In the United States, many states are faced with the challenging task of providing timely and equitable quality care to patients presenting for medical forensic services despite the national shortage of qualified medical forensic examiners. In 2019, Illinois Governor Pritzker signed Public Act 100-0775, which broadened the Sexual Assault Survivors Emergency Treatment Act (SASETA) to ensure all patients presenting for medical forensic services have access to a qualified medical provider (QMP), as defined by the law, within 90 minutes of arrival to a hospital. SASETA (2019) defines QMP as one of the following: a board-certified child abuse pediatrician, a board-eligible child abuse pediatrician, a sexual assault forensic examiner, or a sexual assault nurse examiner (SANE) who has access to photo documentation tools and who participates in peer review.

As of January 2023, hospitals unable to meet the mandate will be prohibited from providing medical forensic services and, therefore, be required to transfer patients presenting for medical forensic services to a treatment hospital (TH). Given the widespread shortage of QMPs, many hospitals have declared their decision to opt out of providing care to patients presenting for medical forensic services because of their inability to maintain staffing levels necessary to meet the required mandates (Illinois Department of Public Health, 2022). As a result, patients presenting for medical forensic services, especially pediatric patients, will be transferred elsewhere. Under SASETA, hospitals designated as “THs” will continue to provide medical forensic services to all patients presenting for medical forensic services regardless of age whereas THs with approved pediatric transfer (THAP) will provide medical forensic services to patients presenting for medical forensic services over the age of 13 years and transfer pediatric patients to an approved pediatric facility. Finally, transfer hospitals (TRHs) will transfer all patients presenting for medical forensic services, regardless of age, to a TH.

Under this plan, roughly half of Illinois hospitals plan to transfer some or all patients presenting for medical forensic services to outside hospitals (Illinois Department of Children and Family Services, 2021). Given that 43.6% of women and 25% of men experience some form of sexual violence in their lifetime (Centers for Disease Control and Prevention, 2015), SASETA has broad implications for healthcare delivery to Illinois residents. Furthermore, because most hospitals are treating adult patients and transferring those under the age of 13 years, this legislation most significantly impacts the delivery of care for Illinois' pediatric populations. Transferring patients presenting for medical forensic services may cause the unintended consequence of atrophying TRHs' expertise and ability to provide care for patients presenting for medical forensic services. For example, a study of various models of SANE staffing across 82 emergency departments (EDs) in Virginia found transferring victims off-site for SANE services led to lower quality care for patients presenting for medical forensic services. Hospitals that transferred patients presenting for medical forensic services were less likely to offer emergency contraception, screen for “date-rape” drugs, make postvisit phone calls, and keep up-to-date with staff training when compared with EDs with other staffing models such as having an on-call or on-duty SANE to provide forensic services (Plichta et al., 2007).

Given the shortage of sexual assault forensic providers, the use of telehealth to link forensic examiners to providers in areas with limited resources has been studied with promising results for improving the confidence of providers in their forensic examination skills, improved quality of care, and patient satisfaction (Miyamoto et al., 2021; Walsh et al., 2019).

Telehealth also holds promise for improving pediatric sexual abuse care and forensic examination in areas with limited access to providers with expertise in these services, leading to higher quality evaluations, more complete examinations, and more accurate diagnoses (MacLeod et al., 2009; Miyamoto et al., 2014). Furthermore, COVID-19 has accelerated acceptance of telehealth as a mode of healthcare delivery, with rates 38 times higher than before the pandemic (Almathami et al., 2020; Kichloo et al., 2020; Kruse et al., 2017; McKinsey, 2021).

On the basis of our literature review, we hypothesized that telehealth may be an acceptable method to facilitate the provision of quality care to patients presenting for medical forensic services while also increasing access to care by allowing hospitals with fewer staffing resources to serve patients with the support of QMPs via telehealth.

Methods

Our research team at Northwestern University Feinberg School of Medicine and Ann & Robert H. Lurie Children's Hospital of Chicago conducted an exploratory survey and in-depth interviews with hospital administrators. Our study was approved by Northwestern University's institutional review board. Informed consent was obtained in accordance with the institutional review board's ethical standards. Survey participants were asked if they would also consent to an optional in-depth interview. Of those who consented, one interviewee from each designation (TRH, TH, and THAP) was randomly selected to participate for a total of three interviews. These interviews averaged an hour, occurred on Zoom, and were recorded with the verbal consent of participants. They were transcribed verbatim with the assistance of an online transcription service.

