Tools
EMS Telemedicine in the Prehospital Setting
Introduction
Telemedicine uses electronic communications to exchange medical information and provide medical care remotely.[1] Telemedicine has been increasingly incorporated into healthcare systems, but it has only recently begun to be adopted in emergency medical services (EMS) and prehospital care. From its inception, EMS was built around radio communication for medical oversight and electrocardiogram transmission, effectively practicing an early, basic form of telemedicine. Many systems still operate in this framework, although patient information can now be transmitted through voice and video.[2] The expansion of this technology allows for enhanced and expedited delivery of prehospital healthcare. The transmission of information can be either real-time or delayed; the information exchanged can be between an EMS clinician and an expert, such as a physician subspecialist, or between a patient and a clinician[3] Patients now can receive timely, individualized care from a medical command clinician or a consultant subspecialist beginning with the initial 911 call, continuing through the EMS response, treatment on scene or during transport, and extending to follow-up care after hospital discharge. Telemedicine offers a powerful tool to augment EMS care through real-time expert input, improved efficiency, and reduced resource use.
One of the primary uses of telemedicine, especially in the prehospital setting, is teleconsultation.[3] Teleconsultation is the interaction between a healthcare professional and a patient. This is sometimes facilitated through an intermediary, such as a paramedic, and can be used to obtain second opinions, consult specialists, determine alternative dispositions from the scene, or initiate earlier hospital-level care for patients in remote areas with extended transport times. Additionally, telecommunication technology can support remote patient monitoring by tracking vital signs and sending medication reminders, an integral approach in community paramedicine and hospital-at-home programs.
Issues of Concern
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Issues of Concern
Telemedicine Applications in Stroke, Myocardial Infarctions, and Behavioral Health Emergencies
Teleconsultation is used routinely when EMS professionals contact their medical command clinician for advice and instructions. Traditionally, this relied on voice communication and has been a core component of EMS systems since their early development. Video communication allows real-time video and audio communication between the EMS professional, the patient, and the clinician.[4] Video communication is less commonly used, but as the evidence base for telemedicine grows, some systems are beginning to fold audiovisual teleconsultation into their routine practices. For instance, Quadflieg et al showed diagnostic concordance between the on-scene and the teleconsult clinician compared to the final hospital diagnosis.[5]
Telemedicine can be used to evaluate and augment time-sensitive stroke treatment. Telestroke services have been widely adopted in the emergency department.[6] In the prehospital setting, sensitivity for stroke has ranged considerably, and there have been several studies with results showing that teleconsultation can be feasible and effective in the care of patients with stroke, allowing for earlier evaluation by a trained neurologist.[6][7] Certain emergency department-based telestroke study results have demonstrated a 55% increase in thrombolysis use at community hospitals and a 10% increase in rural and super rural areas, significantly reducing longstanding geographic and racial disparities in stroke care.[8][9][10] Similar study results have been shown in the prehospital setting, with results from one study in Sweden showing markedly faster endovascular thrombectomy delivery while maintaining thrombolysis time intervals.[11] Bilotta et al also found that EMS telehealth consultation with a clinician reduced door-to-computed-tomography results in patients with suspected stroke by 5 minutes, allowing more patients to stay within the thrombolytic window.[12] Hospitals incorporating telestroke services have reported lower 30-day mortality rates than those without telestroke services.[13]
However, some concerns about the technical implementation include ensuring consistent and prompt teleconsultation access. Some studies' results showed that EMS clinicians only reached the telemedical consultant half the time. An alternative to telemedicine consultation with a stroke neurologist is the mobile stroke unit (MSU), a specialized ambulance equipped with a computed tomography scanner and lab capabilities that allow the stroke team to evaluate and begin treatment at the scene. In the early 2000s, evidence on the impact of EMS MSUs on patient outcomes was mixed.[14][15][16] However, with advancements in technology, more recent data showed that MSU use was associated with quicker times to thrombolysis and reduced disability without increased safety concerns or increased risk of all-cause mortality. This presents a possible alternative or promising complement to telestroke systems.[17][AHA. Impact of Mobile Stroke Units on Patients With Large Vessel Occlusion Acute Ischemic Stroke: A Prespecified BEST-MSU Substudy. 2024]
The treatment of ST-elevation myocardial infarctions (STEMI) has also benefited from telemedicine. Several studies' results have shown that it reduces the time needed to treat individuals with STEMI by facilitating prehospital fibrinolytic use for patients who live in remote locations.[18][19][20] Fibrinolytic therapy is high-risk, and expert consultation helps ensure judicious and timely identification of the best candidates. By allowing for transmission of a prehospital 12-lead electrocardiogram (ECG) to the medical command clinician for interpretation and the interventional cardiologist, telemedicine can lead to decreased time to catheterization lab activation.[21] One European study showed that telemedicine allowed patients to receive treatment within 90 minutes of first medical contact, while those who did not receive a teleconsultation had a 42% longer door-to-balloon time.[22] A systematic review and meta-analysis reported that prehospital ECG transmission reduced door-to-balloon times by an average of 33.3 minutes and was linked to a 47% reduction in mortality compared to cases without prehospital ECG transmission.[23]
