Journal of Public Health

https://doi.org/10.1007/s10389-021-01684-x

REVIEW ARTICLE

Telemedicine in the emergency department: an overview

of systematic reviews
Ali Sharifi Kia1 · Mouna Rafizadeh2 · Leila Shahmoradi3

Received: 13 February 2021 / Accepted: 30 November 2021

© The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature 2021

Abstract
Aim There is both favorable and controversial evidence on the application of telemedicine in the emergency department
(ED), which has created uncertainty regarding the effectiveness of these systems. We performed a systematic review of the
literature on systematic reviews to provide an overview of the benefits and challenges to the application of telemedicine
systems for the ED.
Subject and methods PubMed, Web of Science, Scopus, Cochrane Library, and Google Scholar databases were explored
for systematic reviews of telemedicine applications for the ED. Each review was critically appraised by two authors for data
items to be extracted and evaluated. The most highly recommended technology, feasibility, benefits, and challenges to the
application of telemedicine systems were studied and reported.
Results We identified 18 studies of varying methodological quality and summarized their key findings. Form these 18 stud-
ies, 12 papers yielded a high risk of bias in their investigation. Nine papers concluded that real-time video conferencing was
the best method of delivery, eight papers found cost reduction as an outcome of implementing these systems, and six studies
found technical and infrastructure issues as a challenge when implementing telemedicine for EDs.
Conclusion There is strong evidence suggesting that the use of telemedicine positively impacts patient care. However, there
are many challenges in implementing telemedicine that may impede the process or even impact patient safety. In conclusion,
despite the high potential of telemedicine systems, there is still a need for better quality of evidence in order to confirm their
feasibility in the ED.

Keywords Benefit · Challenge · Telemedicine · Emergency department · Systematic review

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
* Leila Shahmoradi
Lshahmoradi@tums.ac.ir hospital's role in providing services to the people. Each year,
there are approximately 30 million critically ill patients in the
1
Master of Science degree in Health Informatics, Department United States, and the ED provides urgent healthcare for them.
of Health Information Management, School of Health This massive number of admissions decreases the time providers
Management & Information Sciences, Iran University
of Medical Sciences (IUMS), Tehran, Iran can spend with a patient, leading to increased medical error rates
2 (Trzeciak and Rivers 2003). Moreover, it increases the wait time
Master of Science degree in Health Information Technology,
Health Information Management Department, School for treatment, which results in ED overcrowding (Trzeciak and
of Allied Medical Sciences, Tehran University of Medical Rivers 2003).
Sciences (TUMS), Tehran, Iran Due to rising healthcare costs and patient expectations, and in
3
Health Information Management Department, School light of technological advances that have reduced the cost of nec-
of Allied Medical Sciences, Tehran University of Medical essary equipment, the use of telemedicine for providing health-
Sciences (TUMS), No. 17, Farredanesh Alley, Ghods St, care services has seen rapid development (Whitten et al. 2002).
Enghelab Ave, Tehran 14177‑44361, Iran

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Vol.:(0123456789)
 Journal of Public Health

Telemedicine is defined as “providing remote healthcare The objective of this study is to provide an overview
services using information and communication technolo- of systematic reviews regarding the use of telemedicine
gies,” where the information and communication technolo- in the ED. The primary questions to be addressed are as
gies have great potential to be utilized (Sood et al. 2007). follows:
According to recent studies on the application of telemedi-
cine for the ED, these applications include providing spe- I. Is telemedicine technology feasible for the ED?
cialized services to rural areas (Mohr et al. 2018; Ray et al. II. What are the benefits of the application of telemedi-
2017; Ward et al. 2015; Zachrison et al. 2019), reducing ED cine in the ED?
overcrowding (Letvak and Rhew 2015; Rademacher et al. III. What challenges arise when using this technology in
2019; Sun et al. 2018; Tolia et al. 2017), providing special- emergency settings?
ized 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 Material and methods
Falcone 2017).
However, many studies in this area indicate that further Search strategy
research is needed and that current evidence is inadequate
(Ward et al. 2015; Brainard et al. 2016; Salmoiraghi and To investigate the feasibility of telemedicine in the ED and
Hussain 2015; Kelton et al. 2018; Marsh-Feiley et al. 2018; to provide an overview of studies on this topic, a system-
Pak and Pak 2015; Rogers et al. 2017; Kimmel et al. 2019). atic search was carried out in databases including PubMed,
Considering the benefits and challenges of applying tel- Scopus, Web of Science, Cochrane library, and Google
emedicine technology in the ED, which were mentioned in Scholar. In addition, to identify gray literature, we searched
many articles, the usability of these systems seems to be OpenGrey and OpenDOAR databases. Additionally, manual
uncertain, which has given rise to serious questions regard- searches were performed by searching reference lists from
ing their implementation. the included studies. This review was conducted in accord-
Numerous studies have investigated the use of telemedi- ance with the PRISMA protocol.
cine in the ED, and many reviews have attempted to deter- The review was conducted using a combination of MeSH
mine the feasibility of these systems for emergency settings. and relevant terms “Systematic Review,” “Telemedicine,”
However, the results of these studies in many cases tend to and “Emergency.” The last search was performed on Sep-
be in disagreement. Hence we aim to reach a conclusion by tember 15, 2020. The search method for each database is as
presenting an overview of the systematic reviews performed. follows (Table 1):

Table 1  Search strategy

Database Search Strategy Count

PubMed (("Telemedicine"[Title/Abstract] OR "Teleconsultation"[Title/Abstract] OR "Remote Consultation"[Title/ 68

