On-the-Scene Video Consultations With Emergency Physicians Reduce Unnecessary Ambulance Transports and Emergency Department Visits, Connect People to Medical Homes
Snapshot
Summary
Through a program known as ETHAN (“Emergency Telehealth and Navigation”), the City of Houston Fire Department Emergency Medical Services program uses video and other technology to allow emergency physicians to conduct real-time assessments of patients in the field to determine if they require transport to the emergency department or could be better served elsewhere. For those not requiring emergency care, the program can facilitate the scheduling of and transportation to an appointment at a partner clinic that can serve as a medical home. Through another local partner, the program conducts followup monitoring and connects patients to community-based resources that address social service and other health-related needs. In its first 9 months of operation, ETHAN has seen steadily rising use; significantly reduced unnecessary ambulance transports and emergency department visits (and their associated costs); connected a meaningful number of non-emergent patients to primary care medical homes; and freed up significant time for ambulance crews to deal with true emergencies.
Date First Implemented
2014
The innovation was first implemented on December 16, 2014.
Problem Addressed
Many people who call emergency medical services (EMS) are suffering from relatively minor problems. Yet often these individuals end up being transported by ambulance to—and treated in—the emergency department (ED), even though their medical problems could be handled more quickly, effectively, and efficiently in the primary care setting. Treating these patients in the ED unnecessarily drives up costs and contributes to overcrowding and long waits.
- Many primary-care–related 911 calls: Roughly 30 to 40 percent of the 700 to 800 calls to 911 in Houston each day do not involve true emergencies,1including many calls from individuals suffering from minor headaches or lacerations, spider bites, toothaches, simple colds, joint pain, insomnia, and other minor ailments that can be treated effectively and efficiently in the primary care setting. In many instances, patients call 911 because they know they need some type of medical care but do not know how else to access the health care system.
- Unnecessary ED transports: As in most areas around the country, Houston Fire Department EMS providers have historically transported all patients who want treatment to the nearest ED, including those suffering from primary-care–related issues. Overall, patients with primary care–related issues account for an estimated 40 percent of all ED visits in the city.2
- High costs and bottlenecks: Transporting and providing care to non-emergent patients through the ED drives up overall health care costs and contributes to ED and EMS bottlenecks. The average cost of an ambulance transport in Houston is approximately $1,600.1 Treating primary care-related problems in the ED costs $600 to $1,200 per visit, roughly four times what it cost to treat the same problems in an outpatient clinic.3 In addition, using EMS and ED providers to treat patients who could be treated more effectively and efficiently elsewhere takes up scarce resources that could be better deployed treating patients with true emergencies. In Houston, EMS personnel periodically report instances where they cannot respond to true emergencies in their area because they are dealing with non-emergent patients; as a result, an ambulance from farther away must respond, driving up wait times for patients who need immediate attention.3
Description of the Innovative Activity
Through ETHAN, the Houston Fire Department EMS uses video and other technology to allow emergency physicians to conduct real-time assessments of patients in the field to determine if they require transport to the ED or could be better served elsewhere. For those not requiring ED care, the program facilitates the scheduling of and transportation to an appointment at a partner clinic able to serve as a medical home. Through a partner organization, ETHAN also conducts followup monitoring and connects patients to community-based resources that can address social service and other health-related needs. Key program elements are detailed below:
- Initial EMS identification and transport of those requiring ED care: After arriving at the scene, the EMS crew conducts an initial assessment to determine if the patient needs emergency care. If so, the patient is immediately transported via ambulance to an appropriate ED.
- Option for video consultation for non-emergent patients: For non-emergent patients seen during ETHAN’s normal operating hours (8 a.m. to 10 p.m. Monday through Friday, 8 a.m. to 6 p.m. on weekends), EMS personnel explain the ETHAN program and strongly encourage patients to agree to a video consultation with an emergency physician. To date, only a handful of patients have refused; these patients are transported by ambulance to the ED.
