Clinical Case Study: Telehealth for Emergency Medicine

In collaboration with the American College of Emergency Physicians, this interactive session provides an overview of the innovative ways that telehealth is currently being used in emergency medicine. A panel discussion covers a variety of questions on telehealth emergency medicine.

Speakers

• Aditi Joshi, MD, chair, emergency telehealth section, ACEP
• Kelly Rhone, MD, Avel eCare
• Mohsen Saidinejad, MD, Ronald Reagan UCLA Medical Center

Hosts

• Bernadette Lim, program manager of digital health strategy, AMA
• Jeffrey Davis, director of regulatory and external affairs, American College of Emergency Physicians
• Laura Fritsche, program administrator, digital health, AMA

Explore the AMA STEPS Forward® Innovation Academy on-demand library of webinars on physician burnout, digital health, private practice, BHI and more.

Lim: All right. Good morning, everyone, and thank you for tuning in to another telehealth immersion program event. Today's session is focused on telehealth for emergency medicine, and we are honored to host our event today in collaboration with the American College of Emergency Physicians, one of the 25 medical association program collaborators. During our 90 minutes together today, we will start off with a presentation from Dr. Aditi Joshi, chair of the emergency telehealth section at ACEP, who will talk about telehealth as a solution for emergency department challenges and at a high level give an overview of tel-emergency care.

We then have two speakers joining us, Dr. Kelly Rhone from Avel eCare and Dr. Mohsen Saidinejad from Ronald Reagan UCLA Medical Center, who will share how they are leveraging telehealth and emergency medicine at each of their respective organizations. After these three brief presentations will then come together for an interactive panel discussion where we'll invite you as the audience to ask questions live.

And with that, I'd like to introduce Jeffrey Davis, who will introduce our speakers today. Jeffrey Davis is the director of regulatory and external affairs at the American College of Emergency Physicians. In his role, Jeffrey manages ACEP’s formal responses to federal policies and works with federal agencies and other external stakeholders to help advance ACEP’s Federal Affairs agenda. Prior to that, Jeffrey worked in the Budget Office for the U.S. Department of Health and Human Services for nearly eight years.

Jeffrey came to the government as the presidential management fellow and in his position in the budget office, he advised top level officials on major budgetary and policy considerations within Medicare and prepared detailed analyses of Medicare regulations and legislation. Jeffrey has a Master of Science and Health Policy and Management from the Harvard T.H. Chan School of Public Health and a Bachelor of Arts degree from Duke University. Thank you, Jeffrey, for making today's session and collaboration possible. I'll turn the floor over to you.

Davis: Thank you, Bernadette, and thank you so much for the American Medical Association for hosting this event today. We at ACEP are really, really happy to be here and to share some of our experiences in emergency medicine. So, without further ado, our introduce our first speaker, Dr. Aditi Joshi is an emergency physician and digital health consultant who’s worked in telehealth for almost a decade, beginning at a virtual care startup and moving into an academic medical center as medical director of Thomas Jefferson University's telehealth program.

She's a chair of telehealth for the American College of Emergency Physicians. Working specifically on how digital technologies will affect the workforce, education policy and future practice models in this specialty. Dr. Joshi, thank you so much for being here today and I'll turn it over to you.

Dr. Joshi: Thanks, Jeff. Thank you for that introduction, and I am glad to be here. I want to second what he said. Thank you for inviting us from ACEP to come over and speak to you about emergency medicine and telehealth. As mentioned, I’m the current chair of the telehealth section. And we've really worked to try to look at acute care telehealth for almost a decade, and we've seen it change from a very small amount of engagement used in remote areas, to the exponential growth that we have seen over the last few years. ACEP represents about 30,000 emergency physicians, emergency medicine residents and medical students, so they have a lot of advocacy and input on how are we really going to make the future of emergency medicine different and what do we need to do.

And when I thought about giving this presentation, I realized there's a lot of things that we could talk about. But what I really want to get and go over today is what are the ways that emergency medicine has been working in telehealth? That seems very basic, but there's actually a lot of questions about it. Just how does a specialty that works in emergencies, in a once place in the hospital, how can they really do remote care? And so, we're going to answer some of those questions today, after which we're going to have a panel, which I'm looking forward to. You can please keep your questions for any of these things for then. All right. Next slide, please.

I have nothing to disclose. Next slide. So, in general, the emergency department, we consider ourselves what we call availabilists, excuse me. We are a space where anyone can come to get health care, at any time of the day and we're proud of this fact. Anyone can come. Our doors are always open. However, due to numerous factors, this actually becomes a burden, right? We see some of that a lot during this pandemic or even prior. So even prior to the pandemic, the ED visits have risen more than 60% since 1997.

We also have more patient boarding. In the last two years. It's been over 130% of an increase, and we've seen actually more of the negative patient outcomes because of this. It will obviously do that right, with the more waits we have, we have patient harm, worse outcomes. And then, of course, the issue of what's happening to our workforce. We've all heard about how burnout has been a problem, especially during this pandemic, but it didn't start there. It has been slowly increasing over the last decade. It has become part of our consciousness and part of the discussion of how are we going to fix this. So that we have a health care system that can sustain itself. But a lot of this is not new, just worse. Next slide, please.

So, I bring up this slide because I wanted to show you, what is it that the ER really looks like? This is how we think about the air in general, right? We have we go into the waiting room, we go into the ER and we leave and we think this is where the ER physicians work. I'm using just this to show you what the boarding has looked like and why it decreases, how efficient the ER is. But also, I wanted to also state that this is not the only place we work. You want to go to the next slide.

So, as I mentioned, what we are specialists in acute unscheduled care, meaning any type of emergent, acute care that happens that wasn't planned, which hopefully most are not, we are trained specifically to take care of that in any place. So that doesn't mean just the emergency department. So, when we look at what the current models of telehealth are and how we're practicing it, we have virtual urgent cares.

This is the most common thing we think of, the direct-to-consumer models that have existed much longer than these discussions we've had out of health systems. And then teletriage. Now this is very ER specific. People coming through the ER, having a visit remotely and then having their orders put in and then seeing somebody in person, EMS community paramedicine. And then we're having more of the virtual observation, telecom and hospital, at home. And then, of course, telecom stations, which have existed even longer than these virtual urgent care models.

I bring this up because I wanted to say that two things one, that telehealth did not start just recently. It's been going on for even longer than I’m mentioning decades within places that were remote. The military used it. NASA used it because they needed somewhere to be able to deliver health care when they couldn't get there. And then also within emergency medicine. We're not also taking one spot in the health care system and one spot that we practice.

We're practicing all over the community because what emergency medicine is, is the bridge between the outside the community and the inpatient units in the hospital. That's where we sit. We set on the we sit on the first floor. We have EMS coming in. That's who we are. And so, because of that, there's a lot of unique ways that we can use telehealth, remote virtual care to practice now and in the future. Next slide.

All right, so I just brought this up as some definitions of ways that we practice. So telehealth can be defined in a number of different ways. And I won’t go through every single one of them, but I want to take a look and see in the ways that even within these definitions, emergency medicine is practicing it. So, in synchronous versus asynchronous now. This is one of the most classic ways we define telehealth, right? Is it happening real time on a phone or a video visit? Or is it asynchronous and not happening in real time? What we think of chat bots and AI. And the answer is yes, we are practicing this. It's much more obvious how we're doing synchronous care, direct patient care, looking at somebody or talking to someone and saying, all right, we're delivering health care.

But ER physicians are unique in that they are doing asynchronous care because anything that has anything to do with triaging patients, determining, hey, where do they need to go? Can they stay home? Do they need to go to an urgent care, primary care? Or do they need to come to us in the emergency department is a form of triage and we are uniquely skilled in that. So, it is a myth that we don't do any asynchronous care.