Methodology

We sent email surveys via Qualtrics. Given that some administrators were responsible for implementing the new mandates across multiple hospitals, emails were sent to 163 individuals representing 192 hospitals required to comply with the mandates of Public Act 100-0775. We used publicly available data on Illinois Department of Public Health's website that listed hospitals and their designations as of March 2021. Administrators' email addresses were obtained via an email listserv specifically for SASETA administrators and publicly available data. We sent several reminders to participants to garner responses. One survey was a lengthier multipart survey that contained questions specific to TRHs, THs, and THAPs (see Supplemental Digital Content 1, https://links.lww.com/JFN/A120, which provides all the questions asked of participants). Given the busy schedules of the administrators, we conducted a second “short” survey that contained seven of the most salient questions adapted from the longer survey about issues specific to telehealth (see Supplemental Digital Content 1, https://links.lww.com/JFN/A120, “Short Survey” section). Survey data were collected between October 2020 and April 2021.

Survey Respondent Characteristics

Hospital administrators could choose to answer either the long survey, the short telehealth-focused survey, or both. We had 42 responses to the longer survey and 39 responses to the shorter survey. For questions that overlapped between the short and long surveys, we did not double count responses. In total, 65 administrators representing 74 hospitals responded to either one or both surveys. Respondents represented hospitals from all regions of Illinois, with 48% of the hospitals surveyed located within the Chicago region.

Results Findings on Current Staffing vs. Ideal Staffing

When asked for the ideal number of QMPs who provide care for sexual assault patients safely and consistently, responses ranged from one per shift to 50 QMPs in total. On average, hospitals would ideally want an average of 21.74 QMPs and a median of 21 QMPs on staff. However, on average, respondents have 5.4 QMPs and a median of 3 on staff, indicating a misalignment between ideal and current staffing levels.

Barriers to Achieving Ideal Staffing Levels

Most respondents (98%) reported barriers to achieving their ideal staffing levels (see Table 1). The three most cited barriers are related to staffing and training (education and training, unable to find staff interested in becoming a QMP, and staff turnover related to this role).

TABLE 1 - Identified Barriers to Achieving Your Ideal Staffing Levels of QMPs (Respondents Selected All That Applied) by Percentage of Total Responses Education/training 22% Unable to find staff interested in becoming a qualified medical provider 16% Staff turnover related to this role 15% Unable to find qualified applicants 13% Not enough volume of patients who would benefit from services offered by these providers 11% Budget issues 9% Other 7.14% Not a priority for hospital administration 3% No barriers 2%

Note. QMPs = qualified medical providers.

Participants reported the high cost of training, limited availability of training, and regulations increasing the requirements for QMP qualifications as barriers. Furthermore, limited access to qualified instructors and simulations has made training staff difficult.

For rural hospitals, accessing training posed a logistical challenge. The TH interviewee detailed, “Every training was practically up in Wisconsin. It is a hard place to send your nurses when you only have eight of them and they are going to be gone for four days.” COVID-19 also presented additional challenges to the logistics of hosting training sessions. Furthermore, decreases in patient volumes because of COVID-19 made it difficult for trainees to complete the necessary patient contact hours to gain certification.

In free text, survey participants further described issues of staff turnover, including issues of burnout because of rigor of training in addition to existing job duties, difficulty completing training in a timely fashion because of low volumes, and nurses pursuing other opportunities. As respondents wrote, inadequate staffing leads to a cycle of increased work requirements, leading to burnout, and potentially a worsening of the shortage.

Twenty-eight percent of respondents reported “other” barriers for which a low volume of patients requiring acute medical forensic services was frequently cited. As one respondent wrote, low volume was unable to offset “costs of education, competency, on-going training, on call pay, and number of staff needed to maintain call schedule.” Although budget was one of the least cited barriers, budget-specific barriers included insufficient reimbursement for sexual assault forensic services and COVID-19-related budget cuts.

Findings on Telehealth

Telehealth can be used to provide care to patients presenting for medical forensic services through two main telehealth modalities. One form is asynchronous telehealth or the delivery of healthcare data (such as patient information, description of bruise marks, forensic photography, documentation, and decision making or abuse findings) to a forensic examiner for evaluation. Asynchronous telehealth does not allow for access to the provider in real time. Conversely, synchronous or live videoconferencing allows for access to a QMP in real time via videoconferencing. This provider can help evaluate the patient alongside hospital healthcare providers. Survey respondents found synchronous or live videoconferencing as potentially more helpful to serving patients presenting for medical forensic services than nonsynchronous telehealth. About 33% of respondents envisioned asynchronous telehealth as “helpful or very helpful” to serving patients presenting for medical forensic services, whereas 56% envisioned synchronous telehealth as “helpful or very helpful.”

