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ED Tries Telemedicine in Bid to Cut Wait Times

 |  By cclark@healthleadersmedia.com  
   June 20, 2013

A medical center with long emergency department wait times is running a pilot study to test whether telemedicine can connect doctors to the virtual bedside of waiting patients much faster.

That University of California San Diego Medical Center doctors would try something new in an effort to make their emergency care more efficient makes sense for a bunch of reasons.

The 505-bed dual-campus hospital is a major teaching and research center supported by the state. It treats large numbers of uninsured and very sick patients. Its emergency rooms are usually very busy.

And the patients who go there endure insufferable waits that average 296 minutes—longer than at 11 other major hospitals in the county and double the national average—before they are sent home, according to the latest wait times posted on Hospital Compare.

But UCSD also has David Guss, MD, chair of the department of emergency medicine, who realizes only too well that patient demand for immediate care is only going to increase as millions more patients take advantage of coverage options rolling out next year under the Patient Protection and Affordable Care Act.

Why not, he thought to himself about two years ago, do a pilot study to test whether ED telemedicine can connect doctors to the virtualbedside of waiting patients much faster. Could it work? Would it be safe? Are there potential unintended consequences or adverse events? Will the right tests get ordered and can the correct diagnoses be reliably made? Will patients and doctors both be happier about the experience?

Guss doesn't say ED telemedicine is ready for prime time yet. "I can't prove this yet, and I don't know whether we'll ever prove it," he says, "but I have a strong bias that that's going to be at least as reliable" as the way ED care is delivered now. "The question is, what about other parts of a physical exam, and what [are] the limitations?"

As far as he knows, Guss says, UCSD is the only hospital system experimenting with the concept. And since the project began in November, 120 patients who came to the ED during periods of overcrowding have given their consent to be examined by an ED doctor who wasn't physically present in the room, although Guss hopes to recruit a total of 400 by next year.

After patients are given a preliminary assessment by a triage nurse to ascertain that they are well enough to wait—not critically ill and in need of immediate care—they were examined by a series of cameras and microphones connected to a real ED physician, remotely located. .

"One was in the office during administrative time. One was at home during what would otherwise be a day off. And one… was in Chicago visiting his folks, in a private area of the home," Guss says.

At UCSD, six ED bays are equipped with high resolution video equipment capable of seeing a patient's skin lesions with enough detail, and high quality audio. The peripheral devices include a stethoscope "so I can hear breath sounds and another camera that enables me to look inside ears and a patient's throat," Guss says.

What's even better for the patient is that unlike a typical face-to-face visit with an ED physician, the patient can actually see what the remote physician sees inside the patient's ear or throat. "And that draws the patient into their care in a way they can't experience in any other environment," Guss says. "That wasn't something I anticipated when I started this."

"Theoretically, I could be on vacation on a cruise ship and do telemedicine, although that's not really the objective. The notion for this is that the doctor is not constrained to be [physically] in the ED."

Guss explains how this arrangement can streamline emergency processes and improve patient experiences.

Normally, emergency department throughput planners have a general sense of their peak times, and arrange for emergency room physicians to report to work accordingly.

"But in reality, on any given day, anything can happen."

Typically, to deal with unexpected surges or an influx of especially tough patients, there are backup physicians on call.

"If you feel it's busy enough to justify another provider, you can call them in. But you need to appreciate the influences that go into that. Someone has to make the call, and there are some indirect issues. Maybe, you think, it will get better in another hour. But often it's a lot worse (with more patients backing up in the ED) and you've lost precious time."

"Some people are just reluctant to pull the trigger, for whatever reason," he says.

Even when that call is finally made to summon the on-call doctor, "there's a lag time which could be 40 minutes. The doctor is in the gym or in the middle of dinner. They have to get themselves together. And there can be an hour's delay before the person arrives."

Having a physician on-call through telemedicine solves that problem. The exam can speed up the ordering of blood work or imaging, getting those processes started long before they otherwise would be.

Guss says the pilot project hasn't tried it yet, but theoretically, with a secure WIFI connection, a telemedicine exam of an ED patient "could be done if I were in my car with a laptop and a cell phone network. I could pull in to a parking lot and see a patient or two, and then move on.

"You can't do this at Starbucks though. You have to protect the patient's privacy," he says.

So far, Guss says, there have been no adverse events or unintended consequences. One patient with a suspected ear infection was treated and discharged from the ED to home came back with the same complaint and was admitted for one day. The patients are followed to make sure there are no issues related to their visit that resulted in them requiring treatment at UCSD or another hospital.

Often, patients come to the ED with routine requests, for example, a medication refill, for treatment of a sore throat, or even a sprained ankle.
We can evaluate them, make sure there are no other issues, check their medical history and then take the case to completion.

In the pilot study, which received UCSD's institutional review board approval, all patients were also seen by the on-site ED physician before being ultimately released home—a safety net to catch mistakes.

So what could go wrong? "All of the things you might imagine," Guss says. "Perhaps we are more prone to misdiagnosis and miscommunication. I don't have any evidence that's occurred. And though we're talking about a pretty small number of patients at this point, the preliminary results are encouraging."

Guss and his co-investigators at UCSD hope to present their results at the October meeting of the American College of Emergency Physicians, and asked me not to publish the data because it's premature.

But suffice it to say that the telemedicine physician, the ED physician and the RN all received scores higher than 3 from the participants. Best of all, he says, the average length of ED wait for those telemedicine patients was about half the current 296 minutes posted on Hospital Compare.

Guss hopes to eventually analyze the impact of ED telemedicine on the department's bottom line. It may reduce or avoid ED physician services payments or increase revenue because more ED patients would be treated.

Then, he hopes to expand the ED telemedicine to multiple sites across the country, at non-academic community hospitals in large cities and at small rural areas to test the concept further on a large scale.

Guss is optimistic. "So far, the patients love it because they actually feel like they're getting more attention (from the telemedicine doctor), not less. They don't see us in the flesh, but they get more face time."

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