Telemedicine: A lifeline for rural health care

Holley Carlson had good news from her physician following a checkup in February 2009 : a clean bill of health.

It’s nothing earth-shattering for most women her age. But Carlson is in a league of her own. Six months earlier, the otherwise healthy 44-year-old dodged a cerebrovascular bullet when Jefferson Healthcare Emergency Room physicians teamed up telephonically with neurologists from the Swedish Neuroscience Institute, a part of Swedish Medical Center in Seattle to diagnose a severe blockage in her carotid artery.

It’s true that the Port Townsend woman was seen at both facilities following her August 2008 incident. But the critical evaluations came early on, within minutes of her arrival at Jefferson Healthcare. Thanks to a telemedicine program between Jefferson and Swedish, Carlson’s evaluation, diagnosis and treatment unfolded in a timely manner which may well have saved her life.

“I know I was really lucky. I know that,” the Port Townsend Realtor said in an April phone interview.

Her luck started long before she developed tell-tale symptoms, which in her case resembled the migraine headaches she’s suffered for years. Patients arriving at Jefferson Healthcare receive evidence-based care from the start, due to process improvement work in January 2008 __and a formal contractual agreement last December for a Tele-Stroke program which features state-of-the-art technology allowing for video and data transmissions that place Swedish specialists working together with Jefferson Healthcare Emergency Department physicians in early, critical stages.

Jefferson’s Chief Nursing Officer Terri Camp was an early advocate. With backing from the public hospital district’s Board of Directors, and CEO Vic Dirksen, Camp and others at the facility liked what they saw in early interactions with Swedish. Forming a permanent partnership made sense, she said.

“We’re aligned with the Swedish stroke team. They know us,” Camp said. “That’s part of our strategy: Where it’s appropriate to streamline the care for patients who start here, we can connect them with tertiary care as needed.”

Geography plays a role

Telemedicine itself is hardly in its infancy. Health care providers have networked through telecommunications avenues for decades. But with developing technologies, the possibilities become mind-boggling.

Georgia’s Center for Telehealth has identified a “rural penalty” in stroke care for their state – a pattern which logically follows throughout the nation. Their commissioned study showed that nearly 25 percent of patients receiving tPA were treated within 90 minutes of onset of symptoms, and half were treated within two hours. An analogous urban system of stroke intervention showed a rate only slightly better.

Such urban-rural partnerships are especially useful for rural patients who may be hours away from an urban hospital. In Jefferson and Clallam counties the matter becomes critical this month, when the Hood Canal Bridge – a thoroughfare connecting the Olympic Peninsula with access to Seattle – closes for a six-week retrofit.

Yet deeper into Clallam County, Camille Scott faces ongoing obstacles with her patient base at Forks Community Hospital, where she serves as Chief Executive Officer. Nestled in a sparsely-populated, forested haven, Forks depends on a single U.S. highway for traveling to and from metropolitan Western Washington. Consistently low clearance in the treed region makes airlift services impossible.

Even a transport to nearby Olympic Medical Center in Port Angeles may be complicated by weather and other conditions. Scott was resolute about providing first-rate cardiac care for the financially struggling, elderly and indigent population. “Like most rural communities with a high level of chronic illness, we could not get people to see specialists, so we were having to look toward Seattle,” Scott said. “But even if we could find someone, how can we get them there? We’re very far from anywhere.”

Her answer? Expand on their existing network connecting with Jefferson Healthcare and other providers by formally engaging with Kitsap Cardiology on an impressive Tele-Cardiology program.

Like Dirksen and Camp at Jefferson, Scott sought and secured grant funding for a suitable program. Unlike Camp, her telemedicine cases aren’t billed as ER visits; Forks receives a nominal $15 reimbursement per patient session.But without this service, those without any insurance would have to travel to either Seattle or Bremerton to receive care. As a public hospital district that is mission-driven, this is the right thing to do, Scott said. Also unlike Jefferson Healthcare, Scott’s facility qualified for federal funding through the USDA, allowing her to purchase high-end equipment using $300,000 in matched funds – an investment she doesn’t regret.

“To get specialty services to roll in a remote facility like ours, you’re really going to have to look for out-of-the-box, creative ideas,” Scott said.