Abstract] OR "Telehealth"[Title/Abstract] OR "eHealth"[Title/Abstract] OR "Telepathology"[Title/Abstract] OR
"Teleradiology"[Title/Abstract] OR "Telerehabilitation"[Title/Abstract] OR "Mobile Health"[Title/Abstract] OR
"mHealth"[Title/Abstract]) AND ("Emergency"[Title/Abstract] OR "Emergency Department"[Title/Abstract] OR
"Emergency medicine"[Title/Abstract] OR "Emergency Information systems"[Title/Abstract])) AND ("Systematic
Review"[Title/Abstract])
Scopus ( TITLE-ABS-KEY ( "Telemedicine" OR "Teleconsultation" OR "Remote Consultation" OR "Telehealth" OR 179
"eHealth" OR "Telepathology" OR "Teleradiology" OR "Telerehabilitation" OR "Mobile Health" OR "mHealth" )
AND TITLE-ABS-KEY ( "Emergency" OR "Emergency Department" OR "Emergency medicine" OR "Emergency
Information systems" ) AND TITLE-ABS-KEY ( "Systematic Review" ) )
Web of Science TOPIC: (“Telemedicine” OR “Teleconsultation” OR “Remote Consultation” OR “Telehealth” OR “eHealth” OR 74
“Telepathology” OR “Teleradiology” OR “Telerehabilitation” OR “Mobile Health” OR “mHealth”) AND TOPIC:
(“Emergency” OR “Emergency Department” OR “Emergency medicine” OR “Emergency Information systems”)
AND TOPIC: ("Systematic Review")
Cochrane Library “Telemedicine” OR “Teleconsultation” OR “Remote Consultation” OR “Telehealth” OR “eHealth” OR “Telepathol- 15
ogy” OR “Teleradiology” OR “Telerehabilitation” OR “Mobile Health” OR “mHealth” in Title Abstract Keyword
AND “Emergency” OR “Emergency Department” OR “Emergency medicine” OR “Emergency Information
systems” in Title Abstract Keyword AND "Systematic Review" in Title Abstract Keyword - (Word variations have
been searched)
Google Scholar intitle:(“Telemedicine” OR “Teleconsultation” OR “Remote Consultation” OR “Telehealth”) AND 478
intitle:(“Emergency” OR “Emergency Department”) AND intitle:"systematic review"

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Journal of Public Health

Eligibility criteria A. The benefits of telemedicine in the ED

B. Challenges posed by application of telemedicine in the ED
Inclusion criteria for the studies were as follows:
Before these two sections, we first present information on
• Published between 2015 and 2020: because we only article journals, telemedicine technologies, and the impact
wanted the modern and most recent evidence regarding on patient care.
the feasibility of this technology The initial search identified 825 articles. Of these, 491
• Published in the English language articles were removed from the study as duplicates, leav-
• Papers that were systematic reviews: because of the dis- ing 334 papers to be screened against the inclusion crite-
parities among the results of studies regarding the feasi- ria. After screening, 74 studies remained, of which 56 were
bility of these systems, we decided to provide an over- removed by exclusion criteria. Finally, 18 articles were
view of the studies performed in recent years and reach included in the study (Fig. 1).
a conclusion. The year of publication for each of the included studies
is presented in Fig. 2.
Exclusion criteria for the studies were as follows: The journals with the highest number of articles were
Telemedicine and e-Health (three articles) and Journal of
• Not concentrated on the application of telemedicine in Telemedicine and Telecare (two articles).
the ED.
Technologies
Date extraction and synthesis
In most of the papers, one of the telemedicine technologies
Data regarding research characteristics and results were was chosen as the most feasible technology. Some articles
independently extracted by two authors. A narrative review pointed out that usability varied depending on the setting
was then performed, and its findings are presented in a table. 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 con-
Data items
ference method (real-time video and audio) tended to be the
best methods, and for primary care, consultation through
Data items that were extracted from the articles include the
real-time audio was found to be the best method (Winburn
following:
et al. 2018). In another review, it was established that the
best and most cost-effective method was a combination of
• Research’s main finding
video conferencing and store and forward (Bashshur et al.
• Main research question
2016). In total, nine papers mentioned real-time video con-
• Number of articles included in systematic review
ferencing (du Toit et al. 2019; Eder et al. 2018; Gattu et al.
• The most recommended technology
2016; Marsh-Feiley et al. 2018; Salmoiraghi and Hussain
• Journal of publication
2015; Ward et al. 2015; Winburn et al. 2018; Culmer et al.
• Publication year
2019; Nadar et al. 2018), three papers mentioned store and
• Telemedicine method
forward (Marsh-Feiley et al. 2018; Winburn et al. 2018;
• Telemedicine application example in its respective field
Lazarus et al. 2020), one paper discussed tele-monitoring
• Benefits of telemedicine implementation
(Kimmel et al. 2019), and one paper real-time audio con-
• Challenges to telemedicine implementation
ferencing (Winburn et al. 2018) as the most feasible tech-
nology, as presented in Fig. 3. Six papers did not mention
Risk of bias assessment anything concerning the issue (Brainard et al. 2016; Kelton
et al. 2018; Pak and Pak 2015; Rogers et al. 2017; Guevork-
Two reviewers independently evaluated the quality of papers ian 2017; Boggan et al. 2020).
using the ROBIS tool (version 1.2) (Whiting et al. 2016). In
the case of disagreement, the final decision was made based The benefits of telemedicine application in the ED
on consensus.
Table 2 provides a summary of the benefits reported in the
included studies
Results As shown in the results above, telemedicine tends to be
effective in many aspects through various approaches. For
The findings of this study are presented in two main sections: example, it can help to avoid unnecessary transfers from rural

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 Journal of Public Health

Fig. 1  PRISMA flow diagram

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 dem-

onstrated 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 implemen-
Fig. 2  Publication year of articles included in the study tation 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
locations to central hospitals. Since the severity of the injury befit each center’s specific goals and needs. Accordingly, the
can be estimated using telemedicine consultation, not every table below outlines the possible challenges of implementing
potential patient transfer will need to take place (Rademacher and applying telemedicine systems in the EDs, which are
et al. 2019). This consultation could vary from a 24-hour extracted from the included studies (Table 3).

