EMS State of the Sciences Conference: Telehealth Project Helps Cut Transports in Houston

Ed's Note: The annual EMS State of the Sciences Conference, colloquially known as the “Gathering of Eagles,” is held to share the most cutting-edge information and advances in EMS patient care, research and management issues, trending challenges and lessons learned. Speakers include medical directors from the EMS systems of America’s largest cities, plus prestigious physician guests. The 2016 Gathering of Eagles will be held February 19–20 in Dallas, TX. This article profiles a presentation from the 2015 Gathering of Eagles.

Presentation: Taking Down the Walls to Productive House Calls: High-Teching the Home Visit with ETHAN. Presented by David E. Persse, MD, Physician Director, City of Houston EMS and Public Health Authority, City of Houston Department of Health and Human Services; Chair, Board of Directors, NREMT; Professor, Department of Medicine and Surgery, Baylor College of Medicine, Houston.

Healthcare 2015 is all about finding efficiencies, and a new program in Houston is attempting to bring one to that most inefficient of mandates: that EMS transport every patient, no matter how minor their problem, to a hospital emergency department.

Using a video hookup between crews in the field and remote physicians, the Houston Fire Department is helping some low-acuity 9-1-1 callers bypass that result in favor of trips to clinics or other kinds of care.

The effort is called the ETHAN project, for emergency telehealth and navigation. Basically, if an HFD crew arrives, talks to the patient, does its assessment and feels the patient can be more appropriately handled outside an ED, they can dial up a doc to chat with the patient by video. If the doc and patient agree, the patient can get a quick clinic appointment (with a taxi voucher, if needed) or instructions for other follow-up.

 “That interaction with a physician provides everyone with a degree of safety,” says Michael Gonzalez, MD, associate medical director for Houston Fire and head of the project. “In addition to the EMS crew, the physician can talk to the patient and get their own independent history, and everyone can determine jointly, ‘Yes, we think this patient might be more appropriately handled in the clinic setting.’”

Crews use two main criteria to identify candidates: The patient has to be 1) competent to make their own decision (e.g., not intoxicated), and 2) ambulatory (if they’re sent to a clinic by cab, the cabbie can’t be expected to provide physical assistance). But the physician can also overrule the crew, resulting in a normal ED transport. If the doc agrees with the crew but the patient wants to go to the ED anyway, they can get a taxi voucher for that too.

The efficiencies here are multiple: Hospitals aren’t burdened with patients better seen elsewhere. Patients get care in more optimal settings and fewer bills afterward. And the HFD crew can achieve an appropriate patient disposition in a fraction of the time it would have spent transporting and offloading.

The crews use basic Panasonic Toughpad FZ-G1 tablets the department had already acquired to replace older models that lacked audiovisual capabilities. The department installed Cisco’s Jabber communication platform and worked with Cisco to ensure its connections were secure, archivable and HIPAA-compliant. Now calls initiated from the field go through a standard server that records, encrypts and stores everything securely. The physicians are in the 9-1-1 center using Cisco TelePresence EX90 monitor/telepresence systems.

This all started with some pilot testing last September, then went citywide in December. So far results have been good: Through more than 500 patient encounters, roughly 80% received dispositions other than ambulance transport to an emergency department.

Lasting Solutions

Sparing one ED one patient is nice, but the larger goal is to help low-acuity callers get lasting solutions to their problems.

“Emergency departments provide great care and are certainly capable of providing the care these callers need,” says Gonzalez. “But for certain medical emergencies—things like chronic hypertension, management of chronic diabetes, things that are common reasons for people to call 9-1-1—it’s really more appropriate for them to get seen by someone who’s going to manage those issues, in particular in the long term.”

Some of the clinics the department works with have navigators and can help connect patients to permanent care and other resources. For others there’s Care Houston, a collaborative program between the fire department and city Department of Health and Human Services aimed at reducing nonemergency calls through directed interventions. Frequent callers who participate get visited by a nurse case manager who assesses their needs, works with them to develop a service plan, and provides any relevant social or medical referrals, as well as education on alternative options for transportation and other assistance. ETHAN patients can be referred to Care Houston for ongoing help.

“Many of the patients we’ve seen either don’t have access to a primary care physician or don’t feel like they have one to go back to because they’ve historically gotten their care in emergency departments,” says Gonzalez. “By providing that link with ETHAN, we’re hoping we can not only divert the patient from the higher cost of a potentially unnecessary emergency department visit, but also help provide them a medical home.”

Getting the program started required a few things. For one, with equipment and infrastructure, the department faced about a million dollars in startup costs. Grants helped defray that and will hopefully sustain ETHAN as it demonstrates value.

And it’s essential to develop that network of clinic partners. Houston started out with just four but now has 15 and is adding pediatric and psychiatric facilities.

“Those partnerships are absolutely required,” Gonzalez says. “You can’t go out as an EMS service that’s looking to decrease the number of ‘unnecessary’ transports. To make the system work well, you have to reach out to partners and try to enlist everyone and identify common goals. That’s really the reason we’ve been able to make this successful.”