Nuts and bolts

Forks’ program indeed is unique. While urban facilities such as Swedish have well-developed telemedicine programs, very few private practitioners have jumped into the fray. For Forks and Kitsap Cardiology it was an ideal marriage, as cardiologists from Kitsap had long been making the trek westward. Adding Forks as site was not much of a stretch. A streamlined process, aided by technology, made the partnership more enticing.

But don’t look for private-practice clinicians to jump on board en masse. Their reimbursement structure usually makes telemedicine services break-even ventures – if not worse.

“Most cardiology groups look at us and say, ‘Why are you doing this? You’re losing money,’” said Mary Berglind, Clinic Administrator for Kitsap Cardiology. “But we have an exceptional group of physicians who see the overall value in providing these services. Critical-access hospitals are truly unique – people living there are down-to-earth, loyal, good people.”

The Forks-Kitsap program “virtual clinic” features state-of-the-art technology, including electric stethoscopes, EKG streaming, and even hand-held cameras transmitting images of vessels from the side of a patient’s neck. The patient is hooked up to a cart which functions as a computer with a small server. A number of modalities are available, such as EKG and a blood-gas monitor. Attached to exam room walls, hi-resolution screens offer patients and attending physicians face-to-face contact with cardiologists on the remote end, and vice-versa. Better yet, data from prior exams may also be transmitted on the spot, aiding the diagnosis and evaluation process.

Berglind and Scott say patients feel completely comfortable with the process because they can make virtual eye contact with a member of their treatment team.

Jefferson Healthcare’s Tele-Stroke equipment inventory is evolving. The Swedish program offers the opportunity for Jefferson to have access to a specialist virtually. Swedish Medical Center’s Neuroscience stroke team provides expert analysis from their location at work or from their laptops at home. A telephone consultation determines whether there is a need to activate the tele-video connection.

“It’s a really pragmatic decision– we can give the clot-busting drug here and then transport the patient as needed,” Camp said.

Jefferson also works with Kitsap Cardiology for Tele-Cardiology, employing a secure-Internet transmission system routed from a telemedicine cart. Eventually they will convert to broadband. The hospital has current plans to purchase a second cart — estimated to cost about $6,000 — to prepare for the extra caseload anticipated during the Hood Canal Bridge closure.

Berglind said Kitsap Cardiology’s incentive is to provide critical-access hospitals with both convenience and an opportunity for revenues through ancillary services.

“We have a core value. We’re here to do this for the community.

“My goal with all of these smaller hospitals is this: We can help them,” Camp said. “I don’t see a downside to any of it. Telemedicine, echoes …. If they can get trained, they can put in pacemakers. That’s a lot of value for the community.”

Requirements and funding

There are some hurdles to clear before taking on a wide variety of telemedicine programs that can increase the bottom line. Medicare and Medicaid limit reimbursement to facilities working with certified labs. A board-certified cardiologist must examine the program’s quality indicators on a monthly basis. As a cost-defraying measure, Kitsap Cardiology permits its partner facilities to obtain accreditation under their licensure.

Providers must also be trained and certified to use equipment. In many cases, grant funding is available for that purpose.

Ironically, government health care providers have embraced telemedicine earlier and more frequently than those in private-sector services. One reason is fiscal: The United States Armed Forces aren’t compelled to seek grant funding for projects. But dire need also plays a part. Soldiers and other military personnel wounded in conflicts abroad benefit from specialized assessments delivered remotely. In Alaska, where topography makes physician travel extremely difficult, tribal clinics rely on telemedicine for their safety net.

Paying for these programs proves to be an issue for smaller hospitals facing dire revenue cuts in the ever-troubled economy. But a silver lining may be found in the Obama administration’s economic stimulus plan.

The president has addressed his campaign goals for health care reform through a $19 billion slush fund for Health Information Technology, including almost $5 billion for a Broadband Technology Opportunities Program, and an additional $4 billion targeted for distance-learning, telemedicine, equipment purchases, research and telehealth technologies. The funding appears in Obama’s 2010 federal budget.

While eligibility is variable, the movement toward bringing health care into the 21st century is evident. Telemedicine, and its rural facility beneficiaries, will be on the winning end.

That’s good news for Terri Camp and others working diligently to maximize services deliverable to their patient populations. Camp feels telemedicine is a front-runner in those efforts, but is clear about the overall reward it brings.

“We think it provides better care,” Camp said. We are aiming for the most appropriate care for all patients, not just telemedicine patients.”