Review article
Systematic review of telemedicine applications in emergency rooms

https://doi.org/10.1016/j.ijmedinf.2015.05.009Get rights and content

Highlights

  • A frequently implemented telemedicine services is in rural emergency rooms.

  • This systematic review of tele-emergency studies found support for many measures.

  • Support was shown for clinical processes, outcomes, throughput, and disposition.

  • Rigor of the studies was limited and needs additional support.

  • Tele-emergency has considerable potential to address specialist access issues.

Abstract

Context

Despite the frequency of use of telemedicine in emergency care, limited evidence exists on its impacts at the patient, provider, organization, and system level. Hospital-based applications of telemedicine present a potentially important solution, particularly for small and rural hospitals where access to local specialists is rarely available.

Purpose

We conducted a systematic review of telemedicine applications for hospital-based emergency care, which aims to synthesize the existing evidence on the impact of tele-emergency applications that could inform future efforts and research in this area.

Basic procedures

A search of four databases (PubMed, CINAHL, EMBASE, Cochrane) using a combination of telemedicine and emergency room (ER) keywords for publications yielded 340 citations. Four coders independently determined eligibility based on initial criteria and then extracted information on the 38 resulting articles based on four main categories: study setting, type of technology, research methods, and results.

Main findings

Of the 38 articles, 11 studies focused on telemedicine for diffuse patient populations that typically present in ERs, 8 studies considered telemedicine in the context of minor treatment clinics for patients presenting with minor injuries or illnesses, and 19 studies focused on the use of telemedicine to connect providers in ERs to medical specialists for consultations on patients with specific conditions. Overwhelmingly, tele-emergency studies reported positive findings especially in terms of technical quality and user satisfaction. There were also positive findings reported for clinical processes and outcomes, throughput, and disposition, but the rigor of studies using these measures was limited. Studies of economic outcomes are particularly sparse.

Principal conclusions

Despite limitations in their research methodology, the studies on tele-emergency indicate an application with promise to meet the needs of small and rural hospitals to address infrequent but emergency situations requiring specialist care. Similarly, studies indicate that tele-emergency has considerable potential to expand use of minor treatment clinics to address access issues in remote areas and overcrowding of urban ERs.

Introduction

Definitions of telemedicine by the Institute of Medicine (IOM), World Health Organization, and American Telemedicine Association [1], [2], [3] vary somewhat, but the core of most definitions is “the delivery of health care services at a distance, using information and communication technology”, where information and communication technology encompasses a broad range of potential applications [4]. Many telemedicine applications connect patients directly to providers. Other applications focus on clinicians but employ asynchronous communication only, or largely use videoconferencing for educational purposes. An extremely important area of telemedicine connects clinicians during an acute episode of patient care, usually linking small, rural hospital settings that have limited resources to larger, urban medical centers. Telemedicine applications in emergency rooms (tele-emergency) are a prime example. In a recent analysis of the 2011 Health Information and Management Systems Society (HIMSS) Analytics dataset [5], which aimed at deriving national estimates of hospital-based telemedicine use, we found that two of the three most frequently used services were in emergency/trauma care departments and in cardiology/stroke/heart attack programs [6].

Despite this reported frequency of use of telemedicine in emergency care, limited evidence exists on its impacts at various levels related to the technical quality, users’ perceptions, clinical processes and outcomes, disposition and throughput of patients, and economic effects. Hospital-based applications of telemedicine present a potentially important solution, particularly for small and rural hospitals where access to local specialists is rarely available [7]. Yet, a PubMed search for meta-analyses and systematic reviews on telemedicine and telehealth yielded 55 citations, of which only three are focused on hospital-based applications [8], [9], [10]. Interestingly, all three were on telemedicine in intensive care units (ICU). A systematic review on a broad range of applications [11] found generally positive results with the strongest evidence among hospital-based applications in pediatric cardiology, intensive care, and emergency care/trauma. Surprisingly, no meta-analyses or systematic reviews of telemedicine in specific hospital-based applications other than those covering tele-ICU [12] were found. Thus, in view of the relatively frequent use of telemedicine in emergency/trauma care departments and cardiology/stroke/heart attack programs, we undertook a systematic review of the empirical studies of telemedicine applications for hospital-based emergency care to synthesize the existing evidence on the impact of tele-emergency applications, which could inform future efforts and research in this area. This paper presents a systematic review of published research evidence on tele-emergency applications, which synthesizes existing evidence and identifies knowledge gaps in this area. It further provides stakeholders, researchers, and funding agencies with knowledge that focuses attention on priority areas for future investigation, as well as highlights various evidence-based interventions of telemedicine applications in emergency room settings.

Section snippets

Materials and methods

According to Moher et al., a systematic review represents a type of literature review that employs systematic and explicit methods for the identification, selection, and critical appraisal of relevant research in a specific field [13]. It summarizes the results of the empirical studies qualitatively, in a narrative approach, in order to present information on the direction, size, strength of evidence, and consistency of the “effect” across the included studies [14]. Unlike a critical review,

Overview of study characteristics

A total of 38 articles presented data from evaluations of tele-emergency applications in real-world clinical settings. A close examination of these articles revealed clustering of the studies into three major types, which represent different contexts of tele-emergency applications. Full references for these studies are listed in Table 1, and grouped by the three types of tele-emergency applications described below. Within each group, the references are ordered by date from oldest to newest, and

Discussion

Emergency care in the U.S. is plagued by multiple challenges including steadily growing demand for services, increased complexity of cases, and declining financial support [23], [24]. Small and rural hospitals face particular challenges related to shortages of primary care and specialist providers [7], [25]. In addition, and in light of the regionalization movement of emergency care recommended by the IOM (e.g., trauma care, heart attack, stroke), it becomes essential that hospitals have access

Author contributions

All authors made substantial contributions to all of the following: (1) the conception and design of the study, or acquisition of data, or analysis and interpretation of data, (2) drafting the article or revising it critically for important intellectual content, (3) final approval of the version to be submitted.

In particular:

Marcia Ward developed the concept for the systematic review, drafted the initial article, oversaw all data collection and analysis, developed the initial interpretation of

Competing interests

None.

Summary points

What was already known on the topic

  • In a recent analysis of the 2011 HIMSS Analytics dataset, two of the three most frequently implemented telemedicine services were in emergency/trauma care departments and in cardiology/stroke/heart attack programs.

  • Hospital-based applications of telemedicine present a potentially important solution, particularly for small and rural hospitals where access to local specialists is rarely available.

  • A search for meta-analyses and systematic

Acknowledgments

This research was funded by a grant from The Leona M. and Harry B. Helmsley Charitable Trust (Grant no. 2010PG-RHC032). The authors thank Emily Eilers, Stephen Johnson, Madhana Pandian, Adam Price, Lindsey Reed, and Jeralyn Westercamp for assistance with literature retrieval and coding for this paper.

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