Telemedicine
e-Emergency Services Bring Specialists to Rural Patients with the Push of a Button
by Candi Helseth
One afternoon Leonard Hajek sat down to read the newspaper and got ambushed by crushing chest pain. His wife, Audrey, helped him into their car and sped to the local emergency room at St. Michael’s Hospital Avera, a 25-bed critical-access hospital (CAH) in Tyndall, SD. Still conscious in the ER, Hajek was astonished when an e-Emergency physician in Sioux Falls 75 miles away began talking to him from a screen that Hajek thought was a television.
St. Michael’s is among approximately 60 rural sites in South Dakota, Iowa, Minnesota and North Dakota that have signed up for Avera eEmergency Services, a hospital-based telemedicine emergency support service provided by Avera Health in Sioux Falls.
From an operations center at Avera McKennan Hospital and University Health Center, board certified emergency physicians and emergency-trained nurses assist rural ER staffs 24 hours a day, offering treatment advice, initiating diagnostic testing and streamlining the process if critically ill patients need to be transferred.
“I didn’t have any idea this existed,” Hajek said. “The nurse pushed a button and just like that this doctor is on a TV screen talking to me. He says, ‘Leonard, how are you feeling? Explain it to me.’ Then he talked to the doctor in ER about what they all were doing for me. It really got my attention. It was like I had this big-time cardiac surgeon standing right beside my bed. It’s pretty amazing.”
As telehealth expands, clinical applications are virtually placing emergency physicians, neurologists, intensivists (physicians board certified to provide critical care), pharmacists, cardiologists, dermatologists, psychologists, and wound and infectious disease specialists in rural community hospitals whenever their expertise is needed. Avera moved into the virtual world in the 1990s with eConsult, live doctor-patient consultations via closed circuit television. Avera eCARE Services, which began in 2003, include eICU, eEmergency, ePharmacy, eStroke, eConsult, eNursery and eUrgent Care.
Patient Outcomes Improve
Dr. Brian Skow, a physician with Avera, consults with a patient in a distant hospital via his computer.“eEmergency, Avera’s most highly requested eCARE service, has reduced patient length of stay, patient transfers to tertiary facilities and overall costs,” said Deanna Larson, Vice President of Quality Initiatives and eCARE Services. “Clinicians at the remote sites report high levels of satisfaction with the program.”
Northern California-based Sutter Health was the first health care organization on the West Coast to connect a rural hospital to eICU in 2003. Deaths related to sepsis have decreased 28 percent system-wide and ICU patients’ lengths of stay have decreased by 15 percent from 2007 to 2010, according to Sutter’s most recent documented data.
“More than 1,300 lives were saved,” said Teresa Rincon, Sutter Health eICU nurse director. “The eICU plays a vital role in our system-wide efforts to combat sepsis, a life-threatening illness that is triggered by an infection and can create a massive inflammation response that overwhelms the body. Medical staff, eICU nurses, and intensivists work together to more quickly detect and treat the infection and the cascade of life-threatening symptoms that occur in these critically ill patients.”
Sutter Health currently has more than 30,000 critically ill patients being monitored from eICU hubs in Sacramento and San Francisco. In Sutter’s eICU system, intensivists and ICU-trained nurses use early warning software and advanced video and remote monitoring to constantly check critical care patients for any sign of trouble. The Joint Commission (formerly the Joint Commission on Accreditation of Healthcare Organizations, or JCAHO) featured Sutter’s eICU barcoding and electronic health record system in a national videoconference report highlighting innovative telemedicine programs.
Hospital ICUs have the highest mortality rates but eICUs are saving lives, shortening ICU stays and enabling community hospitals to treat more patients because of improved efficiency, according to Critical Care, Critical Choices: The Case for Tele-ICUs in Intensive Care, a study published by NEHI and Massachusetts Technology Collaborative. The study also notes that the number of patients and severity of illness are increasing while intensivists are decreasing in number.
Support Strengthens Rural Providers
Dr. Jill Kruse, a family medicine physician at St. Michael’s Hospital, was on the verge of burnout prior to e-Emergency. Three years ago, fresh out of her medical residency, Kruse began working at St. Michael’s. She had more experience working in rural areas than most new family medicine graduates because she’d trained in a Rural Training Track. Still, she said, being the only physician on-call for emergencies was overwhelming.
