Editors’ Note: This article was accepted on April 26, 2020, and was accurate at that time. Because information about SARS-CoV-2 and COVID-19 is evolving rapidly, please verify these recommendations and information.
Explore This IssueACEP Now: Vol 39 – No 06 – June 2020
Telemedicine has long been suggested as a viable technological solution for improving access to care. But because of barriers around reimbursement, technological limitations, and scalability, health care institutions have been slow to adopt it. Physician and patient preference for in-person care has been another impediment to adoption.
The COVID-19 pandemic shifted this paradigm; telemedicine use has become widespread. Its potential for decreasing emergency department volume, mitigating transmission of SARS-CoV-2, and saving precious resources such as personal protective equipment (PPE) is now apparent.
Case Use in Chicago
Rush University Medical Center in Chicago created its on-demand virtual care platform in 2019 primarily for patients with low-acuity complaints, much like a virtual urgent care. The online platform was expanded in March 2020 in anticipation of increased patient volumes due to the COVID-19 pandemic. The aim was to “flatten the curve” of COVID-19 by facilitating video visits in place of in-person hospital visits when possible. The pandemic created a large demand from patients with concerns about the coronavirus. Video visits were a channel through which health care workers could provide medical advice regarding testing, quarantine and isolation, supportive care, and whether patients should present for in-person care.
Patients with the chief complaint of “concern for novel coronavirus” were provided a free video visit by a physician or advanced practice provider. In anticipation of high volumes, Rush recruited quarantined emergency physicians, primary care physicians whose clinics had closed, residents, and advanced practice providers.
Prior to the pandemic, the platform saw about two patients daily. Within days of expanding operations of the COVID-19 module, use rapidly grew to 100 patients daily.
This new demand for telemedicine visits spurred rapid institutional change that facilitated the opportunity for residents to deliver health care in novel ways. Emergency medicine residents in particular played an integral role in scaling telemedicine visits, specifically by creating training modules, recruiting practitioners, pilot testing, and conducting visits for patients.
On March 18, 2020, the Accreditation Council for Graduate Medical Education recognized the national demand for telemedicine visits and accelerated giving permission to residents and fellows to participate in telemedicine care.1 Additionally, the federal government began relaxing regulations for telemedicine, notably with regard to restrictions for reimbursements.2 In response to this need, Rush increased its training of health care workers for video visits. We also utilized residents on the telemedicine platform as demand continued to outstrip capacity.
To start conducting video visits, residents had to fulfill several requirements, including completing an online training module, registering their devices to be added to the practitioner pool, and attending an in-person or online tutorial conducted by an information technology specialist or health care worker. The entire training process took about an hour.
Rush achieved emergency medicine resident coverage by reassigning two full-time residents to the program after the cancelation of nonessential rotations. Additional emergency medicine resident coverage was provided by residents on nonclinical rotations on a part-time basis. By co-scheduling attendings and residents, Rush essentially doubled capacity for evaluating patients. Residents presented cases to attendings via the Epic electronic medical records system chat function, and faculty were immediately available by phone and video to troubleshoot difficult cases. Patients were dispositioned to outpatient testing centers, home isolation, or the emergency department. Patients directed to the emergency department for in-person care had their visits streamlined through the emergency physician’s direct communication with the receiving charge nurse.
At Rush, emergency residents demonstrated the clinical acumen, adaptability, and technological savvy that allowed for the rapid expansion of the hospital’s telemedicine platform. Although the residents only met with patients confirmed under investigation for having the novel coronavirus, the success of this venture suggests that residents can be assigned to a more diverse set of complaints and gain necessary skills that will become more valuable as telemedicine becomes commonplace.