Risks, Mitigation Strategies, and Modifiability of Telehealth in Rural and Remote Emergency Departments (Preprint)

Abstract

Delivery of health care utilizing telehealth is a recognized and rapidly evolving domain in the delivery of Emergency Medicine. Research suggests a positive impact of telehealth for patients presenting for emergency care, however, the regional challenges of acute telemedicine delivery have not been studied. The WA Country Health Service (WACHS) Emergency Telehealth Service (ETS) commenced operation in 2012 in regional Western Australian emergency departments (EDs). The WACHS ETS serves 87 regional and remote WACHS-run hospitals as well as 10 non-WACHS facilities using high-definition videoconferencing and complementary technologies. This 12-year practical application of emergency telemedicine offers a unique opportunity to explore the barriers and risks of rural and remote virtual care.

This study explores factors influencing telehealth implementation effectiveness in rural and remote WACHS EDs from ETS clinicians’ perspectives. The meaning of implementation effectiveness in this research extended beyond identifying barriers and enablers in making telehealth available to also examine clinicians’ perceived risks, their modifiability, and mitigation strategies in delivering ETS.

Qualitative research guided by a modified Consolidated Framework for Implementation Research. It used purposive and convenience sampling within a constructivist paradigm to qualitatively explore care processes, clinical decision-making factors, risks, and mitigation strategies.

Sixteen doctors, four clinical nurse coordinators, and a nurse educator from WACHS ETS gave their experience and perspectives. Accurate clinical decisions, especially regarding patient disposition, were crucial to virtual care. Timeliness and accuracy were enhanced through a mutual learning model grounded in the local context. Mitigation strategies like improvisation and flexible technology use compensated for technological barriers. Non-modifiable risk factors included patients’ presenting complaint, clinical urgency of presentation, ED capability, clinician scope of practice, and if transfer is required, distance between ED of original presentation to the hospital of definitive care.

Telehealth can enhance clinical decision-making in rural and remote EDs and ETS clinicians prioritize patient safety within local hospital and community contexts. Even with the most experienced clinicians, ETS technology was not identical to face-to-face communication in all circumstances. The impact of ETS on the scope of regional emergency medicine practice warrants further study concerning its overall cost-effectiveness in rural and remote EDs. Findings reported in this paper identified areas for further qualitative research while providing a rich contextual background for rigorous quantitative analysis of ETS effectiveness.

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