“You’re really alone out here a lot of the time,” she said. “I went from my residency where I was supervised and always had a colleague or attending physician to consult with to my first weekend on-call here when I was completely alone. As a brand new grad, I had no one to turn to or ask questions because the other two doctors in my practice were both out of town. Our ER isn’t staffed 24/7. Having e-Emergency has helped when I’m on ER call now. It means there is another doctor instantly available who I can consult and who is going to be helping if I need it. It makes me feel like I’m not as isolated practicing here.”
e-Emergency also offers a valuable second opinion, Kruse said. Late one Friday in June, a mother brought her child to Kruse, saying the four-year-old cried in pain when she tried to walk. A physical exam and X-rays didn’t reveal any breaks or fractures. Reluctant to send the child home over the weekend, Kruse turned to e-Emergency for a second opinion.
“When they say a picture is worth a thousand words, these videos are worth a million,” Kruse said. “I’m not a critical-care pediatrician but that child had access to one with this technology.” The e-Emergency physician confirmed that the child’s problem needed further evaluation and initiated a transfer to a nearby hospital pediatric specialist who treated the child and discharged her the following day.
Most rural communities don’t have a physician in the hospital 24 hours a day, Larson said. e-Emergency physicians fill the gap while nurses wait for the local doctor to arrive.
A 20-bed CAH owned by Catholic Health Initiatives, Oakes Community Hospital was the first North Dakota facility to add Avera’s eEmergency service.
“Having e-Emergency has made our staff a hundred times more comfortable,” Oakes Community Hospital Administrator Lee Boyles said. “When you’re out in the middle of nowhere and you have board certified physicians at your finger tips any time of the day, it makes everyone working here more comfortable. It can be the middle of the night and there is no doctor in house. All our nurses have to do is push a button and they can talk to a doctor immediately.”
“The decision to make the investment was a no-brainer,” Boyles said. “We’re keeping patients closer to home and we’re reducing travel, duplicated tests, additional diagnostics and patient transfers. eEmergency gives us the ability to extend and enhance the level of health care in our community.”
Geographic Barriers Diminish
Six hundred miles from Sioux Falls in western North Dakota, McKenzie County Hospital in Watford City recently implemented e-Emergency. Located in the heart of North Dakota’s booming oil territory, the 24-bed CAH has seen a 40 percent increase in ER patients in the last year. Patients also have more serious injuries, said CEO Dan Kelly.
Staffing the hospital is an ongoing nightmare. “With the significant salaries that are offered by oil companies, many individuals that would historically accept employment with the health care system are going to work for oil-related employers,” Kelly said. “Some families have oil-related income, creating the scenario where family members no longer need or want to work. And our community has a deficiency in homes and rental units so housing is an issue when hiring.”
Currently, the hospital has no staff pharmacist, but will add ePharmacy this fall, which will give hospital staff access to a hospital-trained pharmacist who will review and approve every medication order before it is administered to a patient.
Dr. Sreenivas Ravuri communicates with a patient in northern California through Sutter Health's advanced eICU technology.Like Avera, Sutter Health’s network extends to rural communities far from the network hub, such as Sutter Coast Hospital in Crescent City, 425 miles away. Sutter also offers ePharmacy; its system was developed by staff professionals and recognized by the ASHP Foundation for its "outstanding contribution to biomedical literature describing an innovation in pharmacy practice."
Overall, telehealth hospital-based services improve access and quality care for patients in rural areas, reduce medication errors and patient transfers, and minimize rural workforce shortages, according to Larson.
“Medicine isn’t meant to be practiced in isolation,” she asserted. “There are physicians who want to practice in rural areas but all of a sudden, they’re everything to everyone and it’s impossible to know every facet of medicine. They need access to peers for support. They also need time to sleep and see their families. They can’t work 24 hours a day. eCARE services help with that.”
A year and a half after his heart attack, Leonard Hajek, 84, looks back on his eCARE experience and says he believes his care was equivalent to what he would have received if Audrey had driven him to Sioux Falls—except that he probably wouldn’t have survived long enough to get to Sioux Falls.
“I’d tell people you can be absolutely comfortable with what they can do with this setup,” he said. “I was definitely in good hands.”
