Policy changes related to telemedicine that were quickly implemented during the novel coronavirus pandemic (COVID-19) have created opportunities for technology-based clinical evaluation,

What does this shift in policy mean for Emergency Department (ED) medical providers who are governed by the Emergency Medical Treatment and Labor Act (EMTALA) and must complete legally-defined medical screening exams (MSEs)?

Vanderbilt University Medical Center emergency medicine physicians analyzed the safety, legality and technical factors necessary for implementing electronic personal protective equipment (ePPE) in an article published online in the Journal of the American Medical Informatics Association (JAMIA).

"This policy shift presents an opportunity for the use of ePPE to facilitate on-site ED MSEs without physical contact. This represents a novel strategy to maintain patient access to emergency evaluation and treatment while keeping providers safe and conserving PPE," the authors write.

Electronic PPE consists of telemedicine tools used by on-site emergency providers, such as FaceTime, Skype and Zoom, to evaluate patients who present to the ED with COVID-19 symptoms but are low-risk for complications.

"We liken this approach to the use of two-way phones on opposite sides of glass windows...instead of glass and phones, we advocate for tablets in environments where physical construction of such barriers is not feasible," said first author and emergency medicine physician Rob Turer, MD, who is also a clinical fellow in Biomedical Informatics.

A systematic review of emergency telemedicine found this approach is effective for minor, low-acuity situations and for consultations. Low-risk patients are classified as having reassuring vital signs, few comorbidities, and chief complaints suggesting lower respiratory infection (fever, cough, shortness of breath).

EMTALA was passed as part of the Social Security Act in 1986 by Congress to ensure public access to emergency services, regardless of ability to pay. Generally, EMTALA protects patients, but its role in emergency telemedicine is still evolving.

"Within this context, we propose that MSEs facilitated by electronic means where both clinician and patient are physically present within the ED, but in separate rooms, would allow for rapid and effective evaluation while putting neither patient nor clinician at infectious risk and conserving physical PPE for sicker patients," Turer said.

Based on the research team's review of EMTALA-related precedent and recent waivers relaxing software requirements, ePPE-based exams for low-risk patients meets the requirements as an MSE. If the provider determines that a more in-depth physical exam is needed or the patient requires additional testing or treatment, the ePPE-based visit can progress to a traditional ED visit.

The authors recommend using a streamlined electronic health record-based note to facilitate documentation, guided by local information technology standards and expedited review by compliance committees for adherence to local policy. They also recommend documenting within the medical record that an MSE was performed using electronic PPE.

"We recommend using ePPE to protect staff and conserve PPE while providing rapid access to emergency care and fulfilling EMTALA obligations for low-risk patients during the coronavirus pandemic," the authors write. "ePPE has potential applicability to settings such as emergency medical services, medical wards, and intensive care units, where ePPE may facilitate more frequent patient contact while reducing staff exposure and conserving PPE."

Contributing authors include Ian Jones, MD; S. Trent Rosenbloom, MD, MPH; Corey Slovis, MD; and Michael J. Ward, MD, PhD.