From Feb. 19 to 23, 2017, Orlando’s County Convention Center (OCCC) hosted this year’s largest health IT conference and exhibition, HIMSS17. Cybernet traditionally attended, and we have a lot of news and impressions to share. With 7 million square feet, OCCC is one of the country’s largest convention centers, so there was a lot of ground to cover.

Of particular interest was “Mobile Innovations and Telehealth in Emergency Care” session by Professor James Langabeer, Ph.D., M.B.A. The session focused on how Emergency Telehealth and Navigation program (ETHAN), in conjunction with mobile medical tablets, is helping the City of Houston Fire Department be more efficient in responding to medical emergencies, especially when serving low acuity patients.


ETHAN, funded by Delivery System Reform Incentive Payment, launched in 2015 based on the belief that there must be a more efficient solution to provide care to non-emergent patients. By now, ETHAN has served nearly 9,000 patients, which is approximately 5% of all emergency calls in the city.

The challenge that prompted the City of Houston Fire Department (HFD) to seek better solutions is that of an increasing Emergency Department overload. Long waiting lines in EDs are growing, as increased population is finding it easier to dial 911 from their smartphones.

With 600,000 911 calls and 400 EMS transports per day, HFD is stretched beyond its capacity. If an average person used to call 911 once or twice in a lifetime, the current population has drastically increased the level of 911 engagement. Densely populated cities can not keep up with the number of calls. Prof. Langabeer notes how educational programs that aim to increase population awareness on when to use 911 always end up increasing the number of 911 calls instead of reducing them. In Houston, the number of fear-related, low acuity visits to ED is 20%-50% of all 911 calls.

Hence, HFD ambulances respond to a large number of low acuity situations that do not require medical equipment or urgent medical attention. It is these low acuity visits that call for ETHAN activation.

How It Works

Ambulance and firefighter teams are equipped with mobile tablets running ETHAN program developed by CISCO. It is a commercially available solution customized specifically for the HFD needs. The requirement was to make the solution HIPAA compliant, encrypted, with the capability to record interactions, and guarantee a reliable connection between the ETHAN crew and the remote physician, who might be on the move.

If the crew, upon arrival, decide that the patient may not require an ED visit, they activate ETHAN and initiate a video call with a remote physician using a medical tablet.

The remote emergency physician interviews the patient as if he/she were at the bedside, and, based on vitals, history, and assessment of the medic on site, may offer several options:

  • The ambulance transport to ED.
  • Referral to an ED with a prepaid taxi.
  • Clinic referral with taxi transport.
  • Referral to the primary care provider or home care.


The goals of ETHAN are to:

  • Reduce the number of ambulance ED transports for low-acuity cases that do not require urgent medical attention
  • Improve unit availability & total turnaround times
  • Improve focus on true emergencies
  • Connect patients with a medical home
  • Improve care quality, reduce costs


There are some situations, in which people are over-utilizing 911, says Prof. Langabeer. Patients may be new to the city and do not have a primary care provider yet, or they may have chronic conditions and bounce from ER to ER whereas what they need is an appointment with their primary care provider, and tests, or they just need a medication refill.

If a remote physician decides the case is low acuity, he/she can recommend the patient be redirected to the clinic right away. The physician even schedules an appointment the same day or the next day. The taxi service is prepaid by the HFD. The cost savings are significant, as the taxi fare is several times cheaper than the ambulance transportation.

One of the special features of the program is the follow-up calls. The multiple callers get follow-ups that aim to engage them with other programs (primary care, home care) to reduce the number of non-emergent repeat callers.

Patient Disposition

The results in changing patient disposition are promising. Of a total 8,561 ETHAN patients:

  • 65% chose to go to a hospital ED with a taxi instead of an ambulance.
  • 7% chose the clinic referral with a taxi.
  • 6% chose the referral to PCP or home care.
  • 16% chose ambulance transport to ED.


Results summary:

  • ETHAN unit productivity (39 minutes per visit on average) is higher than that of the traditional EMS units (83 minutes per visit on average) by 44 minutes.
  • The cost of ETHAN unit visit is $167 per patient, while that of the traditional EMS unit is $270/patient.
  • Disposition to ED by ambulance is 67% in ETHAN patients, and 74% in traditional EMS units patients.
  • ETHAN’s ROI is $928,000/year; $2,468/ED visit averted.
  • At the same time, patient satisfaction is even for both ETHAN and traditional EMS patients.


As we can see, the crew productivity is doubled with ETHAN assistance, while cost savings in averted ED visits and reduced ambulance use are significant.


At the same time, there are a few roadblocks that the program encounters:

  • Insufficient budget.
  • Policy and reimbursement issues.
  • Certain resistance from the healthcare community as providers get fewer ED visits that are expensive and more primary care visits that are cheaper (but more relevant).
  • Patient reluctance and lack of awareness, as most patients insist on ED visits and tend to feel their needs are not addressed when offered alternatives.
  • Staff training on the use of telehealth technology and the criteria that call to ETHAN activation.


“If this was your family member, would you be comfortable with sending them somewhere other than the emergency room?” said Prof. Langabeer, when asked about the criteria units rely on to activate ETHAN.

Revolutionizing Healthcare, One Step At A Time

ETHAN is the first of its kind in telehealth and the use of medical tablets, and it revolutionized Houston healthcare by enabling an instant and remote partnership between responders and caregivers. It transformed how the city handles emergency calls from patient, responder and health care perspectives by boosting turnaround time, and minimizing the number of unnecessary ED visits. The cost efficiency is apparent at the payer level, as the patients get expert advice on alternatives that are more reasonable and affordable than an ED ride with an ambulance.

The next step for the program is to expand telehealth into EMS and further incorporate mobile technology solutions. Projects such as ETHAN call for deployment of HIPAA-compliant, EHR-Ready medical tablets with antimicrobial* properties protect the tablet casing from deterioration and degradation. There is a need for hot-swap battery technology to ensure full-shift uptime, and RFID Imprivata SSO with integrated biometric scanner to enable advanced authentication and data protection.