Telemedicine
Telemedicine Reaches Beyond Clinic Walls
Networks Help Extend Access
by Candi Helseth
Telemedicine helps health care providers maximize resources to reach more patients in rural locations where services are limited or even non-existent. But telemedicine services can go well beyond hospital and clinic walls, meeting health care needs among immobile populations such as nursing home residents and prison inmates, and in isolated geographic regions where high rates of poverty and transportation barriers make it unlikely that residents will seek or get the help they need.
Registered Nurse Sharon Daley helps provide primary care services to isolated residents on four Maine islands via telemedicine equipment on the boat, Sunbeam V.“For people in rural areas, the greatest telemedicine benefit is the increasing access to services and resources that would not otherwise be available in their community,” said Sherilyn Pruitt, Director of the Office for Advancement of Telehealth (OAT). “People are less likely to seek help when they have to incur travel costs, a possible hotel stay and time off from work to travel somewhere else in their region for health care services.”
Telemedicine services can travel to patients, via land—or sea. The nearly 500 residents living on four federally underserved islands off the coast of Maine have no bridge access to the mainland and, Registered Nurse Sharon Daley says, residents are likely to ignore health problems if they have to leave the island for care. But when the 75-foot long Sunbeam V docks at Frenchboro Island, the island’s 75 residents welcome the boat—and its telemedicine clinic—like an old friend. For more than 100 years, the faith-based ministry Maine Sea Coast Missions has sent boats to all four islands providing spiritual and social support systems. Ten years ago, Sea Coast Missions hired Daley and added the telemedicine clinic. Patients come on board for both primary care and specialty appointments with physicians in Maine who, via live teleconferencing, diagnose and treat patients. Daley provides a personal touch and hands-on tasks, such as strep screens and blood draws requested by physicians.
In Georgia and Arizona, outcomes have improved and travel costs have been substantially reduced through telemedicine programs with outreaches targeted at immobile populations.
A wound care telemedicine program for rural Georgia nursing home patients substantially reduced the frequency of patient transfers by ambulance to tertiary centers. Patient outcomes also improved. The incidence of pressure ulcers declined among nursing home patients in five rural counties where Archbold Medical Center in Thomasville, Ga., introduced wound telemedicine.
Dr. Sue Sisley, Associate Director for the Arizona Telemedicine Program, demonstrates an otoscope used in telemedicine consultations.“Wound care specialists are in short supply nationwide and almost non-existent in rural areas,” said Dr. Harriett Loehne, clinical educator at Archbold Center for Wound Management and Hyperbaric Medicine. “Patients in nursing homes are at higher risk for pressure ulcers because they frequently are immobile, immune suppressed and have multiple comorbidities. Traveling is also physically difficult for these patients.”
In Arizona, physicians and psychiatrists see prison inmates via live videoconferencing under the umbrella of the Arizona Telemedicine Program (ATP). The Arizona Department of Corrections (ADC) reports a cost savings of more than $1 million since the program’s inception in 1996. Prior to telemedicine, ADC transported prisoners to hospital facilities for appointments. Now over 8,000 prisoners in Arizona’s 10 rural prisons have seen physicians and psychiatrists via video conferencing. Physicians listen to heart sounds using electronic stethoscopes and examine eardrums with high-resolution otoscopes. Prisoners report satisfaction with the program because it has improved their access to health care. ADC is no longer concerned about possible escapes and public safety, major issues associated with transporting prisoners.
Telemedicine makes education and support services more accessible too. Parenting classes and health education, such as a recent seminar on Lyme disease, link residents on the four Maine islands to each other and to specialists leading the sessions.
Networks and Support Systems Increase Access
Bethany Aldridge, an associate with the Georgia Partnership for TeleHealth, helps patient, Lea, consult with Dr. Matt Smith, a dentist in Waycross, Ga.Established networks such as ATP and the Georgia Partnership for Telehealth (GPT) combine a variety of telemedicine technologies to deliver services throughout their states, and in some cases, across state borders. ATP links 170 member sites with more than 300 specialists in adult and pediatric medicine. GPT includes 200 rural and specialty sites with more than 175 specialists representing 40 specialty areas. Although Maine Telemedicine Services (MTS), which worked with Sea Coast Mission to develop its floating telemedicine clinic, isn’t a network, it has developed and supported several telemedicine projects, according to Michael Edwards, MTS director of research and evaluation.
Through live videoconferences from Thomasville, Loehne trains staff working in Georgia’s rural nursing homes to better assess and treat wounds. Using store and forward technology, nursing home staff transmits weekly digital photographs of residents’ wounds for Loehne’s review and recommendations. Loehne also travels monthly to each facility for patient consultations and hands-on education.
