In Houston, telehealth has been deployed to address a specific problem: too many ambulance transports for low-acuity situations such as stubbed toes or upper respiratory infections. The ETHAN (Emergency Tele-Health and Navigation) project has been successful at redirecting those patients to clinics and different forms of transportation. But its financial sustainability remains in question.
Michael G. Gonzalez, M.D., associate medical director for the City of Houston Fire Department/EMS Division, and director of the ETHAN project, described ETHAN’s evolution in a Sept. 19 webinar put on by the National Consortium of Telehealth Resource Centers.
He said that ETHAN, launched five years ago, was the first project to deploy telehealth in the EMS environment. First, he set the stage by describing Houston’s EMS environment. The city has 96 fire stations over 660 square miles in the city borders. On an average day, it responds to 1,500 to 2,000 EMS calls for medical services, with 400 to 500 transports per day. (Gonzalez was speaking on a day when Houston was facing a huge emergency from flooding.) They chose to build strategy around low-acuity callers because Houston has seen such rapid growth, leading to a lack of enough primary care providers and overcrowded emergency departments.
“Our strategy is pre-hospital. We are targeting the walking well, not high utilizers,” Gonzalez said. “In our experience, these people are disconnected from the health care system with no connection to primary care.”
Research suggested that in the City of Houston, up to 40 percent of people transported to hospitals have diagnoses that are primary care-related, and are discharged with no significant intervention. Among other things, this leads to long wait times in the ED.
The goal of ETHAN is to triage and connect low-acuity 9-1-1 callers with primary care resources in the community. Fourteen physicians work on ETHAN and answer calls remotely from their homes. If an EMS team arrives at the site of a 9-1-1 call and no emergency is present, they do an analysis and if the person meets certain criteria, they connect the patient to an emergency physician via telehealth using a ruggedized tablet. While the encounter is taking place, the field crew remains on-scene to assist the physician with any additional patient information. The patient is given the choice of going to the ED by taxi or their own transportation, or they can set up an appointment at a primary care clinic. The service is available 10 a.m. to 10 p.m. every day of the year. Over five years, they have done 25,000 calls with ETHAN.
The savings are considerable, he said. The ambulance can cost $1,000 for and the ED visit around $1,200. Out of the 25,000 times ETHAN has been used, 20,000 avoided ambulance rides. That leads to 44 minutes saved per encounter and $1,387 per trip saved, he added. Estimated savings are $27 million over the life of ETHAN.
It cost about $2.5 million to get off the ground, and costs $1 million to $1.5 million per year to maintain. It was started with some initial federal funding, but “we don’t have a sustainable funding model yet,” Gonzalez admitted. “There is no way for us to bill for an ETHAN encounter.”
One possibility is direct collaborations with payers who are seeing savings from reduced ED visits and ambulance trips. Also, the Center for Medicare & Medicaid Innovation recently announced an ET3 funding model that may open the door for programs like ETHAN to get reimbursed, and Houston is exploring that possibility, he said. “We are not sure ETHAN is going to fit. That is a larger conversation. It is very complicated.”