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Journal of Public Health

Fig. 3  Most feasible technology

Table 2  Benefits of emergency department telemedicine

Benefit Source Ratio

Cost reduction (Brainard et al. 2016; Gattu et al. 2016; Kelton et al. 2018; Kimmel et al. 2019; 8/18
Pak and Pak 2015; Rogers et al. 2017; Salmoiraghi and Hussain 2015; Culmer
et al. 2019)
Improved quality of care (Bashshur et al. 2016; Eder et al. 2018; Gattu et al. 2016; Kelton et al. 2018; Nadar 7/18
et al. 2018; Culmer et al. 2019; Guevorkian 2017)
Decreased patient transfer rate from rural centers to (Brainard et al. 2016; du Toit et al. 2019; Kelton et al. 2018; Winburn et al. 2018; 6/18
major centers Nadar et al. 2018; Culmer et al. 2019)
Reduced mortality rate (Eder et al. 2018; Kimmel et al. 2019; Guevorkian 2017; Nadar et al. 2018; 5/18
Lazarus et al. 2020)
Reduced patient treatment time (Kimmel et al. 2019; Rogers et al. 2017; Nadar et al. 2018; Lazarus et al. 2020; 5/18
Culmer et al. 2019)
Reduced time between first contact and treatment (Pak and Pak 2015; Rogers et al. 2017; Guevorkian 2017; Lazarus et al. 2020; 5/18
Culmer et al. 2019)
Cost effectiveness (Brainard et al. 2016; Kelton et al. 2018; Ward et al. 2015; Guevorkian 2017; 5/18
Lazarus et al. 2020)
Medical staff practice and training (Gattu et al. 2016; Kimmel et al. 2019; Marsh-Feiley et al. 2018; Lazarus et al. 4/18
2020)
Quick access to specialist (Gattu et al. 2016; Marsh-Feiley et al. 2018; Salmoiraghi and Hussain 2015; Ward 4/18
et al. 2015)
Reduced ED overcrowding (Gattu et al. 2016; Kelton et al. 2018; Winburn et al. 2018) 3/18
improved capability of rural centers (du Toit et al. 2019; Ward et al. 2015; Lazarus et al. 2020) 3/18
On-site diagnosis and prescription (Eder et al. 2018; Rogers et al. 2017) 2/18
Reduced return visits for unnecessary cases (Bashshur et al. 2016; Winburn et al. 2018) 2/18
Providing remote specialist care (Salmoiraghi and Hussain 2015; Ward et al. 2015) 2/18
Preventing medication side effects and medical error (Bashshur et al. 2016; Nadar et al. 2018) 2/18
Better management of emergency conditions (Eder et al. 2018) 1/18

Feasibility evidence has demonstrated the feasibility and effective-

ness of telemedicine in emergency care (Winburn et al.
Overall, the use of telemedicine for emergency settings 2018; Brainard et al. 2016; Bashshur et al. 2016; Ward
has shown much potential. Nevertheless, due to the weak et al. 2015). However, three of these studies had a high
study designs, most of the studies were unable to confirm risk of bias (RoB) (Ward et al. 2015; Winburn et al. 2018;
the usability of telemedicine and concluded that further Bashshur et al. 2016). Twelve papers found that despite the
studies were required. Four papers suggested that ample potential, further studies with better quality of evidence

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Table 3  Challenges of emergency department telemedicine

Challenge Source Ratio

Technical issues and difficulties (Brainard et al. 2016; Gattu et al. 2016; Pak and Pak 2015; Rogers 6/18
et al. 2017; Guevorkian 2017; Culmer et al. 2019)
Legislative, ethical and policy issues (Eder et al. 2018; Gattu et al. 2016; Marsh-Feiley et al. 2018; Sal- 5/18
moiraghi and Hussain 2015; Culmer et al. 2019)
Protecting patient privacy, confidentiality and security (Gattu et al. 2016; Marsh-Feiley et al. 2018; Pak and Pak 2015) 3/18
Prolonged consultation time with telemedicine (Gattu et al. 2016; Marsh-Feiley et al. 2018; Pak and Pak 2015) 3/18
Scarce and limited literature on technology implementation (Kelton et al. 2018; Kimmel et al. 2019; Salmoiraghi and Hussain 3/18
2015)
Lack of cooperation from other departments (Eder et al. 2018; Winburn et al. 2018) 2/18
Loss of skill in rural physician (Kelton et al. 2018; Pak and Pak 2015) 2/18
Incompatible pre-existing health systems (Kelton et al. 2018; Pak and Pak 2015) 2/18
Increased anxiety in hub physician (Kelton et al. 2018; Pak and Pak 2015) 2/18
Possible loss of critical data (Marsh-Feiley et al. 2018; Pak and Pak 2015) 2/18
Synchronizing the field of telemedicine and emergency care (Bashshur et al. 2016; Pak and Pak 2015) 2/18
Increased workload in low staff areas (du Toit et al. 2019; Boggan et al. 2020) 2/18
Lower inclination of rural residents for participation (Brainard et al. 2016; Culmer et al. 2019) 2/18
Financial support (Ward et al. 2015; Culmer et al. 2019) 2/18
Additional time needed for setting up equipment (Pak and Pak 2015) 1/18
Disagreement between diagnosis and management between physi- (Pak and Pak 2015) 1/18
cian
User support (du Toit et al. 2019) 1/18
Difficulty of providing care in remote rural EDs (du Toit et al. 2019) 1/18
Implementation costs (Rogers et al. 2017) 1/18
Increased complexity of cases (Ward et al. 2015) 1/18
Difficult system maintenance (Kimmel et al. 2019) 1/18

