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Virtual Medical Care
Topic Collection
March 12, 2020

Topic Collection: Virtual Medical Care

The continuing increase in the use and capabilities of virtual medical care (also referred to as telemedicine, although care may be provided via telephone, web, or other means) has led many in the emergency medical  community to plan or implement call centers and web- or telephone-based triage and treatment systems in anticipation of and during public health emergencies. Additionally, health systems are using virtual platforms to coordinate care and provide remote access to specialty care and assessment (e.g., trauma, stroke, and psychiatric) which can be leveraged during disasters to broaden access to specialty consultation (e.g., for patients with burn injuries or pediatric patients). These resources highlight strategies for implementing virtual medical care during a disaster, including lessons learned from recent events.  

Each resource in this Topic Collection is placed into one or more of the following categories (click on the category name to be taken directly to that set of resources). Resources marked with an asterisk (*) appear in more than one category. Additional information can be found in the following Topic Collections: Influenza Epidemic/ Pandemic; Natural Disasters; SARS/MERS; and Utility Failures.

 

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Must Reads

American Academy of Family Physicians. (2019). Telemedicine.
This webpage provides an overview of key issues related to telemedicine for physicians to reference, including: how to locate resources to support the implementation of telemedicine; how telehealth resource centers can assist providers; legal, regulatory, and licensure issues; and reimbursement issues.
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Association of State and Territorial Health Officials and National Association of County and City Health Officials. (2012). Preliminary Report on the Role of Flu Information and Triage Lines in Reducing Surge in Healthcare Facilities and Increasing Access to Antiviral Medication During the 2009 H1N1 Pandemic.
This report summarizes the experience of jurisdictions across the country using hotlines and call centers to support the response to the 2009 H1N1 influenza pandemic. Algorithms for antiviral distribution; legal opinions on the use of hotlines; risk communication documents; and standing orders are included in the appendices.
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Bassett, J. (2019). Telemedicine in a Hurricane. EMSWorld.
This article describes how telemedicine was used to connect the Chief Medical Officer of an ambulance company located at the company’s base with ambulances on site in Florida following Hurricane Michael in 2018. The main benefit of this care model is noted as “being able to complete assessments and treatments in a patient’s residence that would otherwise require transport to the hospital, thus keeping ambulance crews on the street and able to help more people."
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Bogdan, G., Scherger, D., Seroka, A., et al. (2007). Adapting Community Call Centers for Crisis Support: A Model for Home-Based Care and Monitoring. U.S. Department of Health and Human Services.
The authors explain the development, testing, and implementation of a model to enable community health call centers (e.g., poison control centers, nurse advice lines) to support home-management and shelter-in-place approaches in certain mass casualty or health emergency events. The report includes a matrix with possible call center capabilities aligned with National Planning Scenarios and other guidance that can be tailored by call centers.
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Gonzalez, M. and Langabeer, J. (2017). Mobile Innovations and Telehealth in Emergency Care. Healthcare Information and Management Systems Society.
This presentation discusses how the city of Houston, Texas Emergency Medical Services (EMS) integrated telehealth into pre-hospital care to more efficiently and effectively manage non-emergent cases. Under the program described, only 16% of cases needed transport to the Emergency Department following a videoconference with an Emergency Medicine physician, which resulted in ambulances being back in service 39 minutes sooner, on average, as compared to standard disposition protocols. Such time savings could be significant during disaster response and recovery operations.
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Healthcare Ready. (2019). Telehealth's Applications for Preparedness and Response.
This well-organized 22 page issue brief highlights how telehealth is being used in disaster preparedness and response and summarizes the challenges and potential solutions associated with this mechanism of healthcare delivery.
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Interstate Medical Licensure Compact. (2019). Interstate Medical Licensure Compact.
This webpage provides information on the Interstate Medical Licensure Compact, an agreement between 29 states, the District of Columbia and the Territory of Guam, where physicians are licensed by 43 different Medical and Osteopathic Boards. Under this agreement licensed physicians can qualify to practice medicine across state lines within the Compact if they meet the agreed upon eligibility requirements.
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National Association of County and City Health Officials. (2014). Nurse Triage Line Project Webinar Discussion with Public Health Law Workgroups.
This is a summary of a webinar focused on the Nurse Triage Line Project (including lessons learned from H1N1) that included representation from the public health law workgroups of the National Association of County and City Health Officials (NACCHO), the Association of State and Territorial Health Officials (ASTHO), and the Council of State and Territorial Epidemiologists (CSTE). Participants discussed how a coordinated network of telephone triage lines may be useful during a severe pandemic or other public health emergency; legal issues and concerns that may be associated with using such a network; and possible solutions.
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Oak Ridge Institute for Science and Education. (2009). Coordinating Call Centers for Responding to Pandemic Influenza and Other Public Health Emergencies: A Workbook for State and Local Planners. Centers for Disease Control and Prevention.
This workbook guides planners through the process of determining the need for a call center, as well as how to operationalize a call center during public health emergencies.
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Sorenson, G. (2018). 3 Steps to Telemedicine Disaster Preparedness.
The author proposes 3 steps for telemedicine disaster preparedness: Acknowledge telemedicine as a Standard of Care; establish tools and workflows before disaster strikes; and form partnerships between public and private organizations.
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Spaulding, A.B., Radi, D., Macleod H., et al. (2013). Satisfaction and Public Health Cost of a Statewide Influenza Nurse Triage Line in Response to Pandemic H1N1 Influenza. Plos One. 8(1):e50492.
The authors describe the successful use of a telephone nurse triage line (NTL) set up by the Minnesota Department of Health for evaluating individuals with influenza-like illness and tele-prescribing of anti-virals. The NTL diverted callers from acute care visits at low cost and had a high rate of satisfaction among callers.
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Telligen and gpTRAC. (2014). Telehealth Start-Up and Resource Guide: Version 1.1.
This collaborative resource was created “to provide an overview and framework for implementing telehealth in critical access hospitals and rural areas.” It includes a listing of research related to telehealth and outcomes, and lessons learned and best practices from organizations that successfully implemented telehealth programs and contributed to this document.
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The University of New Mexico School of Medicine. (2016). Project ECHO.
The Extension for Community Health Outcomes (known as Project ECHO) was created to help healthcare providers in rural and underserved areas with information they need to treat conditions such as Hepatitis C, chronic pain, and behavioral health disorders. In the event of a disaster, one or more of ECHO's "hubs" could assist with virtual healthcare education and consultation / provider collaboration.
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Applications for Telemedicine