- Real-time assessment from emergency physician: For non-emergent patients who agree to ETHAN, EMS personnel use a computer tablet to connect the patient to an emergency physician located in the city’s dispatch center. Using secure video teleconferencing software that complies with Health Insurance Portability and Accountability Act (HIPAA) requirements, the physician accesses the patient’s medical record that EMS creates on the scene, including chief complaint, demographics, vital signs, medical history, allergies, and medications. The physician also consults with and assesses the patient over the video, similar to what would be done in person. While the video encounter takes place, the field crew remains on the scene to assist the physician in getting any additional information that may be needed, such as a taking a new set of vital signs or palpating the patient’s pain site. From start to finish, the video encounter typically takes about 10 minutes.
- Disposition decision: The physician makes the final determination regarding the patient disposition and, as necessary, arranges transportation to the recommended care setting, including partner primary care clinics able to handle the patient’s medical issues and serve as an ongoing medical home. Possible disposition scenarios are detailed below:
- Ambulance transport to ED: In some cases, the physician may identify additional signs or symptoms suggesting that the patient requires emergency care. In these instances, the physician instructs the field crew to transport the patient via ambulance to an appropriate ED.
- Appointment at partner clinic able to serve as medical home: For patients in need of primary care, the physician can schedule appointments for patients at one of 19 partner clinics through an integrated system that uses global positioning technology and the patient’s ZIP code to identify the closest location and next available appointment time. The physician uses the same system to schedule a taxi ride for patients from their home to the scheduled appointment. Appointments often occur the same day and no later than the following day. The clinic automatically receives an appointment confirmation that includes the patient’s chief complaint, demographics, and contact information. Clinic providers can view additional information on the patient through the local health information exchange. As part of their contracts with the ETHAN program, all partner clinics must have the capacity to serve as an ongoing medical home; have program or case managers to help eligible patients sign up for insurance; and offer sliding-scale, income-based fees to patients who do not have insurance.
- Referral to regular primary care physician (PCP): Some patients already have a PCP and may prefer to receive care from that physician rather than an unfamiliar clinic. In these instances, the physician encourages the patient to set up an appointment as soon as possible.
- Home/self-care recommendations: Some patients may not need to see a physician, such as an individual who becomes temporarily dehydrated after engaging in physical activity and not drinking enough fluids. In these instances, the physician will provide instructions for self-care at home and encourage the patient to contact a health care provider if the problem recurs.
- Taxi transport to ED: While the physician makes every effort to convince non-emergent patients of the benefits of receiving care in a partner clinic, some will inevitably reject the plan and insist on receiving care in the ED. In these instances, the physician will typically agree to call a local taxi service to transport the patient to the ED. Because ETHAN involves a real-time video assessment of these patients by an emergency physician, the Houston Fire Department EMS program is not legally required to transport them via ambulance to the ED.
- Care manager followup and connections through partner: After each ETHAN encounter, Houston Fire Department forwards all the patient’s information to a navigation program run by the City of Houston Health Department. Known as Care Houston Links, this program uses social workers and care navigators to follow up with ETHAN patients by telephone to confirm attendance at the scheduled visit (if appropriate) and adherence to the care plan. As appropriate, the care manager will identify and seek to address additional human and social service needs by connecting patients with community-based resources. For example, navigators frequently assist in securing free or low-cost health insurance coverage, transportation services, food, counseling, and health literacy support. Care managers typically call patients within a day or two and then continue to follow up with patients as necessary for up to 90 days. Most followup occurs by telephone, but home visits are used as necessary. Due to limited resources, Care Houston Links prioritizes ETHAN patients referred to partner clinics over those who refuse such referrals or have their own PCP since these patients are most likely to accept and benefit from care management services.
- Payment to cover cost of initial clinic visit and taxi service: For uninsured patients referred to a partner clinic, ETHAN pays a flat rate of $128 for the initial visit. As noted, partner clinics must have staff available to help eligible uninsured patients sign up for coverage and offer a sliding-scale fee schedule for future visits for those who do not qualify for coverage. ETHAN also pays for all taxi service ordered in the field, including for those who insist on going to the ED. The partner taxi service receives a flat fee of $25 per ride regardless of destination, plus a 15-percent administrative fee.