were still needed to confirm their findings and the feasi- evidence supported the feasibility of telemedicine; how-
bility of this technology (Eder et al. 2018; Rogers et al. ever, the paper’s main focus was on remote triage and not
2017; Salmoiraghi and Hussain 2015; Kimmel et al. 2019; an overall assessment of all the methods involved (Boggan
Kelton et al. 2018; Marsh-Feiley et al. 2018; Gattu et al. et al. 2020). Also, one paper did not report any outcome
2016; Pak and Pak 2015; Guevorkian 2017; Nadar et al. regarding feasibility and effectiveness (du Toit et al. 2019)
2018; Lazarus et al. 2020; Culmer et al. 2019). Seven (Fig. 4).
of these studies were determined to have a high RoB in Table 4 presents the review results for each article
their investigation (Rogers et al. 2017; Salmoiraghi and included in the study. The application example column
Hussain 2015; Kelton et al. 2018; Gattu et al. 2016; Pak expands on telemedicine applications regarding the
and Pak 2015; Lazarus et al. 2020; Culmer et al. 2019). research field, and the findings column provides a brief
One paper, which had a low RoB, reported that limited summary of the studies’ main findings.

Fig. 4  Feasibility and effective-

ness

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 Table 4  Data extracted from articles
Reference Research questions Number of Method Application Findings
included
articles

Eder et al. (2018) 1- Which telemedicine services in 15 Tele-consultation Providing services using tele- 1- Tele-consultation and pre-noti-
acute trauma care are imple- consultation which a paramedic fication systems have the most
Journal of Public Health

mented, and what was the nature would not normally be able to utilization for acute trauma care
of intervention? do 2- Its application improves patient’s
2- What are the reported effects Telemedical pre-notification Hospital care team awareness of condition
of telemedicine on acute trauma patient’s condition while trans-
care by EMS? ferring the patient
3- Which methodologies were
used to produce knowledge
about telemedicine in included
studies?
Winburn et al. (2018) What is the level of adoption, 68 Tele-consultation Providing pre-hospital counseling 1- It is best to utilize forward and
the format of delivery, and the for stroke, cardiovascular dis- store for cardiovascular diseases
clinical focus for telehealth in ease, and trauma 2- Tele-consultation is commonly
pre-hospital emergency care? used for stroke patient care
du Toit et al. (2019) 1- How has telehealth been used 15 Tele-consultation Linking a small rural ED to a 1- Tele-consultation systems tend
to manage noncritical major ED center and receiving to be more accepted in places
emergency presentations? services and tele-consultation where nurses are the main
2- What were the telehealth pro- from specialists there provider
gram outcomes? 2- Its acceptance seems low in
places where doctors are the main
provider
Rogers et al. (2017) How is telemedicine implemented 23 Tele-consultation Providing tele-consultation for System implementation outcomes
and what are its benefits and on-site and ambulance paramed- have been positive and beneficial
effects? ics by a specialist physician
Brainard et al. (2016) Which health service interven- 33 Tele-consultation Utilizing skills and equipment of The use of these systems is espe-
tions reduce the unplanned use major centers in cities by rural cially cost-effective in rural areas
of healthcare by rural popula- EDs
tions?
Salmoiraghi and Hussain (2015) What are the effects and qualities 23 Tele-consultation Providing psychological coun- 1- Tele-consultation improves
of tele-psychiatry in emergency seling and management services accessibility
settings? in the case of emergency 2- Cost reduction
Ward et al. (2015) What is the impact of hospital- 38 Tele-consultation Decision support for diagnosis 1- Most studies have had positive
based telemedicine systems in and treatment and beneficial outcomes
emergency care settings? Telepresence The remote physician has the role 2- Research design and statistic
of on-site physician assessment of studies was not
robust enough

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 Table 4  (continued)
Reference Research questions Number of Method Application Findings
included

13
articles

Kimmel et al. (2019) Which alert systems improve out- 10 Telemedical notification Integrating care plans with the 1- Telemedical notification reduces
comes and which types of alerts electronic health record (EHR) costs
are effective? and sending reminder to pro- 2- It improves resource consump-
vider at the desired time tion
3- The usability of telemedicine
systems requires further research
Kelton et al. (2018) – 11 Tele-consultation Using less expensive care provid- 1- The highest rate of implementa-
ers, e.g., a nurse, alongside a tion of these systems is in coun-
remote physician tries with diffuse populations
2- The success of these systems
seems to lie not in the specialized
services provided but in the abil-
ity to support patients in need of
urgent care who may not receive
the necessary quality care in other
ways
Marsh-Feiley et al. (2018) Is tele-sonography feasible, 28 Tele-sonography A nonspecialist sonographer con- 1- Tele-sonography is applicable to
diagnostically accurate, and necting a specialist through the a wide range of situations
clinically useful in emergency system, and either the examina- 2- Asynchronous communication
settings? tion is done in real time, or the was the most accessible among
pictures are taken and then sent the available methods
to the specialist
Bashshur et al. (2016) What does the current evidence 86 Tele-consultation Consultation of two specialists or 1- Tele-consultation is effective in
say about the feasibility, accept- providing tele-consultation for primary care
ance, and effect of telemedicine chronic patients instead of refer- 2- It is acceptable for both patient
in primary care? rals to the ED and provider
3- It improves the quality of service
4- It reduces costs
Gattu et al. (2016) – Not stated Tele-consultation Linking two centers and provid- 1- They are usable and reliable
ing consultation 2- Further investigation is required
Tele-monitoring Real-time remote monitoring in the case of pediatric emer-
of the patient’s physiological gency care
status, including vital signs
Pak and Pak (2015) Does telemedicine offer clinical 7 Tele-consultation Provider surveillance, X-ray inter- 1- No clinical benefits were
benefits? pretation, and EKG transmis- observed
Does telemedicine offer the same sion prior to patient transfer to 2- It was safe and satisfactory
outcomes with reduced costs? the center
Guevorkian (2017) What potential does telemedicine 15 Tele-consultation Augmenting the efforts of non- Studies have shown promising
have in pre-hospital care? professional health workers in results, but more robust studies
low-resource settings are needed to confirm the findings
Journal of Public Health
 Table 4  (continued)
Reference Research questions Number of Method Application Findings
included
articles

