Telehealth Cuts Ambulance, Emergency Costs
A Houston telehealth program is cutting emergency room costs by connecting patients with emergency medical staff through a tablet, rather than admitting them to the ED. The easy availability and knowledge of the 911 line has led to many calls, but not all are emergencies, with Houston finding that around 40% are for non-urgent issues or problems that could be treated through primary care. Across the US, this number can be as high as 56%. With the Emergency Telehealth and Navigation (ETHAN) system implemented in Houston, emergency medical technicians arrive at the scene and determine if emergency care is needed. If not, ETHAN can be deployed, connecting patients in real time to doctors at emergency centers, with vital signs transmitted via an encrypted interface. Doctors work in 4-hour shifts, having been certified for emergency medicine, but do not diagnose or prescribe treatment. The physicians can suggest the appropriate course of care, whether through a qualified health center or through their primary care doctor, with the patient given a prepaid taxi voucher and an appointment scheduled for them. In the first year of the program running, there was a 6.7% reduction in the number of unnecessary ER visits and a 44 minute decrease in ambulance service times. Costs per patient also dropped by $103, leading to a saving of $2468 for each averted visit to the ER and a total saving of $928,000 for the year. Patient satisfaction rose 1%. The ETHAN program was funded by the Delivery System Reform Incentive Payment Projects initiative, as Texas is not a Medicaid expansion state.

ORLANDO — A telehealth initiative — in which emergency medical technicians use a tablet to connect patients with doctors instead of taking them to the emergency room — is reducing unnecessary visits and saving money in Houston, a new study shows.

An added benefit of the program is that it connects patients with a medical home, said presenter James Langabeer, PhD, from the University of Texas School of Biomedical Informatics in Houston.

"For a lot of people, the medical home is the emergency department," he told Medscape Medical News here at the Healthcare Information and Management Systems Society 2017 Conference. "They think that's the only way they can pay for care."

Emergency medical services respond to about 650,000 911 calls a year in Houston. And the number of 911 calls is rising, regardless of whether urban areas are gaining or losing population, Dr Langabeer reported.

Houston Has a Problem

This is partly because of the proliferation of cell phones, healthcare policy changes, and the success of the 911 program. Almost everyone knows the number, and most industrialized countries have some version of the program.

"We cannot keep up with the number of calls by adding the requisite number of staff. That is not a judgment call; that is a factual statement," said presenter Michael Gonzalez, MD, associate medical director for the City of Houston Fire Department/EMS Division.

But many of the calls are not emergencies; they are for prescription refills, a ride to a doctor's office, or for a condition better treated in primary care.

In Houston, it is estimated that 40% of calls to emergency medical services are for nonurgent conditions or for conditions that could be treated by a primary care physician, which has led to overcrowding and long wait times in emergency departments. In other areas of the United States, the number of nonurgent calls is as high as 56%.

We really wanted to try to attack a complex problem in a way nobody ever had before.

"We really wanted to try to attack a complex problem in a way nobody ever had before," Dr Gonzalez explained.

The telehealth initiative, known as Emergency Telehealth and Navigation (ETHAN), was the approach they initiated.

When an emergency medical technician arrives at a scene and determines that the situation is not an emergency, he or she can make the decision, having received specialized training, to deploy ETHAN and connect the patient in real time to a physician standing by at an emergency center. A HIPAA-compliant encrypted interface is used to transmit vital signs, a description of the chief complaint, and a brief family history to the responding physician.

Physicians sit for 4-hour shifts in the emergency center to conduct these video conferences. The 16 physicians involved in ETHAN are all board-certified in emergency medicine and work under contract with the Houston Fire Department. However, they do not diagnose or prescribe treatment.

During the teleconference, the physician, technician, and patient discuss how to proceed. The patient is given the option of going to one of 10 federally qualified health centers or to his or her primary care doctor, if the patient has one, and is given a prepaid taxi voucher. The physician schedules the next available appointment at a health center, which is usually in the next day or two.

If the doctor deems a visit to the emergency department to be unnecessary but the patient still wants to go, he or she can be taken there in a prepaid taxi.

After every encounter, regardless of outcome, the patient gets a follow-up call from a navigator at the health department to discuss ways to deal with future nonurgent issues.

Basically, we can double the productivity of our crew and our unit.

A cost–benefit analysis of the 5570 patients treated in the first 12 months of the initiative showed a 6.7% reduction in potentially unnecessary emergency department visits and a 44-minute median reduction in ambulance service times (J Telemed Telecare. Published online December 2, 2016).

"Basically, we can double the productivity of our crew and our units," said Dr Langabeer.

The average cost for a telehealth patient — at $167 — was $103 less than the cost for a patient with similar characteristics and diagnoses who did not use the program (P < .0001).

Overall, the program led to a savings of $2468 for each averted emergency department visit and, when combined with lower provider costs, resulted in a total saving of $928,000 for the year.

"And patient satisfaction went up slightly, from 87% to 88%," Dr Langabeer reported.

Texas is a non-Medicaid expansion state, so funding for the initiative, which was launched in 2015, came from the Delivery System Reform Incentive Payment Projects program.

Joe Dalto, senior data manager at Intermountain Healthcare in Salt Lake City, said he is excited to tell his colleagues in the emergency department about this program.

"The telehealth piece is great because it puts the doc right there and provides a high level of assessment," he told Medscape Medical News. "And the patient always has the option to go to the emergency department. You're not telling them they can't."

ETHAN already operates seven days a week, 365 days a year, but an expansion of daily hours is being looked at. In addition, the network is working with organizations to identify sustainable sources of funding, the researchers report.

"We know that companies, insurers, and ACOs are really winning from this, and may benefit the most because we're really diverting their patients from the most expensive form of care around," Dr Gonzales said.

Dr Langabeer, Dr Gonzales, and Mr Dalto have disclosed no relevant financial relationships.

Healthcare Information and Management Systems Society (HIMSS) 2017 Conference: Session 123. Presented February 21, 2017.