“Tele-Triage”: The COVID-19 Crisis’s Transformation of Emergency Care and Potential Post-Pandemic Opportunities
During the COVID-19 pandemic, health care providers have faced unique challenges in the delivery of health care. As COVID-19 began to spread across the United States, the CDC advised health care providers, especially in areas with widespread COVID-19 transmission, to offer care via telemedicine technologies where appropriate. As a result, although telemedicine has been emerging as an important player in the delivery of health care over the past several years, the pandemic has caused the use of and access to telemedicine to grow to an unprecedented scale. During the pandemic, telemedicine has materialized as an especially useful tool in triaging patients in emergency care settings. This “tele-triage” model provides significant opportunity for the health care industry.
Delivering care through telemedicine modalities has helped providers address several important barriers to accessing health care during the pandemic. At the start of the pandemic, the nation faced an unprecedented shortage of personal protective equipment (PPE), such as masks and gowns. Front-line providers working in hospitals and other emergency care settings faced significantly increased risk of catching and spreading COVID-19, which became especially important as asymptomatic transmission became a significant concern. Moreover, as lockdowns were enforced and individuals were asked to stay home as much as possible, patients began delaying or avoiding health care. By June 30, 2020, the CDC reports that as many as 41% of adults in the United States had “delayed or avoided” routine or emergency medical care. Moreover, emergency departments and urgent care centers saw record levels of overcrowding as COVID-19 spread, causing the need for makeshift hospitals and care below usual standards. As providers began offering telemedicine as an alternative to in-person care, telemedicine emerged as an important tool to conserve the short supply of PPE, keep patients and providers safe, and minimize unnecessary overcrowding of emergency care spaces, all while maintaining continuity of care.
Perhaps one of the most important areas of telemedicine growth has been in the emergency care space. The pandemic has certainly caused emergency department capacities to reach crisis levels nationwide, but even before 2020, overcrowding of emergency departments due to their overuse for primary care is a well-studied phenomenon. It is caused by various factors such as lack of access to primary care, lack of access to health insurance, and the promise of 24/7 care at an emergency department. Use of the emergency department for non-urgent conditions has been proven to drive up national health care spending, contribute to poor care management and continuity for patients, and generate prolonged wait times that ultimately increase patient morbidity and mortality and decrease overall health outcomes. During the pandemic, overuse of the emergency department also became downright dangerous, as emergency departments struggled to develop processes to separate patients who were suspected to have an active COVID-19 infection from those who were not.
To combat these problems, hospitals and other emergency care settings began offering virtual encounters to provide safe and timely care. Providers also used telemedicine to triage patients, providing clarity on whether patients really needed to visit an emergency care setting or if a telemedicine or other office visit would suffice. These “tele-triage” encounters have helped providers quickly and efficiently direct patients to the appropriate care setting, while limiting the overcrowding of emergency departments at a time when emergency department resources had to be preserved for treatment of severely ill COVID-positive patients. Tele-triage also emerged as an important tool for identifying patients who may have been infected with COVID-19, but who did not need emergency care and could remain isolated at home, reducing the risk of transmission to front-line health care workers and other emergency department visitors.
On top of diminishing emergency department bottlenecks that waste critical emergency care resources, telemedicine can greatly reduce the cost of care. The average telemedicine visit costs $40-50, compared to the average emergency room visit, which can cost closer to $2,000. Moreover, cost-effectiveness is typically achieved when health care utilization decreases, which raises concerns that patients are not receiving medically necessary care. However, with greater accessibility to health care through telemedicine, it stands to reason that tele-triage may actually provide greater health care utilization while lowering health care costs by diminishing emergency health care utilization in cases where it is unnecessary.
One reason that has caused emergency care leaders to hesitate in implementing tele-triage models is concern regarding compliance with the Emergency Medical Treatment and Labor Act (EMTALA). EMTALA requires that hospitals conduct medical screening examinations of any patient presenting to the emergency department sufficient to determine whether an emergency medical condition exists. If an emergency medical condition does exist, the hospital is then required to treat or stabilize the patient, or appropriately transfer the patient to another hospital. Although all parts of a hospital’s EMTALA obligations cannot be met with tele-triaging, especially if a patient has already presented to an emergency department, the requisite medical screening examination may be performed using telehealth equipment if clinically appropriate. Further, if tele-triage is performed to prevent patients from going to the emergency department, and the patient is still at home, no EMTALA obligations apply at all. CMS specifically stated, “The use of telehealth to provide evaluation of individuals who have not physically presented to the hospital for treatment does not create an EMTALA obligation.”
Moreover, as lawmakers have realized the importance of telemedicine in health care delivery during the pandemic, many of the existing legal barriers to entry in the telemedicine space have been relaxed. Executive orders issued by state governors, state-by-state changes in laws and regulations, relaxations in the enforcement of HIPAA privacy rules, and CMS’s unprecedented expansion of telemedicine coverage have allowed for greater flexibility in the types of providers that can care for patients via telemedicine, where telemedicine can be provided, which modalities are appropriate for the provision of care, and more. Some of these changes are temporary, leaving providers unsure about whether they will be able to continue to care for patients via telemedicine after the pandemic is over. Some, like many of CMS’s rapid and broad changes to telemedicine coverage, are likely here to stay.
As the pandemic eventually comes to an end, there will still be open questions on the role telemedicine will play in the delivery of health care. But in the emergency care space, telemedicine unquestionably has tremendous value. The opportunity to reimagine emergency care delivery via “tele-triage” could be crucial to delivering cost-effective and high-quality care without compromising health care utilization – even in a traditionally high-cost setting like the emergency department.