Special Topic: The doctor one screen away

Show Notes

In 2022 one emergency department in thirteen lacked an attending physician around the clock. Every rural one should have an emergency physician on video at all hours, paid for by Medicare rather than grants.

Read the special topic and its sources: https://physicianintheloop.org/specials/rural-ed-tele-emergency/

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The doctor one screen away

In 2022 one emergency department in thirteen lacked an attending physician around the clock. Every rural one should have an emergency physician on video at all hours, paid for by Medicare rather than grants.

Deaths after stroke ran higher at the seven community emergency departments that could reach a neurologist only by telephone, if at all, in a study of 52 departments published in July. Risk-adjusted death rates a month after stroke were nearly two percentage points higher than where a neurologist came in person. By video, the gap could not be told from chance. The study compared hospitals, not patients, and cannot show cause. It asks the right question of rural emergency care. Can a physician see the patient?

The three-bed emergency room in Ekalaka, Montana, two hours' drive from the nearest hospital with more advanced services, has not had a physician in at least 30 years, a physician assistant there, Carla Dowdy, told KFF Health News last year. When a patient arrived in June 2025 needing more than the room could have given even with a doctor, Ms. Dowdy called for a plane and called out drugs and doses while a paramedic and nurses gave them. She can phone a physician, a doctor across the state reviews every chart, and the emergency room was working on virtual reality glasses that would let remote physicians see what its staff see. It is not enough. Every rural emergency department should have an emergency physician on video at every hour, paid for by Medicare as standing care rather than by grants that run out.

Ekalaka is an extreme case of a common gap. In a national survey, one emergency department in thirteen reported no attending physician on duty around the clock in 2022, and in the Dakotas more than half did. Nine in ten of those were in critical access hospitals, which federal rules let rely on an on-call clinician, not necessarily a physician, who can arrive within half an hour, or an hour in frontier country. Rural emergency hospitals, which no longer admit patients for acute care, need someone competent in emergency care on site at every hour, the same kind of on-call clinician as a critical access hospital, and a physician reachable by radio, telephone or electronic link.

The evidence is better on speed and judgment. At 14 rural Midwestern hospitals, patients for whom the remote service was called met a clinician six minutes sooner than matched patients, mostly because the remote clinician came first, though they stayed longer in the department. In a randomized trial in 15 rural and community emergency departments in northern California, video rather than telephone consultation about acutely ill children meant fewer transfers. The sharpest result came from 29 rural Australian departments without emergency specialists. A suspected heart attack set off an automatic alert to a referral hospital's coronary care unit, which read the tracing and blood test remotely and phoned the local doctor. Usual care missed about one in three of the heart attacks that need an artery opened at once. The alert system missed none.

On whether patients live longer, evidence is thin. The Australian trial was too small to settle it. In 23 hospitals of an upper Midwestern network that already offered a board-certified emergency physician by video around the clock, patients with sepsis seen through it did no better on days out of hospital or on deaths than matched patients. In Medicare claims for sepsis, patients at hospitals with the service had higher total costs of care and similar outcomes. For patients treated on site only by nonphysician clinicians, a subgroup named in advance, the 23-hospital study suggested fewer deaths with video. It is a reason to measure, not yet a finding.

Software is sold to fill the same gap. Since 2018 the Food and Drug Administration has allowed an app from Viz.AI that reads a brain scan for a blocked artery and texts a specialist. A randomized trial of the company's software at four Houston stroke centers, whose staff the company trained, found it sped the start of clot removal by about 11 minutes, but excluded transfers from other hospitals, the patients a small emergency room sends. The Australian system that worked was an alert that summoned a person. An alert is only as good as whoever answers it, and ten departments with no physician on duty could not reach any physician by voice at every hour.

A payer could read the sepsis studies and refuse. Why pay every month for a service that raised costs and showed no fewer deaths? Fair, as far as it goes. But sepsis is one condition, and the two trials, of video consultation for sick children and of remote review of heart tracings by telephone, found fewer transfers and fewer missed diagnoses. Neither tested round-the-clock video access to an emergency physician. Standby is the condition for treatment, not a treatment to be proved like a drug, and Medicare already pays for it. A critical access hospital can include the cost of a clinician on call who can arrive within 30 or 60 minutes, and a rural emergency hospital gets about $295,000 a month this year for its operation and services, telehealth among them. Neither requires an emergency physician.

So pay for the standby itself. Smaller rural emergency departments are, researchers wrote in 2021, "the most likely to benefit from telemedicine, but the least likely to have it." Departments with it mostly carry the subscription as overhead. Grants fill the gap. In May Kansas awarded $5 million of federal money to a hospital alliance that, with partners, says it will expand emergency and other telehealth to more member hospitals. The federal money behind it is available through fiscal 2030. Medicare should make round-the-clock video access to a board-certified emergency physician a condition for critical access and rural emergency hospitals, with Congress where the law requires, and pay for it every month at every rural hospital. The networks should report how often they are called, how fast a physician appears and what becomes of the patients.

Ekalaka may never have a doctor in the building. It can have one who sees the patient at every hour, not only one who hears about them by telephone. Whether that saves lives in rooms like Ms. Dowdy's is unproven. Paying for it properly is how anyone will find out.

This special topic was read by an AI voice. Its sources are linked at physicianintheloop.org.