How Cleveland Clinic's use of ET3 benefits patients and providers — 4 insights

As the healthcare industry strives to provide higher quality care at a lower cost, early intervention to direct patients to the most appropriate level of care settings is essential. 

During a webinar hosted by Becker's Hospital Review and sponsored by Amwell, Cleveland Clinic's Bryan Graham, DO, medical director of the Virtual Emergency Medicine Program, and Chris O'Rourke, administrator for the Emergency Services Institute, discussed how their health system is using telehealth in emergency medicine to divert unnecessary ED admissions and reduce readmission.

Four key insights were:

1. Many patients who call 911 can be treated in nonemergency room settings. According to Dr. Graham, emergency medical service reimbursement historically required transport to an emergency department. "However, it's estimated that about 16 percent of Medicare fee-for-service transports to the ED could have been treated in lower-acuity settings," he said. "That amounts to $560 million in estimated savings that could be derived from lower-cost alternatives."

As a result, CMS introduced Emergency Triage, Treat and Transport, or ET3, a voluntary, five-year payment model that provides flexibility to triage patients during emergencies, transport them to alternative destinations or treat them in place via telehealth or an in-person practitioner. 

2. COVID-19-related waivers and exceptions accelerated ET3. While the Cleveland Clinic was evaluating which EMS agencies to partner with to implement ET3, the global pandemic began. "Allowing virtual encounters to be initiated at home was a product of the public health emergency waivers," Dr. Graham said. "And then, for the first time, we had the opportunity to utilize ED evaluation and management codes virtually, which gave us an opportunity to demonstrate the value of virtual emergency medicine." 

3. Cleveland Clinic's virtual emergency medicine program benefits patients, providers and payers. Cleveland Clinic's EMS partners now have the flexibility to evaluate a patient who has called 911 to determine whether that patient needs to go to an ER or a lower-acuity treatment alternative, such as urgent care or a rehabilitation facility, or receive at-home telehealth treatment. "The program enhances access by providing an avenue for delivering EMS care in a much more timely manner and in settings that were not historically accessible," Mr. O'Rourke said. "It lowers out-of-pocket expenses for patients and allows EMS partners to get their squads back in service faster. Timely interventions in lower-cost [care] settings drive cost savings for payers as well."

4. Technology, connectivity, compliance and partner training are keys to successful implementation. "We use a technology platform that allows for a seamless patient and partner experience," Mr. O'Rourke said. "To combat connectivity challenges, we leveraged things like Wi-Fi extenders, mobile hot spots and multiple SIM cards. We also had to address significant regulatory and compliance considerations, like contractual licensure and payer enrollment components." 

Dr. Graham added that they had to develop specific approaches to arrive at best practices for partner utilization, engagement and sustainability. As a result of Cleveland Clinic's efforts, the organization has been able to treat more than 70 percent of EMS cases on the scene, with less than 5 percent of patients returning to the ER within the following 48 hours.

This experience has shown Cleveland Clinic that emergency medicine has a place in telehealth and has a significant value proposition.


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