There is an estimate that mental health, behavioral health, and substance-related calls comprise 5% to 15% of 911 ambulance calls in the United States.[24] Over the past decade, efforts have been made to integrate behavioral health expertise into emergency responses. Programs like New York City’s Behavioral Health Assistance Response Division illustrate this approach by dispatching specialized ambulances, staffed with an EMS clinician and a mental health professional, to respond to 911 calls related to behavioral health emergencies. These programs have been found to increase community trust, reduce unnecessary transports, and lessen reliance on police resources; however, some barriers can prevent implementation.[City of New York. Re-imagining New York City's mental health emergency response] The largest of these barriers involves staffing, which some programs have been attempting to mitigate by including a telehealth component early in the response process. The effectiveness of this model has been demonstrated in several large prehospital systems. In Victoria, Australia, a pilot video telehealth program was linked to reduced EMS dispatch rates, increased referrals to alternatives to emergency departments, and high levels of patient satisfaction.[25]
Operational Uses of Telemedicine: Refusal of Medical Care, Destination Guidance, and Treatment in Place
In the United States, EMS clinicians usually contact the medical command clinician for guidance when patients refuse medical care or want to be released after treatment.[26] Study results have shown that patients are more likely to be transported to the hospital if they can speak to a clinician directly.[27][28] Adding video to these interactions could help create a more informed decision and improve the therapeutic alliance between the patient and the command clinician.[29][30] Telemedicine can also be used for destination guidance, helping to reduce the unnecessary use of air medical transport, facilitate treatment-in-place, and assist with end-of-life decisions, potentially avoiding an emergency department visit altogether.[31][32]
Air medical transport is an important part of the EMS system, but there is growing concern about overutilization and associated costs.[33] Results from studies have shown that many airlifted individuals have minor or non-life-threatening injuries.[34][35][36] Telemedicine processes can save money and reduce unnecessary risks to air medical crews. Results from a study in Taiwan found that using video telemedicine to screen patients resulted in a 36.2% reduction in air transport, saving the system nearly half a million dollars.[37] Another study's results found that nearly 1-in-5 burn individuals who were transferred could have been treated at the sending facility.[38] Similar results were found in a study by Bergreath et al, where helicopter EMS use was nearly halved after a full-scale prehospital telemedicine system implementation.[39] These studies' results suggest that telemedicine can improve the cost-effectiveness of the EMS system and reduce unnecessary risks to patients and air medical crews.
Some systems are also piloting treat-in-place models for minor complaints that can be dispositioned from the scene with the help of a clinician's telemedicine visit. The Regional Emergency Medical Services Council of New York City has compiled medical inclusion criteria for 911 patients that can be transitioned into a telemedicine visit, including asymptomatic hypertension, dysuria, toothache, and joint pain. Houston piloted an Emergency Telehealth and Navigation (ETHAN) program to navigate primary care and minor illness patients away from the emergency department. During the first year of the ETHAN program, Houston EMS achieved a 56% reduction in ambulance transports and a 44-minute reduction in turnaround times, as ambulances could immediately return to service once patients were dispositioned from the scene.[40] Similarly, Varughese et al found a 67% reduction in transports, with respiratory complaints being the most likely to result in transport avoidance.[41] Importantly, neither study found an increase in prehospital intervals with telemedicine.
Additional approaches have emerged to enhance patient care while alleviating hospital overcrowding. “Hospital at Home” models enable medical professionals to deliver personalized treatment in the patient’s home, either preventing a hospital admission entirely or reducing inpatient length of stay by transitioning part of the treatment to a home setting. For select acutely ill individuals, this model has proven to be a safe and effective substitute for traditional inpatient care.[42][American College of Cardiology. Hospital-at-home: The new frontier. https://www.acc.org/Latest-in-Cardiology/Articles/2023/10/01/01/42/cover-story-hospital-at-home-the-new-frontier] Community paramedicine, by contrast, operates outside the standard 911 system and integrates EMS clinicians into the broader healthcare network, including outpatient services, to serve a specific local community need.[43] These programs are mostly pilot programs that dispatch EMTs and paramedics to responses that do not require acute life-sustaining EMS intervention. The goals of community paramedicine include assessing for possible social service interventions, alternative modes of transport, treatment in place to avoid a hospital visit, or arranging referrals to non-emergency department settings.[44]
Many community paramedicine programs dispatch clinicians or other healthcare professionals directly into the field, while others use paramedics supported by real-time telemedicine clinician consults. One program in New York City enrolled patients with multiple chronic conditions who had 2 or more hospitalizations in the past year. When paramedics visit patients in their homes, they can conduct safety assessments, perform a full physical exam, and obtain point-of-care blood tests. This also enables a virtual assessment by the same emergency clinicians the patient would see in the emergency department, allowing for earlier, proactive treatment of disease processes. Ultimately, this improved access to care, strengthened patient-provider relationships, and decreased the 30-day and 90-day readmission rate from 12% to 5%.[NEJM Catalyst. Community Tele-Paramedicine to Improve Telehealth Access for Underserved Populations][45]
These programs all rely on telemonitoring, which uses digital technology to remotely monitor a patient’s health data, allowing clinicians to track their condition and respond to changes without being on-site.[46] In the prehospital setting, telemonitoring is used to transmit ECGs, vital signs, and other data to the receiving hospital.[47][48][49] This can be essential in the growth of community paramedicine or hospital-at-home programs, allowing a provider to remotely oversee multiple patients simultaneously.[50] Abnormal vitals caught by the telemonitoring program can then initiate an immediate prehospital response and treatment. While there are no established standards for the protocols within these programs, and further evidence is required to substantiate their safety and efficacy, pilot programs like these show their effectiveness and lay the groundwork for other hospital systems and future research opportunities.
