealth Section. All contributors are board-certified emergency physicians and fellows of ACEP. The group also includes members of the American Telemedicine Association and medical directors, executives and founders of telemedicine services. The participants (N=10) represented both private and public health-care delivery systems, academia and industry, rural and urban settings and practiced various types of telemedicine, including direct to consumer, provider to provider and remote consultation services.

In the initial round, participants were asked to ‘define emergency telemedicine’ in an open-ended fashion. Following the initial round of voting, answers were consolidated and summarised. With each subsequent round, alternatives were eliminated or consolidated. Only one definition remained for the final rounds and efforts focused on generating inclusivity and consensus. Once consensus on content was reached, the group continued edits for clarity. The final definition is presented below.

Emergency telehealth definition

Emergency telehealth is remotely caring for acute illness, injury and exacerbations of chronic diseases, including the initial evaluation, diagnosis, treatment, prevention, coordination of care, disposition and public-health impact of any patient requiring expeditious care, irrespective of any prior relationship. Emergency physicians are uniquely qualified to leverage emergency telehealth, unscheduled or scheduled, to provide medical care across the spectrum of conditions and severity.

The ACEP Emergency Telehealth Section believes the context for the definition of emergency telehealth currently includes the following (1 August 2018):

A provider’s training, expertise, capabilities, capacity, certification and credentialing dictate the quality and range of services offered through telehealth.

We recommend implementing emergency telehealth in a manner that ensures appropriate qualifications of providers, appropriate/parity reimbursement for telehealth services and, most importantly, the delivery of quality care to patients in a safe, efficient, timely and cost-effective manner. We outline the application of emergency telehealth in Table 1 and minimum standards for telehealth practice in Table 2. The future application and expansion of telehealth into emergency medicine has the potential to help emergency providers care for anyone, with any concern, at any time.

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Table 1.

Emergency telehealth applications.

Prehospital	Direct to consumer
Field care	Urgent unscheduled care
Inter-facility transport	Post-discharge follow-up
Retrieval and repatriation	Direct observational therapy
Hospital based emergency departments (urban and rural)	Treatment maintenance/monitoring
Supervision of advanced practice providers	End-of-life care
Provider at triage	Field screening
Alternative care option	Maritime
Freestanding emergency centres	Cargo transport
Urgent care clinic	Cruise ship
Other health maintenance clinics	Dive medicine
Observation units	Aviation and space medicine
Skilled nursing facilities	Military/battlefield
Rehabilitation centres	Disaster relief and emergency response
Areas with patient flight risk
Adult correctional care facilities
Youth detention centers
Immigrant refugee/detention camps

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Table 2.

Recommended minimum standards for telehealth practice.

• Licensure, credentials and location of clinicians should be disclosed; patients should have choice of provider; ensure that providers are licensed in the state where each patient is located

• Verify identity of patients seeking care

• Collect relevant medical history, including a history of present illness, review of systems, current medications, and allergies; if possible, obtain appropriate past medical records

• Clinicians should ask appropriate follow-up questions to complete a patient’s relevant medical history

• Use laboratory studies in clinical scenarios similar to an in-person encounter

• Use existing evidence-based guidelines to provide diagnoses and treatments

• Provide meaningful informed consent; when prescribing medications, include discussion of risks, side-effect risks and pregnancy concerns, and provide a clear follow-up plan

• Identify the patient’s primary health-care provider(s) and provide medical records to relevant members, unless a patient opts out

• Develop relationships with local physicians in all patient treatment regions in order to mitigate emergency department referrals

• Implement quality assurance programs to monitor clinical performance, patient outcomes, including follow-up, and integrated ongoing care

• Educate and disseminate these standards to inform legislation, regulation or a third-party certification process