Case, T., Morrison, C., and Vuylsteke, A. (2012). The Clinical Application of Mobile Technology to Disaster Medicine. (Abstract only.)Prehospital and Disaster Medicine. 27(5):473-80.
The authors conducted a literature review covering 2007-2012 to identify mobile health care technology solutions to aid in disaster management. They found five types of applications: disaster scene management; remote monitoring of casualties; medical image transmission (teleradiology); decision support applications; and field hospital information technology (IT) systems, most of which were still under development at the time of their review.
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Parvizi, D., Giretzlehner , M., Dirnberger, J., et al. (2014). The Use of Telemedicine in Burn Care: Development of a Mobile System for TBSA Documentation and Remote Assessment. Annals of Burns and Fire Disasters. 27(2):94-100.
The authors describe a mobile application that uses digital images of patients' burns superimposed on a patient-specific 3D model. The application was found to more accurately estimate burn size than burn experts when tested at two separate international burn meetings.
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* Xiong, W., Bair, A., and Sandrock, C. (2010). Implementing Telemedicine in Medical Emergency Response: Concept of Operation for a Regional Telemedicine Hub. Journal of Medical Systems. 36(3): 1651-1660.
The authors developed and measured a model application in order to quantitatively analyze the potential health benefits of telemedicine in disaster response. They found that the model can support disaster response activities and enhance surge capacity; enhance the speed and effectiveness of medical response; and improve resource and operations planning, as well as internal and external situational awareness.
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Yperzeele, L., Van Hooff, R.J., De Smedt, A., et al. (2014). Feasibility of AmbulanCe-Based Telemedicine (FACT) Study: Safety, Feasibility and Reliability of Third Generation In-Ambulance Telemedicine. PLoS One. 9(10):e110043.
The authors tested an in-ambulance telemedicine system and found that pre-hospital diagnoses were in agreement with final diagnoses 90% of the time; pre-notification of the hospital via text message was successful 90% of the time; and transmission of a pre-hospital report was completed 95% of the time. Challenges experienced were related primarily to limited connectivity, but also to hardware, software, or human error.
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Call Centers and Triage Lines

