REDUCING ED-CROWDING USING TELE-TRIAGE APPLIED TO TELEMEDICINE Seminar Type: Mid-semester project review (9 units) Table of Contents REDUCING ED-CROWDING 1 1.ABSTRACT 3 2.INTRODUCTION 3 3.BACKGROUND 3 3.1 DEFINITIONS 4 3.2 ISSUES OF ED CROWDING 4 3.3 RESOLVING STRATEGIES FOR ED CROWDING AND ASSOCIATED BENEFITS 5 3.4 FACTORS INVOLVED 6 3.5 LIMITATIONS AND ISSUES INVOLVED 7 4. PROJECT REVIEW 8 4.1PROJECT PLAN FOR DEVELOPING SIMULATION MODEL 8 Step 1: Formulate the problem 8 Step 2: Collect information/data 8 Step3: Tools to develop simulation model 8 3.a. Discrete Event Simulation 8 3.b. Agent Based Simulation 8 3.c. Continues simulation 8 Step4: Scope 8 Step5: Program the model and check validity 9 Step6: Design and analysis experiments 9 Step7: Document and present the simulation result 10 4.2 BENCHMARK AND LIMITATION OF CURRENT PRACTICE 10 4.3 OVERVIEW OF CURRENT STATUS AND PROGRESS 10 5.REFERENCES 11 1.Abstract This project discuses Emergency department (ED) crowding and a potential solution for reducing ED- crowding using tele-triage applied to telemedicine, which has become a most common issue in receiving timely emergency treatment in health care industry. Despite extensive identification of the problem, the research and policy agendas needed to understand and address ED crowding are just beginning to unfold. I present a simulation model for reducing ED crowding to help researchers and software developers understand its causes and develop potential software. 2.Introduction Through the technological boom and the industrial development across the countries in the different parts of the world, people have gained more access to the basic daily life needs such as the education, travelling as well as medical assistance from the hospitals. Although this notion could be regarded as a beneficial outcome result which has been attained in the process but on the contrary, the medical assistance could not be marked as satisfactory to meet the needs of all the people who have visited the hospitals for the problem. The demands of the people who require medical assistance is not satisfactory which has given rise to the problem of the Emergency Department (ED) crowding. The problems are found to be worse in case of the developing countries where the medical facilities are scarce and barely meet the needs of the patients who require the medical assistance (Hodges et al., 2007). In this issue, the patients do not get the assistance that they required while the medical staff members also find it difficult to manage all the people who have come for their problem. The technological boom has made it possible to perform the functions in a timely manner in which the people could be provided with the crucial medical needs which are imperative for them. Along with the newest technological methods, there have been a lot of practices which have been found to be successful in reducing the ED crowding in the medical facility (Alavi-Moghaddam et al., 2012). 3.Background As mentioned earlier, the industrialization and developments have made people to be more connected to the daily life assistance but on the other side of the argument, it has also been a bit problematic to manage the people particularly in the hospitals. This issue is not solely linked to the management of the patients but is in addition found to be linked to the other aspects such as the higher mortality rate, complications in the condition as well as the negative clinical outcomes simultaneously. Some of the countries do not even have the numerical records of the issues (Pines et al., 2011) which suggest that this is an issue and ought to be addressed by devising a solution. The problematic outcomes have essentially given rise to the notion of a middle way which could be devised to overcome this medical obstacle which will save the lives of the people simultaneously. By making the medical treatment process a more structured and well assembled, much of the issues pertaining to the ED crowding could be addressed in which the patients get their desired assistance in short time period and it also becomes manageable for the medical staff side by side (Alavi-Moghaddam et al., 2012). 3.1 Definitions Before going to the detailed discussion of the whole subject matter, it is vital to examine and explain the definition which will provide with the foundation of the concepts. Crowding in the medical terms is defined as follows: “Crowding occurs when the identified need for emergency services exceeds available resources for patient care in the emergency department, hospital, or both.” While an ED is thought to be crowded when insufficient resources in order to meet the patient care requirements further lead to a decrease in the quality of care (American College of Emergency Physicians, 2003). This issue could lead to additional problems which has been the reason why, there is a significant requirement to deal with it at the appropriate time which will save a lot of time and effort as well. The method to resolve this issue has been selected as the tele-triage along with the tele-medicine methods which could be examined through the following definition: Tele-triage is the process of assessing the priority of urgency of 39 the patient’s symptoms by telephone.” (Stacey et al. 2003). (American College of Emergency Physicians, 2006). While the tele-medicine is defined as ‘healing at a distance’ in which the people are more exposed to the opportunities to get treated and it has been marked as an innovative medical strategy. 