Unique Applications and Special Situations
Point-of-care ultrasound (POCUS) is a valuable tool in emergency medicine, aiding diagnosis and procedural guidance; it is also gradually being introduced in the prehospital setting.[51] This modality is most commonly used in those with trauma to look for pneumothorax and other life-threatening conditions.[52] However, unlike many other tests or imaging modalities, ultrasound accuracy is operator-dependent. If the EMS clinician is not trained in ultrasound, they may underdiagnose significant findings or misinterpret normal findings. Telemedicine can be used to improve ultrasound accuracy in the prehospital setting. A remote clinician can guide an EMS clinician in real-time, helping them to obtain and interpret ultrasound images, and this approach has been feasible in several studies.[53] Transmitting images from the prehospital setting can also help expedite in-hospital care. For example, a respiratory therapist can be ready at the bedside for a patient needing noninvasive positive pressure ventilation, or a pericardiocentesis kit can be prepared in advance for a patient with suspected cardiac tamponade due to POCUS findings. Results from a study in Taiwan revealed that telemedicine can be used to diagnose and subsequently give valuable pre-notification information to trauma centers.[54]
The COVID-19 pandemic introduced a range of challenges that accelerated telemedicine adoption across all healthcare areas, including prehospital care. This enabled continued patient care while minimizing in-person contact to protect clinicians and conserve personal protective equipment. In England, telemedicine triage based in dispatch centers was used to safely treat low-acuity calls without needing an in-person provider assessment.[55] Even when EMS personnel are on scene, telemedicine consultation with emergency medicine clinicians can potentially decrease unnecessary transport to emergency departments, especially during periods of overcrowding, such as a pandemic.[EMS1. The expanding use of telemedicine during the COVID-19 pandemic] Outside of pandemics, prehospital telemedicine has demonstrated value during large patient-generating events, such as mass gatherings. These events have incorporated telemedicine into their planning to handle anticipated patient volume surges and support infectious disease surveillance.[56][57][58] Additionally, remote teleconsultation can help augment rapid triage in these high-volume, resource-limited settings.[59]
Many advancements in prehospital care originated from the military. This holds for advancements in remote medical care and telemedicine due to the intrinsic nature of the battlefield. In combat medicine, patients often cannot be extricated rapidly or may be in a remote location far from definitive care, necessitating telemedicine consultation. In the civilian world, these principles are applied in wilderness medicine, where appropriate medical care can be hours away. In these situations, telemedicine can provide immediate, real-time consultations with specialists and appropriate dispatch of scarce wilderness EMS resources.[60] Similarly, these concepts apply to search and rescue operations, where drones can deliver supplies and monitoring equipment to remote environments before medical teams arrive.[61] They are also relevant to tactical EMS, where potential patients may be trapped and unable to be extricated for prolonged periods. Telemedicine has been used to improve the success of prehospital airway management, which may be necessary in the extended prehospital care intervals in tactical EMS.[62] For example, in one study, remotely assisted paramedics could intubate patients more successfully than those who were not.[63]
Clinical Significance
The future of telemedicine in EMS is promising, but more data are needed on its cost-effectiveness and impact on patient outcomes.[64] Prehospital telemedicine can be used for patient monitoring, immediate access to specialists, and aid in destination decisions and treatment-in-place dispositions. Many studies concerning its use are focused on feasibility and lack patient outcomes. Although alternative destination choice via telemedicine consultation is feasible, we have yet to study whether patient outcomes are comparable to those of individuals transported to a traditional emergency department. Likewise, definitive data are still lacking on whether prehospital neurologist teleconsultation improves outcomes such as mortality or functional status in patients with stroke. There is also significant heterogeneity across different prehospital telemedicine solutions that makes comparisons between studies challenging.[65]
A few clinical trials are looking to bring a higher quality of evidence. The first such trial that has been completed took place in Germany and examined the outcomes of patients treated by paramedics paired with a tele-EMS clinician compared to paramedics paired with an on-scene EMS clinician.[66] The randomized clinical trial found noninferiority in the outcomes of the tele-EMS clinician compared to the on-scene clinician in terms of adverse events (such as iatrogenic allergic reactions from a medication) experienced by each patient group.[67]
Barriers to implementing a prehospital telemedicine program include paramedic buy-in and experience in forgoing transport, patient expectations, financial constraints, regulatory barriers, technology limitations, and access to clinician resources.[68][69] For instance, questions may arise about whether a specialty consultant can issue medical orders without a medical command designation, or whether EMS clinicians must transport all 911 callers to the emergency department. There can also be significant upfront economic costs from purchasing the interfaces for video and audio communication, maintenance, and personnel training. Even when established, there may be additional financial restraints regarding reimbursement for ongoing operational costs, billing, and payment requirements from insurers. However, estimates from some studies suggest that granting Medicare the flexibility to reimburse EMS for transports to alternative destinations could save up to $560 million annually, enhancing patient care and reducing emergency department overcrowding.[70]
Clinician resources encompass telemedicine, clinician staffing, developing quality assurance programs, and implementing prehospital protocol changes to facilitate telemedicine visits. This shift could expand the role of EMS clinicians and medical directors, positioning them to oversee the telemedicine interface and support its integration through EMS clinician training, patient education, and quality improvement measures. To help manage patient expectations, EMS clinicians can increase public awareness of these programs in their communities. This will garner further acceptance of prehospital telemedicine through an increased understanding of the new services and how this system will improve EMS patient care. Prehospital telemedicine programs are still nascent, but the potential exists for telemedicine to improve patient outcomes and reduce costs.