And then, as I mentioned, we don't just practice in the ER, we do pre-hospital care, community paramedicine, maybe triaging SNFs when we get calls from EMS telling them what they may need to do, how to treat them. Then of course, we do hospital care. I mentioned teletriage, inpatient consults and just taking care of patients within that space. And then post discharge can be, as I mentioned, the hospital, at home and the virtual observation units.

One thing you may not know is that observation units are many of them are run by emergency departments. They end up being a unit that is between the ER and a full inpatient side. And so, it's a natural extension to try to do any of it remotely through an air practice as well. Specialist consultations is a very old type or classic type, if you can call a few decades classic, form of telehealth where we're doing provider to provider consults.

People mostly think of telestroke, but remember that even though on one side their stroke neurologists, the other side of that call for provider-to-provider, many of them are emergency physicians. And so, they are the recipient hospitals being able to get that care and use the specialist access to take care of their patients. And there are many, many studies talking about how this has improved patient care, decreased transfers and during the pandemic, it was also being used for in-house consults. Telestroke isn't the only form that's out there, but this is just one that has the longest amount of research.

And then lastly, education and training, which is not specific to emergency medicine. But then we do train. We have to train our own medical students, residents. We can use telehealth to do that. But even interesting, like I mentioned before, the fact that we have access to specialists who are remote, a lot of times, that is a form of continuing medical education. Getting information on how to treat a patient that's sitting in front of you because in the future, you may not need to call the specialist, or you may have a better idea of what to do because you did get that education and training without actually signing up for a course. Next slide, please.

And I wanted to mention our section taskforce. You know, the telehealth section has existed for over a decade. We've worked in trying to really make telehealth part of the discussion in emergency medicine, to varying degrees of success. Just like everywhere, there wasn't a lot of engagement in the beginning from even our clinicians or our patients. Despite that, we have written some papers, emergency telehealth primers, in education and training and really looked into quality measures.

However, obviously during the pandemic, when this became a bigger topic and there was a need to really look at, what does it mean for emergency medicine, we actually were tasked with writing a report by the ACEP president. How do we really look at what's the future of emergency care? Next slide, please.

So, there are large five buckets to this report, and I want to bring up this report for two reasons. For anybody here who works in emergency medicine and they want information about the kinds of discussions that are important for us to know, going forward within our own specialty, there is an access to this within our specialty organization. But even for those who are not, if you were from another specialty, these are really important buckets.

This is not specific to emergency medicine. All of these, I'm going to go over, but it's why do we think about, how are we thinking about our own practices in the future? And anyone like the AMA speaks and are advocating for physicians really should look at this as well. These are topics that are not specific to telehealth, of course, but this is something to think of, even when we're looking at how telehealth is going to change the future of the health care workforce.

Care models

So, when the first one we looked at is really care models, this is really a global look. How is the care models going to change for emergency medicine? What is it that we practice now and what are we going to be practicing in the future? So that was really what we looked at the diverse ways that is it? Is it going to change for the positive? What are the barriers for the negative, right? So how do we license, credential? What is the burden of oversight? There's a lot of questions that happen within that. And so, we wanted to make sure that we have discussed that.

So, in the future, when people bring this up, we have a basis to say yes, we understand this is going to be a barrier. What are we going to do about it? So, we're not caught, 10 years from now, not having a plan for it. Malpractice, of course, again, is a risk. And so some of the things that, some of these conversations within the care model have really bled into a number of other committees or other organizations that work on these because telehealth again, is just really a way that we're practicing. It's not its own entity.

Quality

The next is quality. When we talk about physician engagement, I will say this is from my own experience, this ends up being a very big barrier of why people don't want to practice it. How do we ensure that we keep the quality to a level that we are comfortable with? We're not practicing in person. So how do we make sure that we're giving our patients the right type of care? So, a lot of what we are looking at is what's out there right now, what measures are there? The reality is there is no standardized set of measures, within specialties or without. And one comment I want to tell you, is that in the beginning when telehealth, when I started about a decade ago, telehealth was one entity.

We were all working together to figure out what our clinical guidelines, clinical protocols. It was not specialty specific, but after, in the last two years, three years, really, you've seen a lot of that changing because there is that recognition that, yes, we all are physicians, we all are clinicians practicing. But it's the way that we're going to practice emergency medicine is not necessarily going to be the way the dermatology uses it, and their guidelines might be different. The way they can use a go over video might be the same.

If we're going to look at the quality measures for having a good eyesight, good cadence, good empathy with your patient might be the same, but not the way that we're going to practice and we're going to see a lot more of that. There is a significant gap in that evidence-based research. Mercy medicine is not different, but it is a lot less than that. There are some telehealth measures and QF has one. But again, it was based on all clinicians. It wasn't specialty specific. And so, it wasn't. And that's OK because, you know, we took that and you can actually build upon that. But there is a huge dearth of need for more research and how quality measures are going to be in the future of all of our specialties.

Legislative, regulatory and policies

The next is legislative, regulatory and policies. This is a lot of internal policies and what ACEP works on, so I'm not going to bring that up a lot. But because again, ACEP has worked quite a bit and thought about telehealth for a while, there's a lot within there. And then reimbursement, of course, is a big topic of all time. It's a large barrier for easy and widespread telehealth due to parity type of telehealth that was reimbursed.

Who was paying and what CMS waivers will continue? There is a number of legislative work that ACEP does. One example I can give you was EMTALA. For those who are not physicians, it is a law that says that any patient presenting to the ER must be screened for an emergency condition. This is, again, why we see everybody who comes through our door. So, the question is, is EMTALA fulfilled by a telehealth visit? Can we do it remotely if there's a teletriage visit, does that count as a screening exam? Can we send that patient home?

We still don't have an answer on it. People were deciding because we weren't given an answer. But again, this further demonstrates how when we're trying to create something, often tech is faster than what we're able to catch up in practice or practically.

Education

And the last one is education. So, we talk about workforce, care models, oversight. Education has to keep up with it, right. So, most of us who began early in telehealth, emergency telehealth, it’s no difference. There were a small group of people. We learn by experience. We learned by just doing.

Applying what we did in person to some of these models. But that's not really a sustainable model. We need our future doctors to be able to know what telehealth is and be able to practice it. Also, there's going to be little change in the mentality about telehealth unless we are incorporating it into medical education. If we never teach it or telehealth is taught as an afterthought, it doesn't actually be ingrained into medical practice. It's considered something that some people do, and some people don't.

I have had a number of medical students and residents around the country, tell me they wish they had better exposure, but that their programs, they don't have it. They don't have the time for it. Or they don't have anybody there that champions it. Now, if you take out that equation, that there's no champions, that everybody does this, this will make it easier. I know the AMA works on at the AAMC. There's a lot of work being done toward this and it's big, but it's necessary as it's a reality being realized faster and faster. So that is welcome. Next slide, please.

I'm just going to take a very short time just to show you where in the places that emergency medicine practices telehealth. So, I told you about the current places, I already made a few points about how we don't just practice in one spot. We do a lot of different types of care. And so, when we look at what the future areas are using telehealth, we can think about, well, we have the triage portion.

Again, I told you that is something that we do quite a bit of and we're very well attuned to that. We do direct, acute unscheduled care and this is directly taking care of patients, whether it is through e-visits, direct care and the direct-to-consumer, the virtual urgent care or is it the provider-to-provider consults, LTAC SNFs, as we mentioned. And then obviously the out of ED visits, observation units, post ED and remote home monitoring and hospital at home. And we talk about remote home monitoring and hospital at home. They're really just an extension function of telehealth, doing it further in the home with better monitoring and better capabilities. Next slide, please.

And so, these are just some general areas of growth that we are working on right now. This changes depending on what the current status of ACEP is or what we have expertise in at the time. But I will say most of these topics are very common. Whether the expanded scope of practice, what does that mean for the future? Education, like I mentioned, what are the quality measures, metrics and research and standardization? This has been there for quite a while.