Asynchronous Telehealth

Although not seen as helpful to serving those presenting for medical forensic services of sexual assault as synchronous telehealth, when asked to describe how asynchronous telehealth could be used to better serve those presenting for medical forensic services of sexual assault, participants reported the potential for its use during the peer-review process, during training, and when determining the next steps in evaluating a patient.

Synchronous Telehealth

For synchronous telehealth, respondents reported the potential to use the modality for real-time feedback, to guide bedside nursing staff through the evidence collection process, to provide staffing support and information sharing, and to alleviate staffing burdens (see Table 2). Main concerns were for patient comfort with the video technology and issues of privacy, given the sensitive nature of the examinations. Respondents noted the potential for telehealth in providing advocacy and support to patients, particularly with COVID-19 restrictions in place that may not allow for a patient presenting for medical forensic services to have an advocate present. Telehealth can allow for the patient to have a “virtual” advocate as well as social work support. Several respondents detailed the ability to prevent the need for transfer, therefore keeping patients presenting for medical forensic services at their presenting hospital. This can help to reduce the issue of patient retraumatization during the transfer process, who may be asked to reiterate their assault story several times when transferred. This option may be particularly useful when a physical examination is not needed, to avoid transferring a victim for what is essentially an interview and routine medical care.

TABLE 2 - Select Survey Participants' Responses to “Briefly Describe How You Can Envision Synchronous Telehealth Helping Your Hospital in the Treatment of Survivors of Sexual Abuse/Assault” Real-time feedback during forensic examination “Would be nice to consult for something you wanted to talk through. However, unsure what the patient response would be to a telehealth consult.”
“It would be helpful to guide the bedside staff nurse in caring for a survivor.”
“The SANE [via telehealth] could assist the RN in the ED collecting the swabs. The SANE could then complete all of the paperwork while the RN could complete all other aspects to help close the kit in a timelier manner. The SANE could then fax the completed paperwork. The RN at the ED can close the kit and hand it to law enforcement.”
“Synchronous telehealth would be particularly helpful to our staff RNs who complete evidence collection but are not specifically trained SANEs.”
“Several ways—first consultations with an expert who can help move the exam along for those who are inexperienced. Also, someone who can collaborate with the SANE in regards to assessment, documentation etc.” Reduce transfers “Telehealth can allow for the patient to be interviewed once and not having to relive the trauma that they have gone through by being transferred.”
“If there was a qualified provider via live consultation, the current emergency department staff would not have to maintain SANE qualifications and patients would not have to be transferred.” Staffing and resource support “Fill the QMP requirement for hospitals who would not otherwise have access.”
“For pediatric patients, utilizing child abuse pediatrician…to talk with parents/patient regarding specifics of follow-up since there are no pediatric trained SANEs within the ER.”
“Providing best practice recommendations for treatment and services in real time while survivor is still in the ED.”
“Provide resource to staff who are vested in giving good forensic exam. Lessen SANE on call time to prevent turnover due to large amounts of call but low volume.”
“…I envision telehealth being utilized to assist nurses at facilities with limited SANEs…. It would mirror the Boston TeleSane project…. It would be an opportunity for education and mentorship. ‘Consultations’ would be performed in real-time.”
“We would use this for real-time consultation and appropriate treatment mainly for pediatric patients, as we have no SANE-Ps or child abuse pediatrician on staff at our hospital.” Training and information sharing “If there is a newer pediatric SANE in the ED who needs support, a more experienced/certified SANE could provide real time support and advice to care for that patient via telehealth.”
“Professional knowledge and training specific to sexual assault would improve our service to patients. We only have 1 SANE, associates and providers are genuinely not interested in pursuing additional sexual assault education in the ED.”
“I envision this as more of a support for our SANEs after hours. I see this as a way we can provide support to other outside hospitals.”
“Right now, we consult with our ED via phone if we are not available in person. I can see how we could provide better support during off hours. I can see how we could use this tool to assist in the treatment of pediatric patients at other organizations that do not have the expertise.” Technology concerns “I think it would be difficult as another nurse would still have to perform the exam. I could see this being helpful in the pediatric setting. It would however be nice for advocacy. However, there is a concern of video recording during exam and the legal implications of that.”

