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South Dakota Puts Doctors Onboard Ambulances with EMS Telemedicine

Rural residents are 5x more likely than city dwellers to live in an “ambulance desert” where the nearest ambulance station is at least 25 minutes from their home. In raw numbers, that means about 2.3 million rural Americans are at heightened risk in emergency situations. Even the best hospital can do only so much for a patient who lost precious minutes during the so-called “golden hour.”


More than 80% of rural counties have at least one ambulance desert, and the problem is especially acute in the West, where small populations are spread over large areas. South Dakota, for instance, covers 77,000 square miles of territory but has fewer than 1 million residents. According to research from the University of Southern Maine, it’s one of eight states with fewer than three ambulances covering every 1,000 square miles.


Last year, South Dakota funded three innovative programs for strengthening EMS statewide. One of those, Telemedicine in Motion, caught our eye with dramatic media reports of a rancher whose life was saved after being gored by a bull miles from the nearest hospital. With special technology on the ambulance, first responders initiated a virtual physician consult during transport, allowing hospital staff to save precious minutes when the patient finally arrived.


That struck us as a potential solution for other states: a relatively small investment that leverages existing technology to put emergency medicine physicians “onboard” rural ambulances as needed.


We reached out to a spokesperson for the South Dakota Department of Health (SDDOH) to get more details.

Rural Healthcare Initiative: Set the scene for us. What is the EMS situation like in South Dakota?


Tia Kafka, SDDOH Division of Healthcare Access: Dedicated men and women volunteers operate nearly 90 percent of South Dakota’s ambulance services. Many of these agencies are Basic Life Support where transport times range from a few minutes to over an hour. During those transports, EMS professionals are in the back of an ambulance caring for the patient, often times alone. Telemedicine in Motion connects physicians, nurses, and paramedics with EMS clinicians in the field through an audio/video connection; ensuring no one is working alone in the back of an ambulance anymore. Telemedicine in Motion has allowed real-time clinical care at the bedside, giving EMS professionals another tool and advancing the pre-hospital care system in South Dakota.



RHI: We’ve heard about a few other small experiments in ambulance-based telemedicine, but nothing on a statewide scale. Why did South Dakota decide to “go big” in this area? Why did it seem like a good fit for your state?


Tia Kafka: During the 2022 Legislative session, Governor Kristi Noem requested, and the South Dakota Legislature approved, three funding initiatives to infuse about $20 million into emergency medical services in the great state of South Dakota. Since then, the South Dakota Department of Health (DOH), together with our partners, have been telling our story and making huge strides implementing these three initiatives: Telemedicine in Motion, the LIFEPAK 15 replacement devices, and the Regional Services Designation. All at the same time!


These projects are an investment in the future of EMS in South Dakota AND they are all working to ensure a seamless care experience in the most critical times. One of our team’s key strategies built within each project is to build that pipeline for recruitment and retention of the next generation of the EMS workforce.


Specifically, with Telemedicine in Motion, DOH partnered with Avel eCare out of Sioux Falls, SD, to provide licensed ground ambulance services a telehealth solution that includes: hardware, software, installation, training, support, and a telehealth subscription for professional consulting services. The $1.7 million appropriation allowed DOH to fund one telehealth solution for each ambulance service (in total there are 122 services statewide). This was a key component of the initiative.

“We believed a statewide presence with telehealth capabilities was foundational to the success of this pioneering initiative. Within the first few months of the project, 92 of the 122 services indicated support for the initiative. To date we have had over 850 patient encounters using this solution.” – Marty Link, South Dakota EMS Administrator

RHI: What about communications infrastructure? That’s usually a big issue for rural telemedicine – did South Dakota already have the infrastructure in place?


Tia Kafka: Our partner, Avel eCare, has a long history of telehealth service lines. Avel created a software/hardware combination with connectivity challenges in mind. Telemedicine in Motion used two SIM cards allowing for either a Verizon or AT&T signal to connect Avel staff with EMS clinicians in the field through an audio/video connection. This dual SIM card concept provides an up-time of over 90%, even where cellular signals are the weakest. 


RHI: So many rural areas have a hard time staffing EMS. Does this technology do anything to alleviate staffing shortages?


Tia Kafka: Post-encounter surveys conducted following each use of the telehealth system installation have demonstrated a positive curve in retention rates for EMS personnel. Anecdotal feedback has shown that Telemedicine in Motion also has a positive impact on recruitment.


RHI: This program started in the fall of 2022, so you’ve had about a year to evaluate. What kind of data are you seeing in terms of utilization, patient outcomes, EMS satisfaction, or other relevant factors?


Tia Kafka: This effort began on November 14, 2022, and will be a milestone date in history. This was the date when the Dell Rapids, SD, service became the first ambulance service in the country with a Telemedicine in Motion live system. To date, nearly 90 ambulance services have installed the Telemedicine in Motion solution and over 850 patient encounters have been documented.


Altered mental status is the chief complaint followed by chest pain responses. When trauma incidents are compiled, they make up the highest requested use of Telemedicine in Motion.


RHI: From a cost standpoint, how will the state determine if its investment was worthwhile?  How do you do a cost/benefit analysis on a service that touches relatively few lives – but could literally mean the difference between life and death?


Tia Kafka: Analysis of ambulance run data shows that nearly 72 percent of 911 calls for service are lower acuity responses. Meaning the patient’s condition is not a true life-threatening condition, however they still need medical assistance. The remaining 28 percent are patients with a higher acuity, impacted by a more significant illness or injury.


Although Telemedicine in Motion can be used for high or low acuity responses, we typically see utilization for more critical patients. The use of Telemedicine in Motion for those critical life-threatening situations have already demonstrated its value. Patients are getting to definitive care quicker with a high efficacy which improves the overall system of care.

“Every life is precious and matters. We have been saving lives as a result of this initiative and that is the best return on investment there is. There is nothing else like it in the country to advance patient care and support pre-hospital professionals.” – Marty Link

RHI: Finally, would you have any words of advice for other states that might be considering a similar approach?


Tia Kafka: Do it. It is an investment unlike any other. Telemedicine in Motion has been one of the most impactful, statewide initiatives that is lifesaving in the most critical of times. We truly are making a mark for the next generation of EMS here in South Dakota and we have Gov. Kristi Noem, the South Dakota Legislature, and the leadership at the South Dakota Department of Health to thank for all the support and heavy lifting.

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