Adhikari, B.B., Koonin, L.M., Mugambi, M.L., et al. (2018). Estimating Weekly Call Volume to a National Nurse Telephone Triage Line in an Influenza Pandemic. (Abstract only.) Health Security. 16(5):334-340.
The authors developed a Call Volume Projection Tool to estimate national call volume to Flu on Call® during an influenza pandemic. They extrapolated data from the 2009 experience of the Minnesota FluLine (during the H1N1pandemic) and applied it to a 20% attack rate, and case hospitalization rates from the 1968 and 1957 pandemics, respectively, to provide an estimated national weekly call volume.
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* Association of State and Territorial Health Officials and National Association of County and City Health Officials. (2012). Preliminary Report on the Role of Flu Information and Triage Lines in Reducing Surge in Healthcare Facilities and Increasing Access to Antiviral Medication During the 2009 H1N1 Pandemic.
This report summarizes the experience of jurisdictions across the country using hotlines and call centers to support the response to the 2009 H1N1 influenza pandemic. Algorithms for antiviral distribution; legal opinions on the use of hotlines; risk communication documents; and standing orders are included in the appendices.
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* Bogdan, G., Scherger, D., Seroka, A., et al. (2007). Adapting Community Call Centers for Crisis Support: A Model for Home-Based Care and Monitoring. U.S. Department of Health and Human Services.
The authors explain the development, testing, and implementation of a model to enable community health call centers (e.g., poison control centers, nurse advice lines) to support home-management and shelter-in-place approaches in certain mass casualty or health emergency events. The report includes a matrix with possible call center capabilities aligned with National Planning Scenarios and other guidance that can be tailored by call centers.
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Center for Infectious Disease Research and Policy (CIDRAP) at the University of Minnesota. (2013). Using Hotlines in Disaster Preparedness and Response.
This webpage summarizes examples of the way that hotlines have been used to support disaster preparedness and response.
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Fernandez, J.B., Glotzer, D.L., Triola, M.M., and Psoter, W.J. (2008). A Unique Role for Dental School Faculty: Telephone Triage Training and Integration into a Health Departments' Emergency Response Planning. American Journal of Disaster Medicine. 3(3):141-6.
The authors describe a pilot program in which dental school faculty members received training in outbreak investigation and telephone triage to assist the New York City Department of Health and Mental Hygiene in preparing to respond to pandemic influenza. They propose the use of dental professionals and/or other "nontraditional healthcare personnel" in support of call centers and telephone triage lines.
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* Kelly, M. (2018). DC’s New 911 Nurse Triage Program. Annals of Emergency Medicine. 72(4): A15–A17.
This article discusses the successes and challenges experienced by Washington DC since integrating triage nurses into its 911 Call Center in April 2018. Logistical, medical, and financial (including insurance) considerations are presented, and may assist other jurisdictions in developing a similar model, which could support disaster response and recovery through efficient management of ambulance services.
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Koonin, L. and Hanfling, D. (2013). Broadening Access to Medical Care During a Severe Influenza Pandemic: The CDC Nurse Triage Line Project. Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science. 11(1):75-80.
The authors describe the Centers for Disease Control and Prevention's Nurse Triage Line Project and its goals of using a coordinated network of nurse triage telephone lines during a pandemic to assess the health status of callers, help callers determine the most appropriate site for care, disseminate information, provide clinical advice, and provide access to antiviral medications to those who need it.
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National Association of County and City Health Officials. (2017). Flu on Call: Increasing Access to Care and Treatment during Pandemic Influenza.
This webpage includes information about Flu on Call®, an initiative modeled on successful statewide projects that were implemented during the 2009 H1N1 pandemic to establish a national network of telephone help lines designed for use during a severe influenza pandemic. Links to a toolkit, frequently asked questions (FAQs), and relevant publications are included.
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* National Council of State Boards of Nursing. (2012). Nurse Triage Lines: Improving Access, Informing the Public.
This presentation discusses how Nurse Triage Lines (NTLs) may be used during disasters and includes an assessment of laws and regulations that impact the ability to set up NTLs in each state. Minnesota's experience during H1N1, and the CDC's Nurse Triage Line Project, are also discussed.
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* Oak Ridge Institute for Science and Education. (2009). Coordinating Call Centers for Responding to Pandemic Influenza and Other Public Health Emergencies: A Workbook for State and Local Planners. Centers for Disease Control and Prevention.
This workbook guides planners through the process of determining the need for a call center, as well as how to operationalize a call center during public health emergencies.
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Russi, C.S., Beuning, A.J., Powell, R.S. et al. (2018). The Impact on Emergency Department Visits With a Telemedicine Program Interfacing With a Nurse Triage Call Line. Annals of Emergency Medicine. 72(4): S116–S117.
The authors discuss a 3-week observational study they conducted to determine outcomes from a triage protocol that had an emergency medicine physician consult with a triage line nurse, or with a patient directly, when the triage line nurse determined from call line disposition algorithms that a patient should be seen in the Emergency Department (ED). They concluded that this model could safely mitigate some unnecessary ED usage.
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Spaulding, A., Radi, D., Macleod, H., et al. (2012). Design and Implementation of a Statewide Influenza Nurse Triage Line in Response to Pandemic H1N1 Influenza. Public Health Reports. 127(5): 532-540.
The Minnesota Department of Health developed several tools to support healthcare providers during the 2009 H1N1 influenza pandemic, including MN FluLine, a nurse triage line, that reached many rural and uninsured residents, and, according to the authors, may have prevented up to 11,000 in-person health-care encounters.
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* Spaulding, A.B., Radi, D., Macleod H., et al. (2013). Satisfaction and Public Health Cost of a Statewide Influenza Nurse Triage Line in Response to Pandemic H1N1 Influenza. Plos One. 8(1):e50492.
The authors describe the successful use of a telephone nurse triage line (NTL) set up by the Minnesota Department of Health for evaluating individuals with influenza-like illness and tele-prescribing of anti-virals. The NTL diverted callers from acute care visits at low cost and had a high rate of satisfaction among callers.
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The University of New Mexico School of Medicine. (2016). Project ECHO.
The Extension for Community Health Outcomes (known as Project ECHO) was created to help healthcare providers in rural and underserved areas with information they need to treat conditions such as Hepatitis C, chronic pain, and behavioral health disorders. In the event of a disaster, one or more of ECHO's "hubs" could assist with virtual healthcare education and consultation / provider collaboration.
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* Yeager, V. (2009). Emergency Response, Public Health and Poison Control: Logical Linkages for Successful Risk Communication and Improved Disaster and Mass Incident Response. Homeland Security Affairs. 5:Article 2.
The author proposes bringing together the expertise of emergency response organizations, public health agencies, and poison control centers to institute call centers and/or triage lines to disseminate information to the public during emergencies, and answer questions and concerns to keep concerned individuals from flooding local emergency rooms. Real-world examples of successful collaborations from Canada, Great Britain, and the U.S. are included.
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Event-Specific Lessons Learned

