A novel telemedicine EMS program has, among other benefits, eliminated thousands of unnecessary ambulance rides.
by Michael Gonzalez, MD
David Persse, MD
Diaa Alqusairi, PhD
Tiffany Champagne, PhD
Jenny Mikhail, MPH
James Langabeer, PhD
It has been a full year since the Houston Fire Department (HFD) Emergency Medical Services (EMS) launched the ETHAN (Emergency Telehealth and Navigation) initiative. This program is a Mobile Integrated Healthcare initiative, and so far close to 5,400 patients have been a part of the program and that number is steadily increasing each month. Undertaking a telehealth initiative by one of the largest EMS agencies in the country is quite a project. The logic is straightforward: Many EMS patients with non-emergent conditions just do not need to be transported to busy emergency rooms. Telehealth might provide one solution, although it has not been used historically in pre-hospital care.
Every year the Houston 911 system receives approximately 250,000 calls from its covered community of 2+ million people. The result of these calls is more than 300 ambulance transports each day, many of which are determined to be non-urgent, primary care-related events such as reports of headaches, fever, or even needing a prescription refill. The ETHAN program aims to address these non-urgent cases in ways other than using the costly ambulance transport to the emergency department. Both the patient and the community benefit—the patient gets seen by a real physician and navigated to another physician if necessary to follow-up with primary care concerns; the community benefits from lower ED visits and lower city EMS costs. To ensure the safety and proper care of patients, there are a few factors that will automatically exclude a person from being an ETHAN program participant. These include: complaints of chest pain and/or difficulty breathing; fainting episode within the past 24 hours; pediatric patients if non-accidental trauma is suspected; altered mental status; or inability to walk or stand. All first responders are trained on the ETHAN program goals and guidelines and have the tablet computer with them at all times ready to use if appropriate and have access to a physician consult 24 hours a day.
ETHAN’s unique approach of providing face-to-face telehealth physician sessions with patients via Panasonic G1 Toughpads using Cisco Jabber platforms, and then providing personalized navigation based on the diagnosis, is what sets this program apart from others in the country. If an incident is determined to be an ETHAN candidate, the first responder initiates a remote, real-time telemedicine session with a physician at the HFD EMS headquarters. Once the session is completed, the physician will make a recommendation either to go ahead with the ambulance transport to the ED or to schedule an appointment with a partnering clinic in the area for the patient to be seen the same or following day. ETHAN currently collaborates with several safety net clinics who have “reserved” spots for potential ETHAN appointments each day that the referring physician is able to access and schedule.
The ETHAN program also engages the patients post clinic or ED visit with a follow-up phone call from a CARE Houston team member. This follow-up call determines the level of satisfaction the patient has with the program, and helps arrange follow-up appointments and issue taxi vouchers if necessary. The ultimate goal is to match the patient to a permanent medical home for all future medical care.
Of the 5,400 ETHAN incidents reported so far, it was determined in 18% of cases (978) that it was, in fact, an emergency and the patient was transported to an emergency department by ambulance. Of the cases that were determined to be non-urgent and resulted in a referral to a clinic, 59% of patients (3,128) declined the referral and instead took a taxi paid for by the HFD EMS to the ED. The remaining incidents resulted in patients accepting referrals to an ETHAN clinic or to an already established primary care physician using an HFD paid taxi ride if transportation is necessary. Figure 2 summarizes the telehealth participants from December 2014 through December 2015.
To ensure the success of the program, ETHAN has made several strategic partnerships in the community. To be successful, ETHAN required more than agreements with safety net clinics and taxi companies. Strategic partnerships and buy-in from the community have been key to ETHAN’s success in Houston. These partnerships include the local safety net community, telecommunications and software firms, the regional health information exchange, the local health care policy association, and many more.
While the goal is to eventually divert more of these non-urgent patient cases to a clinic, the incidents whereby a patient takes a taxi to the ED have already shown cost savings to the department. By employing a taxi at a negotiated rate of $26.50 per ride, this puts the responding ambulance and first responders back in service sooner, decreasing the overall service time per incident. Based on initial assessments of time saved by returning ambulances and personnel back in service faster, this program could increase the department’s unit productivity nearly 2.5 times! While a full comparative effectiveness study of this program is currently underway by the University of Texas Health Science Center, we anticipate telehealth to be an ongoing part of the HFD operations.