key: cord-0806825-feh88rdp authors: Zachrison, Kori S.; Boggs, Krislyn M.; Hayden, Emily M.; Cash, Rebecca E.; Espinola, Janice A.; Samuels‐Kalow, Margaret E.; Sullivan, Ashley F.; Mehrotra, Ateev; Camargo, Carlos A. title: Factors associated with emergency department adoption of telemedicine: 2014 to 2018 date: 2020-09-01 journal: J Am Coll Emerg Physicians Open DOI: 10.1002/emp2.12233 sha: acf31e6003534e508436386a4f9d64007a8b5378 doc_id: 806825 cord_uid: feh88rdp OBJECTIVE: Telemedicine is used by emergency departments (EDs) to connect patients with specialty consultation and resources not available locally. Despite its utility, uptake of telemedicine in EDs has varied. We studied characteristics associated with telemedicine adoption during a 4‐year period. METHODS: We analyzed data from the 2014 National Emergency Department Inventory (NEDI)–New England survey and follow‐up data from 2016 and 2017 NEDI‐USA and 2018 NEDI‐New England surveys, with data from the Center for Connected Health Policy. Among EDs not using telemedicine in 2014, we examined characteristics associated with adoption by 2018. RESULTS: Of the 159 New England EDs with available data, 80 (50%) and 125 (79%) reported telemedicine receipt in 2014 and 2018, respectively. Among the 79 EDs without telemedicine in 2014, academic EDs were less likely to adopt by 2018 (odds ratio, 0.12; 95% confidence interval, 0.03–0.46). State policy environment was not associated with likelihood of adoption. In 2018, all 7 freestanding EDs received telemedicine, whereas only 1 of 9 academic EDs (11%) did. CONCLUSIONS: Telemedicine use by EDs continues to grow rapidly and by 2018, >3 quarters of EDs in our sample were receiving telemedicine. From 2014 to 2018, the initiation of telemedicine receipt was less common among higher volume and academic EDs. Resource availability in US emergency departments (EDs) varies substantially, with major disparities in access. 1, 2 Growing regionalization with concentration of specialty care at higher volume centers has contributed to decreased consultant availability in many smaller or rural EDs. 3, 4 Telemedicine in the ED, using virtual connections between patients and remote clinicians or specialists, may mitigate these access disparities. This has been shown to be feasible and effective for improving clinical care in EDs, particularly for stroke care. [5] [6] [7] [8] [9] [10] [11] [12] [13] [14] Yet for other patient groups with high levels of evidence for telemedicine efficacy, 8, [15] [16] [17] such as pediatric emergency care, telemedicine remains underused. 5, 7, 18 The value of telemedicine has been recognized by rural EDs, patients, and caregivers. 19 In 2016, 48% of US EDs reported receiving telemedicine services for patient care in their ED (ie, telemedicine receipt). 21 Among rural EDs without telemedicine, cost was the most commonly cited barrier. 22 In non-ED settings, payment policy environment has been associated with telemedicine use. However, there has been little exploration of ED adoption over time, the role of policy in ED adoption, characteristics of EDs that are using it, how it is used, and how it impacts patient care and outcomes. 23, 24 It is important to acknowledge that the optimal rate of telemedicine receipt among US EDs is unknown. Many EDs have comprehensive resources and no need for telemedicine receipt; these EDs may even provide telemedicine services to others. Some EDs have most resources but still need telemedicine for particular clinical indications. Yet other EDs have fewer resources and need telemedicine more broadly. Although it is difficult to determine which EDs fall into these categories, it is likely that there remain EDs that would benefit from telemedicine but do not yet have it. Using combined data from a series of surveys of New England EDs from 2014 to 2018, we describe telemedicine uptake over time and what factors are associated with ED telemedicine adoption (defined as initiation of a program for telemedicine receipt). We also examine whether state policy environment is associated with ED adoption. In an analysis of 159 emergency departments in New England, telemedicine use increased from 50% to 79% during a 4-year period. Adoption of telemedicine was more common in lower volume and non-academic emergency departments. 21 We also used data from the Center for Connected Health Policy to identify states' policy environments with respect to telemedicine. Data were based on state policy in 2014. The surveys were composed largely of questions that have been used in prior studies. 