One new growth, though, that I've seen a lot spoken of is equity. I mean, technology in general moves faster than the law, culture and practice. The reason for health care inequity are systemic and longstanding in an area where we're rushing to catch up. I'm not going to spend a lot of time on that. I believe that we all can think through that. But another thing that we really need to catch up when telehealth is one of those topics. And then last one, next slide, please.

And this is just an idea of some of the other places that we work on and whether or not this might be specific. This is not specific to ER again, you know, we look at telehealth and we think about how do we accredit? What are the quality measures? What are the practice models, like I mentioned, academic affairs, education and the workforce? When we think about, you know, all groups have to train on this portion, and so hopefully this is not just useful for emergency medicine, but for any specialty that's looking at. Next slide, please.

And so, I just want to conclude saying that emergency medicine has a long history of being involved in telehealth. When I say we were doing a decade, even with a small group of us, we have a lot of experience working with it on all of these topics that I'm talking about. And so, if, anybody who wants to work with us, we're always welcoming to try to help or to even learn from anybody else. Talking about the recent expansion, we have a better national discussion and looking forward to working on some of these big topics. Try to plan for our specialty in the future. And just better integration with other committees and partners. And next slide.

Thank you very much, and I'm going to turn it over to our next speaker, and I look forward to your questions during the panel.

Davis: Thank you, Dr. Joshi, so much. Our next speaker is Dr. Kelly Rhone. Dr. Kelly Rhone serves as Avel eCare’s vice president of innovation and outreach. In this role, she's responsible for patient engagement and retention, program development of telemedicine services and educating medical professionals on telemedicine and change management. Dr. Rhone has been practicing emergency management for more than 15 years and joined Avel eCare to help bring cutting edge, emergency and critical care patients bedside, regardless of location.

She serves as an associate professor at the University of South Dakota Stanford School of Medicine and as a fellow at the American College of Emergency Physicians. Dr. Rhone completed her medical education at the University of South Dakota in Vermillion and her emergency medical training at Health Partners Regions Hospital in St Paul, Minnesota. Dr. Rhone I’ll turn it over to you. Thank you so much.

Dr. Rhone: Thank you, Jeffrey. If we could go to the next slide. So today I do work for Avel eCare is the company that I work for and I'm going to be focusing on how we do tel-emergency medicine and just some of the experiences that we've had with that. And next slide.

And so, as in my role, just like Jeffrey was saying, I do a lot of work on innovation. And when we talk about tel-emergency medicine, one of the things that has really helped us in the past is to talk to our partners that we're working with and seeing what their challenges are and looking at how we can incorporate that into our tel-emergency program. And then I do a lot of outreach work with rural hospitals as well as programs such as this, where I really talk about tel-emergency and how it can make a difference in our patient's care. Next slide.

So just like Dr. Joshi was saying, there are a lot of challenges that we have, and I'm really going to focus on rural America in my talk because that's really the lion's share of what we do here at eCare. And we know that 120 hospitals have closed in the past 10 years, and 31 states have seen at least one rural hospital shut down. And I think it's important to note that when a rural hospital shuts down in most communities, that is the largest employer in their community. And what happens then are those employees leave that community, and the second largest employer in most rural communities is the school system. And so when they leave, they take their children out, and this also affects the community.

So, it's a huge economic problem. So, it's not just the health care, but it's also really a community problem when any hospital shuts down. And then 49% of community hospitals reported operating margin of less than 2% So they really struggle to make choices of how they're going to improve their care and how they're going to recruit and retain good staff in their areas, which has been really difficult, particularly over the last year when nursing has been difficult in large centers. We've heard from our rural partners that they're having to spend an immense amount of their margin on locums nursing because many of their nurses have become travelers. Next slide.

And just like Dr. Joshi was saying over the past 10 years, ED visits are up almost 25% and the average time spent waiting in an ED before seeing a physician or an advanced practice provider is 24 minutes. But if you look at rural hospitals, it's actually quite a bit more than that. And the reason for that is in many of these smaller hospitals, if you're there after hours, that provider, whether it's a physician or an advanced practice provider, is oftentimes at home and they're called in. And so, the nurses are really managing those patients until that provider comes into the emergency department. And that's something I think that people don't always realize in smaller communities.

But 20% of our population in the United States live and work in rural communities. And again, there's shortages in staffing, and telehealth has really been, in our experience, a really great way to help not only with provider staffing because people are more willing to go to a rural community when they have this backup, but also on the nursing side, because it's pretty intimidating to be the only nurse in an emergency department at night when your provider isn't even in house, especially as a new nurse. And next slide.

And again, burnout is a huge issue in emergency medicine, we're right back up at the top this year again, so 65% of us believe that it's a serious problem. And when you're isolated and you're the only provider within 100 miles, that can feel like a pretty lonely condition. I mean, I think many of us who work in emergency departments and work single coverage can feel that. But I think it's even worse when you are far away from any other physician help that might be helping you with complex patients. And next slide.

So, our guiding principles have always been to improve access to care and improve our care and outcomes, as well as lower costs and part of that is really helping to recruit and retain that workforce sustainability in rural hospitals, by lowering their cost of locums care so that they can recruit and retain people to live and work in their communities. And go ahead and next slide.

So, this is a little bit of how it works, and in our centers, we have a virtual hospital. We are located in Sioux falls, South Dakota, so that's where our hub is and we work on a hub-and-spoke model. So, what that means is we have a virtual emergency department and you can see that in the top slide. And so, I'm working with a nurse. One of the things I think that makes us a little bit different is that we do work nurse physician in our program.

So, we're not only supporting the provider staff on the other end of the hospital, on the other end of the camera, excuse me, but we're also helping the nursing staff. Because in many cases, we have seen a lot of these complex cases on our bedside care and we see a lot of really, really sick patients. But some of these hospitals may only do one or two cardiac arrests a year, with that provider and nurses may only set up complex drips here and there. So, we're there to really check those to make sure that they're always done in a manner that is perfectly correct and so we can always check all of those dosages.

And on the bottom screen, you can see how it looks on the outside hospital's site. So that is the spoke, like a bicycle. And so, we reach out to multiple hospitals, and it allows one emergency physician and one nurse to cover multiple hospitals, as needed. And the way we've done this, you can see, I don't know if you can see that well, but there's a little red box on the wall and that's how they would activate the system. There's one button and it's been made that way just to act like a code button. And then we are hardwired into their emergency department.

So, once they hit that button, they just say which room they're in and we are able to pull up the video, and that's typically within about 20 to 30 seconds. From there, I have a 20x Zoom Polycom camera on the top of that TV that's hardwired there. And so, I can move with my remote control. I move the camera. They never have to touch anything except for that one button. And we did that because we want to make sure that whatever they're doing, if that patient comes in and they are doing CPR or they have to do an airway or a patient is seizing, we don't want them to go and have to grab a cart and set it up and log in. That's never going to happen. And so, it had to be something from our emergency department where it was really reliable but also easy for them to access.

And the other thing we did is we actually put the microphone right above the patient's feet, and that took some trial and error for us to figure that out. We initially, when we started this in 2008, put it above the patient's head. But there's a lot of really loud things around the patient's head like oxygen and suction and potentially patients yelling and things like that just happened in emergency departments. And so, we found that if we put it over the patient's feet, we could still hear everything that was in the room.

But if I'm talking someone through their first-time chest tube or through an airway, they can stay right exactly by the patient's bedside, and we want them to be able to stay there and take care of the patient. We've also been able to really work on airway. It's certainly the single most scary thing that we do over the camera. And frankly, some of the people that, we work with amazing people on the other side of the camera, but we do work with people who haven't had a lot of airway experience. And so, through the video laryngoscope, we are able to actually just put a cord and hook up so that in my large screen there, I can see exactly what they're seeing in the airway.

