How telemedicine keeps patients in rural communities healthy

Telemedicine is an effective way to provide healthcare to patients in rural areas. It also offers financial benefits to patients and healthcare providers.

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Image: Children's Mercy Kansas City

Technology is often blamed for taking away jobs. In the healthcare industry, radiologists--the people who read MRIs and CT scans--are worried about being replaced by algorithms. One type of technology may actually save healthcare jobs, particularly in rural areas: Telemedicine.

Consulting with a patient via video also has the potential to hit healthcare's triple aim: Better patient experience, better health overall, and lower costs. It also may keep rural hospitals in business.

"Telemedicine is great for families because no one wants a sick loved one 250 miles away," said Mike Phillips, MD, MBA, of Intermountain Healthcare. "It's good for hospitals because it helps them stay fiscally sound, and it's good for local providers, who can work with experts on complicated cases."

Phillips is the managing director at Intermountain Ventures. He was the chief of clinical and outreach services at Intermountain Healthcare previously. Intermountain is a Utah-based not-for-profit system of 23 hospitals, 170 clinics, and about 2,300 physicians.

Connect Care Pro is Intermountain's technology platform and medical care that extends specialist care to rural hospitals. The service includes 35 telehealth programs and about 500 caregivers, and it provides basic medical care, stroke evaluation, mental health counseling, and intensive and newborn critical care.

Providers use the service at Intermountain's 10 rural hospitals, as well as nine hospitals outside of the system. The telemedicine providers have their own command center at Intermountain's main campus in Salt Lake City with dozens of monitors and multiple data streams coming in for each patient. New members of the team work through multiple simulations before working with patients or other doctors remotely.

The platform is a combination of services built in-house and purchased from vendors. "We use Skype for Business for hospital to hospital communications and American Well for our direct to consumer consultations," Phillips said. "80% of the goodness is the solid video connection and the ability to have that right at the bedside. The other 20% is the health record and other information."

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A doctor is doing a stroke evaluation via video.

Image: Intermountain

Successful telemedicine requires highly skilled doctors

Phillips said that finding the right doctor to work in the telemedicine group is as important as having the right technology. "This work takes a master clinician, and we are very careful about who we select," he said.

Morgan Waller, the director of telemedicine business and operations at Children's Mercy Kansas City, said that finding the right doctors and nurses is crucial. If a healthcare provider doesn't see the value in the telemedicine, this can doom an entire project.

"The real problem may be that a provider doesn't want to provide care this way, but technology will get blamed for the failure," she said. One way to get around this is to take advantage of the competitive nature of physicians. "If you can get the early adopters, the rest will follow because they want to keep up with everyone else," she said.

The telemedicine doctors at Intermountain use a tactic called appreciative inquiry. This communications method helps build a good working relationship between the two providers that is collaborative instead of hierarchical. "We don't tell someone they're doing something wrong, we give them a reading of the situation and ask what they think we should do next," he said. Phillips said this technique is critical to developing trust with the person on the other side of the screen.

"This is a huge cultural shift, but that's OK because it's a huge benefit to our patients," Phillips said. "The technology is a vehicle to flex expertise from one geography to another. We want to get our expertise in an appropriate way to any bedside within reach of a cell tower."

Tele-ICU program offers intensive care for adults and newborns

Intermountain's oldest remote care service is the tele-ICU program. This collaboration between doctors in Salt Lake City that work with doctors in rural areas have reduced death rates in intensive care units and helped patients go home sooner.

"We have enabled local providers to take care of sicker people and to do a better job," Phillips said.

Telemedicine services also help mothers and new babies. The team specializes in neonatal resuscitation. About 10% of all babies born each year need help to start breathing. These babies need special care that many doctors do not have. When a rural hospital staff anticipates that a baby will be born early, the Salt Lake City team and the local doctors assemble for a practice run for the delivery.

"This allows everyone to sharpen their skills right before the delivery is going to happen," Phillips said. The medical transport group is also part of this team just in case the baby needs to come to the main hospital. "We can flip to a transport immediately if we need to because they've been watching the case in real time," he said.

Virtual care vital to financial health of rural hospitals

Keeping people in their local hospitals can be the difference between financial success and bankruptcy. Since 2010, 93 rural hospitals have closed, including 17 in Texas, 9 in Tennessee, and 7 in Georgia. This means people who need to see a doctor have to drive hours to do so. In 2014, 54% of rural communities did not have a hospital with a maternity ward. That means about 2.4 million women of childbearing age live in counties without hospitals that deliver babies.

Small and rural hospitals have been under intense financial pressure for decades. Many rural hospitals see fewer patients, and those patients are older, poorer, and sicker than patients at urban hospitals. Rural residents are more likely to get insurance from Medicare and Medicaid also; those programs pay less for healthcare services than insurance from employers. This combination of factors can mean long-term financial difficulties or even going out of business.