21 The primary outcome was ED receipt of telemedicine for each year studied. In 2014, this was based on self-reported response to the survey item "Does your ED obtain consultation via video conferencing equipment? Yes/No." In 2016 to 2018, the survey question was modified for clarity to "Does your ED receive telemedicine services for patient evaluation? Yes/No." EDs were classified by their responses to telemedicine receipt (yes/no) in each year studied. As a secondary outcome, we also examined ED provision of telemedicine. We also collected data on other key ED characteristics related to overall and pediatric visit volumes and the presence of a pediatric area within the ED. We identified academic hospitals based on membership in the Council of Teaching Hospitals. 29 Urban Influence Codes were used to classify EDs as urban (codes 1 and 2) or rural (codes 3-12). 30 We used data from the Center for Connected Health Policy to identify states' policy environments in 2014. We identified presence of any parity law, which is a mandate for reimbursement of telemedicine visits either at a level partially or fully equivalent to inperson visits. Among those with parity laws, we also noted the year the parity law was enacted and state telemedicine "grade" (A, B, C, F (Table A1 and Figure A5 ). Among the 79 EDs without telemedicine receipt in 2014, 45 (57%) initiated receipt of telemedicine by 2018. Relative to those that still did not use telemedicine in 2018, those initiating receipt of the technology were less often academic and more often freestanding (Table 2) . We then grouped EDs into low-volume urban (n = 58, 36%), highvolume urban (n = 80, 50%), and low-volume rural (n = 21, 13%); there were no high-volume rural EDs. Our results are limited to the New England region and may not be 34 Previous work has been primarily focused at the patient level, identifying increasing rates of telemedicine consultations in administrative data. In contrast, we focus at the ED level, examining characteristics associated with EDs' adoption of telemedicine. This ED-level evaluation is particularly valuable for understanding characteristics of EDs that were early adopters, more recent adopters, and those that have not adopted. Although these data cannot provide any insight into the optimal rate of ED telemedicine use, they are valuable to inform our understanding of the current landscape of use and characteristics of early adopters, the early majority, and non-users. Of those that were not receiving telemedicine from 2016 to 2018, ≈1 in 5 were providing telemedicine to other EDs. This suggests that at least some of the EDs not receiving telemedicine had comprehensive resources on site without need for telemedicine receipt. Future work may explore the optimal rate of telemedicine use by more deeply evaluating EDs' resource availability in relation to telemedicine adop-tion and the relationship between telemedicine adoption and patient outcomes. Although our results do provide a relatively comprehensive sense of the extent of telemedicine adoption by EDs in New England, we do not have any data on the extent or success of implementation or integration of telemedicine into clinical workflows. Further mixed methods or qualitative work should explore barriers and facilitators of successful implementation of telemedicine in EDs. It is interesting to note that we did not find an association between state policy environment and ED adoption of telemedicine between 2014 and 2018. There are a few potential explanations for this. It may be that policy environment was a driver for early adopters; however, in more recent years, the early and later majority have recognized the value of telemedicine independent of policy related to payment parity. Alternatively, ED adoption may be driven largely by clinical need and be relatively independent from state payment policy. For example, during the time of this study period, the financial structure of telemedicine use in the ED often did not depend on direct billing to payors and was supported in other ways. Thus, if policy environment is not an important driver of ED telemedicine adoption, then there may be other important strategies to support telemedicine adoption in underresourced EDs, such as grant programs. Further work is needed to explore this question. We found that telemedicine use is increasing among New England EDs. By 2018, ≈3 in 4 EDs were receiving telemedicine. Adoption between 2014 and 2018 was less common among academic EDs, and state policy did not appear to contribute to telemedicine adoption during this time period. We acknowledge Kyle Burton and Andrew Wilcock for their assistance with the compilation of the telemedicine policy data and the New England state coordinators for their assistance with data collection (see the appendix for complete list of individuals). 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