Emergency department boarding remains one of the most stubborn operational challenges facing U.S. hospitals. National data show that more than a quarter of admitted patients now wait four hours or more for an inpatient bed, and waits of 24 hours or longer are becoming more common as ED volumes and patient acuity rise.
Charleston-based Medical University of South Carolina leaders decided that waiting for broader policy or capacity fixes was not enough. Instead of focusing only on downstream bottlenecks, they turned to the very front of the emergency department — redesigning how care begins.
That redesign became “virtual provider in triage,” a telehealth model that places a physician or advanced practice provider into the ED arrival process so patients can be evaluated, orders placed and care initiated while they are still in the waiting room.
“The worst part of the ED experience for most patients is the front-end wait with no information and no clinical momentum,” said Marc Bartman, MD, division director of emergency telehealth at MUSC. “So we flipped that sequence.”
Instead of triage followed by hours of waiting, MUSC now brings a virtual emergency clinician into the visit immediately so care starts when the patient walks through the door, not when a bed opens.
Moving clinical decision-making upstream
What sets VPIT apart from many tele-triage pilots is where it sits in the workflow.
Rather than layering telehealth on top of an already congested ED, MUSC moved clinical decision-making upstream, before delays pile up.
“Emergency medicine led the build because it had to fit a real ED workflow, not a theoretical telehealth workflow,” Dr. Bartman said. “The goal wasn’t to create another task. It was to start care immediately.”
Once a virtual provider is involved, diagnostic tests, lab work and imaging can be ordered early — even while the patient remains in the lobby, which Jeanhyong Park, MD, director of emergency medicine informatics and director of clinical informatics at MUSC, said saved valuable ED time.
“When you start diagnostics, examinations and treatment earlier, patients complete their ED journey sooner,” he said.
What changed for patients — and for staff
MUSC leaders expected VPIT to improve throughput. What surprised them was how much it changed the emotional experience of emergency care.
“Patients have less anxiety when they talk to a provider first,” Dr. Park said. “They know the plan and what comes next.”
That clarity also eased pressure on frontline teams. Before VPIT, triage staff absorbed patient frustration without any way to resolve it.
“There was a lot of anxiety being transferred to staff,” Dr. Bartman said. “Now patient experience is better and morale is better. It’s completely changed the environment.”
The model initially met resistance, in part because EDs have relied on the same front-end workflows for decades. But MUSC leaders avoided framing VPIT as a productivity play.
“We didn’t just focus on metrics,” Dr. Park said. “We focused on the patient experience. Once people saw the results, the buy-in came naturally.”
After launching VPIT in Charleston, MUSC expanded the model to four emergency departments, including community and rural hospitals.
“What mattered was showing this wasn’t just an academic-center solution,” Dr. Park said. “We’ve replicated the success in very different ED environments.”
One of the most important findings: Patients who once would have left without being seen are now staying to complete care.
“Admitted and discharged patients went up,” Dr. Park said. “People were finishing their visits.”
That distinction matters, he added, because it showed VPIT wasn’t simply shifting patients into new categories — it was actually fixing the front door.
Why this isn’t a temporary fix
MUSC’s telehealth leaders do not see VPIT as a short-term crowding solution.
“This isn’t a band-aid,” Dr. Park said. “It’s an operational improvement that creates a better patient experience.”
The system is already extending the model beyond triage. MUSC is developing virtual follow-up visits so ED clinicians can reassess patients after discharge and prevent unnecessary returns. The team is also exploring ways to connect virtual providers to EMS before patients even arrive.
“A lot of our patients can’t get timely follow-up,” Dr. Bartman said. “So we’re creating a virtual clinic so the ED team that saw them can reassess them before they bounce back.”
Instead of each ED being stuck with fixed coverage, MUSC can also shift virtual providers across sites in real time, sending help where surges hit hardest.
“With telehealth, you can balance your workforce across the system,” Dr. Park said. “That’s been a huge advantage.”
A redesigned front door
For MUSC’s leaders, the biggest change is not just faster care — it’s a better beginning.
Instead of patients arriving into uncertainty, VPIT creates what Dr. Bartman describes as an early human connection — a clinician who owns the case, explains what’s happening and gives the patient a plan, even before a room is available.
“People tolerate waiting far better when they understand what’s happening and feel like someone owns their care,” Dr. Bartman said. “Patients feel welcomed. They feel heard. They know there’s a plan.”
That, he said, is what makes VPIT more than a telehealth tool.
“This represents a practical redesign of the front door — starting emergency care when the patient arrives, not when a room becomes available.”
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