Nadar et al. (2018) What is the effect of telemedicine 24 Tele-consultation Assessing the patient in real time, The use of telemedicine showed
on clinical outcomes in pediatric checking clinical positive impacts, but more studies
Journal of Public Health

acute care? data and medical files, observing are needed

medical images and monitoring
equipment, and providing a
beneficial and helpful remote
consultation
Lazarus et al. (2020) Is tele-stroke usable for acute 15 Tele-consultation (tele-stroke) Providing treatment remotely to Telemedicine showed promising
stroke management in rural stroke victims in rural com- results, but further studies are
settings? munities needed to confirm these findings
Boggan et al. (2020) Is remote triage feasible and ben- 8 Tele-consultation (remote triage) Triaging patients to the appropri- There is limited evidence support-
eficial for acute settings? ate level of care through the ing the feasibility of remote triage
use of technological systems in acute settings
that facilitate remote decision-
making
Culmer et al. (2019) Is ambulance-based telemedicine 13 Tele-consultation Transmission of patient 1- Telemedicine is effective in
effective? What is its effect on data from an ambulance to a reducing costs
quality, cost, and satisfaction? hospital’s ED or physician 2- Quality of care is as good or
even better when using telemedi-
cine
3- Increased efficiency when using
telemedicine due to reduced
number and time of travel and
also time of care

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 Journal of Public Health

Risk of bias assessment the management of chronic diseases that require consistent
follow-ups to the hospital and especially the ED.
The included studies were evaluated using the ROBIS tool. On the other hand, implementing this technology can
This tool evaluates the quality of systematic reviews using have unwanted results and may pose some challenges to the
four domains of questions: domain 1, study eligibility crite- organization and patients. Technical issues (Brainard et al.
ria; domain 2, identification and selection of studies; domain 2016; Gattu et al. 2016; Mong et al. 2019; Pak and Pak 2015;
3, data collection and study appraisal; and domain 4, synthe- Rogers et al. 2017; Culmer et al. 2019; Guevorkian 2017),
sis and findings. In another phase, the tool then determines legislation, and ethical and policy issues (Eder et al. 2018;
the risk of bias in the studies based on the answers to those Gattu et al. 2016; Marsh-Feiley et al. 2018; Salmoiraghi and
questions (Table 5). Hussain 2015; Culmer et al. 2019) tend to be the most com-
monly reported issues using this system. If using these sys-
tems delays service provision or endangers patients’ critical
health information, they may think twice before using them.
Discussion This technology can be especially useful in rural areas
where there is a shortage of specialist care and equipment.
Overall, evidence indicates that although telemedicine in Remote consultation can improve access to specialist care,
the ED is both practical and convenient, it presents its own reduce mortality, and facilitate transfer from these areas
challenges. Most of the studies concluded that despite the to major hospitals, which itself can reduce costs and over-
high potential of this technology, its feasibility is uncertain, crowding. These systems have also shown high potential in
and further research is needed (Eder et al. 2018; Kimmel trauma and stroke care. They can provide an opportunity to
et al. 2019; Rogers et al. 2017; Salmoiraghi and Hussain reduce severity and mortality, decrease response and treat-
2015; Kelton et al. 2018; Marsh-Feiley et al. 2018; Pak and ment time, and provide specialist care on-site.
Pak 2015; Gattu et al. 2016; Guevorkian 2017; Nadar et al. During the COVID-19 global pandemic, there has been a
2018; Lazarus et al. 2020; Culmer et al. 2019). surge in the adoption of telemedicine worldwide as a means
Most of the included reviews were published in Telemedi- for remote delivery of non-urgent medical care (Bashshur
cine and e-Health and the Journal of Telemedicine and Tel- et al. 2020; Vidal-Alaball et al. 2020). Increased practice
ecare (Bashshur et al. 2016; Kimmel et al. 2019; Rogers of telemedicine has demonstrated that the infrastructure for
et al. 2017; Culmer et al. 2019; Winburn et al. 2018; du widespread adoption of such technologies may have more
Toit et al. 2019). Most of the articles were also published in availability than previously thought, mainly owing to the
2018, reflecting the recent interest of the researchers to this global adoption of smartphones (Bashshur et al. 2020; Vidal-
field (Eder et al. 2018; Kelton et al. 2018; Marsh-Feiley et al. Alaball et al. 2020). Many governments have temporarily
2018; Winburn et al. 2018; Nadar et al. 2018). ceased all restrictive regulations regarding telemedicine
Real-time video conferencing was the most feasible tech- use, including licensing and reimbursement (Bashshur et al.
nology used in this area, according to the studies (du Toit 2020). However, security risks, confidentiality issues, and
et al. 2019; Eder et al. 2018; Gattu et al. 2016; Marsh-Feiley unauthorized access remain a major concern (Bashshur et al.
et al. 2018; Salmoiraghi and Hussain 2015; Ward et al. 2015; 2020; Vidal-Alaball et al. 2020).
Winburn et al. 2018; Nadar et al. 2018; Culmer et al. 2019). The demonstrated potential of telemedicine during the
Although tele-monitoring has been investigated in previous pandemic can lay the groundwork for further implementa-
years for emergency settings, it was mentioned the least in tion of these technologies for managing chronic diseases
the included studies (Kimmel et al. 2019). such as diabetes, heart conditions, or asthma in routine clini-
Many outcomes were reported as benefits of implement- cal practice in the future (Portnoy et al. 2020; Vidal-Alaball
ing such systems in the ED. Cost reduction (Brainard et al. et al. 2020).
2016; Gattu et al. 2016; Kelton et al. 2018; Kimmel et al.
2019; Pak and Pak 2015; Rogers et al. 2017; Salmoiraghi Limitations
and Hussain 2015), improved quality of care (Bashshur et al.
2016; Eder et al. 2018; Gattu et al. 2016; Kelton et al. 2018), Our study had several limitations that might impact our
decreased patient transfer rate (Brainard et al. 2016; du Toit investigation. Only English-language studies and those
et al. 2019; Kelton et al. 2018; Winburn et al. 2018), reduced published between 2015 and 2020 were included in our
mortality rate (Eder et al. 2018; Kimmel et al. 2019; Mong review, since we wanted only the most recent and up-to-
et al. 2019), and treatment time (Kimmel et al. 2019; Rog- date evidence regarding the issue. Consequently, we did not
ers et al. 2017) are only a few of these cases. Accordingly, include much of the early research on telemedicine use in
implementing this technology can be beneficial for both EDs, especially that related to trauma. Hence, there were
organizations and patients, since it could greatly facilitate likely studies that should have been included and were not,