So, when I trained, we didn't have video laryngoscopy and so my attendings would always say, tell me what you see. And so, I always felt a little bit comfortable with that. But certainly, a picture is worth a thousand words. And so, I can see if all I'm seeing is pink mucosa that they're deep and I just need them to pull back. And then I can go through what the landmarks are and help them to adequately get that airway established.

The other thing is that I can see that, I can see the tube go through the cords and so I know that was a successful intubation and go through that with them will help them to calculate any medications. And we actually have all of their formularies, so we know what they have for medications. We also know what they have for equipment to the point where if they have a locums physician or nurse and I'm asking them to pull out an IO, if they say, I don't know where that is, I can look and say it is in drawer 3 on the wall. And so, we've really spent a lot of time, not just with the process, but how it will work and make it easy on both sides for us to really focus on the medicine.

And then while we're doing this, we also spend time, if that patient were to need to be transferred to a higher level of care. We can make those phone calls in tandem while the bedside staff is working on the patient. And so, this allows us to access a helicopter faster and get that to the patient faster, but also to get an accepting physician for them as long as we're involved in that care. And then our nurses as well will scribe for that patient. And so that helps the nurses on the back end. So, if there's multiple patients, et cetera, we always equip at least two rooms and we use fiber into those rooms so that we're not dealing with Wi-Fi. And so, we always have a good connection.

And then I just would say that if you look at that top screen again or the top picture, I have about 16 setups like that, so the nurse always stays with the patient. But I just like in my own emergency department where I work bedside, I can move from station to station as needed. And so, I might be seeing one patient in Montana on one station and then move and see a patient in South Dakota in another and then move and see a patient in Texas in another. So, it allows us to really be able to take just a few providers, or a few board-certified emergency physicians and have them see a lot of different patients. Next slide.

And so, this is actually a really great picture from the ACEP rural emergency care taskforce. This was put out in October of 2020 and it's the emergency physician density, per 100,000 population by County. And this one actually shows emergency medicine trained or emergency medicine board-certified emergency physicians. And you know what, if I could put an emergency medicine trained board-certified emergency physician in every single emergency department, I certainly would. But we can see that we have a long way to go. And there are certainly places where we have a lot of emergency physicians, but there are a lot of places, all of that white where there aren't any. And so, this is a way that we can have a board-certified emergency physician who is trained and who has experience that can help the bedside provider to care for that patient. Next slide.

And so, this is our footprint and you can see that it's really very similar to the last picture in where we have really looked at where we can provide the best care or make the most difference. So that's not saying that we're not going to expand from there. We certainly will. But currently we're in 14 states and we cover 216 total hospitals. And then on the East coast, there we collaborate with Dartmouth Hitchcock with their Connected Care program. They have been great partners for us and we help cover their cameras at certain hours.

So, it's been a really wonderful experience to take care of patients all over the country. And you know, for the most part, medicine is medicine, but it has been a learning process for all of us because there are some regional differences. I always say, you know, there's certainly snakes they have in Texas that I've had to learn about because we don't have those in South Dakota. They would not tolerate our cold. So, it is, it has been just an incredible experience to work with people all over our country. Next slide, please.

And then I just want to talk a little bit about the impact. Go ahead and next slide. So, we really keep track of all of our avoided transfers, and so we will never try to keep a patient somewhere where they really should be transferred to a higher level of care. Of course, that was a little bit of an issue over the last couple of years when there was no, there were no beds in tertiary hospitals and we were actually doing a lot of ICU care for hours, if not days, on some patients in our rural hospital partners. But we do keep track and oftentimes we can help with definitive care. And keep that patient, actually send them home. Maybe it's a case of SVT that we help them to convert or helping them to do a reduction on a shoulder dislocation and then that patient doesn't have to be transferred. So, sometimes it's really bread and butter emergency medicine that we're doing. We also have other programs that I think help with this.

Many of our hospitals also have our hospitalist program. And so, with those two together, we're able to offer them also a board-certified internist who has hospitalist experience, to see if that patient could be kept locally. And this does a couple of things. It certainly is, patients like to be closer to home when that makes sense, but it also does increase their average daily census and helps with the financials of that hospital.

And then our patient encounters, we see about 1,500 patients a month currently through our ER program and then another 300 to 400 through our behavioral health assessments, which we have psychiatric nurses that help with behavioral health assessments. And then if that patient needs inpatient treatment, they'll call up to six places to try to get them placed, which takes a huge burden off of the emergency department staff. Next slide.

This is just some of the things that we see, cardiac and chest pain is certainly by far our largest. I read a lot of EKGs all day long. I can see an EKG on the back wall as easy as I can if it's just right in front of me. So, it is pretty easy for us to do that. We see trauma every day, stroke every day. We see, currently we're seeing about three cardiac arrests every day we will help with timing. It's time to do another pulse check. We'll watch the monitor and help them through all of those algorithms, et cetera. In the month of January, we did 103 cardiac arrests, so that doesn't count all of the emergency airways and critical patients that we were seeing in January, in our area in the middle of the country. But certainly, we've seen an increase in the critical care that we've done over the last two years of the pandemic.

And then all the way down to obgyn, I always like to share that I have now delivered more babies virtually than I have on camera. It's probably the second scariest thing that I do because these are all hospitals that don't do OB on purpose, and many of the patients have not had prenatal care. And so, you're not really sure how far along these babies are. So, they are fun, but sometimes very terrifying. We've actually had undiagnosed e-twins before, right up on the Canadian border in North Dakota, so, you know, in the middle of a snowstorm. So, there are certainly challenges to this. And next slide.

And then I just wanted to share a couple of other quality pieces. Prior to doing this kind of work, I had never worked anywhere without a Cath lab, have now gotten really good at giving fibrinolytics for STEMI. And we work with the site in order to make sure that we're doing that in a very careful way and making sure that the patient has, understands the risks and benefits to that. And next slide.

And so, you know, we know our benchmark for that is 30 minutes. One of the things that's really difficult in rural hospitals is that after hours, radiology is at home. So again, that can take 25 to 30 minutes and it really is helpful to have that chest X-ray to review, particularly if that patient has any symptoms that you think may indicate a dissection. And so, we do meet that benchmark as much as we can. But we always are working with our partners to tell them, call us early and call in radiology early so we can get those chest x-rays done and we can help them to make sure that they're giving the right doses of fibrinolytics. And then next slide.

But what we found is that we are given the median time that we're giving lytics is 33 minutes, but that's approximately 15 minutes sooner than the average rural hospital without our support. And next slide. And the same goes for stroke. We want to get it in with that 60 minute and we don't always make the mark again, this is because radiology is at home. And so, they come in and they have to warm up the CT scanner.

So, it's much different than, I work in a level 2 trauma center for my bedside time and, you know, we can clear the scanner and get things moving and have a stroke team. And these areas, you don't have a stroke team, it's one provider and two nurses, and that's all that's there. So, we're calling everybody else in on these patients. But we are making a huge difference. And we've seen these numbers improve as time has gone on and we've really made it one of our huge quality measures. Next slide.

This is our president and CEO of Avera Heatlh, which is the health system that our company was born to. And we recently became our own company but work very closely with them still. And just a nice quote, were you saying the three primary areas of focus for their telemedicine investment has been quality, access and workforce, and in a largely rural footprint, all three are critical, but not always a priority. And telemedicine changed that, and it became apparent during COVID. And so, when we came into the pandemic, we really layered telemedicine into every layer ICU, inpatient, pharmacy, ER, outpatient, and it really made a huge difference in managing our patients.

And then in rural, we were able to equip them with heated high flow as well as BiPAP. And then we were able to start our E-respiratory therapy program. So, all of these hospitals that didn't have respiratory therapy could access that through telemedicine as well. And then have infectious disease available to help with any consultation on an inpatient side. So, we were able to keep a lot of patients in our rural hospital and save our tertiary hospital for the sickest of the sick. And next slide.

