ET3 Pilot Hailed as Big Step Toward Fully Leveraging EMS
By Dorothy Brooks
Prehospital providers have long observed that not all patients who call 911 require transport to an ED. Many patients are experiencing minor issues that can be treated at the scene. However, there has been no mechanism in place enabling EMS to be reimbursed for such care. Consequently, many of these patients are transported to EDs, where they may wait hours for care while also driving up costs and potentially contributing to crowding problems.
To surmount this hurdle, in January 2021, the Centers for Medicare & Medicaid Services (CMS) launched a five-year pilot program called Emergency Triage, Treat, and Transport (ET3), an approach that enables participating EMS programs to connect some patients with lower-acuity problems to emergency providers via telemedicine at the scene. (Learn more about the model here.)
A total of 184 EMS providers are engaged in this effort, with some just starting to acquaint EMS providers and patients with this added flexibility. Participants say while there have been multiple challenges in starting their programs, most are excited about leveraging the ET3 approach to accelerate needed care to patients, decompress EDs, and maximize the skills of the EMS workforce.
The implementation of ET3 within the Mount Sinai Hospital EMS Group in New York City began in August 2022. EMS units were gradually trained and phased into the program, explains Kevin Chason, DO, medical director for the Mount Sinai Hospital EMS group. However, he notes administrators estimate 10% of EMS calls meet the low-acuity criteria for ET3, so the program offers significant potential when fully realized.
One big plus to ET3 is that it enables EMS providers to be paid for care they provide outside the hospital. “Previously, if we treated patients outside of the hospital, and then they were not transported, that care, while it was appropriate and necessary — CMS was not paying for it,” Chason explains.
Chason credits CMS and other groups with recognizing problems with that payment methodology. “It is a disincentive for giving patients the best care at the location where they are, and it causes other downstream effects where patients are getting brought to the ED for minor problems that could be treated better with other resources,” he says. “A patient doesn’t want an ED visit if he or she doesn’t need an ED visit.”
Under the ET3 pilot, different participating regions may operate under slightly different protocols that align with their EMS operations and resources. Chason notes Mount Sinai started with deploying an ambulance to the scene after a patient calls 911. “When the ambulance arrives, the patient will be evaluated by the EMS provider, a paramedic, or EMT,” he explains. “Then, there are inclusion and exclusion criteria that allow [EMS] to provide the patient with the option of ET3 involvement.”
Exclusion criteria would cover certain high-acuity medical conditions or abnormal vital signs that would demonstrate the patient really ought to go to the ED. However, if the patient’s complaints are minor, EMS offers a telemedicine option. “CMS requires consent from the patient,” Chason says. “If the patient agrees ... we call our clinical command center electronically through our EMS documentation system and notify the doctor that we have someone ready to be seen by telemedicine.”
Following the virtual provider’s evaluation of the patient, he or she may order medicines and/or follow-up care, thereby concluding the visit. However, the provider also may determine the patient requires treatment that cannot be provided at the scene. In that case, the provider will instruct EMS to transport the patient to the ED.
“At any point in time, we can switch to whatever the patient needs,” Chason says. “Also, the patient still has the choice to say ‘yes’ to the telemedicine or ‘no.’”
For Mount Sinai, the telemedicine provider answering such calls will either be an emergency physician or an advanced practice provider who is on call for telemedicine activities. Also, an emergency physician working at one of the health system’s urgent care sites could handle the request. “We have a backup system if we get multiple calls,” Chason notes.
“I think it is kind of the Holy Grail of connecting patients to the right level of care for the need that they have,” says Nicholas Gavin, MD, vice chair of population health and clinical innovation for the Mount Sinai Health System.
Further, Gavin notes ET3 empowers the health system’s well-trained EMS personnel to determine when patients can be treated in a virtual environment just as well as they can be treated in an ED. “In fact, in many ways, such patients are probably better served because they are getting seen right away,” Gavin says.
However, with just a few months of experience with ET3, it is clear that convincing patients to view ET3 in the same way as Gavin has been a challenge. Program administrators report many patients continue to decline the option to be connected with an emergency clinician virtually. However, Gavin believes patients eventually will warm to ET3.
“There is a lot of work we can do on improving patient acceptance of the program,” Gavin says. “Everyone is just being exposed to what virtual care can be like, and what capabilities we have through a virtual urgent care platform. I think over time, as healthcare consumers become more comfortable with accessing and receiving care through virtual platforms, it will become a little bit more second nature.”