13
 Table 5  Risk of bias assessment
Study Domain 1 Domain 2 Domain 3 Domain 4 Risk of bias FD

1 2 3 4 5 LoC 1 2 3 4 5 LoC 1 2 3 4 5 LoC 1 2 3 4 5 6 LoC 1 2 3 RoB

(Eder et al. Evalua- Y Y Y P-Y P-Y Low Y Y Y Y Y Low P-Y P-Y Y N N-I High Y P-Y Y Y P-Y N UC P-Y Y Y Low Low
2018) tor 1
Journal of Public Health

Evalua- P-Y P-Y Y P-N P-Y Low Y N-I P-Y Y P-Y Low P-N Y P-Y N N-I High P-Y P-Y N-I Y P-Y N Low P-Y Y P-Y Low
tor 2
(Winburn Evalua- Y P-Y P-Y P-Y P-Y Low P-Y P-N P-Y P-N P-Y High N-I P-Y P-Y N N High P-Y Y P-Y Y P-Y N UC N P-Y Y High High
et al. tor 1
2018) Evalua- P-Y P-Y P-N P-Y P-Y Low P-N N P-Y P-N N-I High N-I P-Y P-Y N-I N-I UC P-N P-Y N Y N-I P-N UC P-N P-Y Y High
tor 2
(du Toit Evalua- Y P-Y Y P-Y P-Y Low Y P-N P-Y N P-Y High P-Y Y Y N N High Y P-Y P-Y P-Y Y N High N Y P-Y High High
et al. tor 1
2019) Evalua- P-Y P-N P-Y P-N P-N High P-Y Y P-Y P-N N-I High P-Y P-Y N-I N N High P-N P-Y P-Y P-Y N-I N High N P-Y P-Y High
tor 2
(Rogers Evalua- N-I P-Y Y P-Y P-Y Low P-N Y P-Y N Y High Y Y Y N N High Y P-Y Y Y P-Y N High N P-Y Y High High
et al. tor 1
2017) Evalua- P-Y P-Y P-Y P-Y Y Low P-N N-I P-N P-Y Y High Y P-Y P-Y N N-I UC P-Y P-Y P-Y Y P-N N-I Low P-Y P-Y P-Y Low
tor 2
(Brainard Evalua- Y P-Y Y P-Y P-Y Low Y Y Y P-Y P-Y Low N-I P-Y Y Y N-I Low Y Y Y Y P-Y P-Y Low Y Y Y Low Low
et al. tor 1
2016) Evalua- Y P-Y Y Y Y Low P-Y Y N-I Y P-Y Low P-Y P-Y P-Y Y P-Y Low P-Y Y P-Y Y N-I P-N Low Y P-Y Y Low
tor 2
(Sal- Evalua- N-I Y P-Y Y Y Low Y Y P-Y N Y High N-I P-N Y N N High Y P-Y P-Y Y P-Y N High N Y Y High High
moiraghi tor 1
and Evalua- P-N N-I N N-I P-N High P-Y P-Y P-N P-N Y High N-I P-N P-N N-I N-I High N-I N P-N N-I N N High N P-N P-N High
Hussain tor 2
2015)
(Ward et al. Evalua- Y P-Y P-Y Y Y Low Y N P-Y N Y High Y Y Y N N High Y P-Y Y Y P-Y N High N Y P-Y High High
2015) tor 1
Evalua- Y P-Y P-Y Y P-Y Low Y N-I P-Y P-N Y High N-I P-Y P-Y N-I N-I UC P-Y Y N-I N-I P-Y N High P-N P-Y P-Y High
tor 2
(Kimmel Evalua- Y Y P-Y P-Y Y Low Y P-Y Y Y Y Low Y Y P-Y Y N-I Low Y P-Y Y Y P-Y P-Y Low P-Y P-Y Y Low Low
et al. tor 1
2019) Evalua- P-Y P-Y P-Y P-N Y Low Y P-Y N-I P-Y Y Low Y P-Y P-Y Y N-I Low P-N P-Y P-Y Y P-Y P-Y Low P-Y Y P-Y Low
tor 2
(Kelton Evalua- Y P-Y Y P-Y Y Low Y Y Y P-Y Y Low N-I Y Y N N High Y P-Y Y Y P-Y N High N Y Y High High
et al. tor 1
2018) Evalua- Y Y P-Y P-Y P-Y Low Y P-Y P-Y P-N Y Low N-I P-N P-Y N-I N-I UC Y N-I P-N N-I N-I N-I UC P-N P-Y P-Y UC
tor 2
(Marsh- Evalua- Y Y Y P-Y Y Low Y Y Y Y Y Low Y P-Y P-Y Y Y Low Y Y P-Y Y Y Y Low P-Y Y Y Low Low
Feiley tor 1
et al. Evalua- Y P-Y Y P-Y P-Y Low Y P-Y P-Y P-Y P-Y Low N-I P-Y P-Y Y Y Low P-Y Y P-Y P-Y P-Y P-Y Low Y Y P-Y Low
2018) tor 2

