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The advancement of telehealth: How can it be used in EMS today?

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The advancement of telehealth: How can it be used in EMS today?

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Telemedicine has been around for decades, but it has become more vital to the medical community during the recent pandemic.   The potential uses of telemedicine extend beyond scheduled appointments with providers. In 2019, CMS announced the development of the ET3 model, intended to increase value and reduce costs associated with emergency ambulance services, and provided the most appropriate care to beneficiaries.
The ET3 model allows EMS to work with health care providers via telehealth to order and deliver on-site care when appropriate, along with other services.  Utilizing this communication technology, providers can determine if patients require treatment in an ED, can direct EMS to transport to an urgent care or PCP office if more appropriate, or treat at home. This is a new application of telehealth technology that has potential to improve ED efficiency, reduce health care costs, and deliver care to patients when and where they need it most.

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CMS announced ET3 initiative February 14, 2019

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CMS announced ET3 initiative February 14, 2019

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CMS announced the ET3 initiative in 2019, and began accepting applications for the new program.  The first performance period for participating services began January 1, 2021 (Centers for Medicare and Medicaid Services, 2021).

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HHS launches innovative payment model with new treatment and transport options to more appropriately and effectively meet beneficiaries’ emergency needs
Supporting ambulance triage options aims to allow beneficiaries to receive care at the right time and place

Today, the U.S. Department of Health and Human Services (HHS), Center for Medicare and Medicaid Innovation (Innovation Center), which tests innovative payment and service delivery models to lower costs and improve the quality of care, announced a new payment model for emergency ambulance services that aims to allow Medicare Fee-For-Service (FFS) beneficiaries to receive the most appropriate level of care at the right time and place with the potential for lower out-of-pocket costs.

“This model will create a new set of incentives for emergency transport and care, ensuring patients get convenient, appropriate treatment in whatever setting makes sense for them,” said HHS Secretary Alex Azar. “Today’s announcement shows that we can radically rethink the incentives around care delivery even in one of the trickiest parts of our system. A value-based healthcare system will help deliver each patient the right care, at the right price, in the right setting, from the right provider.”

The new model, the Emergency Triage, Treat and Transport (ET3) model, will make it possible for participating ambulance suppliers and providers to partner with qualified health care practitioners to deliver treatment in place (either on-the-scene or through telehealth) and with alternative destination sites (such as primary care doctors’ offices or urgent-care clinics) to provide care for Medicare beneficiaries following a medical emergency for which they have accessed 911 services. In doing so, the model seeks to engage health care providers across the care continuum to more appropriately and effectively meet beneficiaries’ needs. Additionally, the model will encourage development of medical triage lines for low-acuity 911 calls in regions where participating ambulance suppliers and providers operate. The ET3 model will have a five-year performance period, with an anticipated start date in early 2020.

“The ET3 model is yet another way CMS is transforming America’s healthcare system to deliver better value and results for patients through innovation,” said CMS Administrator Seema Verma. “This model will help make how we pay for care more patient-centric by supporting care in more appropriate settings while saving emergency medical services providers precious time and resources to respond to more serious cases.”

Currently, Medicare primarily pays for unscheduled, emergency ground ambulance services when beneficiaries are transported to a hospital emergency department (ED), creating an incentive to transport all beneficiaries to the hospital even when an alternative treatment option may be more appropriate.  To counter this incentive, the ET3 model will test two new ambulance payments, while continuing to pay for emergency transport for a Medicare beneficiary to a hospital ED or other destination covered under current regulations:

payment for treatment in place with a qualified health care practitioner, either on-the-scene or connected using telehealth; and

payment for unscheduled, emergency transport of Medicare beneficiaries to alternative destinations (such as 24-hour care clinics) other than destinations covered under current regulations (such as hospital EDs).

The ET3 model encourages high-quality provision of care by enabling participating ambulance suppliers and providers to earn up to a 5% payment adjustment in later years of the model based on their achievement of key quality measures.  The quality measurement strategy will aim to avoid adding more burden to participants, including minimizing any new reporting requirements.  Qualified health care practitioners or alternative destination sites that partner with participating ambulance suppliers and providers would receive payment as usual under Medicare for any services rendered.

The model will use a phased approach through multiple application rounds to maximize participation in regions across the country.   In an effort to ensure access to model interventions across all individuals in a region, CMS will encourage ET3 model participants to partner with other payers, including state Medicaid agencies.

CMS anticipates releasing a Request for Applications in Summer 2019 to solicit Medicare-enrolled ambulance suppliers and providers.  In Fall 2019, to implement the triage lines for low-acuity 911 calls, CMS anticipates issuing a Notice of Funding Opportunity for a limited number of two-year cooperative agreements, available to local governments, their designees, or other entities that operate or have authority over one or more 911 dispatches in geographic locations where ambulance suppliers and providers have been selected to participate.

For more information, please visit: https://innovation.cms.gov/initiatives/et3/.