Note. SANE = sexual assault nurse examiner; ED = emergency department; QMP = qualified medical provider.

Telehealth During Sexual Assault Evaluation

Most respondents (95%) could envision using telehealth during the sexual assault evaluation (see Table 3). Respondents showed a roughly equal interest in utilizing telehealth in various stages of the assault evaluation including during the initial intake (obtaining patient history), during the physical examination, during the collection of evidence, documentation of evidence, follow-up care, and review of case, charting, and pictures after evaluation is complete. Our THAP interviewee preferred having trained SANEs perform the sexual assault evaluation; however, they envisioned more experienced SANE nurses using telehealth to guide more nascent SANE nurses. Our TH interviewee did see a potential role for telehealth in assisting outside hospitals with limited access to QMPs:

TABLE 3 - Stages During the Medical Forensic Evaluations That Survey Participants Could Envision Using Telehealth Services? (Participants Could Select All That Applied) by Respondents During the initial intake (obtaining patient history) 45% During the physical examination 55% During the collection of evidence 57% Documentation of evidence 63% Follow-up care (such as STI evaluation/referrals to resources/reporting procedures) 60% Review of case, charting, and pictures after evaluation is complete 63% I do not envision needing telehealth services at any stage 5%

STI = Sexually Transmitted Infections.

In theory we could provide support to other hospitals for the whole Sexual Assault Examination, especially somewhere there is not a SANE nurse and that expertise. Even if it is remote, there is a benefit to the patient. Look at how we live our life. Now that everything is Zoom, I do not think it would be as disconcerting to a patient to use telehealth as it would have been 2 years ago....

Providing Care to Pediatric Patients in Their Communities

Respondents could envision the synchronous telehealth modality as a means of providing acute medical forensic care, particularly in communities with limited access to pediatric QMP providers and situations in which transfer requires extensive travel. Our THAP interviewee described the ability to keep pediatric patients in their community with telehealth:

We don't have the volume to sustain having trained [a] pediatric SANE here. However, the Adult/Adolescent SANEs are familiar with the principles of forensic nursing. If they have someone like [a pediatric SANE] on the other end, who could just walk them through the differences for a pediatric patient and that could be very helpful. And again, keeping the patient in their own community and providing them with the particular resources that we have to follow up would be very beneficial to the patient and their families.

Of main importance to this THAP interviewee was the “provider-to-provider” coaching to enable adolescent/adult SANE to feel comfortable examining pediatric patients in a developmentally appropriate manner. This THAP interviewee described potentially providing this service to keep children in their communities by allowing for QMPs to coach clinicians in lower resourced settings with abbreviated training in pediatric forensic examination areas through the forensic examination.

Streamline Intake Process

Synchronous telehealth can make the transfer process more seamless while also assessing for inappropriate transfers. Our TRH interviewee recounted issues of patients presenting for medical forensic services transferring to their ED only to be determined that a forensic examination would be difficult or not feasible. When asked to describe an example of an inappropriate transfer, the TRH interviewee described:

We could have someone at an outside hospital that had a late disclosure sexual assault, or an assault that happened more than seven days. We could have a process in place where those kids get their medical screening at the hospital where they present via telehealth and then are referred to our clinic to see us, given that it is not an emergent visit. Transferring kids in this instance is costly and it takes them out of their community. It is also stressful. Kids do not need to be in the ED unless it is absolutely needed.

Inappropriate transfers lead to patients presenting for medical forensic services needlessly transferring to hospitals outside their communities. Telehealth can allow for screening of patients presenting for medical forensic services before a transfer. If the QMP deems the transfer appropriate for further examination, the receiving hospital would have all the necessary intake information to prepare for the arrival of the patient. This approach would also reduce redundancy and limit a patient's reiteration of their assault to multiple providers.

If a transfer is necessary, our TH interviewee noted the potential for telehealth in convincing hesitant patients presenting for medical forensic services to transfer, if warranted. Telehealth could be utilized to connect patients presenting for medical forensic services with QMPs that can explain to patients the transfer process and answer any questions, potentially easing concerns.

Backup Support

Synchronous telehealth can allow QMPs to provide backup coverage, “in case of an emergency…like a blizzard or when the nurse can't come to work.” Similarly, our THAP interviewee noted that telehealth could help to fill in scheduling gaps, “The new [Illinois] law requires that a QMP to be present with anyone who [is] in training. Practically, that would be like having two people on call all the time, a trainee, and a QMP, which can be challenging, telehealth would be helpful in any gaps we may have in a schedule.”