“I closely follow every patient,” Loehne said. “This is phenomenal technology for nursing homes where pressure ulcers are always a concern. The wound care software creates a folder that lets me see the wound in chronological order over time and the whole continuum at one time. So we absolutely know what progress we are making.”
ATP pioneered the use of videophone technology for ostomy care. More than 100 cancer patients living in isolated areas have direct access to ostomy-certified nurses at tertiary centers. Using a special close-up lens, nurses can examine the patient’s ostomy site and make recommendations. Previously, these patients traveled long distances regularly to the tertiary center for ostomy care.
Maine, Georgia and Arizona all have a high demand for telepsychiatry. Four mental health providers associated with Arizona’s Regional Behavioral Health Authorities (RBHA) offer telepsychiatry services in every county. Previously, psychiatrists were spending thousands of hours driving long distances to rural areas. Telepsychiatry has resulted in more than 4,700 patient services and approximately $106,000 in cost savings through reduction of psychiatrists’ travel expenses and time.
Maine Sea Coast Mission patients’ most requested services have been mental health, and drug and alcohol abuse counseling, Daley said, adding, “If you’re anxious and depressed, you’re even more unlikely to leave the island to get help because that’s anxiety producing in itself. I’ve seen such improvements in the way people are functioning now that they are getting psychiatric help.” Island residents are also able to attend AA meetings via the technology.
Telemedicine’s growth means rural providers need training relative to its use, said Rena Brewer, director of the Southeast Telehealth Resource Center (SETRC). This summer, SETRC—in collaboration with California Telemedicine and E-Health Center (CTEC) and HomeTown Health University —is rolling out its National School of Applied Telehealth. Students will complete online classes to become certified as telemedicine clinical presenters, telehealth coordinators and telehealth liaisons.
Assistance AIDS Advances
OAT, which is under the federal Office of Rural Health Policy, promotes the use of telehealth technologies for health care delivery, education and health information services. OAT’s functions include coordinating telehealth grant programs and providing technical assistance to communities that are beginning new telehealth programs or enhancing existing ones.
Despite noteworthy advancements, telemedicine coverage is still spotty or unavailable in many rural areas, Pruitt said. Broadband connectivity, often essential to provide the full range of clinical services, isn’t available countrywide. Telephone systems limit scope of services. State laws limiting cross-state licensure and credentialing complicate efforts to advance telemedicine across state borders. Lack of reimbursement can make a program unsustainable. (Medicare reimburses telemedicine nationwide in non-metropolitan areas but private payers’ reimbursements vary from state to state.)
“If there’s no reimbursement, specialists aren’t going to add telehealth into already full schedules,” Pruitt said. “And in rural areas, these clinicians are so busy in their day-to-day practices that they don’t know how or feel they don’t have the time and money it takes to start telemedicine services. There is a lot of upfront work.”
Rural providers also grapple with costs not only of funding new technologies but also upgrading technologies as they advance, Edwards said. The technology on the Sunbeam V is already considered outdated and providers are working to equip the islands with technologies that will alleviate the need for a boat to bring telemedicine services to the islands.
“When states can pull together statewide and regional networks, they improve efficiency and coverage,” Brewer said. “Positive telemedicine legislation is a foundational requirement in establishing a successful statewide telehealth program. Georgia’s experience has been that a statewide, nonprofit network levels the playing field and enables telehealth entities to work together. That improves access to everyone.”
SETRC, which is one of nine regional OAT-funded TeleHealth Resource Centers (TRC), continues to serve Georgia through GPT and has begun working with South Carolina, Florida and Alabama. TRCs provide free technical assistance to rural communities interested in starting or enhancing a telehealth program. OAT also works with state telehealth leaders to help them understand their respective state’s laws and the regulatory changes necessary to successfully implement services.
“We have a passion for helping others with telemedicine,” Brewer asserted. “We’re thankful we can share our experiences in Georgia. The bottom line here is that we want all families in rural America to have access to the kind of expertise that telemedicine provides. We want to take the lessons we’ve learned in Georgia into other states.”
Telemedicine is already dramatically changing the way Americans view the delivery of health care. Within the next 10 years, Pruitt predicted, telehealth will become a major component in the way rural health systems throughout the United States deliver care.
