Wiring in ru­ral pa­tients

More hos­pi­tals are us­ing tech­nol­ogy to im­prove ac­cess and ex­pand their net­works with other hos­pi­tals, physi­cians

Modern Healthcare - - NEWS - By Beth Kutscher

Aeon Strange, 9, sees psy­chi­a­trist Dr. Kyle John four times a year for at­ten­tion deficit hy­per­ac­tiv­ity dis­or­der and anx­i­ety. Un­til re­cently, mak­ing the 200-mile round trip from his home in Rolla, Mo., to see John at the Mercy Health clinic in Spring­field, Mo., meant his miss­ing a day of school and one of his par­ents miss­ing work.

So the Stranges de­cided to par­tic­i­pate in Mercy’s “telepsych” pro­gram, which al­lows Aeon to re­ceive be­hav­ioral health ex­ams with John through a video hookup at his pe­di­a­tri­cian’s of­fice just a few min­utes’ drive from his school. “We re­ally ap­pre­ci­ated it,” said Aeon’s mother, Robyn. “We no longer have to drive two hours there and two hours back.”

Ch­ester­field, Mo.-based Mercy Health be­gan in­vest­ing in ad­vanced tele­health ca­pa­bil­i­ties eight years ago and now op­er­ates pro­grams in spe­cial­ties rang­ing from stroke care to high-risk preg­nan­cies, said Shannon Sock, ex­ec­u­tive vice pres­i­dent for or­ga­ni­za­tional ef­fec­tive­ness. About two years ago, Mercy com­mit­ted $590 mil­lion to in­vest in vir­tual-care tech­nol­ogy, and an­other $90 mil­lion to build a vir­tual-care cen­ter near its head­quar­ters. Nine­teen of its 33 hos­pi­tals have less than 50 beds and are in ru­ral re­gions of Mis­souri, Ok­la­homa, Kansas and Arkansas. The in­vest- ments al­low the sys­tem to ex­pand its pa­tient base as well as its net­work of hos­pi­tals and re­fer­ring physi­cians.

As sys­tems like Mercy shift to al­ter­na­tive pay­ment mod­els re­ward­ing them for keep­ing pa­tients healthy, some are ac­cel­er­at­ing their in­vest­ments in tech­nol­ogy tools and other ini­tia­tives that in­crease ac­cess for ru­ral pa­tients. These in­clude de­ploy­ing clin­i­cians in re­mote lo­ca­tions, adopt­ing tele­health and us­ing in-home mon­i­tor­ing ca­pa­bil­i­ties. These ef­forts are par­tic­u­larly im­por­tant for ru­ral com­mu­ni­ties, where pa­tients of­ten live far from the clos­est full-ser­vice hospi­tal.

Use of tele­health on the rise

“We think the fu­ture is in pro­vid­ing ser­vices not in bricks and mor­tar, but through these other ac­cess points,” Sock said.

More than half of all U.S. hos­pi­tals now use some form of tele­health, said Jonathan Link­ous, CEO of the Amer­i­can Telemedicine As­so­ci­a­tion. There are about 200 telemedicine net­works con­nect­ing large health cen­ters to about 3,000 largely ru­ral sites for spe­cialty con­sul­ta­tions, con­tin­u­ing med­i­cal ed­u­ca­tion and other ser­vices. Also, many emer­gency and crit­i­cal-care fa­cil­i­ties are us­ing tele­health to bring in neu­rol­o­gists to treat stroke pa­tients and in­ten­sivists to look af­ter pa­tients in an ICU.

Telemedicine has gained grow­ing bi­par­ti­san sup­port in Wash­ing­ton. Last month, for­mer U.S. Sens. Tom Daschle, Trent Lott, and John Breaux launched the Al­liance for Con­nected Care to ad­vo­cate for federal and state reg­u­la­tory changes that sup­port tele­health pro­grams. Its board mem­bers in­clude Wel­lPoint, Car­di­nal Health, CVS Care­mark Corp., Wal­green Co. and tech­nol­ogy de­vel­op­ers. Daschle, who rep­re­sented South Dakota in the Se­nate, long has been con­cerned about ru­ral health­care ac­cess.

But providers face fi­nan­cial, tech­no­log­i­cal and reg­u­la­tory chal­lenges in ex­tend­ing ser­vices to ru­ral ar­eas. Even though 20 states have par­ity laws re­quir­ing in­sur­ers to re­im­burse for tele­health ser­vices on par with face-to-face ser­vices, many pay­ers don’t yet cover such ser­vices. There also are is­sues sur­round­ing out-of-state pro­fes­sional li­cens­ing, li­a­bil­ity, data pri­vacy and tech­no­log­i­cal in­fra­struc­ture in ru­ral ar­eas.