Telehealth Usage for Other Modalities

Most survey participants (about 80%) reported their hospitals currently use telehealth for services other than sexual assault and abuse.

About 69% of respondents reported already having telehealth equipment available in their ED. Our TH interviewee reported receiving a federal grant to establish telehealth services in their critical care unit and that they have expanded telehealth services to primary care visits during the COVID-19 crisis. With grants, the hospital has purchased telehealth equipment. They have had great success with this approach, which has allowed for improved access to healthcare in their community, as one person noted, “It's really amazing…. The telehealth doctors are super. They have great bedside manners. They are fantastic on a computer. They are great.”

As a result, this administrator felt comfortable with utilizing telehealth for sexual assault to help guide the bedside nurses through the sexual assault examination just as physicians on telehealth work with staff to provide critical care for ICU patients: “Based on this experience, I just can't imagine anybody in our ER saying no to a SANE specialist nurse [via telehealth].”

In addition to the services listed above, respondents reported the use of telehealth in pediatrics, primary care visits, hospitalist services, and telepsychiatry.

Barriers to Implementing Telehealth

Respondents reported legislative restriction, costs, the sensitive nature of the examination, and current legislative requirements as the most salient barriers to implementing telehealth. Our TRH interviewee noted, “I think the first barrier is that it is not allowed in the law.” Later, this interviewee expressed, “The more laws you make, the more restricted you are in doing, being creative and innovative.” Other barriers included insufficient reimbursement, legal liability, security of data, equipment, and concern that telehealth may lead to the interruption of workflow or interoperability issues. Our TRH interviewee noted, “There is always a concern about liability with outside hospitals…doctors get kind of nervous about giving advice [via telehealth].” Technologically challenged staff, organizational resistance to change, and insufficient reimbursement were identified as barriers, albeit not as significant, to implementing telehealth.

Financially Supporting Telehealth

Most hospitals would not support paying a fee to support telehealth (57%). Of those willing to pay a fee, most would want to pay a flat fee per case (35%) followed by a subscription-based service (30%). Variable fee based on complexity and time spent on consultation (20%) and paying per hour (15%) were the least popular payment methods.

Patient Population Best Served by Telehealth

Only 11% of those surveyed did not believe that telehealth could improve the care of any population of patients presenting for medical forensic services. Hospital administrators surveyed reported adolescents presenting for medical forensic services (those 13–18 years old) as the population most likely to benefit from the use of telehealth (34.75%), followed by the adult population (those over 18 years old; 30.56%). Adolescents presenting for medical forensic services may benefit the most from telehealth, given the difficulties of navigating sexual assault as neither a child nor an adult. As our TRH interviewee described, “The patient I worry about [is] the 13-year-old in an adult ER. A 13-year-old [is] still a child. With telehealth, we could give better support to hospitals caring for that young adolescent age group.”

The ability and willingness to use telehealth for pediatric patients varies based on resource constraints. In rural settings with reduced access to pediatric QMPs, our in-depth interviewees agreed that telehealth may be a way to reduce transfers and keep a pediatric patient presenting for medical forensic services in their community. For all the interviewees, this would mean an adult- and adolescent-trained QMP with abbreviated training in pediatric forensic examinations assisted via telehealth by a pediatric QMP to provide care for this population.

Social Work

Most respondents use social work support services for psychosocial assessments and reports (66.67%). However, most (70%) are not interested in additional social work support via telehealth services. All the in-depth interviewees also echoed this sentiment.

Discussion

Our study affirmed issues of staffing and retaining qualified forensic examiners, especially for the pediatric population and in rural areas. Therefore, state initiatives to provide high-quality care to those presenting for medical forensic services through increased regulatory mandates may inadvertently exacerbate existing barriers (Logan et al., 2005; Munro M. L., 2014). Telehealth represents one avenue for alleviating staffing burdens, improving timely and equitable access to care for those presenting for medical forensic services, and mitigating the need for unnecessary patient transfers. On the basis of this study, we find that hospital administrators are open to telehealth to increase access to care for patients presenting for medical forensic services. This study has identified several ways to utilize telehealth in clinical practice.