3.2 Issues of ED crowding The crowding in the ED has been identified as an issue because of the fact that many of the people go untreated in the whole process which is not a sole problem that is being faced by the patients who are in the process of calling for the medical assistance. In addition, patients who are suffering from the critical conditions do not get timely treated which increases the probability of the mortality rates thus posing a negative outcome and a huge challenge side by side (Singer, Thode Jr, Viccellio and Pines, 2011). Even if the crowding aspect exclusively gets managed by the medical staff, it has also been advocated through the previous findings of the study that the quality of the treating patients gets low which is something that cannot be tolerated in terms of the medical aid. Patients who suffer from the medical problems require assistance, proper diagnosis and a sound treatment which makes them satisfied with the overall procedure of curative strategies. Furthermore, this issue had also been explored through another study which the retrospective cohort method had been integrated along with using the databases of the health administration. The overall findings of the research suggested that a lot of patients are discharged without being seen which also includes the issue of lack of diagnosis at the same time. The research had also put forward that there is a higher risk of the short term death along with the short term adverse effects due to the untreated conditions of the ED crowding (Guttmann, Schull, Vermeulen and Stukel, 2011). It is undeniable fact that someone who requires the medical support at a very short term basis would most certainly fall into a life threatening situation which does explain the problem of the mortality rate. For this reason and for a number of other arising issues in the process, the ED crowding has been recognized as an intense issue. The issue of ED crowding is taking its initial shape which has to be resolved at the right time through the best available strategies in order to control it at the right time. It has been found out that the visits to the ED have increased to 32 percent in number from 1999 to 2009. The waiting time to see the provider has also elevated at the same time (Hing and Bhuiya, 2012). This number is quite outnumbered which is found to be increasing with the time. There are a number of strategies in the form of conceptual models which seem to be quite applicable and assist in lowering the issues of the patient crowding in the emergency department. Although these frameworks help out in resolving the issue on the short term basis (Asplin et al., 2003) but there is a strong need to work on it on the long term and comprehensive span which will further be discussed in the detail. 3.3 Resolving strategies for ED crowding and associated benefits The problem of the ED is not something which is a constant phenomenon but it is a cyclic in which there are certain times of the day, seasons and crisis in which it becomes difficult to manage the whole crowded situation (Han et al., 2007). Hence, there are certain cycles or time period in the health care facility which could be recognized and identified as a problem for which the countering methods could be implemented. Among the most vital ways which have been adopted for addressing this problem in the medical facility, one of the ways is through the operational changes in the hospital as well as the health policy interventions (Pines et al., 2011). As mentioned earlier, the reason for regarding the ED crowding as an issue is the fact that there are negative outcomes which directly influence the people who require emergency assistance from the hospitals. In addition, the patients also seem to be waiting for a longer period of time which results in delaying the assistance that they require at the right time. If they are not given this treatment, it ultimately results to the medical issues, higher rates of mortality, complications in the medical conditions and the like (Bernstein et al., 2009; Pines and Hollander, 2008). For this reason, the countering practices have been carried out which are found to be imperative to be discussed so that the applications along with the usefulness of the countering strategies for the issue could be highlighted. Most of the problems that come out to the front are addressed and the studies have also advocated the similar solutions for it. These studies could be found to be partially applicable in the process of the present research due to the cultural differences and other linked factors which will also be discussed further in detail. Findings of the research postulated that improving the resources within the healthcare facility such as increasing the number of beds for the patients had also found to be quite effective in the process of resolving the ED crowding (Haghighinejad et al., 2016). Another research study had put forward that through recruiting an emergency physician in the ED had also been found to be relieving who worked with the nurses at the triage (Medeiros, Swenson and DeFlitch, 2008). However, the present study focuses primarily on the usage of the tele-triage and tele- medicine method which will now be discussed. There are countless benefits for this mode of treating the patients and it had been found out that through the integration of the tele-triage, there had been very long term benefits that had been attained (Kyriacou, Ricketts, Dyne, McCollough and Talan, 1999). It is the kind of treatment method which is fast and has very productive outcomes in which the patients get satisfied with the treatment methods and is accepted by them (Traub, Butler, Chang and Lipinski, 2013) which gets problematic in case of the ED crowding as mentioned before. Moreover, the similar resolving strategy could also be used in the developing countries where the providence of the medical aid is the main problem (Kamsu- Foguem and Foguem, 2014). Although these strategies of managing the problem could not be called as the cost effective methods as per the finding of the study, but on the other hand they do seem to be more feasible for the healthcare practitioners (Cheng et al., 2015). Hence, the problem for the ED crowding could be tackled through the newest methods in the medical field but they are not as easy as it might seem. There is an involvement of the factors which seem to inhibit or support such treatment methods concurrently. 3.4 Factors involved A number of factors have been found to be involved in the whole process of ED crowding in which some of the dynamics smoothen out the way for better opportunities in this subject matter while some are found as the major barriers side by side. This problem has been regarded as an issue on the international level and the issue of ED is found to be caused by the patients who visit the hospitals on the frequent basis (i.e., frequent flyers), influenza season, and shortages of the bed services etc. The issues that have been resulted due to these issues result in the delays in the transportation, treatment delays along with the financial effects. As per the suggested findings of the research carried out in this domain area, the remedial solutions for such problems included the access to the beds in the hospitals, queuing theory, additional personnel and crowding control measures (Hoot and Aronsky, 2008). All of these resolving strategies seem like appealing measures but they require to be executed in the existence of the suitable factors which facilitate such happenings. For example, the country where there are financial issues along with the economic crisis, suggesting this kind of resolution will not be sufficient. This is when the role of the tele- medicine comes into play which could be applied in diverse cultural and regional settings. Many of the issues that are involved in the process are the lack of development in the region in which the basic healthcare facilities that ought to be provided to the people are quite redundant. There are certain other elements that are marked as the profound barriers and are sometimes political while on the other hand, are related to the cultural practices. When there is a lot of crowing in the ED, it gives rise to the following issues (Muntlin, Carlsson and Gunningberg, 2010): • The patients are seen as the objects. • There is an involvement of the organizational culture in the process to which the nurses and doctors belong. • The organization of the hospital itself is involved in hindering the process of the quality improvement in the facilities. Hence, it could be seen that these are some of the major challenges which need to be altered and challenged in which the governing authorities could play a very significant role. This type of the organizational culture could not be tolerated in the treatment procedure where the human life carries a lot of vitality. These barriers are related to the cultural environment which could either be in the organization or in the social set up in general. This is a barrier in general in which the governing authorities require to have a set up in which there is a strict check and balance on the processes which will assist in improving these types of facilities. However, on such a massive scale, the management could be a bit troubling which is one of the major objectives for the present research study suggesting the tele-triage and tele-medicines could be introduced to deal with this situation. Another significant factor that is involved is the role of management within the hospital environment requires betterment in which the decision making process could help in lowering the numbers of the patients who are in the process of the treatment which will make room for the new ones (Amaral and Costa, 2014). Once this issue is sorted out, it could lead towards the implementation of the tele-triage and tele-medicine in which the gap of the required treatment plan could be administered. In this way, much of the progress could be made in a systematic manner which would most explicably assist in the betterment of the whole procedure side by side. The economic conditions along with the political collaboration with the medical facilities are the major stakeholders who either inhibit the process or help in growing it which is why, this factor cannot be ignored at all. As far as the concept of the tele-medicines and the linked process is concerned, it requires budget which could be provided by the governing authorities which further explains their importance and role for such suggested model. If there is a country which is already undergoing economic crisis and medical facility issues, these could be marked as the major limitations in the form of the barriers which will also be discussed in the subsequent passage. 