Telemedicine links urban centers with rural clinics
February 1, 1997 6 minutes read
Telemedicine links urban centers with rural clinics
How one network put technology to work
Cyberspace offers exciting new options for case managers attempting to link rural clients with the kind of high-quality, cost-effective medical care commonly available only in urban facilities. A telemedicine network launched by Allina Health System in Minneapolis in May 1995 has already proved the benefits of this exciting high-tech tool.
Consider the following scenario: A rural patient undergoes heart bypass surgery in an urban cardiac hospital. A week after his surgery, the patient, now home in a rural county far from the urban cardiac facility, experiences swelling in the leg where surgeons harvested a vein. The patient arrives at the small, rural emergency room with a high fever and chest pains. Instead of taking the patient back to the urban cardiac facility by helicopter, the local primary care physician consults with a cardiovascular surgeon and an infectious disease specialist via telemedicine. Through the link, the rural doctor sends pictures of the leg and the patient's real-time EKG strip and cardiac echo. The information is interpreted by the specialists, who then lead the local doctor through an appropriate course of treatment.
This is a true case history, and the benefits are many and obvious, says William M. Goodall, MD, vice president of medical affairs for Allina Health System. "The patient was delighted that he didn't have to travel so far from home. The procedure saved a $2,000 helicopter ride and an inpatient stay at the urban facility for the health plan. The patient did stay overnight at the rural hospital, which benefited from the business, and the patient's primary care physician maintained control of the care," he notes.
Increasing access to care
The telemedicine network cost between $2 million and $3 million to implement and currently links 21 sites. "A consortium of eight rural hospitals formed the Rural Health Alliance, based in Alexandria, MN. The Rural Health Alliance applied for a grant from the Office of Rural Health Policy in Washington, DC. The initial grant of just over $600,000 paid for the hardware, with Allina supplying matching funds and one of the rural hospitals dipping into its capital funds to cover additional implementation and administration costs," explains Elizabeth A. Murphy, RN, MS, director of clinical education and research for Allina Health System. The system runs over high-speed T-1 telephone lines.
The telemedicine system with its real-time video and vital signs monitoring capacity has been put to a variety of medical and administrative uses, notes Murphy. Those uses include:
• Emergency room care.
"There are two rural hospitals with emergency room departments. Every time a patient would come in, the nurse would care for them until the doctor could be reached by telephone and come into the hospital. This delayed care and inconvenienced rural doctors, making them on call 24 hours a day, seven days a week," says Murphy.
"Now, when a patient comes into the rural emergency room, the nurse fills out the admission forms and faxes them to the urban hospital. Then the nurse establishes a telemedicine link with an emergency room physician at an urban hospital," she explains.
The nurse transmits all vital signs, and conducts a complete physical exam of the patient using the telemedicine link to transmit all data to the urban physician. The system is equipped with probes and a stethoscope, so that the emergency room doctor can, with the nurse's help, see the patient's throat and ears and listen to the patient's chest. In most cases, the physician is able to make a diagnosis for such common minor emergencies as sore throats, ear infections and minor lacerations, and to help the rural nursing staff through an appropriate course of treatment. For example, if the patient needs a prescription, the physician faxes it to the hospital pharmacy and the nurse fills it. For true emergencies, the physician helps the nurse stabilize the patient using the telemedicine system until the local physician arrives at the hospital, she adds.
The system clearly saves rural patients time and inconvenience, and creates prompt access to appropriate medical care. It may also help rural areas retain vitally needed primary care physicians, notes Goodall. "I've had the senior physician in one rural practice tell me that he's certain one of his physicians stayed in the area because the telemedicine system reduced the number of night calls she had," he says.
• Consultations with specialists.
"Many rural patients find it difficult to travel two hours one way into the nearest urban center to consult with medical specialists," notes Murphy. "We've had elderly patients who are truly fearful to drive to the city, or who are too debilitated by their illness to travel great distances, or who simply can't take an entire day off work to travel into the city for one appointment and then drive back. Many of these patients would put off seeing specialists rather than make the trip. The telemedicine system allows them to come into their local primary care physicians and consult with the specialist on-line. This also enhances the primary care physicians' understanding of the necessary care," she adds.
• Meetings of corporate executives.
"Our offices are spread out geographically, and executives spent a great deal of time just traveling to meetings. We have 20,000 employees and manage 17 hospitals. We save a great deal of traveling time by using the telemedicine link to conduct staff meetings," says Murphy.
• Staff education.
Allina also finds the system useful for conducting inservices. "Rural nurses and physicians take advantage of many more of our inservices using the telemedicine system. Before the system was in place, it was often difficult for them to find the time necessary to come into the city to attend inservices," notes Murphy. "Even our urban physicians often couldn't make it to an inservice on the other side of the city. They wasted too much time traveling through heavy traffic," she adds.
• Community education.
"We are just beginning to develop community education programs for use over the system. We recently had a program on breast cancer for women in the rural health alliance," says Murphy.
Limiting risk
Allina took three important preliminary steps to ensure the system's success. "First, our legal department scrutinized the system and the legal issues it raised. If a patient is uncomfortable with the telemedicine system, they have the right to insist on being seen by a physician in person," notes Murphy. "Next, we also presented the system and our plans for it to the state board of nursing, board of medical practice, and board of pharmacy to make sure they had no objections to our intended uses of the system," she adds.
The health system's third step was to conduct education sessions to introduce the technology to its physician and nursing staffs. "We continue to offer training courses in the technology on a regular basis, as there are constantly new employees entering the system," she says.
In the nearly two years since the system has been fully implemented, Allina has carefully tracked both patient and physician satisfaction and the volume of activity on the system. "The most frequent use has become staff meetings," notes Murphy.
Murphy and Goodall both stress that Allina doesn't see the system as replacing the face-to-face practice of medicine. "The system simply saves time and energy for both providers and patients and increases access to care for many rural health plan members," explains Murphy. "And apparently the benefits are clear to all involved, because satisfaction ratings are high for all areas: physician consultations, staff inservices, and emergency room use."
More managed care plans now recognize the benefits of the system. Medica, a 1 million- member managed care plan in Minneapolis, and both Blue Cross/Blue Shield and Medicaid plans in several states are beginning to reimburse regularly for telemedicine consultations. However, Medicare remains an important holdout. "Medicare has argued that the number of consultations will increase if telemedicine is an option," explains Murphy. "Telemedicine consultations are billed just like any other consultation," she adds.
"Increasing the number of consultations with specialists just doesn't make sense," agrees Goodall. "In a managed care organization, we are no more likely to encourage primary care physicians to seek a cardiac consult by telemedicine if there's no good reason for it than we would encourage a face-to-face consult. The number of consultations or referrals to specialists doesn't change just because I have technology to make it more convenient," he argues.
(Telemedicine continues to gain ground nationwide. For discussion of telemedicine's use in home health care and a listing of telemedicine vendors, see Case Manage-ment Advisor, December 1996, pp. 161-163.)
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