References
Shigekawa E, Fix M, Corbett G, Roby DH, Coffman J. The Current State Of Telehealth Evidence: A Rapid Review. Health affairs (Project Hope). 2018 Dec:37(12):1975-1982. doi: 10.1377/hlthaff.2018.05132. Epub [PubMed PMID: 30633674]
Winburn AS, Brixey JJ, Langabeer J 2nd, Champagne-Langabeer T. A systematic review of prehospital telehealth utilization. Journal of telemedicine and telecare. 2018 Aug:24(7):473-481. doi: 10.1177/1357633X17713140. Epub 2017 Jun 22 [PubMed PMID: 29278996]
Level 1 (high-level) evidenceWaller M, Stotler C. Telemedicine: a Primer. Current allergy and asthma reports. 2018 Aug 25:18(10):54. doi: 10.1007/s11882-018-0808-4. Epub 2018 Aug 25 [PubMed PMID: 30145709]
Amadi-Obi A, Gilligan P, Owens N, O'Donnell C. Telemedicine in pre-hospital care: a review of telemedicine applications in the pre-hospital environment. International journal of emergency medicine. 2014:7():29. doi: 10.1186/s12245-014-0029-0. Epub 2014 Jul 5 [PubMed PMID: 25635190]
Quadflieg LTM, Beckers SK, Bergrath S, Brockert AK, Schröder H, Sommer A, Brokmann JC, Rossaint R, Felzen M. Comparing the diagnostic concordance of tele-EMS and on-site-EMS physicians in emergency medical services: a retrospective cohort study. Scientific reports. 2020 Oct 22:10(1):17982. doi: 10.1038/s41598-020-75149-8. Epub 2020 Oct 22 [PubMed PMID: 33093557]
Level 2 (mid-level) evidenceSharma R, Zachrison KS, Viswanathan A, Matiello M, Estrada J, Anderson CD, Etherton M, Silverman S, Rost NS, Feske SK, Schwamm LH. Trends in Telestroke Care Delivery: A 15-Year Experience of an Academic Hub and Its Network of Spokes. Circulation. Cardiovascular quality and outcomes. 2020 Mar:13(3):e005903. doi: 10.1161/CIRCOUTCOMES.119.005903. Epub 2020 Mar 4 [PubMed PMID: 32126805]
Level 2 (mid-level) evidenceBergrath S, Reich A, Rossaint R, Rörtgen D, Gerber J, Fischermann H, Beckers SK, Brokmann JC, Schulz JB, Leber C, Fitzner C, Skorning M. Feasibility of prehospital teleconsultation in acute stroke--a pilot study in clinical routine. PloS one. 2012:7(5):e36796. doi: 10.1371/journal.pone.0036796. Epub 2012 May 18 [PubMed PMID: 22629331]
Level 3 (low-level) evidenceZhang D, Wang G, Zhu W, Thapa JR, Switzer JA, Hess DC, Smith ML, Ritchey MD. Expansion Of Telestroke Services Improves Quality Of Care Provided In Super Rural Areas. Health affairs (Project Hope). 2018 Dec:37(12):2005-2013. doi: 10.1377/hlthaff.2018.05089. Epub [PubMed PMID: 30633675]
Level 2 (mid-level) evidenceChalouhi N, Dressler JA, Kunkel ES, Dalyai R, Jabbour P, Gonzalez LF, Starke RM, Dumont AS, Rosenwasser R, Tjoumakaris S. Intravenous tissue plasminogen activator administration in community hospitals facilitated by telestroke service. Neurosurgery. 2013 Oct:73(4):667-71; discussion 671-2. doi: 10.1227/NEU.0000000000000073. Epub [PubMed PMID: 23842556]
Lyerly MJ, Wu TC, Mullen MT, Albright KC, Wolff C, Boehme AK, Branas CC, Grotta JC, Savitz SI, Carr BG. The effects of telemedicine on racial and ethnic disparities in access to acute stroke care. Journal of telemedicine and telecare. 2016 Mar:22(2):114-20. doi: 10.1177/1357633X15589534. Epub 2015 Jun 26 [PubMed PMID: 26116854]
Mazya MV, Berglund A, Ahmed N, von Euler M, Holmin S, Laska AC, Mathé JM, Sjöstrand C, Eriksson EE. Implementation of a Prehospital Stroke Triage System Using Symptom Severity and Teleconsultation in the Stockholm Stroke Triage Study. JAMA neurology. 2020 Jun 1:77(6):691-699. doi: 10.1001/jamaneurol.2020.0319. Epub [PubMed PMID: 32250423]
Bilotta M, Sigal AP, Shah A, Martin A, Schlappy DA, Sorensen G, Barbera C. A Novel Use of Prehospital Telemedicine to Decrease Door to Computed Tomography Results in Acute Strokes. Journal for healthcare quality : official publication of the National Association for Healthcare Quality. 2020 Sep/Oct:42(5):264-268. doi: 10.1097/JHQ.0000000000000229. Epub [PubMed PMID: 31725488]
Level 2 (mid-level) evidenceWilcock AD, Schwamm LH, Zubizarreta JR, Zachrison KS, Uscher-Pines L, Richard JV, Mehrotra A. Reperfusion Treatment and Stroke Outcomes in Hospitals With Telestroke Capacity. JAMA neurology. 2021 May 1:78(5):527-535. doi: 10.1001/jamaneurol.2021.0023. Epub [PubMed PMID: 33646272]
Schwamm LH, Audebert HJ, Amarenco P, Chumbler NR, Frankel MR, George MG, Gorelick PB, Horton KB, Kaste M, Lackland DT, Levine SR, Meyer BC, Meyers PM, Patterson V, Stranne SK, White CJ, American Heart Association Stroke Council, Council on Epidemiology and Prevention, Interdisciplinary Council on Peripheral Vascular Disease, Council on Cardiovascular Radiology and Intervention. Recommendations for the implementation of telemedicine within stroke systems of care: a policy statement from the American Heart Association. Stroke. 2009 Jul:40(7):2635-60. doi: 10.1161/STROKEAHA.109.192361. Epub 2009 May 7 [PubMed PMID: 19423851]
