From the late 1960s, in an effort to have the emergency department (ED) door unlocked and staff ready upon ambulance arrival, and the early 1970s, when Johnny and Roy from the TV show Emergency! were sending three lead ECG biotelemetry to Rampart General and getting orders to treat, telehealth has been a part of our practice.
With that history, EMS clinicians were likely the first healthcare practitioners to routinely use telehealth capabilities. So, ironically, as telehealth is increasingly defined by convention and the Centers for Medicare and Medicaid Services (CMS) today, why are we apparently late to the game? What opportunities are presented by system and technology changes, and by COVID-19 adaptations, that we embrace in our practice? Do our attitudes keep us from adopting telehealth capabilities?
Our experience has cycled with medical practice, federal reimbursement regulations, and communications technology changes. Eventual physician trust in EMS clinicians to interpret their own three lead (and later 12 lead) ECGs and to generally manage more patient care based on their own training and experience without direct, real-time oversight, changed the nature of medical consultation. Notifying a receiving ED of an arrival required shorter and shorter messages appropriate to the stability of the patient and their needs upon arrival. Medical consultation outside of standing orders became reserved for unusual and potentially jeopardizing patient presentations or circumstances.
A number of solutions (e.g., Pulsara, General Devices, Twiage) are evolving to capture and integrate text, voice, video and biotelemetry data for more efficient packaging at the scene, transmission from the scene or enroute, and consumption by receiving facility/medical oversight staff. Community paramedicine has suggested and, in limited application, demonstrated the use of devices such as electronic stethoscopes which can be remotely monitored by a medical consultant. These platforms, which can be supported by Allerio, a portable hub providing robust cellular connectivity whenever and wherever needed, comprise the foundation for robust EMS telehealth.
A number of telestroke program uses range from employing video for a physician to confirm patient signs by remote video observation to ambulance-borne CT units. If the latter develop a solid evidence base, FirstNet will enable them to send their bandwidth-intensive imaging to a remote physician for interpretation instead of having a doctor physically in the ambulance.
So, with the abundance of new technological capabilities and reliable broadband communications, why have we, the first telehealthers, been slow to integrate such capabilities into our practice? Some early feedback of video in the back of the ambulance demonstrated medic reluctance to have “eyes over their shoulders” when they felt prepared to handle most emergencies. This is a fair assessment, especially in urban settings, where most calls are short, medics are the most qualified by training and experience to operate in that environment, and busy urban ED physicians have more pressing demands than routine EMS calls to directly oversee. Lower volume rural services might have been more supportive users, but broadband speed and coverage issues have precluded its use until recently, with the advent of FirstNet.
A recent study reported in the Journal of Emergency Medical Services (JEMS)1 states that:
“The implementation of video telemedicine into the ambulance for use by emergency medical service (EMS) providers has the potential to enhance the quality of care by decreasing time to definitive care, informing destination decisions and increasing diagnostic accuracy.”
It cited two other survey-based studies of medics which report that most would welcome telemedicine in their practice.2,3 In its own survey of one California municipality’s paramedics, of whom only 44% were aware of telemedicine use in EMS, the JEMS article reported similar enthusiasm for it, including anticipated improvement in patient satisfaction. The study also characterized potential barriers encountered by the survey and the literature, including lack of broadband coverage, obtrusive/intrusive equipment issues, quality of audio and video, and interrupting patient care workflow The article details a comprehensive review of the literature.
One 2016 study4 that wasn’t included was a survey of 670 EMS frontline clinicians (72% of the total), physicians and others who, overall, demonstrated similar enthusiasm for the concept. It asked opinions about EMS telehealth potential in general as well as for specific roles and scenarios.
As an example, potential benefits cited from the medical direction role:
Potential benefits for specific scenarios included:
This study cited similar benefits and disadvantages as discussed above in the JEMS study. In their comments, respondents opined that telemedicine would either be extremely beneficial in EMS or is too untested and is generally a bad idea. The study report is quite detailed in explaining these responses and worth a read.
