Chapter 10: The Future of Digital Health in Emergency Medicine
Preamble: The Lost Tourist
There are no quick solutions to fixing Canada’s emergency care systems. The reality is that pre- pandemic, our EDs were already overcrowded, patients waited too long, and staff suffered from work stress. [1] Our efforts should not be directed towards turning the clock back to pre- pandemic conditions; rather, we should be focused on developing and implementing a blueprint for our ideal vision of Canada’s future emergency care.
The challenge of getting to that state from where we are is reminiscent of the lost tourist driving through rural Ireland who, when he comes across a farmer in a field, stops and asks him how to get to Dublin. The farmer thinks for a moment and replies, “Going to Dublin, are ya? I would not start from here.” Like the traveller, our starting place may not be the one we choose but is where we are.
There are a few key attributes of a better emergency care system we can work towards. One is meaningful horizontal integration with the rest of the healthcare system, especially primary care and community-based services. Too often in the ED we fly blind, with limited access to a patient’s medical history, care providers and prior investigations. Lacking the information to choose wisely, we choose safely, often ordering tests that would not otherwise be necessary. Similarly, our ability to connect patients for needed care or follow-up after ED discharge is often limited to ‘hope-and-a-prayer’ faxes, transmitted to clinics that may or may not agree to see the patient at some uncertain time in the future.
It is critical to ensure primary care and hospital records are available as part of a shared provincial electronic health record (EHR). [2] Better information sharing could also enable more cost-effective virtual emergency care. In some provinces today, the EHR—if it exists at all—consists only of a viewer with a somewhat random and incomplete collection of records in non-standard formats and timeliness. Accountability to populate EHR systems is also lacking: why not make payment for any publicly-funded healthcare service conditional on the real-time uploading of the clinical record to the EHR in a standard format?
A more integrated digital emergency care system will allow an actual appointment, with a date and time to be booked before the patient leaves the ED. Better yet why not have the patient book it themselves, at a time of their choosing? Such certainty gives both ED provider and patient peace of mind. It can also enable the physician to be more circumspect in ED investigations, knowing there will be a timely follow-up.
Giving patients access to their own health data (which increasingly patients are considered to own) will empower them, give them more control, the ability to manage their care, and help improve outcomes. [2] Access does not need to be one way; patients could also enter their own health data (such as biophysical measurements from wearables), [3] report their symptoms, [4], and outcome measures, [5], which are critical to understanding the important results of ED care.
Finally, we must consider whether those we think of as ‘lost ED tourists’ do not see themselves that way. While some patients would almost certainly seek care elsewhere if alternatives were available and accessible, many others decide to go to the emergency department simply because they believe they need care there. [6] The ED provides a one-stop shop for medical assessment, labs tests, imaging, treatment, and consultation with specialists if needed.[10] Many patients know through personal experience that if they look for care elsewhere, they will likely be sent to the ER anyway. Efforts to focus on ‘real’ emergencies by limiting ED access for so-called inappropriate patients may be destined to fail. [7] Societal expectations may be partly at play; many patients today are used to getting what they need when they need it in the most convenient way (think Amazon, Uber Eats or online banking). The ED as a one-stop-shop may be the health system’s version to this phenomenon. Rather than devising strategies to reverse these trends, like generals planning to fight the last war, perhaps we need to embrace the fact that today’s patients are voting with their feet, and plan accordingly.
This requires re-imagining EDs and building the necessary digital integration with primary and community care. The answer lies in an integrated care network with:
Improved supports for older persons with frailty.
Better mental health, addiction, and social services.
Enhanced access to 24/7 diagnostic testing.
A full suite of follow-up clinic and services accessible in the ED.
Although this may seem overly optimistic, the truth is innovative examples are increasingly found in our system but remain a patchwork. These range from EDs designed with specific supports for geriatric care, [8][9] pathways for rapid low-barrier access to addiction services, [10] and homeless shelter services integrated with EMS. [11] They must be scaled up and properly funded, with adequately trained members of a diverse healthcare team.
In this journey of health system transformation, all of us—patients and providers alike—are lost travelers, and it’s a long way to Dublin. If we are ever to find our way, we must envision and then build an innovative and integrated future state for emergency care together, using all the tools at our disposal.
Introduction
This chapter aims to map out the current landscape of Digital Health (DH) and Virtual Care (VC) in emergency medicine, identify opportunities and areas of concern, and propose a roadmap where these tools can be effectively embraced as integral parts of our discipline. We take it as self-evident that Canada should continue to advance the meaningful use and adoption of interoperable electronic health records. They enable healthcare providers to access and exchange patient data easily, even between different EHR platforms. For example, computerized provider order entry, where patient data is recorded electronically, allows doctors and healthcare providers to manage care orders such as prescriptions, tests, or treatments.