* Association of State and Territorial Health Officials and National Association of County and City Health Officials. (2012). Preliminary Report on the Role of Flu Information and Triage Lines in Reducing Surge in Healthcare Facilities and Increasing Access to Antiviral Medication During the 2009 H1N1 Pandemic.
This report summarizes the experience of jurisdictions across the country using hotlines and call centers to support the response to the 2009 H1N1 influenza pandemic. Algorithms for antiviral distribution; legal opinions on the use of hotlines; risk communication documents; and standing orders are included in the appendices.
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Bassett, J. (2019). Telemedicine in a Hurricane. EMSWorld.
This article describes how telemedicine was used to connect the Chief Medical Officer of an ambulance company located at the company’s base with ambulances on site in Florida following Hurricane Michael in 2018. The main benefit of this care model is noted as “being able to complete assessments and treatments in a patient’s residence that would otherwise require transport to the hospital, thus keeping ambulance crews on the street and able to help more people."
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BlueCross and BlueShield of Texas. (2018). What BCBSTX Learned From Hurricane Harvey Insurance Claims.
BlueCross BlueShield of Texas reviewed member claims for the 6 months post-Harvey and compared them to the same time period the previous year and found that “many people turned to technology in the form of telemedicine for the first time.” There was a rise in mental and physical health conditions such as post-traumatic stress disorder (PTSD), as well as infectious and parasitic diseases post-Harvey. The claims data also showed an increase in substance abuse, pneumonia and Chronic Obstructive Pulmonary Disease (COPD).
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Center for Infectious Disease Research and Policy (CIDRAP). (2013). Using Hotlines in Disaster Preparedness and Response. Public Health Practices Brief.
This webpage provides links to multiple examples of the way that hotlines have been used to support disaster preparedness and response.
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Cimons, M. (2018). When There's a Hurricane Between You and The Hospital, Telemedicine Could Save The Day.
This article discusses key findings from the 2018 Usher-Pines, et al. paper, which analyzed the experiences of Doctor on Demand in the weeks following Hurricanes Harvey and Irma in 2017. Study data showed that use of the service peaked three to six days after the hurricanes made landfall, with patients seeking treatment for “chronic conditions, advice, counseling and refills, and back and joint concerns, including injuries.” Notably, referral rates for in-person care were in line with those seen in telemedicine during non-emergency times.
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Cohen, J. (2019). Telemedicine for Disaster Relief: MDLive's Dr. Deborah Mulligan on Responding to Hurricane Harvey. Becker’s Hospital Review.
This resource is a transcript from an interview discussing the use of a specific telemedicine system to provide medical care after Hurricane Harvey. It includes a good characterization of the types of nonemergency medical needs a community may have after a disaster, as well as the role telemedicine can play in response.
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Der-Martirosian, C., Chu, C., Griffin, A., and Dobalian, A. (2018). Telehealth at the US Department of Veterans Affairs after Hurricane Sandy. (Free registration required.)Journal of Telemedicine and Telecare.
This paper identifies the types of Veterans Affairs telehealth services used following Hurricane Sandy (2012) during the 7 months the Manhattan Veterans Affairs Medical Center, and examines the patient characteristics of those users. The most commonly used telehealth services included those for primary care, triage, mental health, home health, and ancillary services.
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Glatter, R., Platt, S., and Pagan, N. (2018). How Telemedicine Can Improve Our Disaster Response.
The presenters in this 17-minute video discuss New York Presbyterian Hospital’s experience leveraging its telemedicine program to bring specialty consultation to Puerto Rico after Hurricane Maria in 2017. They discuss the lessons learned from their experience, which include allowing for time to obtain necessary regulatory approvals, and having the needed equipment and connectivity to successfully establish a telemedicine program to support a disaster-stricken area.
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Grielsamer, A. (2018). VHA’s Telehealth Emergency Medicine Uses Holiday to Test Systems, Prepare for Emergency Responses. U.S. Department of Veterans Affairs, VAntage Point.
The VA’s Telehealth Emergency Medicine team exercised its signal strength capabilities during the July 4th, 2018 holiday on the National Mall to demonstrate how VA technologies could be used during an emergency. This exercise could serve as a reference for other entities when developing testing plans for their respective telemedicine systems.
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Healthcare Ready. (2019). Telehealth's Applications for Preparedness and Response.
This well-organized 22 page issue brief highlights how telehealth is being used in disaster preparedness and response and summarizes the challenges and potential solutions associated with this mechanism of healthcare delivery.
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Heath, S. (2018). DTC Telehealth Ups Patient Access to Care in Natural Disasters. Patient Engagement HIT.
This article reviews findings from the 2018 Uscher-Pines study that looked at telemedicine use by individuals affected by hurricanes Harvey and Irma. Notably, diagnosis codes for the first 7 days of the study were consistent with those for the remaining study days—31% of patients presented with acute respiratory issues, while 8% had rash and dry skin concerns. In addition, researchers found that 63% of patients were new telemedicine users, and that most accessed the service between days 3 and 6 post-disaster.
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Hofmeyer, J., Leider, J., Satorius, J., et al. (2016). Implementation of Telemedicine Consultation to Assess Unplanned Transfers in Rural Long-Term Care Facilities, 2012–2015: A Pilot Study. (Abstract only.)The Journal of Post-Acute and Long-Term Care Medicine. 17(11): 1006–1010.
The authors describe the development of a telemedicine approach to assess residents from rural long-term care facilities for potential (costly) ransfer to hospitals. The pilot test was promising, as it reduced stress levels and costs associated with transfers.
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Kim, T.J., Arrieta, M.I., Eastburn S.L., et al. (2013). Post-disaster Gulf Coast Recovery Using Telehealth. Telemedicine Journal and E-Health. 19(3):200-10.
The authors, whose work focuses on telemedicine to meet post-disaster mental health needs, conducted semi structured interviews with both regional key informants and national organizations with Gulf Coast recovery interests and determined seven factors for telehealth success: funding, regulatory, workflow, attitudes, personnel, technology, and evaluation. Included in this resource is also a discussion of prior research conducted on the use of telemental health services.
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Lurie, N. and Carr, B. (2018). The Role of Telehealth in the Medical Response to Disasters. (Abstract only.)JAMA Internal Medicine. 178(6):745-746.
The authors discuss the use and role of telehealth and how different modalities can be used to help manage disaster-related health effects.
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Maduro, R. (2017). Community Health Network in Houston Leverages Open Source Tech to Help Victims of Hurricane Harvey. Open Health News.
This blog discusses how a health center in Houston used open source technology to support the delivery of telemedicine services after Hurricane Harvey.
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Meehan, T. (2018). Applying Telehealth to Natural Disasters. Health Recovery Solution.
This article discusses telehealth use during past emergencies and disasters, including blizzard and loss of power by Massachusetts General Hospital in 2014 (wound imaging for follow-up of post-operative patients and general maintenance of appointments for patients with chronic illness), and Hurricane Ike in 2008 (wound imaging and video messaging for bites from bees, fire ants, or mosquitoes, wounds or rashes, and skin infections from contaminated floodwaters). It also reviews how telehealth can help with chronic disease monitoring and prescription refills following mass evacuations, and how it could support 911 triage and ambulance deployment.
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Mohr, N., Young T., Harland, K., et al. (2019). Emergency Department Telemedicine Shortens Rural Time-To-Provider and Emergency Department Transfer Times. (Abstract only.)Telemedicine Journal and E-Health. 24(8):582-593.
The authors reviewed incidents where 2,857 of 127,928 qualifying emergency department (ED) encounters consulted telemedicine. They found that telemedicine decreases ED door-to-provider time and length of stay, and they emphasize the need for future research on the impact of telemedicine in rural areas.