“Tele­health ser­vices are rapidly be­com­ing a very im­por­tant part of health­care de­liv­ery un­der the new par­a­digm, but we un­for­tu­nately don’t have a reg­u­la­tory en­vi­ron­ment or pol­icy en­vi­ron­ment that ac­com­mo­dates the new tech­nol­ogy,” Daschle re­cently told the Wash­ing­ton Post.

More pay­ers are em­brac­ing telemedicine for its abil­ity to in­crease qual­ity of care and re­duce costs by re­duc­ing read­mis­sions and un­nec­es­sary emer­gency depart­ment vis­its, said Greg Billings, ex­ec­u­tive di­rec­tor of the Robert J. Wa­ters Cen­ter for Tele­health and eHealth Law in Wash­ing­ton. “I think more and more in­sur­ance com­pa­nies are start­ing to un­der­stand this is­sue,” he said.

Tra­di­tional hospi­tal-to-hospi­tal telemedicine qual­i­fies for Medi­care re­im­burse­ment if it takes place in a ru­ral area with a health­care pro­fes­sional short­age. In Med­i­caid, 45 states of­fer some level of cov­er­age.

De­spite the lin­ger­ing bar­ri­ers, ru­ral providers say telemedicine ser­vices are

help­ing to drive vol­ume, im­prove qual­ity and save on staffing costs. “It is the thing that is go­ing to al­low small hos­pi­tals to con­tinue pro­vid­ing qual­ity care,” said Dr. Ste­van Whitt, chief med­i­cal of­fi­cer at the Univer­sity of Mis­souri Health Care.

Tele­health pro­grams can take a wide range of forms. One type is e-ICUs, which al­low in­ten­sive-care pa­tients in small hos­pi­tals to re­ceive care from spe­cial­ists at a ter­tiary-care fa­cil­ity. An­other is wire­less re­mote blood-su­gar mon­i­tor­ing of pa­tients by nurse prac­ti­tion­ers. They also in­clude di­rect-to-pa­tient ser­vices, such as ex­ams con­ducted over the In­ter­net from a pa­tient’s liv­ing room.

Re­mote vis­its of­fered

The five-hospi­tal Univer­sity of Mis­souri Health Care sys­tem has used one form of tele­health ser­vices to solve its high rate of pa­tient no-shows. The Columbia-based sys­tem serves a 25-county area, with more than 60% of pa­tients com­ing from out­side its Boone County base. Partly as a re­sult, lots of pa­tients don’t show up for ap­point­ments.

So the sys­tem now of­fers them re­mote vis­its in­stead, Whitt said. For a $10 charge added to their reg­u­lar co­pay­ment, pa­tients can book a fiveminute phone call or an e-visit, of­ten via we­b­cam, with their physi­cian. That works be­cause up to 70% of pa­tients don’t re­quire a phys­i­cal exam dur­ing an of­fice visit, said Mitch Was­den, UM Health Care’s CEO. The ortho­pe­dics depart­ment also is ex­per­i­ment­ing with e-vis­its at nurs­ing homes to save on trans­porta­tion costs, he added.

Some physi­cians are con­cerned that they may miss med­i­cal is­sues with re­mote vis­its and face mal­prac­tice suits. But Whitt notes that many doc- tors al­ready are asked to take short­cuts, such as pre­scrib­ing an an­tibi­otic when a pa­tient calls in to avoid an of­fice visit. “I think (e-vis­its) can ac­tu­ally re­duce li­a­bil­ity,” Whitt said.

In­vest­ing in tele­health may make more fi­nan­cial sense for health sys­tems with ru­ral fa­cil­i­ties than staffing up those fa­cil­i­ties with specialist providers. To have a sus­tain­able crit­i­cal-care ser­vice at a 100-bed hospi­tal, Whitt said, the fa­cil­ity would need three sub­spe­cial­ists, each com­mand­ing an aver­age salary of $300,000. The tech­nol­ogy in­vest­ment looks like a bet­ter deal, he ar­gued.

Tele­health also can help im­prove qual­ity of care for ru­ral pa­tients, par­tic­u­larly when data sug­gest that they face the great­est out­come dis­par­i­ties in emer­gency sit­u­a­tions. “If you’re a small crit­i­cal-care hospi­tal, you’re not go­ing to have a car­di­ol­o­gist stand­ing by wait­ing for some­one to come in with a my­ocar­dial in­farc­tion,” said Dr. Peter Kaboli, di­rec­tor of the Vet­er­ans Ru­ral Health Re­source Cen­ter at the Vet­er­ans Af­fairs Of­fice of Ru­ral Health.

At Mercy’s ru­ral hos­pi­tals, the sys­tem has in­tro­duced an e-ICU pro­gram, us­ing cam­eras and com­put­ers to mon­i­tor the sick­est pa­tients. Pa­tients at risk for sep­sis, for in­stance, are iden­ti­fied through an al­go­rithm in their elec­tronic health record and placed in a vir­tual sep­sis unit for mon­i­tor­ing. The EHR also flags pa­tients who need an IV re­place­ment or are at risk for blood clots. The pro­gram has yielded ma­jor out­come im­prove­ments, such as a 20% re­duc­tion in mor­tal­ity rates, an 82% re­duc­tion in ven­ti­la­tor-ac­quired pneu­mo­nia and a nearly 50% re­duc­tion in deaths from sep­sis, Sock said. In ad­di­tion, the e-ICU pro­gram saves $25 mil­lion an­nu­ally from re­duc­ing ICU length of stay.

