Canadians deserve the very best in emergency care . Let's work to restore their confidence in the emergency health care system.

Telehealth: Is it of any use to the Emergency department? (No!)

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Over a particularly busy weekend one ER nurse mused that the Telehealth line seemed to be of little use in preventing non-emergent visits to our local ER. From her perspective non-urgent patients might be perceived as a nuisance; from mine they are not as they do not cause ER crowding and use little resources. Nevertheless, the question of the effectiveness of Telehealth Ontario (and by definition other provincial telehealth lines) was an intriguing one.

Most emergency physicians that I know perceive no value to Telehealth lines for there seems to be a steady stream of patients referred to the ER with non-urgent problems that could have been addressed with a dose of common sense. The more cynical of us perceive that Telehealth programs are yet one more way that government can pretend to be doing something about health care without actually doing anything of significance. Lastly, in an era where accountability and assessment of value for dollar seems to be an important driver in health care, it seems very little is published about the effectiveness of a multi- million dollar health care expenditure.

The stated objective of the Telehealth program is to facilitate the most appropriate use of health services and improve decision making by health care consumers. To those of us in the emergency department, we would expect that such a service would direct patients with comparatively minor problems to seek appropriate care in the non-urgent setting. From that perspective, many of us pereceive the program to be entirely ineffective. One elderly person with a 3AM ER visit for a day of constipation lends credence to that concern (and we see many of these!).

A brief search of the net has raised a few interesting points about the Ontario Telehealth program:

“A 2004 study by the Institute for Clinical Evaluative Sciences examined changes in the utilization rates at emergency departments following the implementation of Telehealth Ontario, and found no significant impact on emergency department utilization rates in five of the six regions it examined. In the sixth region, the study noted slightly higher emergency department utilization rates following Telehealth Ontario’s implementation. The study did not look at, amongst other things, the quality of care or clinical outcomes resulting from Telehealth Ontario. It also indicated that further research would be needed to assess these. At the time of our audit, no additional analysis had been done.”

“We analyzed the data documented by the service provider on callers’ initially planned actions compared to the advice they were given by the nurse. For our analysis, we considered the levels of care, from lowest to highest, to be self-treat, see a doctor, or go to the emergency department. We noted that 38% of callers were advised to use the same level of care as they originally planned, 33% were advised to use a lower level of care, and 29% were advised to use a higher level of care. Overall, about the same percentage of callers were advised to go to the emergency department as had originally intended to go there, but many of the callers who were referred to the emergency department were not the ones who had originally planned to go.(Ontario Auditor General)

The Auditor General of Ontario rveiewed the program for the 2008/2009 fiscal year. The office found “that those who used Telehealth Ontario were generally satisfied. However, only a small portion of Ontario’s population uses the services. In addition, based on our analysis of information at the service provider, as well as practices in other jurisdictions, there are improvements that could be made to enhance the services for Ontarians.”

They also found the program has incomplete penetrance with the Ontario health consumer. “Not only has the number of calls to teletriage services been declining over the last few years, but the number of calls as a proportion of the population is significantly less in Ontario than is the case in Alberta and Quebec. Ontario had 905,000 calls to teletriage services in the 2008/09 fiscal year, out of Ontario’s population of 12.2 million, while Quebec’s Info-Santé received 2 million calls out of a population of 7.4 million and Health Link Alberta received 1 million calls out of a population of 3.3 million. One reason may be that the Ministry did minimal advertising of the services during 2007 and 2008. We also noted that the number of calls concerning seniors as a proportion of Ontario’s senior population was low—only 4% (72,000 calls out of a population of 1.6 million).” Furthermore, “in the 2008/09 fiscal year the teletriage services received more than 1.1 million calls, and nurses responded to 905,000 of those calls. Our analysis indicated that a maximum of 650,000 unique callers, or about 5% of Ontario’s 12.2 million population, made those calls: that is, the total included about 250,000 calls made by individuals who had already called at least once before during that fiscal year. “The program calls for nurses with three years of clinical experience to man the phone lines.

The Auditors review found that “Although the service provider had indicated in its proposal submitted to the Ministry in 2007 that its nurses would have at least three years of any type of nursing experience, its policies require nurses to have one to three years of clinical experience. We noted from our sample of nurses hired in 2008 that 23% had less than one year of acute-care experience, and 20% had less than three years of total nursing experience.” Telehealth adbvice cannot be provided by health care rookies without the expectation that there will be more referrals into the department as a result of lack of confidence of the service provider.

A particular concern si the issue of the elderly and chronic disease management being conducted in the ER. The Auditor found: “8% of telehealth calls concerned seniors aged 65 and older. Although there are more than 1.6 million seniors in Ontario (about 14% of the province’s population), fewer than 72,000 (about 4% of Ontario’s seniors) of the calls to teletriage services concerned seniors. Of the seniors who responded to our independent survey and were aware of Telehealth Ontario, 44% indicated that they did not call it because they would rather contact a doctor directly.

The service is also not cheap and out of line with other Canadian provincial health lines. “In 2008/09, the Ministry paid the service provider about $39 for each of the first 900,000 registered calls to teletriage services, and about $27 per call after that. The three other provinces that shared cost information with us indicated that their teletriage services costs were about $20 per call. The Ministry had not conducted any work aimed at determining the reason for the significant difference between Ontario’s costs and the costs in other provinces.”

Auditing of the program seems too in-house and often is not done:”During 2008, at one call centre, no call audits were conducted for three months and only five audits a month were conducted for another three months. We were informed that this situation had since been corrected. The service provider does not periodically analyze the results to determine whether there are any trends or systemic deficiencies in the call audit process or the quality of the advice provided.

“We noted that the service provider does not survey other stakeholders, such as family physicians and emergency departments. We noted that other provinces periodically survey health-care providers to determine their awareness of the province’s teletriage services as well as their opinion about the value of the services. The jurisdictions we spoke to indicated that health-care professionals’ support and acceptance of the teletriage services was crucial to the success of their programs.”

All in all it sounds like a program that is fundamentally broken, ineffective and expensive.

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