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National Association of County and City Health Officials. (2014). Nurse Triage Line Project Webinar Discussion with Public Health Law Workgroups.
This is a summary of a webinar focused on the Nurse Triage Line Project (including lessons learned from H1N1) that included representation from the public health law workgroups of the National Association of County and City Health Officials (NACCHO), the Association of State and Territorial Health Officials (ASTHO), and the Council of State and Territorial Epidemiologists (CSTE). Participants discussed how a coordinated network of telephone triage lines may be useful during a severe pandemic or other public health emergency; legal issues and concerns that may be associated with using such a network; and possible solutions.
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* National Council of State Boards of Nursing. (2012). Nurse Triage Lines: Improving Access, Informing the Public.
This presentation discusses how Nurse Triage Lines (NTLs) may be used during disasters and includes an assessment of laws and regulations that impact the ability to set up NTLs in each state. Minnesota's experience during H1N1, and the CDC's Nurse Triage Line Project, are also discussed.
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Park, B., Raegen, C., Caflisch, S., and Granovsky, M. (2019). Hurricane Florence and the Use of Telemedicine. ACEP Now.
In 2018, Hurricane Florence forced thousands to evacuate their homes in Wake County, NC. Six shelters were set up and a local telemedicine firm staffed them. Of the 95 patients seen over a 10 day period, nine were sent to the emergency room for further evaluation. Eighty percent reported that they would have gone to the emergency room had they not been cared for by a telemedicine provider.
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Piza, F., Steinman, M., Baldisserotto, S., et al. (2014). Is There a Role for Telemedicine in Disaster Medicine? Critical Care. 18(6): 646.
The authors describe the successful use of a telemedicine videoconferencing system to treat patients following a 2013 nightclub fire in Brazil.
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Rand Corporation. (2018). Direct-to-Consumer Telemedicine Can Deliver Routine Care to Affected People Following Natural Disasters.
This press release describes the findings of the 2018 Uscher-Pines, et al. report, “The Role of Direct-to-Consumer Telemedicine in Caring for People Impacted by Natural Disasters.” Specifically, the study found that the most frequent diagnoses during the first month post-hurricane included acute respiratory illnesses and skin problems, and “during the first week post-hurricane, telemedicine visits for chronic conditions, advice, counseling and refills, and back and joint concerns, including injuries, were more common among people affected by the hurricanes than among the other patients treated by the service.”
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Reichert, C. (2018). How the University of Virginia Delivered Telehealth to Ebola-Stricken Africa. ZDNet.
This article describes how the University of Virginia used telehealth to support communication with patients in isolation, as well as to allow health care professionals in PPE to visually consult with physicians back in the United States without having to doff their PPE.
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Siwicki, B. (2018). Telehealth Success Story: 97% of Harris County TB Patients Took Their Meds During Hurricane Harvey. Healthcare IT News.
During Hurricane Harvey and its aftermath in 2017, Harris County, Texas public health staff reached out to tuberculosis (TB) patients via mobile phone, landline or text messages to patients via its telemedicine application (app) to support medication compliance. Patients were given a month’s worth of medication prior to the storm, and asked to upload videos of themselves taking their medication through the app.
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* Spaulding, A.B., Radi, D., Macleod H., et al. (2013). Satisfaction and Public Health Cost of a Statewide Influenza Nurse Triage Line in Response to Pandemic H1N1 Influenza. Plos One. 8(1):e50492.
The authors describe the successful use of a telephone nurse triage line (NTL) set up by the Minnesota Department of Health for evaluating individuals with influenza-like illness and tele-prescribing of anti-virals. The NTL diverted callers from acute care visits at low cost and had a high rate of satisfaction among callers.
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Spitzer, J. (2017). Telemedicine Interest Surges During Hurricane Irma. Becker’s Hospital Review.
The author discusses patient demand for telehealth services from 2 Florida hospitals during Hurricane Irma in 2017. One saw a 554% increase in installation of its telemedicine application, and the other had more than 2,700 patients sign up over a 3-day period.
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* Telligen and gpTRAC. (2014). Telehealth Start-Up and Resource Guide: Version 1.1.
This collaborative resource was created “to provide an overview and framework for implementing telehealth in critical access hospitals and rural areas.” It includes a listing of research related to telehealth and outcomes, and lessons learned and best practices from organizations that successfully implemented telehealth programs and contributed to this document.
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Tintinalli, J. (2018). From the Front Lines of Hurricane Florence. Emergency Physicians Monthly.
The second story in this article discusses how telemedicine was implemented in shelters following hurricane Florence in 2018 to provide care, order prescriptions, and minimize transport to emergency departments (EDs). Emergency Medical Services (EMS) Branch Directors were assigned to each shelter, all of which had iPads to connect with the telemedicine application used by a local hospital ED, with power and internet service provided through generators and portable WiFi units.
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Uscher-Pines, L., Fischer, S.H., Tong, I., et al. (2018). Virtual First Responders: The Role of Direct-to-Consumer Telemedicine in Caring for People Impacted by Natural Disasters. (Abstract only.)Journal of General Internal Medicine. 33(8): 1242-1244.
The authors analyzed administrative data from Doctor on Demand in the 30 days following Hurricanes Harvey and Irma (August–September 2017) to characterize post-disaster telemedicine use. Use peaked on days 4-6 after landfall and 63% of the patients were first-time users.
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Van Oeveren, L., Donner, J., Fantegrossi, A., et al. (2017). Telemedicine-Assisted Intubation in Rural Emergency Departments: A National Emergency Airway Registry Study. (Abstract only.)Telemedicine Journal and E-Health. 23(4):290-297.
The authors reviewed data on 206 patients who had an intubation attempt while on a video telemedicine link from May 1, 2014 to April 30, 2015. The success rate (96%) matched those of large-center studies.
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Vo, A.H., Brooks, G.B., Bourdeau, M., et al. (2010). University of Texas Medical Branch Telemedicine Disaster Response and Recovery: Lessons Learned from Hurricane Ike. (Abstract only.)Telemedicine and E Health. 16(5): 627-633.
Authors from the University of Texas Medical Branch (UTMB) describe how UTMB was able to get its telemedicine services up and running within a week following Hurricane Ike due in part to the flexibility of its data network and plasticity of its telemedicine program. They offer lessons learned from the UTMB experience for future disasters.
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Weigel, P., Merchant, K., Wittrock, A. et al. (2019). Paediatric Tele-emergency Care: A Study of Two Delivery Models. (Abstract only.) Journal of Telemedicine and Telecare.
The authors examined two types of tele-emergency department (ED) pediatric programs (specialized and general) to determine how "tele-ED models have implications for evaluative measures."
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* Yeager, V. (2009). Emergency Response, Public Health and Poison Control: Logical Linkages for Successful Risk Communication and Improved Disaster and Mass Incident Response. Homeland Security Affairs. 5:Article 2.
The author proposes bringing together the expertise of emergency response organizations, public health agencies, and poison control centers to institute call centers and/or triage lines to disseminate information to the public during emergencies, and answer questions and concerns to keep concerned individuals from flooding local emergency rooms. Real-world examples of successful collaborations from Canada, Great Britain, and the U.S. are included.
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Yu, J.N., Brock, T.K., Mecozzi, D.M., et al. (2010). Future Connectivity for Disaster and Emergency Point of Care. Point of Care. 9(4):185-192.
Using experience from the 2010 Haiti earthquake, the authors discuss the need to ensure that networks are properly constructed and wireless connectivity is robust to optimize health care delivery, medical documentation, logistics, response coordination, communication, and telemedicine during disasters.
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General Information

