Introduction

Emergency departments (ED) are one of the most critical and sensitive sections of the hospital, and how they function can have a considerable effect on other sections and patient satisfaction. The performance of the ED is a key measure in evaluating a hospital's role in providing services to the people. Each year, there are approximately 30 million critically ill patients in the United States, and the ED provides urgent healthcare for them. This massive number of admissions decreases the time providers can spend with a patient, leading to increased medical error rates (Trzeciak and Rivers 2003). Moreover, it increases the wait time for treatment, which results in ED overcrowding (Trzeciak and Rivers 2003).

Due to rising healthcare costs and patient expectations, and in light of technological advances that have reduced the cost of necessary equipment, the use of telemedicine for providing healthcare services has seen rapid development (Whitten et al. 2002).

Telemedicine is defined as “providing remote healthcare services using information and communication technologies,” where the information and communication technologies have great potential to be utilized (Sood et al. 2007). According to recent studies on the application of telemedicine for the ED, these applications include providing specialized services to rural areas (Mohr et al. 2018; Ray et al. 2017; Ward et al. 2015; Zachrison et al. 2019), reducing ED overcrowding (Letvak and Rhew 2015; Rademacher et al. 2019; Sun et al. 2018; Tolia et al. 2017), providing specialized services to paramedics, better crisis management, and reducing the time between accidents and patients’ arrival at the hospital (Cho et al. 2015; Doggett et al. 2018; Kim and Falcone 2017).

However, many studies in this area indicate that further research is needed and that current evidence is inadequate (Ward et al. 2015; Brainard et al. 2016; Salmoiraghi and Hussain 2015; Kelton et al. 2018; Marsh-Feiley et al. 2018; Pak and Pak 2015; Rogers et al. 2017; Kimmel et al. 2019).

Considering the benefits and challenges of applying telemedicine technology in the ED, which were mentioned in many articles, the usability of these systems seems to be uncertain, which has given rise to serious questions regarding their implementation.

Numerous studies have investigated the use of telemedicine in the ED, and many reviews have attempted to determine the feasibility of these systems for emergency settings. However, the results of these studies in many cases tend to be in disagreement. Hence we aim to reach a conclusion by presenting an overview of the systematic reviews performed.

The objective of this study is to provide an overview of systematic reviews regarding the use of telemedicine in the ED. The primary questions to be addressed are as follows:

  1. I.

    Is telemedicine technology feasible for the ED?

  2. II.

    What are the benefits of the application of telemedicine in the ED?

  3. III.

    What challenges arise when using this technology in emergency settings?

Material and methods

Search strategy

To investigate the feasibility of telemedicine in the ED and to provide an overview of studies on this topic, a systematic search was carried out in databases including PubMed, Scopus, Web of Science, Cochrane library, and Google Scholar. In addition, to identify gray literature, we searched OpenGrey and OpenDOAR databases. Additionally, manual searches were performed by searching reference lists from the included studies. This review was conducted in accordance with the PRISMA protocol.

The review was conducted using a combination of MeSH and relevant terms “Systematic Review,” “Telemedicine,” and “Emergency.” The last search was performed on September 15, 2020. The search method for each database is as follows (Table 1):

Table 1 Search strategy
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Eligibility criteria

Inclusion criteria for the studies were as follows:

  • Published between 2015 and 2020: because we only wanted the modern and most recent evidence regarding the feasibility of this technology

  • Published in the English language

  • Papers that were systematic reviews: because of the disparities among the results of studies regarding the feasibility of these systems, we decided to provide an overview of the studies performed in recent years and reach a conclusion.

Exclusion criteria for the studies were as follows:

  • Not concentrated on the application of telemedicine in the ED.

Date extraction and synthesis

Data regarding research characteristics and results were independently extracted by two authors. A narrative review was then performed, and its findings are presented in a table.

