Virtual emergency department: It is not all in the name

Telemedicine and digital technologies have been supporting the provision of emergency care for more than 20 years. Recent technological advances enabling ubiquitous, high quality, secure video conferencing, remote monitoring and digital ordering and review of investigations and therapies have further expanded the possibilities for delivering emergency care beyond the traditional ED. These advances, when combined with the social licence for rapid healthcare system change provided by the COVID-19 pandemic, have seen an explosion in virtual care models in many aspects of healthcare. Emergency and pre-hospital care is no exception, with new virtual ED models evolving rapidly. The Quadruple Aim of Healthcare Improvement seeks increased efficiency, improved population health, better consumer experience and excellent provider experience.1 There is no doubt that virtual care will enable essential components of the system redesign required to meet today's healthcare challenges. In particular, the ability to provide specialist decision-making, advice and monitoring where it might otherwise not be available is a major advantage of virtual emergency care. Remote and pre-hospital retrieval environments are areas where the virtual presence of specialist emergency physicians has shown particular benefits. However, as we move to more widespread uptake of virtual care models in other areas of emergency care, the situation becomes less clear. Provision of low acuity and minor illness care or advice as part of ED avoidance strategies are increasingly common goals of FACEM-led virtual care models. Despite many of these service models being badged ‘virtual ED’ none of them provide (or are intended to provide) the same depth or breadth of care as that provided in a ‘real ED’. Many models are targeted towards a patient cohort that is a subset of the overall ‘real ED’ patient cohort, others appear to further extend into the space traditionally attributed to primary care. As we see further expansion of these and other novel models of emergency care provision, it is essential that we apply academically rigorous evaluation and ongoing monitoring of the impacts of these models to help guide policy and resourcing decisions. In line with the Quadruple Aim, a detailed understanding of the type of care provided, clinical outcomes, economic and efficiency outcomes, consumer experience and staff satisfaction are all elements of quality evaluation that should guide resourcing and policy decisions in this space. The marked heterogeneity of models of virtual care, methods of delivery, and target patient cohorts provide some challenges to the performance, interpretation and translation of virtual care evaluation studies. In particular, identifying an appropriately matching comparison group for ‘usual care’ must be carefully undertaken to ensure valid results in any study. As no ‘virtual ED’ is designed to fully replace the care provided in a ‘real ED’, a comparison to outcomes or costs of usual care provided to a closely matching patient cohort through ED and other alternative models should be undertaken. Where no such matching patient group exists, then the virtual service is unlikely to be providing ED-equivalent care. Evaluations limited to daily census and assumptions that most patients attending a virtual ED would otherwise have gone to an ED, are largely inadequate to justify the significant investment in virtual ED models. The article by Le et al. published in this issue demonstrates the importance and some of the difficulties in the evaluation of virtual emergency care models, with a wide range of potential economic outcomes based on the assumptions made in the selection of a comparison, usual care cohort.2 There are other impacts of virtual emergency care that are harder to evaluate, but no less important. The implications for the emergency and primary care workforces, particularly in rural and regional centres, are potentially far-reaching, but as yet, rarely discussed and even less well understood. Virtual emergency care, whereas being focussed on specialist-level decision-making and communication, does not involve many of the other aspects of a FACEM's skillset which may potentially impact skills maintenance. On the other hand, some of the assessment and communication skills required for high-quality virtual care may not yet well exist in emergency medicine training, and the provision of virtual emergency care may prolong the careers of some emergency specialists. The involvement of FACEMs, who understand the nuances of the clinical ED systems and various patient cohorts involved, is essential to the quality evaluation of virtual emergency care services in Australasia. Robust evaluation is essential to maximise the benefits and minimise the unintended disbenefits of novel emergency care service provision. Virtual emergency care is no exception. AS is an Academic Emergency Physician and Medical Informatician with research grants and PhD students in digital health, including virtual care. SG is the President-Elect for the Australasian College for Emergency Medicine.