American Academy of Family Physicians. (2019). Telemedicine.
This webpage provides an overview of key issues related to telemedicine for physicians to reference, including: how to locate resources to support the implementation of telemedicine; how telehealth resource centers can assist providers; legal, regulatory, and licensure issues; and reimbursement issues.
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Association of State and Territorial Health Officers. (2017). Telehealth Resource Guide.
This guide includes background information on telehealth and its different modalities, telehealth legislation and regulation at the federal and state level, and considerations for developing a telehealth pilot. Case studies on how ten states are using telehealth to improve health outcomes in their jurisdictions are included.
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Atiyeh, B., Dibo, S.A., and Janom, H.H. (2014). Telemedicine and Burns: An Overview. Annals of Burns and Fire Disasters. 27(2):87-93.
The authors discuss the use of telemedicine to bring the specialized expertise of burn centers to more patients. They also describe its challenges, including technical difficulties, legal uncertainties, limited financial support, reimbursement issues, and the need for more evidence of its value and efficiency.
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Burroughs, J. (2018). Telehealth-Credentialing, Privileging and Quality Oversight.
This presentation, created for the Washington Association of Medical Staff Services, discusses The Joint Commission (TJC) and Centers for Medicare and Medicaid Services (CMS) standards with regard to credentialing and privileging telehealth providers, as well as common pitfalls and best practices related to credentialing and privileging for telehealth.
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Doarn, C., Latifi, R., Poropatich, R., et al. (2018). Development and Validation of Telemedicine for Disaster Response: The North Atlantic Treaty Organization Multinational System. (Abstract only.)Telemedicine and e-Health.
This report describes the Multinational Telemedicine System (MnTS) for disaster response, developed by subject matter experts from Europe and the U.S.
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Edison, K. (n.d.). Adopting Telemedicine in Practice. (Accessed 12/9/2019.)
This e-learning module reviews: how to select a telemedicine service model; steps to determine the technology and support needed while following all applicable privacy, state, and federal laws; and practice guidelines to initiate a telemedicine service model.
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Gonzalez, M. and Langabeer, J. (2017). Mobile Innovations and Telehealth in Emergency Care. Healthcare Information and Management Systems Society.
This presentation discusses how the city of Houston, Texas Emergency Medical Services (EMS) integrated telehealth into pre-hospital care to more efficiently and effectively manage non-emergent cases. Under the program described, only 16% of cases needed transport to the Emergency Department following a videoconference with an Emergency Medicine physician, which resulted in ambulances being back in service 39 minutes sooner, on average, as compared to standard disposition protocols. Such time savings could be significant during disaster response and recovery operations.
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HealthIT Outcomes (2018). Telehealth Underground: Why Subterranean Data Centers Provide The Most Resilient Infrastructure For Telemedicine Data.
The author presents a rationale for locating telemedicine data centers below ground to limit the potential for operational disruption during natural disasters.
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Johnson, A. (2019). Telehealth: The Beginner’s Guide to Legal Pitfalls. Frost, Brown, Todd, LLC.
This article discusses key legal considerations for providers to consider in their provision of telehealth services. Specifically, it discusses: the Anti-Kickback Statute and Stark Law; the Corporate Practice of Medicine Doctrine; and scope of practice and licensure issues.
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Latifi, R. (2010). Telemedicine for Trauma, Emergencies, and Disaster Management. (Book available for purchase.)
This book discusses the use of telemedicine in the management of trauma, disaster, and emergency situations. Critical discussions on the practicality, logistics, and safety of telemedicine from recognized experts in the field are included.
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Latifi, R. and Tilley, E. H. (2014). Telemedicine for Disaster Management: Can it Transform Chaos into an Organized, Structured Care From the Distance? (Abstract only.)American Journal of Disaster Medicine,9(1): 25-37.
The authors conducted a literature review covering 1980-2013 to identify when telemedicine or telepresence was reported for disaster management, both in real life and in mock and simulation situations. They concluded that it is critical to establish telemedicine infrastructure and protocols in areas prone to disasters prior to an event occurring to avoid having to establish a telemedicine program in a chaotic environment.
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Lopez, A. (2014). Treatment of Ebola in the Digital Age. Arizona Telemedicine Program.
The author presents strategies for preventing Ebola disease transmission through the use of telemedicine. Specifically, she discusses a national Ebola hotline to triage at-risk cases; using Bluetooth digital monitoring for high-risk suspect cases without symptoms; video enabled ambulance transfers; and an electronic ICU set up that minimizes exposure of live caregivers. Similar strategies could be applied to the management of other emerging infectious disease outbreaks.
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Simmons, S., Alverson, D., Poropatich, R., et al. (2008). Applying Telehealth in Natural and Anthropogenic Disasters. (Abstract only.)Telemedicine Journal and E-Health. 14(9):968-71.
The authors discuss how telehealth provides surge capacity by providing medical and public health expertise at a distance, limiting safety and logistical concerns. They note several applications for telehealth in disaster response, and propose ways to expand its use more broadly in future.
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Sorenson, G. (2018). 3 Steps to Telemedicine Disaster Preparedness.
The author proposes 3 steps for telemedicine disaster preparedness: Acknowledge telemedicine as a Standard of Care; establish tools and workflows before disaster strikes; and form partnerships between public and private organizations.
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State of Florida, Telehealth Advisory Council. (2017). Expanding Florida’s Use and Accessibility of Telehealth.
Though written for the state of Florida, the analysis and recommendations related to the 6 topic areas for potential expansion of telemedicine services (defining telehealth; health insurance coverage; reimbursement for telehealth; health care practitioner licensure; patient/consumer protections; and technology) may be valuable to planners in other jurisdictions as they develop or expand their respective telemedicine programs in support of disaster response.
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Telequality Communications. (2018). Beginner’s Guide to Telehealth Reimbursement.
This blog reviews key aspects of billing for telehealth reimbursement, including considerations related to Medicare, Medicaid, and private insurance.
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* Telligen and gpTRAC. (2014). Telehealth Start-Up and Resource Guide: Version 1.1.
This collaborative resource was created “to provide an overview and framework for implementing telehealth in critical access hospitals and rural areas.” It includes a listing of research related to telehealth and outcomes, and lessons learned and best practices from organizations that successfully implemented telehealth programs and contributed to this document.
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Turnock, M., Mastouri, N., and Jivraj, A. (2008). Pre-hospital Application of Telemedicine in Acute-Onset Disaster Situations. United Nations.
This paper describes the use of telemedicine in the pre-hospital setting for disaster response. The authors discuss telemedicine disaster applications and technology, as well as implementation barriers and legal and ethical issues.
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* U.S. Department of Health and Human Services. (2009). Pandemic and All-Hazards Preparedness Act (Public Law 109-417) Telehealth Report to Congress.
This report to Congress discusses telehealth and its potential uses during public health emergencies and disaster medical responses. Payment and reimbursement considerations, as well as pertinent legal issues, are included.
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Upper Midwest Telehealth Resource Center. (n.d.). Resources. (Accessed 11/7/2019.)
This webpage includes links to resources to assist healthcare facilities with developing telemedicine programs. Included are: a business plan template; a fact sheet that discusses services for Medicare beneficiaries; links to archived webinars; and a report that discusses coverage of, and payment for, telemedicine. (Users can choose resources from tabs located on the left of the page.)
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Uscher-Pines, L., Fischer, S., and Chari, R. (2016). The Promise of Direct-to-Consumer Telehealth for Disaster Response and Recovery. Pre-Hospital and Disaster Medicine. 31(4):454-6.
This resource discusses several potential uses of Direct-to-Consumer (DTC) telehealth across the acute response, subacute response, and recovery phase of a disaster, and reviews the logistical, legal, and policy challenges that must be addressed to allow for expanded use.
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VSee. (n.d.). What is Telehealth? (Accessed 11/11/2019.)
This resource includes a comprehensive overview of telemedicine, including content that discusses benefits and shortcomings of telemedicine; applications for telemedicine; regulations and reimbursement considerations; and barriers to telemedicine and associated solutions.
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* Xiong, W., Bair, A., and Sandrock, C. (2010). Implementing Telemedicine in Medical Emergency Response: Concept of Operation for a Regional Telemedicine Hub. Journal of Medical Systems. 36(3): 1651-1660.
The authors developed and measured a model application in order to quantitatively analyze the potential health benefits of telemedicine in disaster response. They found that the model can support disaster response activities and enhance surge capacity; enhance the speed and effectiveness of medical response; and improve resource and operations planning, as well as internal and external situational awareness.
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Centers for Medicare & Medicaid Services. (n.d.). Medicare & Coronavirus. (Accessed 3/12/2020.)
This web page provides general information on COVID-19 and lists what is covered by Medicare, including "virtual check-ins."
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Centers for Medicare & Medicaid Services. (2018). ACO Next Generation Model Telehealth Waiver Frequently Asked Questions.
This document provides frequently asked questions and answers related to the Telehealth Expansion Waiver. The first section includes questions around waiver policy, and the second section describes questions around data submission requirements.
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Centers for Medicare & Medicaid Services. (2018). List of Telehealth Services.
This resource discusses the list of services payable under the Medicare Physician Fee Schedule when furnished via telehealth for coverage years 2018 and 2019.
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Centers for Medicare & Medicaid Services. (2018). Telehealth Services.
This short guide discusses the following in the context of reimbursable services: originating sites; distant site practitioners; telehealth services; billing and payment for professional services furnished via telehealth; and billing and payment for the originating site facility fee. It also includes a resource listing.
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Centers for Medicare & Medicaid Services. (2019). Telehealth Services.
This guidance document is geared towards Medicare Fee-For-Service Providers. It highlights the sites that are eligible for Medicare-covered "specific (Part B) physician or practitioner services furnished through a telecommunications system. Telehealth services substitute for an in-person encounter."
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Centers for Medicare & Medicaid Services. (2020). Telehealth Benefits in Medicare are a Lifeline for Patients During Coronavirus Outbreak.
This article explains how the Centers for Medicare & Medicaid Services have worked to enable virtual check-ins and related services possible since 2019. This can be especially helpful during an infectious disease outbreak.
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Davidsen, B. (2017). Considerations When Treating Natural Disaster Victims Through Telemental/Telebehavioral Health Program. Epstein, Becker, Green, P.C.
This article provides a general overview of limitations in state laws that may create liability associated with the delivery of behavioral health services through telehealth technology.
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Ferrante, T. and Lacktman, N. (2018). Top 5 Ways Telehealth Will Change Under the New Federal Funding Bill. Foley & Lardner, LLP.
The authors discuss the implications for practice following the passage of new telehealth-related legislation in February of 2018.
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Gonzalez, G. (2018). Telemedicine Expands Care, Adds Exposures. Business Insurance.
This resource discusses the increased potential for medical malpractice risks, cyber risks, and challenges related to regulatory and legal exposures stemming from telemedicine use as technology has outpaced laws and regulations that govern healthcare practice.
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Interstate Medical Licensure Compact. (2019). Interstate Medical Licensure Compact.
This webpage provides information on the Interstate Medical Licensure Compact, an agreement between 29 states, the District of Columbia and the Territory of Guam, where physicians are licensed by 43 different Medical and Osteopathic Boards. Under this agreement licensed physicians can qualify to practice medicine across state lines within the Compact if they meet the agreed upon eligibility requirements.
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* Kelly, M. (2018). DC’s New 911 Nurse Triage Program. Annals of Emergency Medicine. 72(4): A15–A17.
This article discusses the successes and challenges experienced by Washington DC since integrating triage nurses into its 911 Call Center in April 2018. Logistical, medical, and financial (including insurance) considerations are presented, and may assist other jurisdictions in developing a similar model, which could support disaster response and recovery through efficient management of ambulance services.
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Roberts, S. (2018). ASHRM Whitepaper – Telemedicine: Risk Management Considerations. American Society for Health Care Risk Management.
This resources is a detailed review of the ASHRM Telemedicine Whitepaper (which users must log into ASHRM to obtain), which provides a general overview of telemedicine, and discusses the potential risks of telemedicine under a risk management framework provided by ASHRM.
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* U.S. Department of Health and Human Services. (2009). Pandemic and All-Hazards Preparedness Act (Public Law 109-417) Telehealth Report to Congress.
This report to Congress discusses telehealth and its potential uses during public health emergencies and disaster medical responses. Payment and reimbursement considerations, as well as pertinent legal issues, are included.
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Plans, Tools, and Templates