Schwamm LH, Holloway RG, Amarenco P, Audebert HJ, Bakas T, Chumbler NR, Handschu R, Jauch EC, Knight WA 4th, Levine SR, Mayberg M, Meyer BC, Meyers PM, Skalabrin E, Wechsler LR, American Heart Association Stroke Council, Interdisciplinary Council on Peripheral Vascular Disease. A review of the evidence for the use of telemedicine within stroke systems of care: a scientific statement from the American Heart Association/American Stroke Association. Stroke. 2009 Jul:40(7):2616-34. doi: 10.1161/STROKEAHA.109.192360. Epub 2009 May 7 [PubMed PMID: 19423852]
Walter S, Kostopoulos P, Haass A, Keller I, Lesmeister M, Schlechtriemen T, Roth C, Papanagiotou P, Grunwald I, Schumacher H, Helwig S, Viera J, Körner H, Alexandrou M, Yilmaz U, Ziegler K, Schmidt K, Dabew R, Kubulus D, Liu Y, Volk T, Kronfeld K, Ruckes C, Bertsch T, Reith W, Fassbender K. Diagnosis and treatment of patients with stroke in a mobile stroke unit versus in hospital: a randomised controlled trial. The Lancet. Neurology. 2012 May:11(5):397-404. doi: 10.1016/S1474-4422(12)70057-1. Epub 2012 Apr 11 [PubMed PMID: 22497929]
Level 1 (high-level) evidenceTurc G, Hadziahmetovic M, Walter S, Churilov L, Larsen K, Grotta JC, Yamal JM, Bowry R, Katsanos AH, Zhao H, Donnan G, Davis SM, Hussain MS, Uchino K, Helwig SA, Johns H, Weber JE, Nolte CH, Kunz A, Steiner T, Sacco S, Ebinger M, Tsivgoulis G, Faßbender K, Audebert HJ. Comparison of Mobile Stroke Unit With Usual Care for Acute Ischemic Stroke Management: A Systematic Review and Meta-analysis. JAMA neurology. 2022 Mar 1:79(3):281-290. doi: 10.1001/jamaneurol.2021.5321. Epub [PubMed PMID: 35129584]
Level 1 (high-level) evidenceEuropean Myocardial Infarction Project Group. Prehospital thrombolytic therapy in patients with suspected acute myocardial infarction. The New England journal of medicine. 1993 Aug 5:329(6):383-9 [PubMed PMID: 8326971]
Level 1 (high-level) evidenceWeaver WD, Cerqueira M, Hallstrom AP, Litwin PE, Martin JS, Kudenchuk PJ, Eisenberg M. Prehospital-initiated vs hospital-initiated thrombolytic therapy. The Myocardial Infarction Triage and Intervention Trial. JAMA. 1993 Sep 8:270(10):1211-6 [PubMed PMID: 8355383]
Level 1 (high-level) evidenceRawles JM. Quantification of the benefit of earlier thrombolytic therapy: five-year results of the Grampian Region Early Anistreplase Trial (GREAT). Journal of the American College of Cardiology. 1997 Nov 1:30(5):1181-6 [PubMed PMID: 9350912]
Level 1 (high-level) evidenceMavrogeni SI, Tsirintani M, Kleanthous C, Vranakis K, Secheta E, Mihelakis D, Sotiriou D, Gatzonis M, Tsolas C, Kontaratos AN, Cokkinos DV. Supervision of thrombolysis of acute myocardial infarction using telemedicine. Journal of telemedicine and telecare. 2000:6(1):54-8 [PubMed PMID: 10824393]
Björklund E, Stenestrand U, Lindbäck J, Svensson L, Wallentin L, Lindahl B. Pre-hospital thrombolysis delivered by paramedics is associated with reduced time delay and mortality in ambulance-transported real-life patients with ST-elevation myocardial infarction. European heart journal. 2006 May:27(10):1146-52 [PubMed PMID: 16624832]
Level 2 (mid-level) evidenceMoxham RN, d'Entremont MA, Mir H, Schwalm JD, Natarajan MK, Jolly SS. Effect of Prehospital Digital Electrocardiogram Transmission on Revascularization Delays and Mortality in ST-Elevation Myocardial Infarction Patients: Systematic Review and Meta-Analysis. CJC open. 2024 Oct:6(10):1199-1206. doi: 10.1016/j.cjco.2024.06.012. Epub 2024 Jul 9 [PubMed PMID: 39525334]
Level 1 (high-level) evidenceDing ML, Gerberi DJ, McCoy RG. Engaging emergency medical services to improve postacute management of behavioural health emergency calls: a protocol of a scoping literature review. BMJ open. 2023 Mar 13:13(3):e067272. doi: 10.1136/bmjopen-2022-067272. Epub 2023 Mar 13 [PubMed PMID: 36914186]
Level 2 (mid-level) evidenceNehme E, Magnuson N, Mackay L, Becker G, Wilson M, Smith K. Study of prehospital video telehealth for callers with mental health-related complaints. Emergency medicine journal : EMJ. 2023 Feb:40(2):128-133. doi: 10.1136/emermed-2022-212456. Epub 2022 Dec 1 [PubMed PMID: 36456169]
Rai B, Tennyson J, Marshall RT. Retrospective Analysis of Emergency Medical Services (EMS) Physician Medical Control Calls. The western journal of emergency medicine. 2020 Apr 22:21(3):665-670. doi: 10.5811/westjem.2020.1.44943. Epub 2020 Apr 22 [PubMed PMID: 32421517]
