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Avera eCARE

  • Need: Rural hospitals and healthcare providers have less access to specialty care support.
  • Intervention: A service was created at Avera Health that provides 24-hour virtual access to specialty care physicians, nurses and pharmacists.
  • Results: Rural patients can receive specialty care without leaving their communities, and rural healthcare providers can get needed support in providing quality care to their patients.


Effective (About evidence-level criteria)


Avera Health, a South Dakota non-profit healthcare system, developed a suite of services called Avera eCARE to support participating rural healthcare providers in caring for patients. Avera eCARE connects providers by video to a team of specialists in an urban hub location. Avera eCARE offers rural providers collegial support that can ease the pressure and isolation of practicing in a rural setting, while offering patients specialty care in their own communities.

Avera eCare Logo

Take a virtual tour of Avera eCARE's hub to learn how it provides support to rural hospitals:

To leverage expertise and extend their resources, Avera eCARE collaborates with health systems such as Dartmouth-Hitchcock Health, The University of Kansas Health Authority, Catholic Health Initiatives, Allina Health, Emerus, and Indian Health Service.

Through its Rural Healthcare Program, the Leona M. and Harry B. Helmsley Charitable Trust has funded hundreds of rural hospitals to implement specific Avera's eCARE services.

Services offered

Avera eCARE services provide around-the-clock care that includes:

  • eCARE Emergency: Access to board-certified emergency physicians and experienced emergency nurses, and other specialists as needed. With eCARE Emergency, 28% of facilities have a hub physician available approximately 21 minutes sooner than a local physician. Headquarters can answer as many as 13 calls at one time to provide assistance to rural emergency rooms.
  • eCARE ICU: Remote intensive care monitoring of critically ill patients by a team of intensivists and critical care nurses.
  • eCARE Pharmacy: Access to hospital-trained pharmacists, ensuring medication review by a pharmacist before administration to patients. Read about the program in the American Hospital Association's 2017 case study.
  • eCARE Specialty Clinic: Access to specialty care for patients at their local facilities via 2-way video technology.
  • eCARE Senior Care: On-demand urgent care services for long-term-care and assisted living facilities. Read about the related SD eResidential Facilities Healthcare Services Access Project.
  • eCARE Correctional Health: On-demand urgent care services for inmates in 4 penitentiaries. 
  • eCARE Behavioral Health: A team of psychiatric nurses provides support to hospital emergency rooms for appropriate documentation, screening, and disposition of patients.
  • eCARE Hospitalist: Hospital support via a mobile cart to provide specialized care to adults in the hospital for general medical and surgical care.
  • eCARE School Health: Provides school staff with an experienced nurse to assist students with chronic and unscheduled health needs.
  • Professional/Continuing Education: Virtual education for providers on topics such as chronic pain management, left atrial appendage occlusion, and alcohol intoxication and withdrawal.
  • AveraNow: A virtual app that connects patients to a provider for treatment of simple illnesses. AveraNow kiosks are also located in supermarkets, giving customers direct access to healthcare services.

This video features a true story of how Avera's eCARE Emergency program helped save the life of one little girl in Nebraska.

Avera eCARE hosts other videos that give testimony to the program's effectiveness on their website.


Results of Avera eCARE services are described by Avera eCARE Data Set (unpublished) from the service's inception to August 2018.

  • Over 2 million residents now have remote access to board-certified physicians and specialized healthcare services.
  • Over $190 million total health care costs saved.
  • eCARE Emergency has experienced over 100,000 video encounters.
  • eCARE ICU reduced the length of stay by 3.38 hospital days; time on ventilators was reduced by 13 hours.
  • eCARE Pharmacy avoided 61,000 potentially adverse drug events.
  • 90% of eCARE Senior Care residents were treated in place, avoiding transfers to higher levels of care.
  • 410 total sites served in 20 states.
  • Support has been given to rural hospital quality initiatives that implements best practices and improves patient care.

Additional results about each service can be found on their By the Numbers page.

Avera eCARE Doctors in Action in the eEmergency Suite
eCARE staff in the eCARE Emergency hub

The Avera eCARE program has been recognized in the Agency for Healthcare Research and Quality Innovations Exchange as a program with moderate evidence for effectiveness. Program results identified by AHRQ include:

  • Reduction in mortality
  • Shorter patient stays
  • Fewer patient transfers
  • Cost savings
  • High levels of satisfaction for healthcare providers

For more detailed information about program effectiveness:

  • Clinicians in Tertiary Hospital Monitor Critical Care Patients in Rural Facilities via Telemedicine, Leading to Reductions in Mortality, Length of Stay, Patient Transfers, and Costs, Agency for Healthcare Research and Quality Innovations Exchange
  • Lilly et al. (2014). Critical Care Telemedicine: Evolution and State of the Art. Critical Care Medicine, 42:2429-2436. Article Abstract
  • Mueller, K. J., Potter, A. J., MacKinney, A. C., & Ward, M. M. (2014). Lessons from Tele-emergency: Improving Care Quality and Health Outcomes by Expanding Support for Rural Care Systems. Health Affairs (Project Hope), 33(2), 228-234. Article Abstract
  • Potter, A. J., Mueller, K. J., McKinney, A. C., & Ward, M. M. (2014). Effect of Tele-emergency Services on Recruitment and Retention of US Rural Physicians. Rural And Remote Health, 14(3), 2787.
  • Stingley, S., & Schultz, H. (2014). Helmsley Trust Support for Telehealth Improves Access to Care In Rural and Frontier Areas. Health Affairs (Project Hope), 33(2), 336-341. Article Abstract
  • Ward, M. M., Ullrich, F., MacKinney, A. C., Bell, A. L., Shipp, S., & Mueller, K. J. (2015). Tele-emergency Utilization: In What Clinical Situations Is Tele-emergency Activated? Journal Of Telemedicine And Telecare. Article Abstract
  • Ward, M. M., Ullrich, F., Potter, A. J., MacKinney, A. C., Kappel, S., & Mueller, K. J. (2015). Factors Affecting Staff Perceptions of Tele-ICU Service in Rural Hospitals. Telemedicine Journal And E-Health: The Official Journal Of The American Telemedicine Association, 21(6), 459-466. Article Abstract
  • Zawada, E. J., Herr, P., Larson, D., Fromm, R., Kapaska, D., & Erickson, D. (2009). Impact of An Intensive Care Unit Telemedicine Program on a Rural Health Care System. Postgraduate Medicine, 121(3), 160-170. Article Abstract
  • Zawada, E. J., Kapaska, D., Herr, P., Aaronson, M., Bennett, J., Hurley, B., & Johnson, T. (2006). Prognostic Outcomes after the Initiation of an Electronic Telemedicine Intensive Care Unit (eICU) in a Rural Health System. South Dakota Medicine: The Journal Of The South Dakota State Medical Association, 59(9), 391-393. Article Abstract
  • Zawada, E,T., Jr., Aaronson M.L., Herr, P, and Erickson, D. (2006). Relationship Between Levels Of Consultative Management and Outcomes in a Telemedicine Intensivist Staffing Program (TISP) in a Rural Health System. Chest, 130, 226s. Article Abstract
  • Zawada, E.T., Jr.,Herr, P. (2008). ICU Telemedicine Improves Care to Rural Hospitals Reducing Costly Transports. Critical Care Medicine, 36(12):A172
  • Zawada, E.T., Jr., Herr, P. , Erickson, D. & Hitt, J. (2007). Financial Benefit of a Tele-intensivist Program to a Rural Health System. Chest, 132, 444. Article Abstract
  • Zawada, E.T., Jr., Herr,P., & Lindgren, L. (2008). Clinical and Fiscal Impact of a Rural Tele-intensivist Staffing Program on Transfer of Patients From Their Community to a Tertiary Care Hospital. Critical Care Medicine, 36(A86).

Media publications can be found on the Avera eCARE website.

This program is also featured in RHIhub's Access to Care for Rural People with Disabilities Toolkit Program Clearinghouse.


Some of the barriers experienced by Avera eCARE, as described in a 2014 Health Affairs journal publication, include:

  • Challenges related to reimbursement for telehealth services
  • Variations in how hospitals are paid by Medicare
  • Physician and pharmacist licensure requirements in the state where the patient is located
  • Physician credentialing at the facilities receiving telehealth services
  • Access to adequate broadband


Avera eCARE has served as a model for local, national, and international organizations wanting to offer telehealth services.

The The National Consortium of Telehealth Resource Centers, which is funded by Health Resources and Services Administration Office for the Advancement of Telehealth, can provide assistance to organizations interested in implementing a similar approach.

Contact Information

Jay Weems, Vice President Operations, eCARE Services
Avera Health
Avera eCARE Services


States served
National/Multi-State, South Dakota

Date added
April 21, 2014

Date updated or reviewed
September 10, 2018

Please contact the models and innovations contact directly for the most complete and current information about this program. Summaries of models and innovations are provided by RHIhub for your convenience. The programs described are not endorsed by RHIhub or by the Federal Office of Rural Health Policy. Each rural community should consider whether a particular project or approach is a good match for their community’s needs and capacity. While it is sometimes possible to adapt program components to match your resources, keep in mind that changes to the program design may impact results.