So, telemedicine, really, when you're looking at it, you want to see how can I make lives easier? And this picture is probably more similar to what I see in my tertiary hospital when I work there, where you have multiple people coming in and working on one patient. But remember that in our case, most of the time in rural hospitals, again, it's one provider and two nurses doing the same work that all of these people would be doing. And so how do you help them to share that load and to bring them more expertise, more hands and more people just double-checking things to make sure we're always doing things perfectly correct? And next slide?

And this is really more of what we're seeing with the hospitals that we see, this is McKinney, Texas, who is one of our partner hospitals that is about an hour South of Odessa, Texas. And this is, our town is so small we had to borrow a horse to make a one-horse town. And I think when I saw that sign and I took this picture, I was like, you know what? That that is so much of what we do and making a difference in rural health and really changing the way patients are cared for and bringing cutting edge emergency medicine to the bedside has been just such a wonderful experience. So, and next slide.

I want to thank everybody for listening and wanted to again, thank AMA and ACEP for bringing on this program. Thank you.

Davis: Thank you so much, Dr. Rhone. Really appreciate your insights. Our next speaker is Dr. Mohsen Saidinejad. Dr. Saidinejad is a professor of emergency medicine and pediatrics at the David Geffen School of Medicine at UCLA and a faculty member in the Department of Emergency Medicine at Harbor UCLA Medical Center. He also serves as the director for the Institute of Health services and outcomes research at the Rehnquist Institute for Biomedical Innovation at Harvard UCLA.

He is very active in leadership within the American Academy of Pediatrics, and the Americas College of Emergency Physicians and serves as the chair of pediatric committee of the Society of Academic Emergency Medicine. Prior to joining Harbor UCLA faculty in 2015, he served for nine years as faculty in the Division of Emergency Medicine at Turner's National Hospital in Washington, DC. He completed pediatric residency training at State University of New York Downstate Medical Center and his pediatric emergency medicine fellowship at the Children's Hospital of Michigan. Dr. Saidinejad please, I'll turn it over to you. Thank you so much.

Dr. Saidinejad: Thank you very much. I really appreciate the opportunity to be here with you guys. I am going to represent the other extreme of the rural hospital being centered in a major Metropolitan area of Los Angeles, where the County of Los Angeles itself has over 10 million patients in it. And the ability to provide telehealth services is going to be very interestingly different from what you guys have heard. But I will present some of the same considerations and challenges that you heard from our other panelists. I want to see if my slides advanced for me.

OK, so I have no specific disclosures here. I am a faculty member at UCL School of medicine, so I have that UCLA Health part of my life. And then I'm also faculty at Harbor UCLA, which is one of the major teaching hospitals for the County of Los Angeles. I'm also a county employee, which is really interesting. I'm going to be giving you both of those perspectives as I go along with this. I also serve as the immediate past chair of the pediatric emergency medicine committee of ACEP and I've been involved with ACEP since, I would say since 2012 now, it's almost 10 years, so. And just give you a little bit of background.

So, I'm going to talk a little bit more specific on the pediatrics aspect of it and the care of children through telehealth, because that is an area that has not been as developed as the adults. We are using it tremendously less. Although in the past couple of years with the increasing need for, inpatient, sorry I just had my radio turn up, so increased need for having patients be seen despite the limitations with travel and all of this stay-at-home orders. All the children needed their normal routine care or vaccinations, so there has been a significant need for increasing some form of telehealth services. So, with that, there has been tremendous acceleration of the use of telehealth during the COVID pandemic.

I'm going to talk a little bit about the challenges involving telehealth and again, children. Telehealth services have the same challenges as adults do. A lot of the challenges are at least the perception that setting up a telehealth program is extremely expensive and complicated. A lot of the providers feel like the technology might be too overwhelming for them. As also mentioned before, how do we build for these services? Do we have the right codes? Will Medicare pay for these services? How do we maintain confidentiality of telehealth visits? Where do we store video visit recordings? How will they become part of the electronic health record? And so on. These are some of the challenges that are continuing to affect our ability to use telehealth services. But we do know there's plenty of evidence out there that telehealth is extremely valuable and it's a great addition to in-person visits for a variety of different medical problems that affect children and their families.

This was a talk that I saw later turned into a manuscript, I was a really good way of looking at some of the challenges that are at least perceived by pediatricians who are looking at providing telehealth services. And it looks like the most important consideration really is that payment and reimbursement. How do I get paid for doing a telehealth visit when I could be spending my time providing an in-person visit where I know all the billing codes and I know how to get proper compensation for? The other part of it that people are concerned with is the cost of setting up equipment. Finding out the right vendor who would be reliable, cost efficient. And least important were issues such as I don't have good internet access or patients don't like the use of telehealth services, they prefer to have inpatient. All of those are a part of the considerations as well.

So, there is an emergency medicine, at least there are situations where you absolutely need to have an in-person visit. It will be very hard to press on a belly and try to rule out appendicitis using a person at a remote site. It is possible, but it's not one of those use cases or actually performing the appendectomy itself. Those are some certain situations where you want to have in-person visits. We did hear just a little bit about rural areas and some of the challenges in the rural areas is that being able to connect to a rural site might not be so easy sometimes because the internet connection speeds and ability to stream videos might be affected.

So, this would be specifically affecting those areas. The most important thing is the pediatric specialists. We just don't have a ton of pediatric specialists available to go around and to find a pediatric specialist that is able to involve in telehealth is going to be a little bit of a challenge. And the pediatricians who work in more urban areas and bigger cities, they don't probably have the bandwidth to also perform telehealth services. These are all perceptions, not necessarily reality. We talk a little bit about documentation and privacy, specifically in children.

This affects those group of children who are minors, who are of age of ascent, who may have conditions such as pregnancy status, substance use or situations where mental health is affecting them, that some of that information needs to be kept private and confidential. And if the parent or a caregiver has access to that records, this will be an area that can provide some challenges. So being able to document the security and privacy and ownership of the records is important as well. Licensing and credentialing was spoken about before. The big issue is we don't really have great rules and protocols in place of what would be the minimum requirement for somebody to provide telehealth service within their specialty, outside of their jurisdiction, interstate telehealth services, coverage for liability insurance.

Some of these issues need to be resolved before telehealth services can be established between two remote sites. In terms of family and patient experience, this is a matter of education, letting people know that these services actually do provide great value. And when people are involved with telehealth services, the evidence suggests that families and children really find the experience to be positive and, in many ways, superior to having to go through the pain of actually showing up at an in-person visit. Sometimes, you know, in a place like L.A., you may have to fight traffic, especially if you're using public transportation system, to and from is a challenge that could easily be avoided with a telehealth visit.

So, I'm going to talk a little bit about some of our local area solutions related to telehealth. Kaiser Permanente, which is a very major provider of health care in Southern California, has a really nice model for how they optimize the use of telehealth and how to reduce their expenses and costs. They do have a lot of screening that can be done using video visit or phone visits, and that actually helps patients get triaged into what sort of need they have. They actually decide whether this patient actually needs to come in for an in-patient visit, or can it be managed with a video visit, a telehealth visit and this is something that is handled through an intake form.

So, if you need a medication refill, if you need a follow up with your provider, if you need work excuse notes or things that are really simple, instead of crowding their urgent care or their emergency departments, this is something that it can easily get screened and avoid the visit. Actually, my wife works for Kaiser and they do have a interesting ER system where you come in, you parking in the parking lot and you either call in or you get onto your app and you state your reason for visit and they will basically vet what you're here for. And if your visit requires in person, they ask you to just get out of your car and come upstairs. Otherwise, they'll take care of your visit while you're sitting in a car. It's kind of an interesting way that they're approaching this.