Level 2 (mid-level) evidenceAlicandro J, Hollander JE, Henry MC, Sciammarella J, Stapleton E, Gentile D. Impact of interventions for patients refusing emergency medical services transport. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 1995 Jun:2(6):480-5 [PubMed PMID: 7497046]
Hoyt BT, Norton RL. Online medical control and initial refusal of care: does it help to talk with the patient? Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 2001 Jul:8(7):725-30 [PubMed PMID: 11435188]
Level 2 (mid-level) evidenceBurstein JL, Hollander JE, Delagi R, Gold M, Henry MC, Alicandro JM. Refusal of out-of-hospital medical care: effect of medical-control physician assertiveness on transport rate. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 1998 Jan:5(1):4-8 [PubMed PMID: 9444335]
Level 2 (mid-level) evidenceCukor P, Baer L, Willis BS, Leahy L, O'Laughlen J, Murphy M, Withers M, Martin E. Use of videophones and low-cost standard telephone lines to provide a social presence in telepsychiatry. Telemedicine journal : the official journal of the American Telemedicine Association. 1998 Winter:4(4):313-21 [PubMed PMID: 10220471]
Level 3 (low-level) evidenceWaldrop DP, Waldrop MR, McGinley JM, Crowley CR, Clemency B. Prehospital Providers' Perspectives about Online Medical Direction in Emergency End-of-Life Decision-Making. Prehospital emergency care. 2022 Mar-Apr:26(2):223-232. doi: 10.1080/10903127.2020.1863532. Epub 2021 Feb 2 [PubMed PMID: 33320725]
Level 3 (low-level) evidenceBreyre AM, Sporer KA, Davenport G, Isaacs E, Glomb NW. Paramedic use of the Physician Order for Life-Sustaining Treatment (POLST) for medical intervention and transportation decisions. BMC emergency medicine. 2022 Aug 11:22(1):145. doi: 10.1186/s12873-022-00697-3. Epub 2022 Aug 11 [PubMed PMID: 35948964]
McSwain NE Jr. Controversies in prehospital care. Emergency medicine clinics of North America. 1990 Feb:8(1):145-54 [PubMed PMID: 2295307]
Shatney CH, Homan SJ, Sherck JP, Ho CC. The utility of helicopter transport of trauma patients from the injury scene in an urban trauma system. The Journal of trauma. 2002 Nov:53(5):817-22 [PubMed PMID: 12435928]
Level 2 (mid-level) evidenceBledsoe BE, Wesley AK, Eckstein M, Dunn TM, O'Keefe MF. Helicopter scene transport of trauma patients with nonlife-threatening injuries: a meta-analysis. The Journal of trauma. 2006 Jun:60(6):1257-65; discussion 1265-6 [PubMed PMID: 16766969]
Level 1 (high-level) evidenceDelgado MK, Staudenmayer KL, Wang NE, Spain DA, Weir S, Owens DK, Goldhaber-Fiebert JD. Cost-effectiveness of helicopter versus ground emergency medical services for trauma scene transport in the United States. Annals of emergency medicine. 2013 Oct:62(4):351-364.e19. doi: 10.1016/j.annemergmed.2013.02.025. Epub 2013 Apr 9 [PubMed PMID: 23582619]
Tsai SH, Kraus J, Wu HR, Chen WL, Chiang MF, Lu LH, Chang CE, Chiu WT. The effectiveness of video-telemedicine for screening of patients requesting emergency air medical transport (EAMT). The Journal of trauma. 2007 Feb:62(2):504-11 [PubMed PMID: 17297342]
Saffle JR, Edelman L, Morris SE. Regional air transport of burn patients: a case for telemedicine? The Journal of trauma. 2004 Jul:57(1):57-64; discussion 64 [PubMed PMID: 15284549]
Level 2 (mid-level) evidenceBergrath S, Brokmann JC, Beckers S, Felzen M, Czaplik M, Rossaint R. Implementation of a full-scale prehospital telemedicine system: evaluation of the process and systemic effects in a pre-post intervention study. BMJ open. 2021 Mar 24:11(3):e041942. doi: 10.1136/bmjopen-2020-041942. Epub 2021 Mar 24 [PubMed PMID: 33762230]
Langabeer JR 2nd, Gonzalez M, Alqusairi D, Champagne-Langabeer T, Jackson A, Mikhail J, Persse D. Telehealth-Enabled Emergency Medical Services Program Reduces Ambulance Transport to Urban Emergency Departments. The western journal of emergency medicine. 2016 Nov:17(6):713-720 [PubMed PMID: 27833678]
Varughese R, Cater-Cyker M, Sabbineni R, Sigler S, Champoux S, Gamber M, Burnett SJ, Troutman G, Chuang C, Sanders R, Doran J, Nataneli N, Cooney DR, Bloomstone JA, Clemency BM. Transport Rates and Prehospital Intervals for an EMS Telemedicine Intervention. Prehospital emergency care. 2024:28(5):706-711. doi: 10.1080/10903127.2023.2266023. Epub 2023 Oct 27 [PubMed PMID: 37800855]
Schröder H, Beckers SK, Borgs C, Sommer A, Rossaint R, Grüßer L, Felzen M. Long-term effects of a prehospital telemedicine system on structural and process quality indicators of an emergency medical service. Scientific reports. 2024 Jan 3:14(1):310. doi: 10.1038/s41598-023-50924-5. Epub 2024 Jan 3 [PubMed PMID: 38172217]
