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OBJECTIVE: To conduct a mixed-methods evaluation of an emergency telehealth intervention in unscheduled settings (emergency department [ED] and urgent care clinic [UCC]) within the Veterans Health Administration (VHA). MATERIALS AND METHODS: We used the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework to conduct a mixed-methods evaluation of a novel telehealth program implemented in the VHA (Hospital System) in March 2020. We compared the 3 months preimplementation (December 1, 2019 through February 29, 2020) with the 3 months postimplementation (April 1, 2020 through June 30, 2020), then followed sustainability through January 31, 2021. Qualitative data were obtained from surveys and semistructured interviews of staff and providers and analyzed with thematic analysis. RESULTS: Patient demographics and dispositions were similar pre- and postimplementation. The telemental health intervention was used in 319 (83%) unscheduled mental health consultations in the postimplementation phase. After implementation, we did not detect adverse trends in length of stay, 7-day revisits, or 30-day mortality. Use remained high with 82% (n = 1,010) of all unscheduled mental health consultations performed by telemental health in the sustainability phase. Staff and clinician interviews identified the following themes in the use of telemental health: (1) enhanced efficiency without compromising quality and safety, (2) initial apprehension, (3) the COVID-19 pandemic, and (4) sustainability after resolution of the COVID-19 pandemic. CONCLUSIONS: This mixed-methods evaluation of unscheduled telemental health implementation found that its use was feasible, did not impact the safety and efficacy of mental health consultations, and was highly acceptable and sustainable in unscheduled settings.

Objective: This analysis identified the rate of transfers and averted transfers and their associated costs across multiple emergency department telemedicine (teleED) networks. Methods: This study is a prospective cohort analysis in six teleED networks operating in 65 hospitals in 11 states across the United States. Each submitted uniform data on all teleED encounters for a 26-month period to a data co-ordinating center. Averted transfers were identified if an encounter met specific criteria. Cost savings from averted transfers were estimated from hospital-specific costs of transferred patients. Results: A total of 4,324 teleED encounters were reported. Excluding patients who died, 1,934 (46.2%) were transferred to another inpatient facility. Records of the remaining 2,248 teleED patients were examined and 882 (39.2% of nontransfers; 20.4% of all teleED cases) teleED patients met the criteria for an averted transfer. Of the averted transfer cases, 53.3% were admitted to the local inpatient facility, and 43.5% were discharged. Patients who averted transfer had lower levels of severity and less billed services than those who were transferred. Transport savings for averted transfers were estimated to total $1,074,663 annually across the six teleED networks. Average estimated transport savings were $2,673 for each averted transfer. Conclusions: In a large cohort of teleED cases, 39% of nontransfer cases were averted transfers (20% of all teleED cases). Importantly, 43% of these patients were routinely discharged rather than being transferred. Averted transfers saved on average $2,673 in avoidable transport costs per patient, with 63.6% of these cost savings accruing to public insurance.

Background: The low volume and the intermittent nature of serious emergencies presenting to rural emergency departments (EDs) make it difficult to plan and deliver pertinent professional training. Telemedicine provides multiple avenues for training rural ED clinicians. This study examines how telemedicine contributes to professional training in rural EDs through both structured and unstructured approaches. Methods: This qualitative study examined training experiences in 18 hospitals located in 6 Midwest states in the United States, which participated in a single hub-and-spoke telemedicine network. Twenty-eight interviews were conducted with 7 physicians, 10 advanced practice providers, and 11 nurses. Standard, inductive qualitative analysis was used to identify key themes related to experiences with telemedicine-based training and its impact on rural ED practice. Results: For structured formal training, rural ED clinicians used asynchronous sessions more often than live sessions. It was reported that the formal training program may not have been fully utilized due to time and workload constraints. Rural clinicians strongly valued unstructured real-time training during telemedicine consultations. It was perceived consistently across professional groups that real-time training occurred frequently and its spontaneous nature was beneficial. Hub providers offering suggestions respectfully and explaining the rationale behind recommendations facilitated real-time learning. Rural providers and nurses perceived several effects of real-time training, including keeping rural practice up to date, instilling confidence, and improving performance. Discussion: Our research shows that telemedicine provided rural ED providers and nurses both formal training and real-time training opportunities. Real-time training occurred frequently, complemented formal training, and was perceived to have many advantages.

Meeting time goals for patients with time-sensitive conditions can be challenging in rural emergency departments (EDs), and adopting policies is critical. ED-based telemedicine has been proposed to improve quality and timeliness of care in rural EDs.The objective of this study was to test the hypothesis that diagnostic testing in telemedicine-supplemented ED care for patients with myocardial infarction (MI) and stroke would be faster than nontelemedicine care in rural EDs.This observational cohort study included all ED patients with MI or stroke in 19 rural critical access hospitals served by a single real-time contract-based telemedicine provider in the upper Midwest (2007-2015). The primary outcome for the MI cohort was time-to-electrocardiogram (EKG) and for the stroke cohort was time-to-head computed tomography (CT) interpretation. To measure the relationship between telemedicine and timeliness parameters, generalized estimating equations models were used, clustering on presenting hospital.Of participating ED visits, 756 were included in the MI cohort (29% used telemedicine) and 140 were included in the stroke cohort (30% used telemedicine). Time-to-EKG did not differ when telemedicine was used (1% faster, 95% confidence interval [CI] -4% to 7%), or after telemedicine was implemented (4% faster, 95% CI -3% to 10%). Head CT interpretation was faster for telemedicine cases (15% faster, 95% CI 4-26%). No differences were observed in time to reperfusion therapy.Telemedicine implementation was associated with more timely head CT interpretation for rural patients with stroke, but no difference in early MI care. Future work will focus on the specific manner in which telemedicine changes ED care processes and ongoing professional education.

Background: Telemedicine allows patients to connect with healthcare providers remotely. It has recently expanded to evaluate low-acuity illnesses such as pharyngitis by using patients' personal communication devices. The purpose of our study was to compare the telemedicine-facilitated physical examination with an in-person examination in emergency department (ED) patients with sore throat. Materials and Methods: This was a prospective, observational, blinded diagnostic concordance study of patients being seen for sore throat in a 60,000-visit Midwestern academic ED. A telemedicine and a face-to-face examination were performed independently by two advanced practice providers (APP), blinded to the results of the other evaluator. The primary outcome was agreement on pharyngeal redness between the evaluators, with secondary outcomes of agreement and inter-rater reliability on 14 other aspects of the pharyngeal physical examination. We also conducted a survey of patients and providers to evaluate perceptions and preferences for sore throat evaluation using telemedicine. Results: Sixty-two patients were enrolled, with a median tonsil size of 1.0. Inter-rater agreement (kappa) for tonsil size was 0.394, which was worse than our predetermined concordance threshold. Other kappa values ranged from 0 to 0.434, and telemedicine was best for detecting abnormal coloration of the palate and tender superficial cervical lymph nodes (anterior structures), but poor for detecting abnormal submandibular lymph nodes or asymmetry of the posterior pharynx (posterior structures). In survey responses, telemedicine was judged easier to use and more comfortable for providers than patients; however, neither patients nor providers preferred in-person to telemedicine evaluation. Conclusion: Telemedicine exhibited poor agreement with the in-person physical examination on the primary outcome of tonsil size, but exhibited moderate agreement on coloration of the palate and cervical lymphadenopathy. Future work should better characterize the importance of the physical examination in treatment decisions for patients with sore throat and the use of telemedicine in avoiding in-person healthcare visits.