COVID-19 revealed some telehealth adaptations, such as medics using devices to communicate by voice, video or both directly with persons inside a call location to determine the specific urgency and nature of the call before entering the premises. This enables responders to tailor the number and type of PPE-clad responders to match that and the status of others in the potential COVID-19 environment.
COVID-19 also induced CMS to waive telehealth restrictions on the types of communication and applications employed (e.g., audio only consults and the use of less security-proven applications were allowed,) but only by CMS “qualified healthcare practitioners,” which EMS personnel are not. While CMS postponed implementation of the new Emergency Triage, Treat, and Transport (ET3) program until this fall, the agency also did enable broadened use of alternative destinations (which is permitted in the ET3 model).
The interesting question is which CMS changes to the telehealth and ET3 restrictions during COVID-19 will be kept in place when the crisis winds down? Some state Medicaid programs, such as Maine, enabled reimbursement for non-transport care of COVID-19 patients. Will this momentum move CMS to move faster with enabling ET3-like provisions for all? Anecdotal reports suggest that both EMS and physicians strongly support the continued use of telehealth in the manner it has been conducted in the last two months of the pandemic.
Technology solutions such as Allerio, FirstNet and Pulsara are increasingly available to make telehealth a reliable and safe method for delivery of patient care. With EMS personnel and clinicians both receptive to its potential, we collectively need to support and advocate for widespread implementation and use of available telehealth tools and capabilities , which have now been expanded under the COVID-19 challenge, and equally important for the implementation of rapid CMS policy and other regulatory changes to accommodate and fully embrace these new and more efficient healthcare tools.
1. Simon LE, et al. Paramedics’ Perspectives on telemedicine in the ambulance: A survey study. JEMS; April 30, 2020. https://www.jems.com/2020/04/30/perspectives-on-telemedicine/
2. Gilligan P, Bennett A, Houlihan A, et al. The doctor can see you now: a key stakeholder study into the acceptability of ambulance based telemedicine. Ir Med J. 2018;111(6):769.
3. Rogers H, Madathil KC, Agnisarman S, et al. A systematic review of the implementation challenges of telemedicine systems in ambulances. Telemed J Health. 2017;23(9):707-717.
4. NASEMSO/NPSTC. EMS telemedicine report: Prehospital use of video technologies final report. National Association of State EMS Officials/National Public Safety Telecommunications Council. 2016. EMS Telemedicine Report Prehospital Use of Video Technologies Final Report.
Kevin McGinnis, MPS, Paramedic Service Chief (Ret.) has been an EMS system builder since 1974. He is the communications technology advisor for five national EMS associations, and program manager for public safety communications, rural EMS and community paramedicine for the National Association of State EMS Officials (NASEMSO).
He received undergraduate and graduate degrees from Brown University and Cornell University in health care delivery systems and hospital administration. Kevin has been a paramedic, a paramedic service chief for volunteer, private, and hospital-based services, a hospital emergency department director, and Maine’s state EMS director.
He is the past Chairman of the U.S. Department of Homeland Security’s SafeCom Program and continues to serve on its Executive Committee. Kevin is Vice-Chair of the Governing Board of the National Public Safety Telecommunications Council and was bestowed its top honor, the Richard DeMello Award, in 2017.
Kevin has been an energetic promoter of the nationwide public safety broadband network since 2006. In August, 2015, he was named by the U.S. Secretary of Commerce to a second three-year term on the First Responder Network Authority (FirstNet) Board of Directors and termed out in October, 2018. He currently serves as the NASEMSO representative to the FirstNet Public Safety Advisory Committee. In 2018, Kevin received the Journal of EMS “Top Ten Innovator Award” for his FirstNet work. He was named by the Government Technology/Solutions for State and Local Government magazine as one of its 2013 “Top 25 Doers, Dreamers & Drivers in Public-Sector Innovation”.