* Association of State and Territorial Health Officials and National Association of County and City Health Officials. (2012). Preliminary Report on the Role of Flu Information and Triage Lines in Reducing Surge in Healthcare Facilities and Increasing Access to Antiviral Medication During the 2009 H1N1 Pandemic.
This report summarizes the experience of jurisdictions across the country using hotlines and call centers to support the response to the 2009 H1N1 influenza pandemic. Algorithms for antiviral distribution; legal opinions on the use of hotlines; risk communication documents; and standing orders are included in the appendices.
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* Bogdan, G., Scherger, D., Seroka, A., et al. (2007). Adapting Community Call Centers for Crisis Support: A Model for Home-Based Care and Monitoring. U.S. Department of Health and Human Services.
The authors explain the development, testing, and implementation of a model to enable community health call centers (e.g., poison control centers, nurse advice lines) to support home-management and shelter-in-place approaches in certain mass casualty or health emergency events. The report includes a matrix with possible call center capabilities aligned with National Planning Scenarios and other guidance that can be tailored by call centers.
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Centers for Disease Control and Prevention. (n.d.). Medical Office Telephone Evaluation of Patients with Possible Influenza. (Accessed 11/7/2019.) U.S. Department of Health and Human Services.
This flowchart can aid medical staff in triaging calls. The tool may identify high-risk patients for consideration of initiation of antiviral treatment prior to an office visit.
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National Association of County and City Health Officials. (2017). The Flu on Call® Infographic.
This infographic reviews the Flu on Call® triage process. Free log-in to the NACCHO toolbox is required.
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* Oak Ridge Institute for Science and Education. (2009). Coordinating Call Centers for Responding to Pandemic Influenza and Other Public Health Emergencies: A Workbook for State and Local Planners. Centers for Disease Control and Prevention.
This workbook guides planners through the process of determining the need for a call center, as well as how to operationalize a call center during public health emergencies.
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Agencies and Organizations