So overall, we know that the reason that telehealth is not as extensive as it is because a lot of telehealth services haven't been really established nationally. In terms of pediatrics, sufficient evidence exists that not only that, telehealth visits can help with managing symptoms and complaints, some of the health maintenance in terms of when you should schedule your vaccination, so that you can just have a nurse visit for vaccination instead of making a doctor visit that includes vaccination in it.

Also, in terms of medication adherence, there are ways that medication adherence can be tracked. They also found that people are more likely to complete a telehealth visit than an in-person visit and in no way causes them to fall off the grid and have worsening of their disease progression. So those are all some of the things that we have also experienced in our own system. So, I will tell you that the major element of telehealth for us here at UCLA Health is the patient portal. And up to almost 50% of our patients within the UCLA Health system have been enrolled in the portal and about 2/3 of them are actively engaged with the portal.

So, when they have lab results, they actually go themselves and check their lab results. They communicate with their physician about questions they have, about visits that they want to have. So, for UCLA Health, we're doing pretty well. But I'll tell you that L.A. County Department of Health Services on that side, we're not doing so well in terms of our patient portal.

So, this was also mentioned in the grid that Dr. Rhone showed earlier about where the specialists are. We have the same issue related to pediatric emergency physicians and as you would expect, the majority of them are in tertiary care centers who can afford and feel like they need that specialty service. So, on the other side of this, we also know that more than 80% of all acutely ill and injured children present to a non-children hospital, a non-pediatric medical center, a place where they actually aren't comfortable taking care of kids.

Some places have a pediatric volume of less than 10 per day. So, people when a sick child comes, they feel really uncomfortable because they don't have practice, they feel that they don't have the resources they need. They don't even know where their equipment are. We are doing a project here in L.A. County related to the L.A. County Pediatric Readiness Project, where we went out and did a site visit to 24 of our, what we call non EDAP.

EDAP stands for emergency department approved for pediatrics. These are non-approved pediatric emergency departments and we basically did mock codes and have their providers do them out codes and see what their comfort level was and how they did the management. And then we provided them a gap analysis at the end. And we found that while generally knowledge base is there, but because you don't practice it, the knowledge to practice part was hard and they were struggling with the timing of action items that they need to perform.

So, this basically suggested to us that it's not enough for us to show up every once, every two years or so and do a mock code with them. We do need to have an ongoing relationship with them where we can help with educating them and showing them what the latest evidence is, giving them opportunities to have pediatric cases to work on through simulation, through virtual ways. But most importantly, we need to be available to them through telehealth. And this is one of the areas that we're working on in L.A. County. In L.A. County we have 73 hospitals and only 13 of them are pediatric medical centers. So even in an urban County like Los Angeles, this problem is pretty significant, too. That needs to be overcome.

This is just showing you that the pediatric emergency department can be a link to the community. We talked, I think Dr. Rhone talked about this hub-and-spokes model. So, we have our pediatric emergency department and academic center serve as a hub that essentially adopts another 10 to 15 hospitals around us and we maintain communication with them as the referral site. So, the primary care providers can communicate with us. The urgent care centers can communicate all of the community EDs. We also have schools that can participate through telehealth, basically sending us a request for a patient encounter that can start from school, and we can then tell them whether the patient needs to come in or something like a allergic reaction and things like that as a proof of concept.

So, pre-hospital is another area, so we actually currently have not 29 different pre-hospital agencies in the County of Los Angeles, each having their own system and Harbor-UCLA is a regional referral center and a base station. So, we are a receiving site for a lot of hospitals around the area, as well as schools and homes. So, some of the use cases for telehealth in our system is the ability to do destination decision. Does this patient really need to come to the pediatric center? Does this patient need to go to the closest hospital because they are not stable?

Or can this patient go to a community ED or a general ED? In addition to that, we can help them with field intervention. And you heard a little bit about that case of video learn that Dr. Rhone talked about. But similar things like EKG interpretation, use of medications for antiepileptic, for example, dosing, double checks and things like that, as well as some of the stabilization that needs to happen before the patient can come.

And sometimes that's stabilization makes all the difference in the world in terms of how much more work needs to be done in that versus setting. And telepsychiatry is the biggest, one of those use cases, we obviously don't have enough psychiatric specialists to go around, even in L.A., we are struggling with the number of pediatric psychiatrists. So, the ability to be able to screen for suicide risk screening for patients who require medication for agitation. Some of the issues related to environmental modification ambulance setups for managing and transporting an agitated patient. Trying to find out if agitation is due to a medical organic cause or is it simply behavioral?

Some of those kind of communications through a psychiatrist would be extremely useful. We don't really have great bandwidth for this. We have a limited amount of psychiatric time where people can do these kind of visits with us, but we're really working on expanding that infrastructure because we simply have no choice. This is this is going to be an important area. The prevalence of mental health in children is just increasing and skyrocketing.

We can't keep up with it. We need to have a way where a specialist, at a remote site, can provide care to multiple different hospitals. One psychiatrist may have to respond to a variety of different scenarios from different hospitals. This is again showing you that while ED visits for psychiatry has decreased, but the telehealth psychiatry is continuing to expand. And that is during COVID the last couple of years. As you can see, the use of telehealth for telepsychiatry has picked up again because we have no choice. We have not been able to have in-person evaluation of patients a lot of times who have psychiatric issues.

Just briefly talking about the other portal, which is the L.A. County Department of Health services, this is L.A. health portal. L.A. County DHS serves about a million of the 12 million patient population in the County of Los Angeles, so it's actually the biggest health care provider for the County of Los Angeles. We also care for others who may not be empaneled to our Department of Health Services because, as mentioned, EMTALA rules suggest that if a patient shows up to our ER, we just have to take care of them, regardless of whether they're empaneled to us or not.

So, the L.A. health portal is a way for us to continue follow up after the visit, get their prescriptions through their school notes. They can follow up on lab results that didn't get completed, like a COVID test that when we do it, it takes at least 12 hours for the result to come back, so they can go and check those results through the L.A. health portal. And again, portal is one of our major ways that we are doing telehealth in our system. This also allows video visits, communication with the providers. This is again the range of services that L.A. health portal offers that patients use quite a bit.

 

The lab and imaging, also our own physician notes, are visible to patients. So, if we have sensitive information we don't want to share, there's a specific template called sensitive note template that's not visible to the patients. But everything is and we've had to work really hard to train our trainees, our residents, that be careful what you write because patients can see everything you do.

And that's just a checklist we already talked about this one, school-based, there was an example of this in Georgia. I talked about how our school system is, we're working on trying to get them connected to us so they can actually telehealth into us and see whether a child needs to be brought into the ER or how we can manage them outside of having to come in.

And lastly, is the tele-learning this ability for our residents and trainees to be able to learn through the platforms like Zoom and Microsoft Teams have been incredible. We're also doing courses through Coursera and OpenPediatrics for them, lots of video kind of educational webinars and podcasts that are available for them. And finally, in response to the telehealth need during COVID, the Center for Medicare Services is also increasing their payments and technology to help patients get through these hard times.

And just to conclude here, pediatric telehealth is expanding and trying to catch up to where adults are. There's many different special use cases and COVID has accelerated this. And if you are to provide a telehealth service, you have to think about the cost, the infrastructure, your personnel and how to make best use of your resources. Remember that dedicated telehealth practitioners is important because I can't be working in the ER seeing patients clinically and answering telehealth calls at the same time. So, I know there's a lot to cover in a short period, but that's the end of my talk. Any questions?

Lim: Thank you Saidinejad and thank you, everyone for just joining. We'll move to the panel discussion portion now and I invite Dr. Joshi, who will be moderating. If you have any questions, please use the raise Hand function. You can access that from clicking on reactions at the bottom of your screen and then raise your hand. And then at this time too, we're going to just launch a brief, three-question feedback survey. We just thank you in advance for taking that. Dr. Joshi, I'll turn it over to you.

