By Dorothy Brooks
Seeing all the ways technology could be leveraged to deliver care to patients remotely during the COVID-19 pandemic, emergency medicine leaders in the Manchester, NH-based Elliot Health System recently have considered how they might optimize their use of telemedicine going forward. This has resulted in a new virtual ED program that is designed not only to appeal to patients, but also to help the system ensure that patients are receiving care in the most appropriate setting for their needs.
“Our group provides care at our Level II trauma center, but our physicians and nurse practitioners (NP) and physician assistants (PA) also work at three urgent care sites — so [they work] across the spectrum of acuity and management in emergency medicine,” explains Matthew C. Dayno, MD, FACEP, the section chief and medical director in the Department of Emergency Medicine and Urgent Cares in the Elliot Health System. “What we saw is that if we could to try to help get patients to the right place at the right time, that might benefit both the patients’ experience, but also [provide benefits] in terms of load balancing, demand for services, and access to care.”
The virtual ED program debuted in January 2024, enabling patients to connect with a care provider through the hospital website between the hours of 10 a.m. and 6 p.m. during weekdays. “It’s a little bit different than a classic virtual care program or outpatient telehealth visit in that it involves a patient connecting directly with a board-certified emergency physician,” states Dayno.
The emergency physician then has the ability to render care completely over a virtual platform or to triage the patient to either one of the health system’s urgent care sites or to the ED if a higher level of care is required, observes Dayno. “Oftentimes, patients may self-identify that they need to be in urgent care and maybe their complaint is better cared for in the emergency department or vice versa,” he says.
The virtual ED visits are billed as a physician office/telehealth visit, so the Emergency Medical Treatment and Labor Act (EMTALA) does not come into play unless the patient is then referred to the ED, explains Dayno. However, he also explains that in cases where the patient is referred to either the ED or one of the health system’s urgent care sites, then there is no billing associated with the virtual ED encounter; it is just part of the subsequent visit to the ED or urgent care site.
There are essentially three pathways for patients who take advantage of the virtual ED service, states Dayno:
• The patient can be managed completely virtually with no need to access any additional care.
• The patient may require some testing, in which case an order will be placed and the patient will complete that testing outside of the virtual visit to complete their care.
• The patient will be referred to either an urgent care site or the ED.
While the emergency medicine team in the Elliot Health System includes some advanced practice providers, only emergency physicians are involved with the virtual ED program, notes Dayno. Further, he shares that the physicians typically handle the virtual role from an office that is on the hospital site but outside of the ED or from an offsite location that is in one of the health system’s administrative buildings. Also, some of the physicians are equipped to cover the service from their homes, he adds.
There were some hurdles involved with setting up the virtual ED program. For example, while the health system had experience in using IT infrastructure in the ambulatory environment, more work was required to integrate this type of approach into emergency medicine. For example, Dayno explains that the emergency physicians needed to be oriented on what it is like to see someone virtually, what the limitations are around what you can do safely, and how to effectively navigate the encounter and triage patients to the appropriate location when needed.
“We set up a policy and guidelines, but a lot of it was at-the-elbow training,” states Dayno. “We had superusers within our group that started during our pilot process, and then we [used them] as a resource whenever a physician was first starting an initial shift in this role.”
Interestingly, there are no ancillary staff involved with the virtual encounters. It is a very streamlined approach that is managed entirely by the physicians. There is not a lot of administrative backbone involved for the patient or for the physician, observes Dayno. “It is really just set up and ready to go in terms of the entry of the patient,” he explains.
In terms of implementation, what worked well was first piloting the approach with a small group of patients who first attempted to be seen in primary care but were then told by the office either that they did not have the capacity to see the patients expeditiously or that the patients required emergency care. “We had a lot of success with this subgroup in improving the patient experience, but also making sure that the patients arrived at the right care setting because it wasn’t uncommon for patients to be referred to the ED when they could have been appropriately cared for in urgent care,” shares Dayno, adding that the reverse was true as well. “Patients may have been referred by their primary care office to urgent care when they actually required services in the ED.”
The virtual ED was opened to the public in January 2024, and administrators are pleased with the results thus far. Dayno explains there is a downward trend in the leave-without-being-seen rate in the ED, and he also reports significant success in getting patients to the right location for their care needs. “We’re reducing the volume of patients at urgent care sites that need to be transferred to the ED as well as the volume of patients that are in the ED that don’t require emergency-level care,” he says. “There has been an improvement in all aspects of mistriage by patient selection.”
Further, Dayno notes that roughly 65% of patients who access the virtual ED can complete their care virtually. This includes patients who may require laboratory or imaging tests but do not need a separate in-person visit with a provider.
Dayno’s advice to other hospitals or EDs interested in potentially deploying a similar solution is to first take stock of all the resources in place to care for patients who do not require emergency-level care. Healthcare organizations that have a “spread of services across levels of acuity” will be better positioned to use such a service to load balance across their system, he explains. Also, keep in mind that you likely will require some investments in IT infrastructure and the administrative support to be creative in designing a service that fits with community and health system needs, he says.
“We’ve had a lot of [organizational] support for this because the demand for service is so high — at least in our health system,” says Dayno. “There has been a lot of buy-in.”
In fact, administrators next plan to expand the hours of operation of the virtual ED service in the coming months, and they also are thinking about other ways telemedicine can be leveraged to improve ED operations and access to care.