Data items

Data items that were extracted from the articles include the following:

  • Research’s main finding

  • Main research question

  • Number of articles included in systematic review

  • The most recommended technology

  • Journal of publication

  • Publication year

  • Telemedicine method

  • Telemedicine application example in its respective field

  • Benefits of telemedicine implementation

  • Challenges to telemedicine implementation

Risk of bias assessment

Two reviewers independently evaluated the quality of papers using the ROBIS tool (version 1.2) (Whiting et al. 2016). In the case of disagreement, the final decision was made based on consensus.

Results

The findings of this study are presented in two main sections:

  1. A.

    The benefits of telemedicine in the ED

  2. B.

    Challenges posed by application of telemedicine in the ED

Before these two sections, we first present information on article journals, telemedicine technologies, and the impact on patient care.

The initial search identified 825 articles. Of these, 491 articles were removed from the study as duplicates, leaving 334 papers to be screened against the inclusion criteria. After screening, 74 studies remained, of which 56 were removed by exclusion criteria. Finally, 18 articles were included in the study (Fig. 1).

Fig. 1
figure 1

PRISMA flow diagram

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The year of publication for each of the included studies is presented in Fig. 2.

Fig. 2
figure 2

Publication year of articles included in the study

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The journals with the highest number of articles were Telemedicine and e-Health (three articles) and Journal of Telemedicine and Telecare (two articles).

Technologies

In most of the papers, one of the telemedicine technologies was chosen as the most feasible technology. Some articles pointed out that usability varied depending on the setting and the situation. For instance, in cardiovascular disease centers, the store and forward method, for supporting stroke patients before arriving at the hospital, and the video conference method (real-time video and audio) tended to be the best methods, and for primary care, consultation through real-time audio was found to be the best method (Winburn et al. 2018). In another review, it was established that the best and most cost-effective method was a combination of video conferencing and store and forward (Bashshur et al. 2016). In total, nine papers mentioned real-time video conferencing (du Toit et al. 2019; Eder et al. 2018; Gattu et al. 2016; Marsh-Feiley et al. 2018; Salmoiraghi and Hussain 2015; Ward et al. 2015; Winburn et al. 2018; Culmer et al. 2019; Nadar et al. 2018), three papers mentioned store and forward (Marsh-Feiley et al. 2018; Winburn et al. 2018; Lazarus et al. 2020), one paper discussed tele-monitoring (Kimmel et al. 2019), and one paper real-time audio conferencing (Winburn et al. 2018) as the most feasible technology, as presented in Fig. 3. Six papers did not mention anything concerning the issue (Brainard et al. 2016; Kelton et al. 2018; Pak and Pak 2015; Rogers et al. 2017; Guevorkian 2017; Boggan et al. 2020).

Fig. 3
figure 3

Most feasible technology

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The benefits of telemedicine application in the ED

Table 2 provides a summary of the benefits reported in the included studies

Table 2 Benefits of emergency department telemedicine
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As shown in the results above, telemedicine tends to be effective in many aspects through various approaches. For example, it can help to avoid unnecessary transfers from rural locations to central hospitals. Since the severity of the injury can be estimated using telemedicine consultation, not every potential patient transfer will need to take place (Rademacher et al. 2019). This consultation could vary from a 24-hour consulting nurse (Ray et al. 2017) to video evaluation, usually combined with radiology images (specifically in the diagnosis of minor fractures) (Cho et al. 2015). Furthermore, due to the high accuracy of telemedicine diagnosis either in an ambulance or on the scene, the patient’s treatment time also seems to be considerably shorter (Mohr et al. 2018).

Challenges posed by application of telemedicine in the emergency department

Although the benefits of telemedicine in EDs were demonstrated in every article included, its challenges, varying from technical and infrastructure issues (Brainard et al. 2016; Gattu et al. 2016; Pak and Pak 2015; Rogers et al. 2017; Culmer et al. 2019; Guevorkian 2017) to implementation costs (Rogers et al. 2017), remain. Addressing the challenges ahead for telemedicine programs to be applied most efficiently is just as vital as identifying its benefits that befit each center’s specific goals and needs. Accordingly, the table below outlines the possible challenges of implementing and applying telemedicine systems in the EDs, which are extracted from the included studies (Table 3).