Context of the Innovation
Covering more than 600 square miles, the City of Houston is home to more than 2.1 million residents. In addition, roughly 1 million individuals work in Houston during the day but live outside the city. Administered and overseen by Houston Fire Department, Houston’s EMS program handles more than 275,000 EMS calls each year and transports more than 400 patients a day. On average, EMS responds to 31 incidents each hour, or one every 2 minutes.
The impetus for ETHAN began in the late 2000s with the growing recognition by Houston Fire Department EMS program leaders that many 911 callers had minor problems that did not require ED care. To address this issue, they first set up a nurse triage phone line in 2009 that first responders could access from the field. Through this line, patients spoke with nurses who used a computer-based algorithm to triage them and determine the most appropriate disposition. Later, fire department paramedics replaced nurses in this role, using the same algorithm. However, the conservative design of the algorithm meant that roughly 90 percent of non-emergent patients still went to the ED. Not surprisingly, EMS crews began viewing the triage line as a waste of time and most stopped using it. (The line received only about 700 calls a year, or fewer than 15 each week.) As a result, program leaders terminated the program in 2011 and began investigating the possibility of a new strategy—i.e., enabling ED physicians to see and evaluate patients in real time via video and other technologies. The goal was to significantly improve the accuracy of triage results and disposition decisions. To that end, program leaders began searching for funding to support development and implementation of such a program.
Results
In its first 9 months of operation, ETHAN has seen steadily rising use by EMS crews; reduced unnecessary ambulance transports and ED visits (and their associated costs); connected a meaningful number of non-emergent patients to primary care medical homes; and freed up significant time for ambulance crews to deal with true emergencies.
- Steadily rising use: After averaging only 15 to 20 video consultations a week for the first few months, use of ETHAN has increased significantly, to an average of 180 to 190 weekly consultations. (The Planning and Development Process and Adoption Considerations sections include a discussion of how field-based retraining sessions helped spur much of this increase.)
- Fewer ambulance transports (and associated cost savings): Overall, only 19 percent of those served by the program (740 out of 3,938) during its first 9.5 months (December 16, 2014 to September 27, 2015) required transport via ambulance to the ED. Prior to implementation of this program, virtually all of these patients would have been transferred by ambulance. Consequently, the program has likely avoided approximately 3,200 ambulance transports to the ED during this period, yielding over $4.1 million in cost savings. (Each avoided transfer generates roughly $1,300 in estimated savings—the $1,600 average transport cost less $300 in ETHAN program costs. These estimates are based on preliminary research findings, and a formal cost analysis will be forthcoming.)
- Fewer ED visits (and associated cost savings): During the same period, 675 of the 3,938 patients (17 percent) accepted a referral to a partner clinic, their own PCP, or home care. For these patients, the ETHAN program not only avoided an ambulance transport, but also saved nearly $320,000 in ED costs by reducing the need for ED-based primary care. (This calculation assumes savings of $472 per avoided ED visit— the $600 average cost for ED-based primary care, less $128 to cover the costs of a primary care visit at a partner clinic.)
- More connections to primary care medical homes: During the same period, roughly 10 percent of all patients served by the program (381 out of 3,938 patients) received a referral to a partner clinic able to serve as a medical home.
- More EMS time to deal with true emergencies: During the same period, about 30–40 percent of patients served by ETHAN insisted on an ED visit and were transported there by taxi. While not an ideal scenario (since non-emergent patients still end up in the ED), sending these patients to the ED by taxi rather than ambulance frees up significant time for EMS teams in the field to handle true emergencies.
Planning and Development Process
Key steps in the planning and development process included the following:
- Securing financial support: The State of Texas secured a Federal waiver program through Section 1115 of the Social Security Act. This waiver gives the Federal Government the authority to provide funding to municipal programs that use innovative service delivery systems to improve care, increase efficiency, and reduce costs in ways that promote the goals of Medicaid and the Children’s Health Insurance Program. In 2012, the City of Houston received funding through this waiver. The funds then were distributed through an application process to sponsors of approximately 20 projects, one of which was the ETHAN program.