Below, we focus on VC as well as some emerging technologies that could make a valuable contribution to emergency care.
The Pros and Cons of Digital Health and Virtual Care
Digital Health (DH) encompasses a rapidly advancing collection of technology-enabled tools to improve access to healthcare services and information. The Health Information and Management Systems Society (HIMSS) states that, “Digital health connects and empowers people and populations to manage health and wellness, augmented by accessible and supportive provider teams working within . . . digitally-enabled care environments that strategically leverage digital tools, technologies and services to transform care delivery.” [12]
The World Health Organization (WHO) identifies three key objectives in adopting and scaling up DH to “accelerate global attainment of health and wellbeing”: [13]
Translating the latest data, research, and evidence into action.
Enhancing knowledge through scientific communities of practice.
Systematically assessing and linking country needs with supply of innovations.
Emergency medicine can capably contribute to all three objectives through health services research and implementation in urgent and emergency care domains.
While the potential for DH to transform healthcare has been recognized for several decades, the pandemic precipitated its rapid and massive clinical adoption through Virtual Care services and remote patient monitoring. [14] These practices facilitated the delivery of services, while maintaining social isolation to avoid viral transmission, in compliance with public health policies. The rapidity of DH adoption led to both opportunities [15] and challenges [16] for emergency medicine.
On the one hand, appropriate use of DH and VC can potentially reduce emergency department surges, overcrowding and long wait times. It can provide support and knowledge exchange with colleagues practicing in rural communities, as well as supporting safe discharge and patient self-management through remote monitoring.
On the other hand, flawed design and implementation can result in paradoxical overcrowding of EDs through poor VC case management by health professionals who unnecessarily send patients to the emergency for care. Additionally, VC’s attractive practice and compensation models can draw emergency physicians away from the ED where they are most needed.
It’s essential to purposefully integrate these approaches with traditional emergency medicine service delivery; they can maximize patient safety and convenience, and provide value to the healthcare system. Working towards a future of hybrid care [17] that fulfills the Quintuple Aim will preclude the need to choose between VC or in-person care, but rather encourage the thoughtful combination of both to optimize emergency health service delivery and transform our specialty. [18]
How Can Digital Health Creatively Support EM?
VC is the best-known and most widely used type of digital health in emergency medicine. COVID-19 provided the impetus for many hospital-led VC programs across the country. Their adoption aimed to preserve the healthcare system’s scarce in-person resources, while increasing access to care. Some EDs in Ontario began offering a virtual ED for patients with urgent, but non-life-threatening concerns.
Prior to the pandemic, other emergency VC services included telemedicine to support prehospital care. [19] Patients in BC and Alberta who contacted 811 were triaged by a nurse to attend an ED, and instead were assessed virtually by an emergency physician. The preliminary results were promising, with such physicians safely and cost-effectively diverting a significant number of patients away from the emergency department. [20][21]
Post-pandemic, EDs face overcrowding and long wait times. [22][23] VC can mitigate this, as evidenced by British Columbia’s HEiDi project, which resulted in high patient satisfaction and ED avoidance in lower acuity cases. [20] DH is especially beneficial for healthcare providers if VC is accessed with provincial health records; this offers seamless communication with primary care, along with more transparent and efficient prescribing of diagnostics and therapies.
Patients who need emergency care can benefit from home monitoring and wearable technologies which can be divided into out-of-hospital and in-hospital devices. In the community, these can be paired with smartphone apps that can detect chronic deteriorating health conditions, such as rhythm changes in patients with atrial fibrillation, track changes in spirometry (breathing capacity) in those with lung disease, [24][25] and measure adherence to oral medications. [24] Monitoring medications after discharge from an ED can help patients recovering from acute injury, tracking opioid use for example. [26] Other wearables are specifically designed to act as an overall health safety net, capable of tracking and automatically alerting family and/or healthcare providers about changes in vital signs, and potential falls. [27] In hospital, wearables can monitor patient vital signs, and remote telemetry can gather real-time information on patients who are not in a physical space with monitors. [28] Given worsening crowding problems in Canada’s EDs, this could be particularly beneficial.
In the future, machine learning (ML) and artificial intelligence (AI) will play important roles in the ED. While the black box of AI functionality, privacy and medical liability need to be addressed, there is no doubt it can lessen cognitive load and stress by adding a level of predictive modelling to medical decision-making for physicians. [29-31] AI has demonstrated promise in helping to interpret diagnostic imaging and predicting fatal infections like sepsis. It has also been able to assess patients who may suffer a lack of blood flow to the brain and might be at risk of a future cardiac event. Recent leaps in large language processing, such as ChatGPT, suggest AI’s added potential to help provide detailed medical records based on short instructions, without providers having to create a template.