Dr. Joshi: Right, thank you, everybody. I see that there's a couple of hands raised, so I will take those and I'm going to alternate with some of the submitted questions that we have. So, we have a hand raised with Ash Varma. If you want to unmute and ask your question. OK, I'm going to move on to one of the submitted.

Varma: Yes, can you hear me? Yes, I can hear you. Yeah, thank you. I'm Ash from San Francisco. I have a question for Dr. Rhone. She mentioned about doing a endotracheal intubation using video scope. I was wondering as to how would you direct the person who is doing it, especially when it's a difficult intubation?

Dr. Rhone: Yeah, and like I said, and so I thank you for that question. It is the single most scary thing that we do, and I think even in the emergency department, it probably is. It is the biggest procedure that we do that can give life or take life away. So, I will say that when I'm working bedside, if I'm going to intubate a patient, I intubate the patient, you know. I know what my skills are. And even if I am working with a resident or a student, if they can't get it, I can simply bump them out of the way and take over.

And that is not the case when you're 1,000 miles away. And so, we really spend a lot of time trying to decide what is a crash away and what is a airway that I can temporize if I have a helicopter landing in five minutes. I may temporize that airway if it's not a crash airway and we really talk, we go through an entire checklist, have everything ready, just like we would at the bedside. We do that in our own practice. But what is your backup? And we talk a lot about what is good bagging technique and we actually offer the Difficult Airway course to our partner sites every year. So, Dr. Calvin Brown from a Difficult Airway course comes and we do a live training, which we do every Spring. It's coming up here in May.

And we actually had a case a couple of months ago with a physician who works in one of the rural areas here in South Dakota, who had taken that course and they had a Ludwig's angina and there was actually a CRNA in house at the time, it was during the day and could not get the patient intubated. And with our help, we kind of talked her through and she did a Crake over the camera and she said, you know, the fact that we were there with her, as well as the fact that she had practiced that at that course really made a difference and saved his life, ultimately.

But we do spend a lot of time really thinking about, am I going to intubate this patient right now or and who is the most experienced in the room to do that? And then we also really look at, does this patient look like they're going to be a difficult airway? And how can I optimize that patient?

So, it is, I think it is different than when I'm at the bedside because I understand my own intubating strategy and how I do that and sometimes I'm working with someone I've never worked with before. And so, I'm asking them, how comfortable do you feel with doing this airway? You know, and we talk about exactly how we're going to do this. What are your backups and what are we going to do?

So, it's not an easy thing, but no matter what, that patient is going to need an airway. And so, if the patient needs an airway, they need an airway and we need to help them to establish that. And we are actually part of the National Emergency Airway registry. You know, I think it's much different because we have honestly non-intubators sometimes intubating and having that access to the video layer endoscopy has been a real game changer for us. So, I hope that answered your question.

Varma: Do you also suggest to have…?

Dr. Rhone: I'm sorry. I apologize. I need to move on. We have quite a few questions. I do appreciate it if we could just keep it to one question. Dr. Rhone, I thank you for that answer. I wanted to just talk specifically about how education is really important. And so, one of the questions I wanted to ask to both you and Dr. Saidinejad is how is it that you're able to make sure that the emergency physicians are all physicians, are tapped in and feel trained in this? And is there a way also that you can also make the hospital or medical groups feel comfortable running these programs? And I’ll have either of you answer that question.

Dr. Saidinejad: Yeah, I can tell you that from our standpoint, again, bearing in mind that I am in a major Metropolitan area, completely different set up than in a rural environment. So, the biggest challenges we have is that perception of the challenge and the technology. So, it's the first area of it would be to show how this can be done, integrated into your current workflow. So, if it's part of your workflow, it makes it a lot easier to do. If you have to stop what you're doing and log into a new environment and sit there and wait for it to warm up and things like that, it becomes a little bit of a challenge.

The other question is, when you log into that area, is the patient already waiting there or you have to do is click on it. And next thing you know, a patient appears or doesn't require many, many different steps. So, the first thing I think you need to think about is optimizing that system. So it flows well. It feels right to have that kind of practice nailed down so you can train it one time and one person can go and train others.

So, sort of a train-to-train our model. So, I think the biggest challenge is complexity of this kind of a system. If you can get through the complexity, people who are providing the care are not going to worry about the billing and reimbursement piece, somebody else will. But if people are providing that telehealth service, A, need to have time. So that's why I was saying that you should have dedicated time and personnel to do this. You can't ask somebody who's working clinically to also stop that and go answer a telehealth call. So, one thing is just simplicity. Having a process that is easily understood, like a checklist that people can follow.

And number three is a system that doesn't crash, a system that is reliable. And then setting expectations of what kind of services can one provide through telehealth. What is possible? What is not possible? And ideally, if I can log in and I already know my patient has been screened for appropriateness of this video visit, and I don't have to have a discussion and find out, oh, this, this patient needs so many other things. I can't do this with telehealth.

So, I think just having an outline of what it is that the service is going to offer, how it's going to work. So that it makes sense to you and you kind of feel like you can teach it to others. I think that be the most critical element of being able to pull off a service like this.

Dr. Joshi: Thanks, Dr. Saidinejad. That makes great sense, right? A lot of it is just being able to do that. The reimbursement part is a large section of it, and we work a lot with Jeff Davis, who has a lot of expertise in there. And he reminded me that actually, ACEP was able to advocate for telehealth to be considered an EMTALA telehealth screening exam. So that's really an important clarification I wanted to just mention. I want to move on to the next raised hand by Jay Hawk if you want to unmute and ask your question. You're muted again.

Hawk: Hello. Thanks for this great talk. I had a question. I don't know if this is outside of the scope of this session, but I'm interested in how telehealth would figure into a medical toxicology consult service. If any of the experts there want to speak knowledgeably about this or send me towards a resource that I can learn more about that I'd really appreciate it.

Dr. Rhone: So I can start that. So, I don't know of one specifically, but I know that it would be absolutely doable if you have, especially if you have a network within your own toxicology area, similar to what they were, what Dr. Saidinejad was talking about in UCLA or with our program. And so, we do something similar with burn. And so regionally, we don't have a burn center in North or South Dakota. And so, everybody goes to Minnesota, and we have worked with one of the burn programs at regions hospital.

So, in that region, we can do a three-way call and bring that burn surgeon right into our emergency department and have them see the patient through our cameras, so they don't have to have a separate camera system and can just use our cameras and help us because it's such a visual diagnosis with burn. But I think that's also true, probably in toxicology, where you're looking for, you know, toxidromes and things like that.

I think that you could work in a hub-and-spoke type model like that or a possibility is working with your poison control center, regionally and seeing if they have interest in that. There could even probably be some grant type monies involved that you could look into.

Dr. Saidinejad: Yeah, I would also add to that exactly the last thing you said, Dr. That I would go to poison centers because the number for poison center, everybody has it. Everybody contacts them. Poisons center folks are amazing. We just love working with them. Sometimes it's a matter of identifying a substance that was ingested or, as you mentioned, toxidromes identified as poison plants or something like that. And I think there are apps already that kind of do that, but I don't know how much I trust those and they're also not free.

I think if there was a structure that worked with the regional poison center, because people already know that I'm going to call the poison center if I have a toxicology question, probably would be the best way to do. And it has a national catchment area to develop telehealth for a hospital system. A

gain, even in L.A., even in my hospital at Harbor-UCLA, we have two toxicologists. That's it. And a lot of times they're not on duty. So that's why we also rely heavily on poison centers. And I think that might be the greatest place to start. If we can get them into a video scenario, that would be probably the best way to do this.

