In the 7 years since the passage of the Affordable Care Act, the number of Emergency Department (ED) visits has steadily increased while the number of EDs has fallen — resulting in increased pressure on hospitals. Consequently, health care systems find themselves challenged to develop innovative ways of accommodating this growing volume while still providing high-quality and efficient medical care. The surge in smartphone use, combined with the advancement of provider-focused telehealth capabilities, has created an opportunity for systems to leverage technology in service of these goals. Today, the American Telemedicine Association reports that there are currently 200 active telemedicine networks, with over half of U.S. hospitals now using some form of telemedicine.
This is the context in which NewYork-Presbyterian (NYP) and Weill Cornell Medicine jointly launched their cutting-edge Emergency Department Telehealth Express Care Service (ECS). This innovative program has enabled us to provide a much better experience for low-acuity patients presenting to the EDs at NewYork-Presbyterian/Weill Cornell Medical Center and NewYork-Presbyterian/Lower Manhattan Hospital. Building upon this success, NYP has recently expanded ECS to the Columbia-affiliated NewYork-Presbyterian/Columbia University Medical Center and NewYork-Presbyterian/Allen Hospital campuses, and similar expansions at the NYP regional hospitals are expected in the coming months.
Emergency Department Core Measures
When NYP first launched its NYP OnDemand telehealth program in early 2016, we were in the midst of working to improve ED core measures. Today, EDs are held accountable for operational metrics such as wait times to see providers, walk-out rates, and total length of stay in the ED, along with patient experience scores and feedback. Because we manage a number of crowded urban EDs, we have long sought to address the ED wait times that are frequently cited as one of the biggest sources of frustration for patients — and that lead to high walk-out rates (i.e., patients leaving the ED prior to being seen by a provider). Patients with low-acuity complaints find these delays even more frustrating and have disproportionately negative patient experience scores. Regulatory scrutiny has given us the opportunity to focus on improving our performance in these areas, creating heightened awareness of wait times and patient experience when developing Emergency Department workflows and protocols.
NYP OnDemand ED Express Care Service
This was the context in which we conceived and launched the ED Telehealth Express Care Service for low-acuity patients presenting to the ED. To operationalize this program, we first identified the conditions that would be amenable to treatment via telehealth, including minor rashes, sprains and contusions, upper respiratory infections, wound checks, suture removals, and tetanus immunizations. Next, we developed our workflow: after an initial RN triage and medical screening exam by a physician assistant or nurse practitioner, qualifying ED patients are offered a real-time video visit with one of our board-certified Emergency Medicine faculty physicians.
This ECS consultation is conducted in a private patient room with comfortable lounge chairs and a monitor, and the patient is connected to a physician located in a separate room. Patients are interviewed by the physicians remotely while they are in the private room and then directly discharged from the room. Discharge paperwork is printed directly in the room and prescriptions are called in electronically to the patient’s pharmacy. Importantly, the remote physician covers both Express Care sites, offering us economies of scale by having a single “server” for multiple queues.
Planning & Operationalization
The launch of ECS was the result of a collaboration with the NYP Innovation, Strategy, Legal, Corporate Compliance, Patient Experience, and Registration teams. After conducting several focus groups and meetings, we decided to pilot this service 4 hours per day for a select set of low-acuity complaints. Today, we offer ECS from 8 a.m. to midnight, 7 days a week, and we expect to expand coverage in the near future.
Initial concerns relating to patient demand, financial implications, provider comfort, and patient safety were all addressed in an operational plan. We identified the opportunity to accept insurance and bill these as ED visits because each patient receives a full ED triage and in-person medical screening exam and evaluation. Today, we continually review all aspects of ECS and evaluate patient and provider feedback to refine workflows and processes on a regular basis.
Since ECS was launched in July 2016, we have seen more than 3,000 patients with a typical length of stay of 35 to 40 minutes — as compared to an average of 2 to 2.5 hours’ stay in the ED for patients seen in person via the traditional ED pathway. Patient satisfaction scores for ECS have been outstanding, ranking in the 99th percentile. Our physicians have also indicated that they enjoy providing this virtual care. When we initially implemented the program, we anticipated that patients’ age would skew younger because of their greater adoption of new technology. To our surprise, however, while our patients’ ages have ranged from 19 to 99, approximately 20% of our ECS patients have been over the age of 60.
As part of our ongoing quality assurance program, we monitor 72-hour ED revisit rates for our ECS patients. Currently, the number of ECS patients who revisit the ED within 72 hours of their virtual visit is less than 3%, which is lower than the 3.5% to 7.5% that has been reported for ED patients in traditional settings. When we account for revisits that were part of the initial treatment plan, the revisit rate is less than 2%. The majority of these unplanned returns do not result in any change in treatment. Even more impressively, none of these ECS 72-hour return-visit patients have required an admission for inpatient hospitalization.
We are proud of our hard work, and our success has not gone unnoticed: ECS has been profiled in several media outlets, including in The Wall Street Journal, Crain’s New York, Health IT News, and Modern Healthcare. We have also attracted significant provider attention, as more than 20 health systems have approached us to learn from our experience.
While our ED Telehealth Express Care Service has been successful from an efficiency and patient experience standpoint, we know that this is just the beginning of a long journey in a changing landscape. Looking ahead, we are focused on two key practices that will enable us to evolve and change as necessary: (1) engagement of all key stakeholders and (2) commitment to modifying workflows and policies in response to regular feedback and data.