American Hospital Association. Telehealth.
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American Telemedicine Association.
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Arizona Telemedicine Program.
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Center for Connected Health Policy, Current State Laws & Reimbursement Policies.
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Center for Connected Health Policy, Legislation & Regulation Tracking.
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Center for Telehealth and e-Health Law.
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mHealth Intelligence.
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Missouri Telehealth Network.
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The GW Medical Faculty Associates. Telemedicine.
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The National Consortium of Telehealth Resource Centers.
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The National Telehealth Policy Resource Center.
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The National Telehealth Technology Assessment Resource Center.
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U.S. Department of Health and Human Services, Health Resources and Services Administration. Telehealth Programs.
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UNM Center for Telehealth.
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VA Telehealth Services.
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Workgroup for Electronic Data Interchange (WEDI).
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This ASPR TRACIE Topic Collection was comprehensively refreshed and reviewed in December 2019 by the following subject matter experts (listed alphabetically): John Hick, MD, HHS ASPR and Hennepin County Medical Center; Matt McQuisten, MBA, NRP, eEmergency Account Executive, Avera eCARE; Kelly Rhone, MD, FACEP, Medical Director of Outreach and Innovation, Avera eCARE; and Mary Russell, EdD MSN, Healthcare Emergency Response Coalition, Palm Beach County Florida.

 

It was comprehensively reviewed in March 2016 by the following subject matter experts (listed in alphabetical order): Dale C. Alverson, MD Professor Emeritus and Medical Director, University of New Mexico Center for Telehealth Chairman, New Mexico Telehealth Alliance, CMIO, New Mexico Health Information Exchange Chairman, American Telemedicine Association Interstate Telehealth Discussion Group; Timothy E. Davis, MD, MPH, Branch Chief, NDMS Operational Medicine, HHS ASPR; and John Hick, MD, HHS ASPR and Hennepin County Medical Center.

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