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HHS launches innovative payment model with new treatment and transport options to more appropriately and effectively meet beneficiaries’ emergency needs | CMS

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Today, HHS and CMS announced a new payment model for emergency ambulance services that aims to allow Medicare Fee-For-Service (FFS) beneficiaries to receive the most appropriate level of care at the right time and place with the potential for lower out-of-pocket costs.

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A vital component of the ET3 model allows EMS to partner with providers and deliver healthcare via telemedicine on scene when appropriate.  With this innovative use of current technology, providers can lay eyes and communicate with patients and EMS at the scene, begin the decision making process, ordering care at the moment and potentially reducing transport needs (Fisher Titus, 2020).

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Increased patient satisfaction- patients who receive care on site and avoid transport to the ED, therefore avoiding ED wait times, invasive labs/monitoring, and possible admission to the hospital may report increased patient satisfaction.

Reduction in health care costs- the use of telemedicine on site will result in  saved health care dollars.  CMS payouts for transports may decrease, along with costs associated with ED and inpatient hospital stays (Centers for Medicare and Medicaid Services, 2021).

Appropriate use of the ED-  by redirecting care with telehealth, EDs may experience an improvement in congestion caused by unnecessary visits (Colombia Southern University, 2019).

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Missed diagnoses- even in the ED, the potential for missed diagnoses and unfavorable outcomes exists, but the risk may increase when using telehealth in the field, given the lack of resources (radiology, lab, etc).  The solution for this lies with extensive training and experienced providers.

Risk of patients bypassing EMS- if the community has a misunderstanding of how ET3 and telehealth in EMS works, there may be an increase of patients choosing to drive directly to the ED in order to avoid being redirected.   In some cases, this may create a danger or delay in care for patients.   This problem could be mitigated by extensive community education.

Cost of implementation- In order to implement telehealth in EMS, initial outlay of costs would include equipment- iPads or smartphones enabled with software that can protect patient information while allowing for real time transmission of data, training for staff, and the costs associated with partnering with physicians or practitioners who provide the telehealth services.

Reduced income for EMS,  EDs and hospitals- EMS collects a fee for each Medicare and Medicaid patient transported to the ED.   The ET3 model will pay for transporting patients to PCP and urgent cares, and will also pay for telehealth care delivered on site.  However this income stream may not equal previous payouts by CMS.  Additionally, EDs and hospitals may see drop in income due to reduced visits.  Although redirecting some patients to other sources of care is appropriate, this may result in reduced payouts to hospitals from what was previously a guaranteed payor.

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Utilizing telehealth in EMS is a feasible solution to the problem of inappropriate ED visits. 

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Utilizing telehealth in EMS is a feasible solution to the problem of inappropriate ED visits. 

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It is imperative that health care resources be utilized fairly, and the ET3 program is an important part of regulating over use of the ED.  By providing care at the scene via telehealth, or diverting traffic to PCP offices or urgent care centers, EMS services can help preserve the use of EDs for true emergencies.
The 5 year trial of ET3 has potential to make a tremendous impact on the costs associated with inappropriate ED usage. CMS payouts for ED and inpatient stays may decrease, but there is potential for revenue in payment to telehealth providers, as well as  transport to non-emergent destinations.   Furthermore, if the ET3 program is successful, private insurance companies may be incentivized to take part as well.  Hospitals and EMS companies would be well-advised to explore financial opportunities in these areas.

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My own strengths of Intellection, Learner, Input, Achiever, and Strategic allow me to collect and analyze data effectively, using that knowledge to produce ideas that will lead decision making.
The following members' strengths compliment my own and each others', creating an effective team that can lead our project to fruition.
The Activator, Andrew- Andrew's strength of turning thought into action will spur the implementation process of any project.
Chelsea, with the strength of Command, would make an effective leader, directing efforts and guiding decision making.  Each team needs a clear leader, preventing confusion and stagnation.
The Maximizer- Matthew's job on the team is to direct member's strengths to creating an project that overcomes obstacles and achieves success.  Maximizers promote excellence.
Rachel, with the strength of Restorative, works as our problem-solver.    During the process, all projects are subject to obstacles, and Rachel's job is identifying the issue and determining a resolution.
And finally, with the strength of Communication, Carter will work on the team as the person who gets stakeholders on board, disseminating the concept of using telemedicine in EMS to the public, explaining the benefits of appropriate levels of care, cost reduction, and decreased ED congestion.

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Centers for Medicare and Medicaid Services. (2019, February 14). HHS launches innovative payment model with new treatment and transport options to more appropriately and effectively meet beneficiaries’ emergency needs. Retrieved from CMS.gov.

Centers for Medicare and Medicaid Services. (2021, September 23). Emergency triage, treat, and transport (ET3) model. Retrieved June 9, 2022, from CMS.gov: https://innovation.cms.gov/innovation-models/et3

Colombia Southern University. (2019, January 29). Retrieved June 12, 2022, from Colombia Southern University: The Link: https://columbiasouthern.edu/blog/blog-articles/2019/january/ems-telemedicine/

Fisher Titus. (2020, December 18). Fisher Titus North Central EMS ET3 Program. Retrieved June 12, 2022, from https://www.youtube.com/watch?v=4s78SOkdO5U