Table 3 Challenges of emergency department telemedicine
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Feasibility

Overall, the use of telemedicine for emergency settings has shown much potential. Nevertheless, due to the weak study designs, most of the studies were unable to confirm the usability of telemedicine and concluded that further studies were required. Four papers suggested that ample evidence has demonstrated the feasibility and effectiveness of telemedicine in emergency care (Winburn et al. 2018; Brainard et al. 2016; Bashshur et al. 2016; Ward et al. 2015). However, three of these studies had a high risk of bias (RoB) (Ward et al. 2015; Winburn et al. 2018; Bashshur et al. 2016). Twelve papers found that despite the potential, further studies with better quality of evidence were still needed to confirm their findings and the feasibility of this technology (Eder et al. 2018; Rogers et al. 2017; Salmoiraghi and Hussain 2015; Kimmel et al. 2019; Kelton et al. 2018; Marsh-Feiley et al. 2018; Gattu et al. 2016; Pak and Pak 2015; Guevorkian 2017; Nadar et al. 2018; Lazarus et al. 2020; Culmer et al. 2019). Seven of these studies were determined to have a high RoB in their investigation (Rogers et al. 2017; Salmoiraghi and Hussain 2015; Kelton et al. 2018; Gattu et al. 2016; Pak and Pak 2015; Lazarus et al. 2020; Culmer et al. 2019). One paper, which had a low RoB, reported that limited evidence supported the feasibility of telemedicine; however, the paper’s main focus was on remote triage and not an overall assessment of all the methods involved (Boggan et al. 2020). Also, one paper did not report any outcome regarding feasibility and effectiveness (du Toit et al. 2019) (Fig. 4).

Fig. 4
figure 4

Feasibility and effectiveness

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Table 4 presents the review results for each article included in the study. The application example column expands on telemedicine applications regarding the research field, and the findings column provides a brief summary of the studies’ main findings.

Table 4 Data extracted from articles
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Risk of bias assessment

The included studies were evaluated using the ROBIS tool. This tool evaluates the quality of systematic reviews using four domains of questions: domain 1, study eligibility criteria; domain 2, identification and selection of studies; domain 3, data collection and study appraisal; and domain 4, synthesis and findings. In another phase, the tool then determines the risk of bias in the studies based on the answers to those questions (Table 5).

Table 5 Risk of bias assessment
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Discussion

Overall, evidence indicates that although telemedicine in the ED is both practical and convenient, it presents its own challenges. Most of the studies concluded that despite the high potential of this technology, its feasibility is uncertain, and further research is needed (Eder et al. 2018; Kimmel et al. 2019; Rogers et al. 2017; Salmoiraghi and Hussain 2015; Kelton et al. 2018; Marsh-Feiley et al. 2018; Pak and Pak 2015; Gattu et al. 2016; Guevorkian 2017; Nadar et al. 2018; Lazarus et al. 2020; Culmer et al. 2019).

Most of the included reviews were published in Telemedicine and e-Health and the Journal of Telemedicine and Telecare (Bashshur et al. 2016; Kimmel et al. 2019; Rogers et al. 2017; Culmer et al. 2019; Winburn et al. 2018; du Toit et al. 2019). Most of the articles were also published in 2018, reflecting the recent interest of the researchers to this field (Eder et al. 2018; Kelton et al. 2018; Marsh-Feiley et al. 2018; Winburn et al. 2018; Nadar et al. 2018).

Real-time video conferencing was the most feasible technology used in this area, according to the studies (du Toit et al. 2019; Eder et al. 2018; Gattu et al. 2016; Marsh-Feiley et al. 2018; Salmoiraghi and Hussain 2015; Ward et al. 2015; Winburn et al. 2018; Nadar et al. 2018; Culmer et al. 2019). Although tele-monitoring has been investigated in previous years for emergency settings, it was mentioned the least in the included studies (Kimmel et al. 2019).