3.5 Limitations and Issues involved Although it seems like a linear process in which the tele-medicine could be given to the people who are in need and it will help in lowering the issues of the ED crowding. While on the contrary, this problem is very challenging and at the same time, it could be risky as well in which the people might not be able to make a diagnosis appropriately. In the medical issues, there are a number of times when the problem is not generally linked to the symptoms and has another root cause. If the tele-medicine treats the person inappropriately, chances are high that the problem might even become difficult to handle or even unmanageable. Nonetheless, the general and small level problems could be administered via this method of tele-medicine and triage model in which the small injuries or the people suffering from the seasonal diseases could be addressed via this method (Dethleff et al., 2016). It is also beneficial to attain the required outcome results in which the patient gets treated (Bhowmik, Duraivel, Singh and Kumar, 2013) and this consultation process also lowers the chances of the ED crowding simultaneously which is an inevitable factor in the health care system. However, the limitations of this method could also be marked as high because for a medical diagnosis and treatment, the medical setting is still quite significant. If the number of patients who get their basic health care need through the method of the tele-medicine, it will assist in dealing with the health issues as well. This is due to the fact that much of the people who had been acutely ill could be dealt with the newest means of the technology and it will save their needless trip to the hospital. Moreover, it will also enable the people to take their condition seriously and come to the hospital for a proper check up in order to treat their illness at the right time. Nevertheless, it is not a straight forward process and requires a proper well structured medical training of the staff that has a hold over the medical knowledge and a proper diagnosing system that will assist in the timely (or fast) diagnosis of the individual. The research on this matter is not present and requires to be further explored which will enable in identifying the possible barriers along with the problems that could be talked about further. However, the application of the model will not only be beneficial in the urbanized settings but also in the rural set up in which as a consequence, maximum number of the people will be able to gain benefit out of it (Mehrotra et al., 2016) which will be explored further through the present research as well. 4. Project review 4.1Project plan for developing simulation model Step 1: Formulate the problem In this step, the system will be observed to formulate the problem and understand the flow of the entities, key players, availability of resources and overall generic agenda. Step 2: Collect information/data In this step, I shall collect the statistics from Australian health emergency care department site for past year data and identify the common issues related to waiting time, boarding time in emergency department. This step is not limited to collecting data however, reducing waiting time using tele-triage is what our major focus is on. By focusing on the statistics first, we shall derive a fair idea of how this problem can be solved, combined with providing better health care service. Using all this information I shall formulate a simulation model and documentation so that stakeholders can gain basic knowledge to develop a software or an application quickly, instead of going through dozens of papers of all the various information. Step3: Tools to develop simulation model 3.a. Discrete Event Simulation This models are referred as a discrete sequence of the events of time in the system. Each event occurs at a specific moment in time and denote a change of state in the system, this appears differently in relation to continuous simulation in which the simulation continuously tracks the system progress over time. 3.b. Agent Based Simulation In this type of simulation model modeler identifies the active entities, the agents and their behavior, establishes connections and run the model. 