Wiring in rural patients

(This article has been updated with a correction.)

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 more than $500 million to invest in virtual-care technology, and another $50 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 investments 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.

“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.

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 five-minute 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 doctors 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.

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.

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 10 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.”

Follow Beth Kutscher on Twitter: @MHbkutscher

(This article has been corrected to indicate that Mercy Health has invested more than $500 million for technology infrastructure and another $50 million for a virtual care center. In addition, its recent USDA grant covers 10 communities.)