For the seven physicians on staff at an 18-bed rural hospital, the demands of rotating on-call duties at the emergency department had stretched their schedules thin.The everpresent prospect of an e mergency call from Kirby Hospital also had worn thin personally for doctors hard-pressed for some family life in Monticello, Ill."They were threatening to resign from the staff unless something was done about the call (burden)," said Wayne Mathews, who's since become part of the response to that problem.The obvious alternative to stretching the on-call rotation was to stretch the facility's budget thin instead, by hiring an outside emergency-medicine servi ce. That was a tall order for the smallest hospital in the state.But along came a pilot project that virtually solved the money and manpower problems by making Kirby Hospital's facility a virtual emergency room within the larger de partment of a full-service hospital 25 miles away.To spare the local doctors, the ER at Kirby is now staffed by physician assistants, at about one-third the cost of hiring an on-site physician.But when tough cases come through the door, an emergency medicine specialist is always ready to spring into action-at Carle Foundation Hospital, a 275-bed medical center in Champaign, Ill.The backup arrangement employs the technology of telemedicine for interactive con sultations between a Carle physician and a Kirby physician assistant or nurse practitioner.The equipment at Kirby includes:
An interactive video camera displaying high-resolution views on monitors at both ends of the connection.
An overhead camera to transmit radiological images and electrocardiograms to Carle.
A stethoscope that's electronically hooked up to the consulting physician.
A low-magnification dermascope to help diagnose surface-level medical problems.
The video and audio are transmitted over two dedicated high-speed phone lines operated by Ameritech Corp.The Chicago-based Baby Bell company proposed the project to Carle Foundation, a 275-physician group practice based i n Champaign, as a way to test telemedicine's ability to integrate a rural facility with an urban medical center, said Mathews, project director at Kirby.Through the Center for Rural Health, operated by Carle Foundation, Ameritech a nd Carle went looking for promising rural facilities to be put to the test. At Kirby, the pieces all fit into place, Mathews said.The hospital was considering using physician assistants to relieve doctors of the more routine traffi c in the emergency room. But policy positions of groups such as the American College of Physicians emphasized the need for improved communication links with health professionals to get the proper assistance when necessary.Physician assistants also required a clear set of protocols for varying levels of patient distress, governing whether a mid-level practitioner treats a patient solo, calls for backup on a more complicated case or immediately stabilizes the patient for transfer to a more comprehensive facility.Mathews worked both ends of the equation. A physician assistant at Carle for five years, he already was familiar with its physicians and with protocols set up to decide whether to direct patients to the emergency department or an adjacent urgent-care center for lesser problems.In July 1994 he became Kirby's first physician assistant on the emergency staff. A second assistant was hired in October 1994 to d ouble the number of shifts covered, Mathews said. A registered nurse also is on every shift, supplemented by an inpatient nurse when the ER gets busy, he said.Just having the physician assistant on duty has improved the situation f or the doctors on staff, said William Linker, M.D., a general practitioner for the past 10 years at Kirby who also has staff privileges at Carle.The Kirby emergency room, with about 3,600 visits a year, wasn't a high-volume burden, but "it only takes one patient an hour to keep you from getting any sleep," Linker said.Physicians had to be within 15 minutes of the hospital and ready to go in again and again. "They were having to come in on every sore throa t and laceration before," Mathews said.Now they're still on backup call for cases that need a physician presence. But in many of those cases, the on-duty staffers just need a question answered or a condition evaluated to determine its seriousness, Linker said. Sometimes the situation calls for a specialist opinion, which can get expensive if it involves an ambulance ride to Champaign.In those cases, the Kirby staff calls to alert Carle of an imminent consul tation and then moves the patient into position at the interactive video console, Mathews said. The physician on duty at Carle goes to the telemedicine station that's always set up for action about 10 steps away from the main ER de sk. The consulting physician isn't pulled out of a routine because he or she is working the patient into a regular shift, Linker said. It's another stop in a scene where doctors duck into one draped-off area after another.The physi cian gets a $60 consulting fee for every telemedicine consultation, Mathews said. Kirby absorbs the fee as part of its overhead costs, but the financial benefits of the telemedicine program still outweigh the costs by more than 2-t o-1 (See chart).The bulk of savings is in medical salary costs avoided by hiring physician assistants. The $178,000 saved between July 1994 and the end of 1995 represents the difference between $100 an hour for outside emergency-me dicine service and $33 an hour for a physician assistant, Mathews said.The rest of the savings can be traced to diagnoses confirmed over the telemedicine link that headed off a patient transfer to Carle or another higher-level faci lity.Through the middle of March, 84 patients had required an on-line look, and Kirby staffers saved 20 transfers by getting enough resolution of the diagnosis to either admit or discharge a patient on the spot instead of ordering an ambulance run just to be safe, Mathews said.For example, a 14-year-old boy had a metallic fragment removed from his eye by the physician assistant, but something was still there, Mathews said. A physician at Carle looked at it t hrough the dermascope and diagnosed it as rust residue, which needed only local follow-up a few days later by an ophthalmologist.Continued on p. 53Continued from p. 48In another case, a 16-year-old football player suffered a minor concussion. Cervical spine films were judged normal in a telemedicine review and he was discharged.Kirby has kept track of the telemedicine consultations to check for shortcomings in care, but through the middle of March it had rec orded no readmissions to a hospital or emergency department with 48 hours of such a consultation, one measure of quality, Mathews said. The percentage of unstable transfers also decreased to 5% from 7%.With telemedicine and mid-lev el clinicians, "we have the same number of physicians in the community but have been able to extend the manpower considerably," Linker said.Kirby's physicians are rapidly expanding the potential into other areas, especially conti nuing medical education. The link allows 35-minute interactive teaching sessions instead of the usual "canned" video presentations that don't provide opportunities to stop the instruction and ask questions, Linker said.And it kee ps Kirby's seven physicians connected with current medicine at the University of Illinois' medical school environment in Champaign without having to leave isolated Monticello. Meanwhile, the electronic link has saved an additional $63,000 in travel and teaching expenses, according to Mathews' figures.Kirby recently began to work telemedicine into its inpatient and nursing-home operations. Already it has avoided transporting some frail patients to specialists , heading off expenses that aren't reimbursed under flat Medicare fees, Linker said.