- Purchasing and customizing hardware and software: As part of a previously scheduled upgrade going on at the time, Houston Fire Department purchased computer tablets with video capacity for use in the field by all ambulance units. Using the Federal waiver funds, the fire department purchased all other hardware and software systems needed for ETHAN, including the two work stations used by the emergency physicians. Each work station has multiple computer screens that allow the physician to see the patient, the clinic scheduling system, and the taxi dispatch system simultaneously. After these purchases, information technology (IT) staff worked with vendors to customize the software to meet program needs, including communication linkages across systems.
- Expanding partnerships: Houston Fire Department already had a number of partnerships in place stemming from the nurse triage program described earlier. These partnerships included formal arrangements with multiple clinics, a local cab company, and a nonprofit organization that provided various program-related services. Concurrent with the hardware/software purchases, program leaders expanded the number of partnerships to meet program needs. For example, they identified geographic areas where additional clinic capacity was needed and then met with clinic leaders in these areas to explain the program and forge an agreement. (In some cases clinic leaders approached them after hearing about ETHAN.) To date, ETHAN has formal agreements with 19 clinics, including federally qualified health centers, nonprofit community clinics, and clinics owned by Memorial Hermann Hospital and Texas Children’s Hospital. These formal contracts spell out various terms, including the flat-fee pricing for uninsured patients and requirements related to providing patients with a medical home. Additional formal partnerships exist with the Houston Health Department (which provides the care management followup described earlier), Community Health Choice (a local, nonprofit health plan that administers clinic claims for a flat fee of $7 per claim), County RIDES (the local taxi service), Greater Houston Healthconnect (the regional health information exchange and scheduling system), and Verizon Wireless (which provides connectivity and coverage for devices in the field).
- Hiring qualified physicians: To date, Houston Fire Department has hired 16 emergency physicians who all work for ETHAN on a part-time basis. When the program began, hired physicians collectively provided coverage for 40 hours a week (10 a.m. to 6 p.m. on weekdays). As demand increased, additional physicians were hired to expand coverage to 14 hours on weekdays (8 a.m. to 10 p.m.) and 8 hours on weekends (10 a.m. to 6 p.m.). The staffing model currently uses two physicians to provide dual coverage during the busiest periods (10 a.m. to 3 p.m. on weekdays).
- Conducting initial training: Roughly 1,200 of Houston Fire Department’s 3,000 emergency medical technicians (EMTs) and firefighters completed a face-to-face program that offered hands-on training on all aspects of their role in ETHAN, including initiating calls and transferring records from the field to the physician. Led by the EMS medical director, an associate medical director, and a fire chief, these four half-day sessions also included presentations to highlight the benefits of the program to the ambulance crews and the community at large. The remaining 1,800 EMTs and firefighters completed an online version of the same program and received support from their peers who attended the face-to-face training sessions. All training occurred during the first 2 weeks of December 2014, after which ETHAN launched on December 16.
- Using targeted retraining in the field: During the first few months, ETHAN generated only about 15 to 20 calls per week, as EMS personnel remained skeptical of the new approach because of the disappointing experience with the earlier nurse triage phone line. Program leaders identified geographic areas where they expected to see higher usage and then accompanied crews in these areas on rides so they could see ETHAN in action and better appreciate its value.
Resources Used and Skills Needed
- Staffing: Total program staffing equates to 2.5 full-time emergency physicians. As noted previously, 16 part-time physicians share coverage during operating hours, each of whom is a board-certified emergency physician.
- Costs: Estimated operating costs are $1 million a year, which covers compensation for the physicians and management team and other ongoing operational expenses, including IT-related maintenance and payments to the taxi company, partner clinics, and claims processor. At current call volumes, this figure equates to approximately $300 per patient served. In addition, ETHAN has required an investment of roughly $1.1 million for IT infrastructure, including purchase, customization, and ongoing enhancements to the videoconferencing hardware and software; administrative hardware; systems to handle patient record exchange, video storing and logging, and online appointment scheduling; and system integration and interfaces.
Funding Sources
The aforementioned Federal waiver program provides approximately $12 million in funding to ETHAN over a 5-year period; this figure represents the estimated cost savings expected from the program during this time. The program has received additional grant funding from Houston’s Pay-or-Play Fund, a pool of money paid to the City of Houston as a result of a legal provision requiring companies that do business with the city to either provide health insurance to employees or pay a penalty. Because many companies have chosen to pay the penalty, this fund has become a significant source of grant funding for local health care programs, including ETHAN and the nurse triage program that preceded it.