Gavin also notes scripting should help EMS personnel better explain ET3 to patients. “We absolutely do not want patients to feel like we are shirking our responsibilities here,” he says. “We are connecting them with a Mount Sinai provider who is exactly [the same type of] provider they would be seeing if they came into the ED.”
Eventually, the plan is to expand the program to enable EMS providers to take some ET3 patients who do not require emergency care to alternative sites that may serve their needs better. This could include urgent care facilities, for example, or even behavioral health (BH) providers, although it will take some work to ensure there is access to those services.
“The capacity of different community-based organizations or BH care centers to receive walk-in patients can be unpredictable,” Gavin admits.
Further, while BH patients, particularly those waiting for admission to a BH unit, are a key contributor to ED crowding, clinicians must ensure safety during this period. That is challenging outside the ED.
“There aren’t large numbers of community-based organizations or mental health service providers who can provide that level of safety,” Gavin says. “We have to make sure that we are not reducing what our expectations are or failing to meet the standard of care.”
Despite the obstacles that lie ahead, Gavin is bullish about the potential of ET3 to improve healthcare delivery. “We can’t really predict all of the scenarios that our EMS personnel get into every day,” he observes. “We are really trying to figure out all the best-case uses for this. Our hope is to really empower the paramedics and the EMTs, and put more trust in their hands.”
Global Medical Response (GMR) oversees more than 50 EMS providers across the country that are participating in ET3, most of which have been in the program for 12 to 18 months of experience with the approach thus far, explains Gerad Troutman, MD, FACEP, FAEMS. As with anything new, there have been some challenges involved with rolling out the program, which includes integrating paramedics into the bigger picture.
“When you look at the way the EMS system has always worked, it has always been a U-Haul type system where the patient calls 911, and we take them to the ED. But we know there is a different way,” says Troutman, national medical director of innovative practices for GMR.
Troutman says although some EMS providers were thrilled about ET3, others took more time to warm up — but they came around, too. “All of our providers see that this adds incredible value for the patient,” says Troutman, EMS medical director for both Lubbock and Amarillo, TX. “It is the right thing to do for the patient whenever we can just give them the care they need right there in their homes — and with the same quality as if we transported them to the ED.”
While Troutman has not gathered data from specific EDs about the impact of ET3 on volume or crowding, he notes ET3 participants in the GMR system have treated more than 3,000 patients in their homes. “That is 3,000 patients who ultimately didn’t go to one of the various EDs. That can only positively affect ED volume and boarding issues,” he says.
Troutman also notes access to emergency physicians to handle telemedicine calls has not been a problem because GMR partnered with an emergency medicine group to provide that service on a 24/7 basis. “We feel that patients seeking emergency services should be cared for by a board-certified emergency physician,” Troutman says. “The patient is getting the right kind of physician treating them for what they believe is an emergency.”
Just as with some EMS providers, Troutman says some patients pushed back against the program, but they also eventually warmed up to it. “We find that if we really dig in and give patients the details about who is going to be delivering the care, they are more apt to consent and give it a try,” he observes. “I think it is just like anything new and different for Americans to experience. It takes time for adoption.”
Sometimes, in the field, technology can frustrate all parties. “Certainly, in some of our more rural markets we have had issues having enough bandwidth to do video chat,” Troutman shares. “It is important for the physicians to see the patients and ... for the patients to see the physician, and know there is a real person there talking to them.”
In some cases, the ET3 approach is no longer an option. Still, Troutman suggests the bandwidth issue is improving as cellular coverage extends into more rural communities. Despite such setbacks, Troutman stresses the ET3 program continues upward. “We have had steady month-over-month growth of the program ... as more paramedics utilize it, and more patients utilize it and talk to their friends about it,” he says. “We have seen ongoing increases in use amongst all of our markets.”
While ET3 is just a pilot, Troutman sees the program as part of a larger trend where EMS is moving toward an out-of-hospital care system. “A patient calls 911 looking for a solution to their problem. That solution could be everything from a helicopter to an ambulance to treatment in place with a facilitated paramedic visit,” he says.
Other care options may include nurse navigation or just nurse advisors. “I always bring it back to: What is the right thing to do for that individualized patient,” Troutman adds. “If the right thing to do is a telehealth visit, then that is what we should be doing.”
In January 2021, the Centers for Medicare & Medicaid Services launched a five-year pilot program called Emergency Triage, Treat, and Transport (ET3), an approach that enables participating EMS programs to connect some patients with lower-acuity problems to emergency providers via telemedicine at the scene. Most participants are excited about leveraging the approach to accelerate needed care to patients, decompress EDs, and maximize the skills of the EMS workforce.
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