3.c. Continues simulation This simulation models are quite opposite to discrete simulation model. Step4: Scope To identify what the scope of this report is and who the beneficiaries of this report will be. The identification of the beneficiaries is as follows– Patients, health care industries Transport system, Government and new researchers or developers. Extended benefit of this thesis will be quick and easy understanding of the problem of ED crowding and simulation model for further developments of software will be used as as baseline design. Step5: Program the model and check validity Once the research is completed I will start working on simulation model using Anylogic software (free for students) to develop an understandable and solution oriented model. The validity of the simulation model will be checked by confirming that each entity flows as expected to be and the statistical information generated by the model is similar to the collected information. Step6: Design and analysis experiments Figure: 1: Tele- triage process flow diagram • Call emergency service of the region. • Call will be directed to tele-triage in case of medical emergency otherwise call will not be diverted. • As soon as the triage receives call, will ask a set of questions (Name, gender, age, date of birth, current location, contact no, emergency contact, address) and register patient. • Then triage will ask symptoms and its details (issue, pain level 1-10, etc.). • According to the description by patient emergency is classified into minor or major • If minor: triage will check for the similar record in database. • If similar record is found: triage will read the data and advise prescription to patient. • If similar record is not found: triage will create new record, consult a doctor on duty and advise prescription to patient. • Then save the data for future requirement. • If major: triage will check vacant bed space in nearest hospital from patient’s current location and inform patient about it (shortest time taken to reach hospital). • Then ask for further assistance with ambulance service and provide one if requested. • Triage will assist the patient till he gets satisfactory help. • Save the record for future requirement. Above design will be used as a baseline model for developing simulation model using Anylogic software and experiments will be performed on different scenarios using data collected from research. Step7: Document and present the simulation result After completing research approval process and finishing the documentation of all the information gathered from past theories and evaluating current practices and other information sources to compose data in an easy-to-read format, a simulation model and its outcome in easy-to-run format using Anylogic software, this thesis report will be produced in a professional presentational format for future uses. 4.2 Benchmark and limitation of current practice CURRENT PRACTICE: Baptist health south Florida, usa information regarding vacant beds in the nearest hospital’s ED to the patients in emergency need. 4.3 Overview of current status and progress Initial steps of writing this report have involved reading and evaluating journal papers available from different sources such as Flinders university library, Google and Government approved sites. All of the information are easily available online in pdf format. I have picked some selected articles which are baseline for this thesis project. Also I have searched for few online software which are available for developing simulation model in java programing language, among all the software available I choose Anylogic to work on this project as suggested by superviser. Documentation of thesis project is progressing. Identification of key points that would benchmark the solution to the problem of ED crowding and benefit further developments for health care system in the field of telemedicine. 4.3.1 Project time-line 5.References Alavi-Moghaddam, M., Forouzanfar, R., Alamdari, S., Shahrami, A., Kariman, H., Amini, A., Pourbabaee, S. and Shirvani, A., 2012. Application of queuing analytic theory to decrease waiting times in emergency department: does it make sense?. Archives of trauma research, 1(3), pp.101-107. Amaral, T.M. and Costa, A.P., 2014. Improving decision-making and management of hospital resources: An application of the PROMETHEE II method in an Emergency Department. Operations Research for Health Care, 3(1), pp.1-6. American College of Emergency Physicians. Crowding, 2006. Ann Emerg Med. 47:585. American College of Emergency Physicians, 2003. Crowding Resources Task Force. Responding to Emergency Department Crowding: A Guidebook for Chapters. Dallas, TX: American College of Emergency Physicians; 2002. Asplin, B.R., Magid, D.J., Rhodes, K.V., Solberg, L.I., Lurie, N. and Camargo, C.A., 2003. A conceptual model of emergency department crowding. Annals of emergency medicine, 42(2), pp.173-180. Bernstein, S.L., Aronsky, D., Duseja, R., Epstein, S., Handel, D., Hwang, U., McCarthy, M., John McConnell, K., Pines, J.M., Rathlev, N. and Schafermeyer, R., 2009. Society for Academic Emergency Medicine, Emergency Department Crowding Task Force. The effect of emergency department crowding on clinically oriented outcomes. Acad Emerg Med, 16(1), pp.1-10. Bhowmik, D., Duraivel, S., Singh, R.K. and Kumar, K.S., 2013. Telemedicine-an innovating healthcare system in India. The Pharma Innovation, 2(4). Bost, N., Crilly, J. and Wallen, K., 2014. Characteristics and process outcomes of patients presenting to an Australian emergency department for mental health and non-mental health diagnoses. International emergency nursing, 22(3), pp.146-152. Cheng, I., Castren, M., Kiss, A., Zwarenstein, M., Brommels, M. and Mittmann, N., 2016. Cost- effectiveness of a physician-nurse supplementary triage assessment team at an academic tertiary care emergency department. Cjem, 