Telemedicine for Ambulance Crews Has a Future, Despite Fiasco of ET3

Telemedicine for the EMS personnel of MedStar Mobile Healthcare, a governmental EMS system in Fort Worth, Texas, is linked through an app on their Android hand-held phones, says Matt Zavadsky, MS-HSA, NREMT, MedStar’s chief transformation officer.

“The crew does everything with their Android phone. They get their calls and their post moves, they get routed by the live routing system, they text with dispatch, they text with each other,” Zavadsky explains. “When they get to the scene of a call, they pop the phone out of its drop-in cradle charger at the front of the truck and bring it with them.”

Telemedicine, which can connect them virtually with physicians from integrative emergency services and the physician with the patient, has been a positive experience for MedStar’s field staff, Zavadsky says. “Every EMT or paramedic who works out in the field knows that a fair percentage, some might say the majority, of our patients, don’t actually need to go to the emergency room.” Is it safe for this patient to go to urgent care? Can they get a prescription written for a new medicine or refill an existing prescription?

A virtual physician visit can answer these questions, and having that telemedicine backup facilitates the paramedics and EMTs to provide more patient-centric care, says Zavadsky, who also takes occasional EMT shifts himself. “We are helping the patient navigate the health care system to the most appropriate setting. One of the tools we use is telemedicine, just like we use a 12-lead EKG monitor.”

ET3 Held Promise for EMS

Utilizing telemedicine to provide medical backup and consultations virtually to ambulance crews in the field was easier under Emergency Triage, Treat, and Transport (ET3), a model of the federal Centers for Medicare and Medicaid Innovation (CMMI), Zavadsky says. Initially billed as a harbinger of EMS’s future, ET3 was shut down by the government at the end of 2023 because of lower-than-expected agency participation in the pilot and lower utilization by participating agencies.

ET3 paid participating EMS services to transport Medicare beneficiaries to appropriate alternative destination partners such as a primary care medical office, urgent care clinic, or community mental health center or to initiate medical treatment virtually at the scene of the call via telemedicine.

Many in the field viewed the government’s decision to shut down ET3 as a step backward for mobile integrated healthcare (MIH), which is a term encompassing a variety of patient-centered mobile resources in the out-of-hospital environment, including community paramedics in expanded roles, transport or referral to a broad spectrum of appropriate alternate care, and post-discharge follow-up. Telemedicine typically is used for somewhat lower acuity cases and excludes obstetric and pregnancy complaints, patients under a year old, and suspected higher acuity illnesses, among other categories.

Despite the setback for ET3, experts believe that the forces driving MIH to address EMS staffing shortages, increased call volumes, the COVID pandemic and fentanyl epidemic, emergency department overcrowding and boarding, and the need for other options for patients will be hard to stop. Some Medicare Advantage plans Medicaid programs, and private payers are getting on board to reimburse agencies for providing frontline response even when the patient doesn’t get transported to an ER.

An Imperfect but Valuable Model

ET3 was a wonderful idea, says Hanan Cohen, Director of Mobile Healthcare for Empress EMS, a division of PatientCare EMS Solutions in Yonkers, N.Y. Cohen helped implement the model at his agency. “All of us who applied knew it was imperfect. But we realized that the parts we thought were imperfect shouldn’t prevent us from going forward with it.”

Telemedicine was a huge part of the demo, Cohen says. Reaching out and partnering with a telemedicine partner was a step forward for EMS services like his, “because that meant they were working for us, as opposed to us going up the food chain to a hospital to ask for orders on a typical 911 call. It really was a partnership—a care partnership.” Empress contracted with a local stand-alone physician practice for its telemedicine.

“I truly think telemedicine has become an absolute key to having a fully successful, fully integrated EMS program,” he says. Empress also runs an extensive community paramedic program and had already worked with telehealth before ET3. The agency employed 14-inch iPad Pro tablets for the three-way conversations between the ambulance crew, the patient, and the virtual physician.

For patients who were refusing to go to the hospital even though they needed to, the telemedicine doctor could often convince them to go, Cohen says. But for those for whom the ER was the last place they needed to be, it facilitated other options.

With the closure of ET3, Empress is not currently offering telemedicine back-up to its 911-responding ambulance crews, although it retains telemedicine for its community paramedics, Cohen says. “Right now, New York State, through its Medicaid program, is revisiting telemedicine, which is a very proactive stance for this state.” Empress is now interviewing other providers and looking to reinstitute telemedicine even before New York passes any legislation.”

Telemedicine Systems

EMS telemedicine and its ability to help facilitate consultations with specialist clinicians and make alternative dispositions or transport based on the patient’s actual needs also depends on the patient’s insurance coverage—Medicare fee-for-service, Medicare Advantage, Medicaid, private insurance—along with a patchwork of state laws and agency protocols defining who can be seen or who must be carted off to the emergency room.