Level 2 (mid-level) evidencevan Vuuren J, Thomas B, Agarwal G, MacDermott S, Kinsman L, O'Meara P, Spelten E. Reshaping healthcare delivery for elderly patients: the role of community paramedicine; a systematic review. BMC health services research. 2021 Jan 6:21(1):29. doi: 10.1186/s12913-020-06037-0. Epub 2021 Jan 6 [PubMed PMID: 33407406]
Chan J, Griffith LE, Costa AP, Leyenaar MS, Agarwal G. Community paramedicine: A systematic review of program descriptions and training. CJEM. 2019 Nov:21(6):749-761. doi: 10.1017/cem.2019.14. Epub [PubMed PMID: 30885280]
Level 1 (high-level) evidenceDaniels B, McGinnis C, Topaz LS, Greenwald P, Turchioe MR, Creber RMM, Sharma R. Bridging the digital health divide-patient experiences with mobile integrated health and facilitated telehealth by community-level indicators of health disparity. Journal of the American Medical Informatics Association : JAMIA. 2024 Apr 3:31(4):875-883. doi: 10.1093/jamia/ocae007. Epub [PubMed PMID: 38269583]
Nangalia V, Prytherch DR, Smith GB. Health technology assessment review: remote monitoring of vital signs--current status and future challenges. Critical care (London, England). 2010:14(5):233. doi: 10.1186/cc9208. Epub 2010 Sep 24 [PubMed PMID: 20875149]
Meystre S. The current state of telemonitoring: a comment on the literature. Telemedicine journal and e-health : the official journal of the American Telemedicine Association. 2005 Feb:11(1):63-9 [PubMed PMID: 15785222]
Level 3 (low-level) evidenceGrim P, Feldman T, Martin M, Donovan R, Nevins V, Childers RW. Cellular telephone transmission of 12-lead electrocardiograms from ambulance to hospital. The American journal of cardiology. 1987 Sep 15:60(8):715-20 [PubMed PMID: 3661440]
Anantharaman V, Swee Han L. Hospital and emergency ambulance link: using IT to enhance emergency pre-hospital care. International journal of medical informatics. 2001 May:61(2-3):147-61 [PubMed PMID: 11311669]
Choi BY, Blumberg C, Williams K. Mobile Integrated Health Care and Community Paramedicine: An Emerging Emergency Medical Services Concept. Annals of emergency medicine. 2016 Mar:67(3):361-6. doi: 10.1016/j.annemergmed.2015.06.005. Epub 2015 Jul 11 [PubMed PMID: 26169927]
El Sayed MJ, Zaghrini E. Prehospital emergency ultrasound: a review of current clinical applications, challenges, and future implications. Emergency medicine international. 2013:2013():531674. doi: 10.1155/2013/531674. Epub 2013 Sep 19 [PubMed PMID: 24171113]
Roline CE, Heegaard WG, Moore JC, Joing SA, Hildebrandt DA, Biros MH, Caroon LV, Plummer DW, Reardon RF. Feasibility of bedside thoracic ultrasound in the helicopter emergency medical services setting. Air medical journal. 2013 May-Jun:32(3):153-7. doi: 10.1016/j.amj.2012.10.013. Epub [PubMed PMID: 23632224]
Level 2 (mid-level) evidenceSu MJ, Ma HM, Ko CI, Chiang WC, Yang CW, Chen SJ, Chen R, Chen HS. Application of tele-ultrasound in emergency medical services. Telemedicine journal and e-health : the official journal of the American Telemedicine Association. 2008 Oct:14(8):816-24. doi: 10.1089/tmj.2008.0076. Epub [PubMed PMID: 18954253]
Sibert K, Ricci MA, Caputo M, Callas PW, Rogers FB, Charash W, Malone P, Leffler SM, Clark H, Salinas J, Wall J, Kocmoud C. The feasibility of using ultrasound and video laryngoscopy in a mobile telemedicine consult. Telemedicine journal and e-health : the official journal of the American Telemedicine Association. 2008 Apr:14(3):266-72. doi: 10.1089/tmj.2007.0050. Epub [PubMed PMID: 18570551]
Level 2 (mid-level) evidenceBell F, Pilbery R, Connell R, Fletcher D, Leatherland T, Cottrell L, Webster P. The acceptability and safety of video triage for ambulance service patients and clinicians during the COVID-19 pandemic. British paramedic journal. 2021 Sep 1:6(2):49-58. doi: 10.29045/14784726.2021.9.6.2.49. Epub [PubMed PMID: 34539255]
Dergaa I, Chamari K, Farahat RA, Romdhani M, Taheri M, Memish ZA, Al Abdulla SA. Telemedicine during the FIFA World Cup 2022: a potential tool to curtail the spread of infectious disease during times of pandemic. International journal of surgery (London, England). 2023 Feb 1:109(2):147-149. doi: 10.1097/JS9.0000000000000004. Epub 2023 Feb 1 [PubMed PMID: 36799832]
Nsoesie EO, Kluberg SA, Mekaru SR, Majumder MS, Khan K, Hay SI, Brownstein JS. New digital technologies for the surveillance of infectious diseases at mass gathering events. Clinical microbiology and infection : the official publication of the European Society of Clinical Microbiology and Infectious Diseases. 2015 Feb:21(2):134-40. doi: 10.1016/j.cmi.2014.12.017. Epub 2014 Dec 31 [PubMed PMID: 25636385]