13
 Table 5  (continued)
Study Domain 1 Domain 2 Domain 3 Domain 4 Risk of bias FD

1 2 3 4 5 LoC 1 2 3 4 5 LoC 1 2 3 4 5 LoC 1 2 3 4 5 6 LoC 1 2 3 RoB

13
(Bashshur Evalua- P-Y P-Y N P-N P-Y High N-I N-I N-I N N-I High N-I P-Y Y N N High P-Y Y P-Y P-Y Y N High N N-I Y High High
et al. tor 1
2016)
Evalua- P-Y P-N P-N P-N N High N-I N-I N-I P-N N-I High N-I N-I P-N N-I N-I High P-Y N-I P-Y N-I N-I N-I UC P-N P-N N-I High
tor 2
(Gattu Evalua- Y Y P-Y N-I P-Y Low N-I N-I N-I P-Y N-I UC N-I P-Y Y N N High P-Y P-Y P-Y P-Y N-I N High N P-Y P-Y High High
et al. tor 1
2016) Evalua- P-Y Y P-N N-I N-I UC N-I N-I N-I N-I N-I UC N-I P-Y N-I N N High P-Y N-I P-Y P-N N-I N High N P-Y N-I High
tor 2
(Pak and Evalua- N-I P-Y Y P-Y P-Y Low Y Y Y N Y High Y Y Y N N High P-Y P-Y Y P-Y P-Y N High N P-Y Y High High
Pak tor 1
2015) Evalua- Y P-Y P-Y P-Y P-N Low Y Y P-Y P-N Y Low Y P-Y P-N N-I N-I UC P-N N P-Y P-Y P-Y N-I High N P-Y P-Y High
tor 2
(Guevork- Evalua- N-I P-Y Y P-Y P-Y Low Y P-Y Y P-Y N High N P-Y Y Y N High Y Y P-Y Y P-Y P-Y Low Y P-Y Y Low Low
ian 2017) tor 1
Evalua- Y P-Y Y P-Y P-Y Low P-Y P-Y P-Y P-Y N High N P-Y P-Y Y N High P-Y Y P-Y P-Y P-Y P-Y Low P-Y P-Y Y Low
tor 2
(Nadar Evalua- Y P-Y Y P-Y P-Y Low Y Y Y P-Y Y Low Y P-Y Y Y Y Low Y Y Y Y P-Y Y Low P-Y Y P-Y Low Low
et al. tor 1
2018) Evalua- Y P-Y Y P-Y P-N Low Y Y Y P-Y Y Low Y P-Y Y P-Y Y Low Y P-Y Y Y P-Y Y Low Y Y P-Y Low
tor 2
(Lazarus Evalua- Y Y Y P-Y P-Y Low P-Y Y Y N N High N Y P-Y Y N High Y Y P-Y Y P-Y Y Low N P-Y Y High High
et al. tor 1
2020) Evalua- Y Y P-Y P-Y P-Y Low P-Y Y P-Y P-N P-N High N-I P-Y P-Y Y Y Low P-Y Y Y Y P-Y Y Low P-N P-Y Y UC
tor 2
(Boggan Evalua- Y P-Y Y P-Y P-Y Low Y P-Y Y P-Y Y Low Y Y P-Y Y Y Low Y P-Y Y P-Y P-Y P-Y Low Y P-Y P-Y Low Low
et al. tor 1
2020) Evalua- P-Y P-Y P-Y N-I P-N UC P-Y P-Y Y P-Y Y Low Y Y P-Y Y Y Low P-Y Y Y Y P-Y P-Y Low P-Y P-Y P-Y Low
tor 2
(Culmer Evalua- Y P-Y Y P-Y P-Y Low P-Y N P-Y N Y High Y P-Y Y Y N-I Low Y P-Y Y Y P-Y P-Y Low N P-Y Y High High
et al. tor 1
2019) Evalua- Y P-Y Y P-Y P-Y Low P-Y N P-N N Y High Y Y P-Y Y N-I Low P-Y P-Y Y P-Y P-Y P-Y Low P-N P-Y Y High
tor 2