The Challenges of Incorporating DH and VC into Emergency Medicine
VC in medicine is well over a century old, [32] and remote communities in Canada have used it to help treat emergency patients well before the COVID-19 pandemic.
Nevertheless, there are ongoing challenges that must be addressed, including:
Data security concerns and privacy.
Limited physical exam options.
Health equity concerns, for example the risk of alienating vulnerable groups due to technology and access issues. The homeless, older persons and new immigrant populations are prime examples.
The perception among many emergency physicians that virtual visits have increased ED visits. A recent study by Kiran et al demonstrated that physicians with a high proportion of VC did not have higher ED visits for their patients than those who provided the lowest levels of virtual care. [33] Further study, addressing the full spectrum of ED-UC VC, is needed.
Workforce issues, including those in which the limited resource of emergency physicians is drawn to less onerous, but less essential work in certain VC settings
The loss of in-person care, which could adversely affect the culture of emergency medicine and the benefits accrued from face-to-face care contact between doctor and patient.
The Canadian Medical Protective Association (CMPA) has set out the following additional challenges that must be considered when providing VC: [34]
Risk of exacerbating the fragmented approach to healthcare across Canada.
Inconsistency in standards and guidelines regarding when it is reasonable to use virtual care.
Lack of proper infrastructure and training on the various modalities of virtual care.
Lack of access to secure virtual care platforms.
A major concern is the private involvement in DH development. While innovation is welcome and fuelled by entrepreneurship, careful guardrails are needed to ensure that private interest does not influence the processes or privacy of care. [35,36] Precious resources must be focused on safe public delivery of ED care—and not on DH privatization.
Visioning the Future with Digital Emergency Medicine
The need for emergency medical services continues to rise, resulting in a shortage of resources and an overwhelming workload for EM practitioners. The situation has been extensively described elsewhere in this report overcrowded EDs, long wait times, and limited availability of essential supplies and equipment. DH includes a set of invaluable tools to help emergency care systems scale up services, improve patient outcomes, reduce mortality and morbidity, and better manage data to deliver healthcare. [37] DH must not replace in-person care, with its attendant tangible and intangible benefits, but can augment and complement its overall provision.
DH should also be considered an adjunct to human resources. ED staff can actively participate to integrate and implement DH into the clinical workflow by identifying the “why, what, how” of DH projects and prioritize them in specific purposes. ED leaders are encouraged to participate in DH research and implementation in an integrated manner within the community healthcare system (hospital, primary care, mental health program, etc.) as well as within provincial, national, and international networks.
Conclusion
Digital and technological innovations are scaling rapidly, and medicine continues to adopt and implement the best of them into every specialty. In a future not too far from now, DH will transform medicine. Metabolomic (the study of small molecules in a cell or tissue) and genomic (gene-related) findings mean treatments can be customized to a person’s genetic makeup. This will change the way we treat patients, choose and tailor pain medications, antibiotics, or anti-depressants for instance. AI will accelerate notetaking and prescribing, [38] as well as helping to monitor patients, and detect diseases in early stages. These areas of research will open doors to personalized diagnostics and treatment. Emergency medicine leaders must be proactive by integrating these technologies to enable the best possible patient outcomes.
DH is an inevitability in emergency care. The question is not whether DH will be adopted, but rather how technology can help forge a path to achieve the Quintuple Aim of improved patient experience, better population outcomes, lower costs, an empowered workforce, and health equity for all Canadians. The latter two are worth reiterating: if DH proves a burden to providers, and inaccessible to our most vulnerable, this technological revolution will be met with resistance rather than acceptance. It’s therefore imperative to understand both the vast potential and the pitfalls of DH, so we can choose future applications and resource allocations wisely.
Recommendations for Digital Health in the EM
EM leaders in Canada must work together with all stakeholders to build a DH record system which allows access for both patients and direct healthcare providers.
To achieve this, health information systems should be integrated at regional, as well as F/P/T levels.
Emergency physicians must embrace leadership and stewardship roles in DH, to ensure that the most effective initiatives are supported and that precious public resources are not diverted to frivolous ventures or privatization of DH.
EM specialists should assume key roles in the regulation of DH applications in healthcare by way of legislation and government policies.
Departments of EM and EM professional societies should collaborate in national and global translational (practically-oriented) research to best apply digital heath’s strengths to EM’s needs.
EM training and professional development should be reviewed to ensure core competencies related to the use of DH are taught.
Digital health should be a focus of quality improvement initiatives at hospital EDs and academic ED departments.
Appropriate consideration should be given to the varying levels of digital literacy, access, and education in Canada’s populations to help prevent barriers to the equitable and fair implementation of digital ED health. [39,40]
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