Telemedicine for the ambulance crew is facilitated by the equipment—hardware, software, and apps—and then by the providers at the other end of the line—whether contract physicians, a local medical group, doctors at the local emergency department, or a staffing company. One example of the technology is Pulsara, which is like “a HIPAA-compliant Facetime or What’s App and communication channel,” explains its Chief Growth Officer, Kris Kaull.

Pulsara’s system enables dynamic network communication, involving other specialties and care team providers, even across organizations, as the case evolves. It connects EMS personnel in real-time with the other providers, sharing patient information including videos, photographs, audio clips, ECGs, and vital signs, Kaull says. “The data shows that patients receive time-sensitive treatment in less time because the clinical team has reduced many common inefficiencies.”

MD Ally Telehealth Services is a leading provider of virtual care links to clinicians, largely in Arizona, California, and Florida. Its VP of Partner Success, Ivan Whitaker, MBA, PMD, explains that MIH programs and EMS telemedicine began sprouting to make the EMS system more efficient at a time when call volume—including low acuity calls—is increasing. “We have a relationship with most of the local services that have already proven valuable to EMS patients,” Whitaker says. “What we really do is expand the health care options for the patient.”

Harmandeep Dhillon, DO, board certified in family medicine, is one of MD Ally’s clinicians, residing in New Jersey but able to practice in several states. She received much of her medical training in the hospital and emergency department, seeing patients of all different ages in varied settings. “Since I completed my medical training and after the pandemic started, I’ve been doing telemedicine exclusively. On a typical day, we do shift work where we’re on call, exclusively available, in front of our laptop and computer.”

That might mean practicing from an office or from her home office. “But it’s always HIPAA-compliant, with the patient getting my undivided attention,” she says. MD Ally’s care concierge role facilitates and gathers needed information from the patients, working closely with its partnering EMS services. Often the call goes from the 911 dispatcher to the care concierge and then the clinician to talk to the patient and determine the best course of action before an ambulance has been dispatched.

“I think telemedicine is transformational—providing the care to patients who don’t need an ambulance ride, who might not have the understanding that they don’t need an ambulance ride,” Dr. Dhillon says.

“We have strict criteria on what types of patients meet our eligibility to be able to be seen via telehealth,” explains MD Ally’s Vice President of Clinical Services, Karrie Escobedo. “If our virtual emergency medicine physician is uncomfortable with a patient’s acuity, we will re-escalate back to 911 and have the ambulance sent,” she says.

“Our clinicians have seen what over-utilization in the emergency room looks like. They’re excited to be part of this new generation of physicians leveraging quality care through telehealth.”

Basic Requirements

The way telemedicine worked for MedStar in Fort Worth, the ambulance crews weren’t talking to the doctor on every case, Zavadsky reports. Three requirements had to be met. The first was for the patient to be insured by a payer that is willing to cover not bringing the patient to the hospital when that is appropriate. Second, they had to meet clinical eligibility as outlined by MedStar’s medical director. And third, the patient needed to consent to telemedicine.

Matt Hansen is a paramedic with MedStar and he had one of its highest rates of enrolling potential candidates in EMS telemedicine. “Going into it, I was standoffish. You know, human beings don’t like change. But I started seeing the benefits of telemedicine, the buy-in,” he says.

“I’ve been in EMS since 1991. Since coming out here to Fort Worth, I treat more repeat customers than ever before,” he says. “Many people we respond to don’t need an ambulance, but they may not know any other means to address their medical needs.” Or they might, for example, have a doctor’s visit scheduled in a few days but their pain has become intolerable.

“With ET3, we were able to call our telemedicine doctor and have a conversation with the family. They had the comfort of seeing and talking with an emergency room doctor and getting the same level of care without going to the hospital. I think we lost one of our most valuable tools, telemedicine, just when we thought it was working,” Hansen says.

The reality today is that you first have to ask the patient what their insurance is, Zavadsky notes. And if that insurance plan has decided it doesn’t want to play ball with telemedicine and cover non-transport calls, that’s a clear choice it has made. “We’re not giving away our professional services for free.” When MedStar surveyed patients who received a telemedicine intervention, their satisfaction rate was 98 percent, compared with a 91 percent rating for ‘traditional’ EMS care, including transport to the ER.

Congress has drafted two bills that would change the Social Security Act to make ambulance response and non-transport a covered benefit under Medicare, Zavadsky says. Texas recently passed a law making Medicaid patients eligible for covered telehealth when they are not transported. Anthem, Cigna, and a number of other commercial payers in his region are looking to follow suit.

“Our future as EMS delivery people lies in proving economic value to the people who are paying our bills.” That includes navigating the patient through the system, not just taking every patient to the emergency room, Zavadsky says. Effective navigation for EMTs and paramedics means being trained in how to decide when it’s safe or not safe to take somebody to the hospital, and when to call in a backup to confirm that what they’re thinking is correct.

“And that is how we are going to advance our profession beyond being viewed by many as Uber drivers or having people refer to us as just ambulance drivers—to being seen as EMS clinicians who do the right thing for our patients.”