Perceived Risks, Mitigation Strategies, and Modifiability of Telehealth in Rural and Remote Emergency Departments: Qualitative Exploration Study.

Background: Telehealth is a recognized and rapidly evolving domain in the delivery of emergency medicine. Research suggests a positive impact of telehealth in patients presenting for emergency care; however, the regional challenges of acute telemedicine delivery have not been studied. The WA Country Health Service (WACHS) established the Emergency Telehealth Service (ETS) in 2012 to provide telehealth and other technology-enabled services to regional Western Australian hospitals and clinics. The WACHS ETS supports 87 rural and remote WACHS-operated hospitals as well as 10 non-WACHS health clinics via high-definition audio-visual equipment installed in the resuscitation bay of the emergency department (ED) at each site. This 12-year practical application of emergency telemedicine offers a unique opportunity to explore the experiences and perceptions of clinicians delivering virtual care to rural and remote communities.

Objective:  This study explores the perceptions of ETS clinicians regarding acceptability, appropriateness, and clinical decision-making when delivering emergency telemedicine in rural and remote settings.

Methods: This qualitative study used semistructured interviews to explore the perspectives of ETS clinicians regarding the factors influencing their clinical decision-making. It explored how ETS clinicians determine and modify clinical risks associated with using audio-visual equipment to deliver care. Emerging themes were compared with the concepts arising from the interim guidance of the Medical Board of Australia, and both the Australian and New Zealand, and American Colleges of Emergency Medicine.

Results: Overall, 16 doctors, 4 clinical nurse coordinators, and a nurse educator from WACHS ETS provided their experiences and perspectives. Accurate clinical decisions, especially regarding patient disposition, were crucial to virtual care. Timeliness and accuracy were enhanced through a mutual learning model grounded in the local context. Mitigation strategies such as improvisation and flexible technology use compensated for technological barriers. Nonmodifiable risk factors included patients' presenting complaints, clinical urgency of presentation, ED capability, clinician scope of practice, and, if a transfer was required, the distance between the ED of original presentation and the hospital of definitive care.

Conclusions: Telehealth can enhance clinical decision-making in rural and remote EDs, and ETS clinicians can prioritize patient safety through a lens incorporating both local hospital capabilities and community contexts. Even for the most experienced clinicians, telehealth was not comparable to face-to-face communication in all circumstances. The impact of the ETS on the scope of the regional emergency medicine practice and on the building of clinical skills warrants further study in relation to its overall effectiveness and cost-effectiveness in rural and remote EDs. These findings identify areas for further qualitative research while providing a rich contextual background for rigorous quantitative analysis of the effectiveness of the ETS.