Dr. Joshi: Thank you for those answers. And I will just add those are great, very practical applications that any type of program that you can probably imagine that is hosted out of the ER can be done there. Telehealth, again, is really just a matter of how you're functioning and using these tools, rather than, limited by what you're actually practicing. Doing innovations as a great example of that. So, I wasn't joking when I said that within ACEP and within our group, there are a number of people who have tried different things. So, there's got to be somebody who has. I'm happy to connect with someone reaching out to our group, if that would be of help. Go ahead and connect with me.

All right, so thank you for your question. All right, so one question that was in the chat that I would just say, is there a best practices, training or certification to gain expertise in doing telehealth in the ED? I could let anyone else answer. I'm happy to answer that quickly.

Dr. Saidinejad: Yeah, go for it.

Dr. Joshi: I was just going to say there are a few certifications out there, but as far as best practices, really what has been created right now is what I mentioned before. It's really based on our experiences and people just doing it over and over. There have been a few ways that a consensus group has created checklist for telehealth, but they're still in the process of validation. So really, what's out there is that type of certification from experts teaching it. That's OK.

But just with that best practice training, there is no standardized version. That's probably going to have to come through undergraduate or graduate medical education and be formalized in that process. And that's probably going to be what those best practices eventually will come from.

Dr. Saidinejad: And I also will add that there is no one telehealth service, telehealth is a broad definition, and people use telehealth for different purposes. There is that telepractice that everything you do is going through telehealth. There's teleconsultation. There's telelearning. There's all different kind of components. I think the important thing is to know what extent of service are you offering to telehealth? And based on that, trying to create competencies and learning how to do that probably will be not a one size fits all.

Dr. Rhone: I will say, I'll add to that AAMC did come out with competencies in, I want to say 2020 and there are, just like was said, there are a few programs out there that are more general telehealth programs. I don't know of one that is specific to tel-emergency care. But there are a few out there that at least give you some of the background on the legal and regulatory issues.

Dr. Joshi: Much of it just because it was a single entity. So, one question that we touched on is the challenges. As we're slowly wrapping up, I know we're talking about the challenges in emergency departments around the country with staffing shortages and boarding. Both of you touched on this a bit, but how do you find, briefly, overall, how this is going to be a means for the future to address some of these challenges? And how do you see or the needs for the workforce that we need to address right now?

Dr. Rhone: Well, I can start with that, I mean, I think, you know, we need to start with our students and you know, really encouraging them to go into areas of need and we need to use telehealth as a tool to help them to do that. I think, you know, getting in front of our students early on in their medical careers and nursing students as well, so that they're comfortable with this and then looking at areas such as pediatric emergency medicine or rural emergency care and then making sure that those people are trained.

And probably having some bar of the training that has to happen for you to work in an emergency department I think is really important. You know, there really isn't one now and I think there are some good programs out there that can add to the education. We do a ton of education, just like you both were saying through your programs. But I do think if there was a standard of what you needed besides just ACLS and PALS, that could go a long way in care of emergency patients.

Dr. Saidinejad: And the other thing I would add is that although I totally agree that students and residents and a future generation and looking at this longitudinally would be the way to go, but also generating buy-in from the current mid to older folks like myself, to see that there is actually a different way to do it than to send a fax over or pick up the phone and try to reach somebody. And the value proposition is always what's in it for me that people need to be convinced of. And I think just optimizing, we talked about it, optimizing the payment, knowing that you can build for this. It's not a lost revenue that you instead of going and seeing a patient and building now you're stuck in a screen with some video visit that you can't bill for.

So that value proposition is going to be important. I think the training and teaching is just a matter of your attitude towards it. If you feel this is something that's good for you and good for your patients. I would feel comfortable that people can be taught. But if it's a drag, people don't want to do it and they don't feel like there's adds any value, then you're going to have all sorts of challenges and people are not going to buy in and it's not going to sustain. So, sustainability is another piece by having to continue to show value.

Dr. Joshi: It's a two prongs, right? You have to get the buy in for people who are currently practicing, but also make sure the ones who are in training by an early so we don't have this overarching continuous cycle problem. Thank you both for those answers and we have Daniel Martin with his hand up. I asked your question on the chat, but if you wanted to ask a different one, please go ahead.

Daniel Martin: I have several, but I just have one more. And that is, I'm just wondering in terms of other uses for telehealth, I know I have a friend, Ed Barthel, you guys probably know him they do a lot of triage with telehealth, which is great work. I'm just wondering if you know of EDs that are geographically large places. So, after your original H and P and plotting out a plan, I could see a big value for being able to beam in and out of rooms to update patients on where their workup stands and how long things are going to take as opposed to, not that I'm a lazy slug, but I just think it'd be easier to go right into people's rooms. Similarly, I was wondering if you know of any follow up programs from either observation units or in the ED that utilize telehealth as a follow up visit with an emergency medicine provider or physician?

Dr. Rhone: So I can take the first question. Actually, when COVID hit and we were really low on PPE, we actually set up iPads in all of our rooms at our tertiary center where I work. And so, we would go in and assess the patient. But then for further, I just got your chest X-ray back or things like that on patients that we were concerned about COVID. That way, we didn't have to burn another set of PPE.

It worked, OK, and the patients at that time were really appreciative of it. I have found that, we found that after that piece, once we all had PPE and that it was just, patients like it when you go to their bedside if you're there. They do really appreciate specialty consultation when it's not available, whether that's through teleneurology or tel-emergency medicine. But you know, when they know you're there, I think they want you to come in the room.

And I'm a huge telehealth advocate. But, you know, I would say that was our experience. That may not be the experience of the future and I'd be willing to try it again, but we're no longer using that practice.

Martin: I wonder, could you think part of it is the iPad hookup? I mean, those are kind of small. We in our new numerous department that we have and we're already revamping another one that's going to be built. This is at Ohio State. We have these huge LCD screens for patients to watch TV. I don't know why I couldn't just beam into that instead of worrying about an iPad. These things are gigantic and they probably costs much more than a new computer would cost.

Dr. Joshi: Yeah, absolutely. I wanted to see if Dr. Saidinejad had any comments, but I can answer the second one quickly. Is that, yes, I do. So, there are some virtual ops programs out there. Hospital home does have some as well. There's more of them. However, they're usually run by inernal medicine or virtual always emergency medicine. OK, so, Dr. Saidinejad has one comment, this will be the last one.

Dr. Saidinejad: We're just really quickly. Yes, so we also for our follow ups, we do offer the possibility of a video follow up and our advanced practice providers who are assigned to those who will make the connection and ask if people want a video visit. So that's one thing. And also, the beaming into the giant screen. Definitely, the technology exists. You would have to basically have the patient says, click OK, I want to see you or not, because you don't want to just interrupt their TV programming. I guess they don't like that. But I know that there are places that already are doing that. The place that where my little daughter was born in Michigan, they had that. So, I would actually have a video visit with the doctor. But that was not an ER, that was the inpatient unit. So, I'm sure if that technology exists for that, we can easily do that same thing.

Dr. Joshi: And I would be interested to see if patients would just be interested in seeing how long the wait is. Obviously, the doctor will come back in, but maybe just having an idea of what the process is in the ER.

So I want to thank our panelists and everyone who ask any questions and submitted questions. We tried to get as many or incorporate them together. Going to back to Bernadette.

Lim: Thanks so much. And just a couple of quick program announcements before we close here. Our next event will be held on May 18, and we'll highlight telehealth use in dermatology. Registration is now available and can be accessed on our website. And then, Laura, I'll turn it over to you for just a quick mention about our AMA Physician Innovation Network.

Fritsche: I'd like to make you aware of another resource that may provides. This is the physician Innovation Network. It's a free social networking platform where you can connect with likeminded peers through messaging, virtual panel discussions, et cetera. And here's a QR code and we'll also send this in a follow up.

Lim: All right, and with that, we'll close today's session, thank you all for attending and thank you to our speakers. There are any additional questions, I know we weren't able to get to all of them today, feel free to send it our way and we'll coordinate a response back to you. Thank you all so much and have a great day.

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Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.