LoC = level of concern, Y = yes , FD = final decision, UC = unclear, N-I = no information, RoB = risk of bias, N = no, P-Y = probably yes, P-N = probably no
Journal of Public Health
Journal of Public Health

and likewise also studies that were less relevant but were specialist at another location. It
included. Another limitation of our study was that most of is not unlike email, but it is done
the papers included had a high RoB in their investigation. using a solution that has built-in,
Hence, further research with higher quality of evidence is sophisticated security features to
needed to reach a conclusion on the feasibility of telemedi- ensure patient confidentiality [2].
cine for emergency care. Tele-monitoring Transmission of patient vital and non-vital
signs from patient site to the doctor. It is
more suited for patients with chronic ill-
Conclusion nesses such as hypertension or diabetes
[3].
The application of telemedicine for the ED still has a long Telepresence Feeling present in a remote but real envi-
way to go, and there are many unknown areas that have yet ronment through telecommunications in
to be investigated. This review has highlighted the benefits order to perform tasks [4].
and challenges faced while implementing and using telemed- Tele-consultation Synchronous or asynchronous consulta-
icine in the ED. The majority of reviews found evidence of tion using information and communica-
cost reduction for both hospital and patient. For example, tion technology to omit geographical and
for chronic disease management, which requires constant functional distance. Its goals are for diag-
follow-up, telemedicine can alleviate the issue by reducing nostics or treatment between two or more
the costs and overcrowding. Nevertheless, if the proper tech- geographically separated health provid-
nical infrastructure is not available for these systems, the ers (for example, physicians or nurses) or
expected effectiveness cannot be realized, and may lead to between health providers and patients [5].
reduced hospital productivity and even prolonged treatment Tele-psychiatry The practice of delivering psychiatric
time. Altogether, telemedicine for the ED has high potential care using communications technology
to impact patient care; however, due to the low quality of as a remote linkage between health-care
studies and scarce clinical trials regarding the issue, its fea- providers and patients. Enables the pro-
sibility cannot be confirmed, and further studies with better ductive interaction for clinical assessment,
quality of evidence are needed. diagnosis, medication management, and
therapy [6].
Future research suggestion Tele-stroke A network of audiovisual communica-
tion and computer systems providing the
Future research should focus on providing better quality foundation for a collaborative, interprofes-
of evidence and more robust study designs. There is also sional care model focusing on acute stroke
a paucity of clinical trials regarding the implementation of patients [7].
telemedicine in EDs. Tele-sonography Combination of the use of ultrasound with
telemedicine, allows for off-site expert
interpretation as a solution to the major
disadvantage of ultrasound, namely the
Glossary skill required to interpret images [8].
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Author contributions Leila Shahmordai prepared the study conception Use of telehealth in the management of non-critical emergencies
and design, reviewed the final manuscript, critically revised the paper, in rural or remote emergency departments: a systematic review. J
and approved the final version of manuscript. Material preparation, data Telemed Telecare 25: 3-16. https://​doi.​org/​10.​1177/​13576​33X17​
collection, and analysis were performed by Ali Sharifi Kia and Mouna 734239
Rafizadeh. The first draft of the manuscript was written by Ali Sharifi Eder PA, Reime B, Wurmb T, Kippnich U, Shammas L, Rashid A
Kia, and all authors commented on previous versions of the manuscript. (2018) Prehospital Telemedical Emergency Management of
Severely Injured Trauma Patients. Methods Inf Med 57:231–242.
Funding The authors did not receive support from any organization https://​doi.​org/​10.​1055/s-​0039-​16810​89
for the submitted work. Gattu R, Teshome G, Lichenstein R (2016) Telemedicine applications
for the pediatric emergency medicine: a review of the current lit-
erature. Pediatr Emerg Care 32:123–130. https://​doi.​org/​10.​1097/​
Availability of data and material The lead author affirms that this pec.​00000​00000​000712
manuscript is an honest, accurate, and transparent account of the Guevorkian M (2017) Is Prehospital Emergency Telemedicine Imple-
study being reported, that no important aspects of the study have been mentation Feasible In Non-Traditional EMS Settings: A System-
omitted, and that any discrepancies from the study as planned (and, if atic Literature Review. University of Arizona. http://​hdl.​handle.​
relevant, registered) have been explained. net/​10150/​623626
Kelton DK, Szulewski A, Howes D (2018) Real-time video telemedi-
Code availability Not applicable cine applications in the emergency department: a scoping review
of literature. CJEM 20:920–928. https://​doi.​org/​10.​1017/​cem.​
Declarations 2017.​382
Kim PT, Falcone RA Jr (2017) The use of telemedicine in the care of
the pediatric trauma patient. Semin Pediatr Surg 47-53. Elsevier.
Ethics approval The authors declare that this review was completed in https://​doi.​org/​10.​1053/j.​sempe​dsurg.​2017.​01.​008
compliance with ethical standards. Kimmel HJ, Brice YN, Trikalinos TA, Sarkar IN, Ranney ML (2019)
Real-Time Emergency Department Electronic Notifications
Conflict of Interest The authors have no relevant financial or nonfinan- Regarding High-Risk Patients: A Systematic Review. Telemed
cial interests to disclose. J E Health 25:604–618. https://​doi.​org/​10.​1089/​tmj.​2018.​0117
Lazarus, G, Permana AF, Nugroho SW, Audrey J, Wijaya DN, Widya-
Consent to participate Not applicable hening IS (2020) Telestroke strategies to enhance acute stroke
management in rural settings: A systematic review and meta-
Consent for publication Not applicable analysis. Brain Behav e01787. https://​doi.​org/​10.​1002/​brb3.​1787
Letvak S, Rhew D (2015) Assuring quality health care in the emer-
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