Alquayt A, Aljuhani O, Alharthi AF, Alqahtani R, Khan A, Al-Jedai A, Almoeen A, Alshennawi M, Badreldin HA, Aljouie A, Alnasser LA, Alshehri AM, Alzahrani MY, Alhaidal HA, Alhajaji R, Alotaibi S, Redhwan EZ, Alharthi F, Alghamdi BG, Al Sulaiman K. AI-driven healthcare innovations for enhancing clinical services during mass gatherings (Hajj): task force insights and future directions. BMC health services research. 2025 Jul 1:25(1):876. doi: 10.1186/s12913-025-13045-5. Epub 2025 Jul 1 [PubMed PMID: 40598365]
Level 3 (low-level) evidenceMüller A, Arimond R, Kunczik J, Rossaint R, Czaplik M, Follmann A. Feasibility of telemedicine in civil protection: a prospective observational study during a music festival. World journal of emergency medicine. 2025:16(2):121-128. doi: 10.5847/wjem.j.1920-8642.2025.027. Epub [PubMed PMID: 40135220]
Level 2 (mid-level) evidenceMadsen C, Poropatich R, Koehlmoos TP. Telehealth in the Military Health System: Impact, Obstacles, and Opportunities. Military medicine. 2023 Mar 6:188(Suppl 1):15-23. doi: 10.1093/milmed/usac207. Epub [PubMed PMID: 36882030]
Davis CB, Lorentzen AK, Patel H, Cheung D, Wright A, Lemery J, Penninga L. The Intersection of Telemedicine and Wilderness Care: Past, Present, and Future. Wilderness & environmental medicine. 2022 Jun:33(2):224-231. doi: 10.1016/j.wem.2022.02.012. Epub 2022 Apr 19 [PubMed PMID: 35459612]
Cho J, Chung HS, Choa M, Yoo SK, Kim J. A pilot study of the Tele-Airway Management System in a hospital emergency department. Journal of telemedicine and telecare. 2011:17(1):49-53. doi: 10.1258/jtt.2010.100202. Epub 2010 Nov 19 [PubMed PMID: 21097567]
Level 3 (low-level) evidenceSakles JC, Mosier J, Hadeed G, Hudson M, Valenzuela T, Latifi R. Telemedicine and telepresence for prehospital and remote hospital tracheal intubation using a GlideScope™ videolaryngoscope: a model for tele-intubation. Telemedicine journal and e-health : the official journal of the American Telemedicine Association. 2011 Apr:17(3):185-8. doi: 10.1089/tmj.2010.0119. Epub 2011 Mar 28 [PubMed PMID: 21443441]
Level 3 (low-level) evidenceCulmer N, Smith T, Stager C, Meyer H, Quick S, Grimm K. Evaluation of the triple aim of medicine in prehospital telemedicine: A systematic literature review. Journal of telemedicine and telecare. 2020 Dec:26(10):571-580. doi: 10.1177/1357633X19853461. Epub 2019 Jun 25 [PubMed PMID: 31238783]
Level 1 (high-level) evidenceKim Y, Groombridge C, Romero L, Clare S, Fitzgerald MC. Decision Support Capabilities of Telemedicine in Emergency Prehospital Care: Systematic Review. Journal of medical Internet research. 2020 Dec 8:22(12):e18959. doi: 10.2196/18959. Epub 2020 Dec 8 [PubMed PMID: 33289672]
Level 1 (high-level) evidenceStevanovic A, Beckers SK, Czaplik M, Bergrath S, Coburn M, Brokmann JC, Hilgers RD, Rossaint R, TEMS Collaboration Group. Telemedical support for prehospital Emergency Medical Service (TEMS trial): study protocol for a randomized controlled trial. Trials. 2017 Jan 26:18(1):43. doi: 10.1186/s13063-017-1781-2. Epub 2017 Jan 26 [PubMed PMID: 28126019]
Level 1 (high-level) evidenceKowark A, Felzen M, Ziemann S, Wied S, Czaplik M, Beckers SK, Brokmann JC, Hilgers RD, Rossaint R, TEMS-study group. Telemedical support for prehospital emergency medical service in severe emergencies: an open-label randomised non-inferiority clinical trial. Critical care (London, England). 2023 Jun 30:27(1):256. doi: 10.1186/s13054-023-04545-z. Epub 2023 Jun 30 [PubMed PMID: 37391836]
Level 1 (high-level) evidenceJaeger LR, McCartin MP, Haamid A, Weber JM, Tataris KL. TeleEMS: An EMS Telemedicine Pilot Program Barriers to Implementation. Prehospital emergency care. 2024:28(2):363-368. doi: 10.1080/10903127.2023.2172495. Epub 2023 Feb 3 [PubMed PMID: 36692384]
Level 3 (low-level) evidenceTohira H, Fatovich D, Williams TA, Bremner AP, Arendts G, Rogers IR, Celenza A, Mountain D, Cameron P, Sprivulis P, Ahern T, Finn J. Is it Appropriate for Patients to be Discharged at the Scene by Paramedics? Prehospital emergency care. 2016 Jul-Aug:20(4):539-49. doi: 10.3109/10903127.2015.1128028. Epub 2016 Feb 2 [PubMed PMID: 26836060]
Alpert A, Morganti KG, Margolis GS, Wasserman J, Kellermann AL. Giving EMS flexibility in transporting low-acuity patients could generate substantial Medicare savings. Health affairs (Project Hope). 2013 Dec:32(12):2142-8. doi: 10.1377/hlthaff.2013.0741. Epub [PubMed PMID: 24301398]