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The political whiplash around healthcare has also threatened the financial health of rural hospitals. Hospitals in states that expanded Medicaid as part of the Affordable Care Act are in better financial shape because more people have health insurance. Small hospitals are also supported by Medicare "extenders," extra payments designed to help them survive. These extenders cover everything from low patient volume to rural ambulance services.

Phillips said the most important goal for telemedicine is to keep patients at their local hospital. Some babies born prematurely are healthy enough to breathe on their own but need to gain weight before they can leave the hospital. "The worst thing you can do is separate mom and baby," he said. "With the appropriate monitoring and right people on the ground, we can keep mom and baby together."

Extending specialist care to rural areas

Children's Mercy Kansas City uses telemedicine to keep kids and families at home instead of driving anywhere from 4 to 8 hours to get to a specialist. Instead of emergency care, Mercy doctors and nurses use technology for routine checkups and speciality care.

"Kids who have a chronic health condition have to go to the doctor up to six times per year, and you can only get specialist care at certain hospitals," said Morgan Waller, MBA, BSN, RN. "These doctors wouldn't be able to pay off their med school loans if they lived in rural America."

Mercy serves rural and urban patients in Kansas and Missouri. The main hospital offers 47 specialities and 30 of those providers offer telemedicine services. The hospital has has four regional outreach centers that offer specialty care.

Waller joined the telemedicine department in 2012 with a new chief medical informatics officer and one part-time physician. "Everything I wanted to do, I got 'No,' for an answer from risk management and billing and legal," she said.

Until recently there was no consistent approach from state to state for telemedicine. In May 2017, Texas was the last state to allow a doctor to see a patient for the first time via screen, instead of requiring an in-person meeting first. Also in 2017, the Interstate Medical Licensure Compact went live; this makes it easier for physicians in member states to obtain licenses to practice in multiple states. Each of the 22 member states retains its right to regulate clinicians and take punitive action, as needed. Kansas participates in this agreement--Missouri does not.

In Kansas and Missouri, a doctor must be licensed in that state to practice medicine there. This common rule has slowed the adoption of telemedicine because getting licensed in multiple states can be difficult and expensive. Legislatures in both states have started to modernize these rules, but progress has been slow.

Virtual healthcare is just as effective

In 2018, Children's Mercy had 2,341 patient visits across all specialties via telemedicine. This was up from 1,644 telemedicine appointments in 2017.

Mercy's four satellite clinics use InTouch, a modular telehealth platform that can integrate with existing health IT systems or stand-alone. The InTouch software ensures a reliable video connection by giving video traffic priority. "It's a great system that manages bandwidth to make sure you get priority on network traffic," Waller said. "InTouch is like an ambulance."

During a telemedicine visit, a nurse or respiratory therapist manages the technology. The "tele-facilitator" starts the video connection with the doctor at the main Mercy campus. The facilitator uses the video connection, as well as instruments such as a digital stethoscope, an otoscope, and a high-resolution camera, to conduct the exam. These devices allow the doctor in Kansas City, MO, to see exactly what the nurse in Junction City, KS, is seeing.

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Image: Children's Mercy Kansas City

The telemedicine platform also allows interpreters to be present for a visit. "Our interpreters can be in the room with the provider or sign in virtually and join in a third video stream," Waller said.

A recent study that involved Mercy patients with asthma found that virtual visits are just as effective as in-person visits at helping kids get control of asthma symptoms.

Mercy also tracks patient satisfaction with telemedicine visits compared to in-person visits. A recent survey showed that 65% of parents and kids were equally satisfied and 33% were more satisfied with telemedicine care. Additionally, 82% of parents said their child could see a specialist sooner via telemedicine, which improves both access and quality of care.

Waller said that initially it was a challenge to find nurses to run the remote clinics; over time, the technology element of the job has become a recruitment tool. "These jobs are considered an expanded nursing role and because they see patients with several different illnesses, these nurses become multi-speciality facilitators," Waller said.

The daily variety in the work also keeps nurses engaged. "We are able to attract the best of the best because the work is never boring," she said. "We offer tons of autonomy also, and highly skilled nurses really appreciate that."

What's the next frontier?

As government officials and health insurance companies slowly solve the payment problem for telemedicine, hospital systems can expand their offerings.

Phillips at Intermountain said one of his top priorities is a mental health integration program. "We will be delivering behavioral health in the primary care doctor's office with the help of telemedicine," he said. "We want to help primary care doctors globally care for the health of the patient in part because people with depression will end up having more physical diseases as well."

Intermountain also will add rheumatology and dermatology to its list of telemedicine services.

At Mercy, Waller wants to go where the patients are. "I want very very much for us to be in schools so kids can see speciality providers in school," she said. "And hopefully because they are a captive audience they won't miss the appointment."

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