Mak­ing care more eas­ily ac­ces­si­ble to ru­ral pa­tients with­out long travel it­self can im­prove out­comes. A study pub­lished last Oc­to­ber in the jour­nal Cancer Epi­demi­ol­ogy, Biomark­ers & Preven­tion found that older cancer sur­vivors in ru­ral ar­eas were 66% more likely to forgo med­i­cal care than their ur­ban coun­ter­parts. Since both groups were cov­ered by Medi­care, re­searchers at­trib­uted the dif­fer­ence to travel costs and lack of so­cial sup­port.

‘Cre­at­ing a new dis­par­ity’

The far­ther pa­tients need to travel for care, the more likely they are to put off med­i­cal ap­point­ments. While pa­tients ac­cept that they will need to travel to an ur­ban cen­ter for spe­cialty care, they are less will­ing to do so for rou­tine ser­vices, Kaboli said. Tele­health is one way to over­come the ac­tual and per­ceived bar­ri­ers to care. “It’s a par­tial so­lu­tion,” he said. “I think the value will go up as the costs come down and cer­tainly as re­im­burse­ment catches up.”

Still, pa­tients’ ac­cess to and open­ness to us­ing dig­i­tal tech­nol­ogy varies. “You’re cre­at­ing a new dis­par­ity for people who don’t have dig­i­tal ac­cess,” Kaboli said. “It doesn’t mean we shouldn’t do it, just that we should be cog­nizant that it ex­ists.”

Daschle said tele­health is also limited by the speed, qual­ity and avail­abil­ity of In­ter­net con­nec­tions in ru­ral

ar­eas. His al­liance plans to pro­mote the in­stal­la­tion of high-speed net­works in un­der­served ar­eas.

An­other on­go­ing chal­lenge is that physi­cians and other providers gen­er­ally must be li­censed in the same state in which they are di­rect­ing care for a pa­tient, which can ham­per some telemedicine ef­forts, Billings said.

Other ways to con­nect

Given those bar­ri­ers, hos­pi­tals and health sys­tems are look­ing for additional, less tech­nol­ogy-ori­ented ways to con­nect with pa­tients in re­mote lo­ca­tions. Dr. Patrick Bro­phy, as­sis­tant vice pres­i­dent of eHealth and in­no­va­tion at Univer­sity of Iowa Health­care, Iowa City, said his or­ga­ni­za­tion is find­ing other ways to help pa­tients in their homes, such as teach­ing them to do pro­ce­dures such as peri­toneal dial­y­sis at home.

San­ford Health, which has 33 hos­pi­tals in North and South Dakota, Min­nesota and Iowa, reg­u­larly trans­ports ru­ral pa­tients by air to its fa­cil­i­ties and pro­vides lodg­ing to them and their fam­i­lies. It has com­mit­ted it­self to pro­vid­ing a health­care ac­cess point for pa­tients within 40 min­utes of where they live, said Ruth Krystopol­ski, ex­ec­u­tive vice pres­i­dent of de­vel­op­ment and re­search. “We do a lot with lo­gis­tics, be­cause we have to.”

Mean­while, though, many health sys­tems are ex­pand­ing their tele­health pro­grams. Last month, Mercy Health re­ceived a grant from the U.S. Depart­ment of Agri­cul­ture to ex­pand tele­health in nine com­mu­ni­ties with less than 5,000 res­i­dents. Mercy will in­stall au­dio/video tech­nol­ogy in three school districts, six med­i­cal clin­ics and a crit­i­cal-ac­cess hospi­tal that will al­low vir­tual vis­its with physi­cians. In ru­ral Ok­la­homa, Mercy is test­ing its Healthspot con­cept, a walk-in med­i­cal kiosk staffed by a med­i­cal as­sis­tant that links to a doc­tor through video equip­ment and med­i­cal de­vices that can stream bio­med­i­cal in­for­ma­tion.

Back at his pe­di­a­tri­cian’s of­fice in Rolla, Mo., Aeon Strange sits in a room with a large screen that con­nects him with his psy­chi­a­trist, Dr. John, who’s watch­ing from his Mercy of­fice in Spring­field. “There’s still a very close con­nec­tion be­tween the two of them,” Robyn Strange said. “I think it’s a won­der­ful pro­gram.”

Dr. Kyle John talks with a pe­di­atric pa­tient and her mother. The pa­tient is a par­tic­i­pant in Mercy Health’s telepysch pro­gram.

Newspapers in English

Newspapers from USA

© PressReader. All rights reserved.