Many outcomes were reported as benefits of implementing such systems in the ED. Cost reduction (Brainard et al. 2016; Gattu et al. 2016; Kelton et al. 2018; Kimmel et al. 2019; Pak and Pak 2015; Rogers et al. 2017; Salmoiraghi and Hussain 2015), improved quality of care (Bashshur et al. 2016; Eder et al. 2018; Gattu et al. 2016; Kelton et al. 2018), decreased patient transfer rate (Brainard et al. 2016; du Toit et al. 2019; Kelton et al. 2018; Winburn et al. 2018), reduced mortality rate (Eder et al. 2018; Kimmel et al. 2019; Mong et al. 2019), and treatment time (Kimmel et al. 2019; Rogers et al. 2017) are only a few of these cases. Accordingly, implementing this technology can be beneficial for both organizations and patients, since it could greatly facilitate the management of chronic diseases that require consistent follow-ups to the hospital and especially the ED.

On the other hand, implementing this technology can have unwanted results and may pose some challenges to the organization and patients. Technical issues (Brainard et al. 2016; Gattu et al. 2016; Mong et al. 2019; Pak and Pak 2015; Rogers et al. 2017; Culmer et al. 2019; Guevorkian 2017), legislation, and ethical and policy issues (Eder et al. 2018; Gattu et al. 2016; Marsh-Feiley et al. 2018; Salmoiraghi and Hussain 2015; Culmer et al. 2019) tend to be the most commonly reported issues using this system. If using these systems delays service provision or endangers patients’ critical health information, they may think twice before using them.

This technology can be especially useful in rural areas where there is a shortage of specialist care and equipment. Remote consultation can improve access to specialist care, reduce mortality, and facilitate transfer from these areas to major hospitals, which itself can reduce costs and overcrowding. These systems have also shown high potential in trauma and stroke care. They can provide an opportunity to reduce severity and mortality, decrease response and treatment time, and provide specialist care on-site.

During the COVID-19 global pandemic, there has been a surge in the adoption of telemedicine worldwide as a means for remote delivery of non-urgent medical care (Bashshur et al. 2020; Vidal-Alaball et al. 2020). Increased practice of telemedicine has demonstrated that the infrastructure for widespread adoption of such technologies may have more availability than previously thought, mainly owing to the global adoption of smartphones (Bashshur et al. 2020; Vidal-Alaball et al. 2020). Many governments have temporarily ceased all restrictive regulations regarding telemedicine use, including licensing and reimbursement (Bashshur et al. 2020). However, security risks, confidentiality issues, and unauthorized access remain a major concern (Bashshur et al. 2020; Vidal-Alaball et al. 2020).

The demonstrated potential of telemedicine during the pandemic can lay the groundwork for further implementation of these technologies for managing chronic diseases such as diabetes, heart conditions, or asthma in routine clinical practice in the future (Portnoy et al. 2020; Vidal-Alaball et al. 2020).

Limitations

Our study had several limitations that might impact our investigation. Only English-language studies and those published between 2015 and 2020 were included in our review, since we wanted only the most recent and up-to-date evidence regarding the issue. Consequently, we did not include much of the early research on telemedicine use in EDs, especially that related to trauma. Hence, there were likely studies that should have been included and were not, and likewise also studies that were less relevant but were included. Another limitation of our study was that most of the papers included had a high RoB in their investigation. Hence, further research with higher quality of evidence is needed to reach a conclusion on the feasibility of telemedicine for emergency care.

Conclusion

The application of telemedicine for the ED still has a long way to go, and there are many unknown areas that have yet to be investigated. This review has highlighted the benefits and challenges faced while implementing and using telemedicine in the ED. The majority of reviews found evidence of cost reduction for both hospital and patient. For example, for chronic disease management, which requires constant follow-up, telemedicine can alleviate the issue by reducing the costs and overcrowding. Nevertheless, if the proper technical infrastructure is not available for these systems, the expected effectiveness cannot be realized, and may lead to reduced hospital productivity and even prolonged treatment time. Altogether, telemedicine for the ED has high potential to impact patient care; however, due to the low quality of studies and scarce clinical trials regarding the issue, its feasibility cannot be confirmed, and further studies with better quality of evidence are needed.

Future research suggestion

Future research should focus on providing better quality of evidence and more robust study designs. There is also a paucity of clinical trials regarding the implementation of telemedicine in EDs.