18(03), pp.191-204. Dethleff, D., Weinrich, N., Kowald, B., Hory, D., Franz, R., Nielsen, M.V., Seide, K., Jürgens, C. and Stuhr, M., 2016. Air medical evacuations from the German North Sea Wind Farm Bard Offshore 1: traumatic injuries, acute diseases, and rescue process times (2011-2013). Air medical journal, 35(4), pp.216-226. Goodwin, S., 2007. Telephone nursing: an emerging practice area. Nurs Leadersh, 20(4), pp.37-45. Guttmann, A., Schull, M.J., Vermeulen, M.J. and Stukel, T.A., 2011. Association between waiting times and short term mortality and hospital admission after departure from emergency department: population based cohort study from Ontario, Canada. Bmj, 342, p.d2983. Haghighinejad, H.A., Kharazmi, E., Hatam, N., Yousefi, S., Hesami, S.A., Danaei, M. and Askarian, M., 2016. Using queuing theory and simulation modelling to reduce waiting times in an Iranian emergency department. International journal of community based nursing and midwifery, 4(1), p.11. Han, J.H., Zhou, C., France, D.J., Zhong, S., Jones, I., Storrow, A.B. and Aronsky, D., 2007. The effect of emergency department expansion on emergency department overcrowding. Academic Emergency Medicine, 14(4), pp.338-343. Hing, E. and Bhuiya, F.A., 2012. Wait Time for Treatment in Hospital Emergency Departments, 2009. US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics. Hodges, S.C., Mijumbi, C., Okello, M., McCormick, B.A., Walker, I.A. and Wilson, I.H., 2007. Anaesthesia services in developing countries: defining the problems. Anaesthesia, 62(1), pp.4-11. Hoot, N.R. and Aronsky, D., 2008. Systematic review of emergency department crowding: causes, effects, and solutions. Annals of emergency medicine, 52(2), pp.126-136. Kamsu-Foguem, B. and Foguem, C., 2014. Telemedicine and mobile health with integrative medicine in developing countries. Health Policy and Technology, 3(4), pp.264-271. Kyriacou, D.N., Ricketts, V., Dyne, P.L., McCollough, M.D. and Talan, D.A., 1999. A 5-year time study analysis of emergency department patient care efficiency. Annals of emergency medicine, 34(3), pp.326-335. Langabeer, J.R., II, M.G., Alqusairi, D., Champagne-Langabeer, T., Jackson, A., Mikhail, J. and Persse, D., 2016. Telehealth-Enabled Emergency Medical Services Program Reduces Ambulance Transport to Urban Emergency Departments. Western Journal of Emergency Medicine, 17(6), p.713. Letvak, S. and Rhew, D., 2015, August. Assuring Quality Health Care in the Emergency Department. In Healthcare (Vol. 3, No. 3, pp. 726-732). Multidisciplinary Digital Publishing Institute. Medeiros, D.J., Swenson, E. and DeFlitch, C., 2008, December. Improving patient flow in a hospital emergency department. In Proceedings of the 40th Conference on Winter Simulation (pp. 1526-1531). Winter Simulation Conference. Mehrotra, A., Jena, A.B., Busch, A.B., Souza, J., Uscher-Pines, L. and Landon, B.E., 2016. Utilization of Telemedicine Among Rural Medicare Beneficiaries. Jama, 315(18), pp.2015-2016. Mohsin, M., Forero, R., Ieraci, S., Bauman, A.E., Young, L. and Santiano, N., 2007. A population follow-up study of patients who left an emergency department without being seen by a medical officer. Emergency Medicine Journal, 24(3), pp.175-179. Muntlin, Å., Carlsson, M. and Gunningberg, L., 2010. Barriers to change hindering quality improvement: the reality of emergency care. Journal of Emergency Nursing, 36(4), pp.317-323. Pines, J.M., Hilton, J.A., Weber, E.J., Alkemade, A.J., Al Shabanah, H., Anderson, P.D., Bernhard, M., Bertini, A., Gries, A., Ferrandiz, S. and Kumar, V.A., 2011. International perspectives on emergency department crowding. Academic Emergency Medicine, 18(12), pp.1358-1370. Pines, J.M. and Hollander, J.E., 2008. Emergency department crowding is associated with poor care for patients with severe pain. Annals of emergency medicine, 51(1), pp.1-5. Sills, M.R., Fairclough, D., Ranade, D. and Kahn, M.G., 2011. Emergency department crowding is associated with decreased quality of care for children with acute asthma. Annals of emergency medicine, 57(3), pp.191-200. Singer, A.J., Thode Jr, H.C., Viccellio, P. and Pines, J.M., 2011. The association between length of emergency department boarding and mortality. Academic Emergency Medicine, 18(12), pp.1324-1329. Soremekun, O.A., Takayesu, J.K. and Bohan, S.J., 2011. Framework for analyzing wait times and other factors that impact patient satisfaction in the emergency department. The Journal of emergency medicine, 41(6), pp.686-692. Shah, M.N., Wasserman, E.B., Wang, H., Gillespie, S.M., Noyes, K., Wood, N.E., Nelson, D., Dozier, A. and McConnochie, K.M., 2016. High-intensity telemedicine decreases emergency department use by senior living community residents. Telemedicine and e- Health, 22(3), pp.251-258. Stacey, D., Noorani, H.Z., Fisher, A., Robinson, D., Joyce, J. and Pong, R.W., 2003. Telephone triage services: systematic review and a survey of Canadian call centre programs. Ottawa: Canadian Coordinating Office for Health Technology Assessment. Traub, S.J., Butler, R., Chang, Y.H. and Lipinski, C., 2013. Emergency department physician telemedical triage. Telemedicine and e-Health, 19(11), pp.841-845. World Health Organization, 2010. Telemedicine: opportunities and developments in member states. Report on the second global survey on eHealth. World Health Organization.