- Increased access to care: In areas with a shortage of QMPs to serve patients presenting for medical forensic services, telehealth can be utilized to provide clinicians in these areas with support from QMPs so that patients presenting for medical forensic services can receive treatment in their communities. - Initial intake process, if transferring: In areas without QMPs, telehealth can allow for a QMP to provide patients presenting for medical forensic services with information about next steps of the forensic process, reducing stress on the patient and, if applicable, the guardian. If for some reason the patient decides not to transfer, the QMP can still outline follow-up steps and community resources via telehealth. - Telehealth for backup coverage: QMPs can provide backup for one another in cases of emergencies or schedule changes via telehealth. - Training: Cost, distance to training, and time away from clinical duties represent one of the major barriers for hospitals to establish enough providers. Conducting as much training as feasible in a virtual format could lessen the training burden through remote access to a qualified preceptor. In addition, training can continue during periods of disruption such as seasonal travel advisories, inclement weather, or stay-at-home orders. - Mentorship: Telehealth can be utilized to provide real-time feedback and mentorship between more experienced QMPs and those with less experience to build the capacity of junior QMPs to operate independently. - Peer-review process: Asynchronous telehealth can allow for hospitals to share cases, documentations, and photos on a secure platform that will enable information sharing between experts from other hospitals as a means of peer-reviewing and providing expert second opinion.

More ambitiously, states can implement a network of synchronous 24/7 support to hospitals using the model studied by the National Pilot Program (Walsh et al., 2019). The options for telehealth are expansive and flexible to meet the needs of each state or hospital system(s).

Limitations

We only captured about 40% of all the hospitals in Illinois subject to SASETA mandates. Furthermore, we only surveyed about 26% of the TRHs, making it difficult to get a full picture of the issues facing these hospitals. It is possible that the types of hospitals surveyed in this study are different from hospital administrators who chose not to complete the survey. For example, the hospitals that completed the survey may have more staffing resources devoted to SASETA that enables them to complete a survey or agree to participate in an in-depth interview. In addition, this survey can only assess current attitudes toward the transition to Illinois mandates, QMP staffing, and the potential use of telehealth to deliver care to patients presenting for medical forensic services; it cannot determine how telehealth could impact access and quality of care relative to the current standard of care. Finally, our survey was conducted before the more severe nursing shortages and rise in travel nursing that occurred in response to the COVID-19 pandemic, which anecdotally has created further decreases in the number of QMPs at Illinois hospitals (Yang & Mason, 2022). Consequently, our survey may underestimate the current shortage of QMPs and the further reduction of access to care.

Conclusion

As states grapple with the expanding access to services with limited staffing resources, telehealth provides an opportunity to expand safe and effective sexual assault services to children, adolescents, and adults. Illinois has committed to improving the care of patients presenting for medical forensic services and can utilize telehealth to achieve this goal. Our survey of hospital administrators in Illinois shows that most professionals providing these services recognize the promise of integrating telehealth in service delivery, training, and consultation. States facing similar challenges are well positioned to examine the potential role of telehealth in optimizing service delivery, staffing, patient experience, and outcomes.

Implications for Clinical Forensic Nursing Practice

This study has practical implications for forensic nurse examiners interested in utilizing telehealth to support clinical practice. Most immediately, asynchronous telehealth can allow for virtual training and education. Our respondents reported both the personal and financial costs of attending in-person training sessions. This application of technology is a low-hanging fruit and likely requires no major legislative changes.

Other uses of telehealth may require legislative support to accomplish. Collaboration between child abuse pediatricians, SANEs, sexual assault forensic examiners, hospital administrators, and advocates is crucial to pushing forward legislation. When seeking legislative changes, forensic nurse examiners should emphasize telehealth's applicability to each step of the forensic examination, as shown in our study. Accordingly, synchronous telehealth can allow for forensic nurse examiners in higher-resourced and higher-volume hospitals to support examiners in lower-resourced and lower-volume areas. In this way, telehealth empowers all hospitals to care for their community and reduce transfers. Asynchronous telehealth can further improve quality of care through the peer-review process.

Forensic examiners lobbying for these changes must advocate for the funding necessary to provide high-quality equipment and staffing for these endeavors. The initial investment will pay off through reduced transfers, more streamlined information sharing, and the more efficient utilization of the forensic nurse examiner workforce.

The legal implications of telehealth will need thoughtful consideration and clarification. We also anticipate increased training needs to be focused on the role of “tele”-forensic nurse examiners—or those who provide care via telehealth—in legal proceedings. Despite this, telehealth will significantly improve the delivery of equitable care to patients requiring forensic examinations, making it well worth the challenge of overcoming these barriers.