Getting Started with This Innovation
- Bring key stakeholders together: The program cannot succeed without the cooperation of various entities, including city government, county government, transportation companies, hospitals, primary care providers, and EDs. When Houston Fire Department began planning for the nurse triage line in the late 2000s, program leaders worked with a local nonprofit organization, the Harris County Healthcare Alliance, to bring relevant stakeholders together and secure their cooperation. (The Alliance’s mission was to bring stakeholders together for these types of projects.) The partnerships and relationships formed during this earlier process have proven critical to ETHAN’s success.
- Secure leadership and union approval: Frontline firefighters and EMTs will not accept this type of program unless their leaders (including union chiefs) strongly support it. To win their support, it is necessary to address any misconceptions they may have about the program, such as the potential for layoffs because EMTs and firefighters will be spending less time on unnecessary ambulance transports. Union leaders will be especially critical in responding to frontline resistance to the program, as firefighters and EMTs often trust them more than department leadership.
- Make system easy to use for those in the field: EMTs and firefighters will not use a program that takes a lot of time to use, as it will be easier and quicker to transport the patient to the ED. To avoid this problem, ETHAN’s IT systems were deliberately designed to be very easy for both EMS crews and physicians to use, with video calls initiated in a few seconds with the click of a button and consultations generally lasting 10 minutes or less.
- Educate end users on program benefits, need for culture change: EMTs and firefighters have automatically transported patients to EDs for decades, to the point that this approach is part of the ingrained culture of most fire departments. However, these highly trained professionals do not like functioning as a glorified taxi service and hence will be attracted to a program that allows them to spend more time dealing with true emergencies. Because past attempts to address this issue have often been ineffective (including Houston Fire Department’s nurse triage line), resistance to new approaches may initially be quite strong. To overcome such resistance, significant efforts should be made to educate those in the field on why this type of program is different and will work.
Sustaining This Innovation
- Use local champions to promote program through social media: Many younger firefighters and EMTs will be attracted to this type of technology-based program. These individuals can promote the program on social media platforms, including responding to misconceptions and addressing program-related problems that their peers may raise on such platforms.
- Hold field-based retraining as needed: As noted, use of ETHAN initially lagged well below expectations, with weekly call volumes never exceeding 50 during the first 5 months. After field-based retraining was held in May 2014, volumes quickly jumped to over 100 calls a week and now consistently range between 150 and 200 calls a week.
Contact the Innovator
Diaa Alqusairi, PhD
Emergency Telehealth and Navigation (ETHAN)
Houston Fire Department-EMS
Office: (832) 394-6844
E-mail: Diaa.Alqusairi@houstontx.gov
Innovator Disclosures
Dr. Alqusairi reported that Houston Fire Department has received program-related funding from The City of Houston, the Centers for Medicare & Medicaid Services, and the Texas Department of Health and Human Services.
References/Related Articles
Gonzalez M, Alqusairi D, Jackson A, Champagne T, Langabeer J, Persse D. Houston EMS advances mobile integrated healthcare through the ETHAN program. Journal of Emergency Medical Services. Nov 2015;40(11). Available at:http://www.jems.com/articles/print/volume-40/issue-11/features/houston-ems-advances-mobile-integrated-healthcare-through-the-ethan-program.html.
Footnotes
- Arnold R. New hi-tech program helps to curb unnecessary ambulance rides. Click2houston.com. May 13, 2014. Available at:http://www.click2houston.com/news/new-hitech-program-helps-to-curb-unnecessary-ambulance-rides/25964116.
- Begley C., Courtney C., Abbass I., et al. Houston hospitals emergency department use study. 2013. The University of Texas School of Public Health. Report prepared by the Houston Health Services Research Collaborative.
- Feibel C. Houston firefighters bring digital doctors on calls—program connects residents in their homes with a doctor. Emergency Medicine. 2015 April 10. Available at:http://www.medpagetoday.com/EmergencyMedicine/EmergencyMedicine/50932.
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