Telemedicine Reaches Beyond Clinic Walls

Networks Help Extend Access

by Candi Helseth

Telemedicine helps health care providers maximize resources to reach more patients in rural locations where services are limited or even non-existent. But telemedicine services can go well beyond hospital and clinic walls, meeting health care needs among immobile populations such as nursing home residents and prison inmates, and in isolated geographic regions where high rates of poverty and transportation barriers make it unlikely that residents will seek or get the help they need.

Sharon Daley

Registered Nurse Sharon Daley helps provide primary care services to isolated residents on four Maine islands via telemedicine equipment on the boat, Sunbeam V.

“For people in rural areas, the greatest telemedicine benefit is the increasing access to services and resources that would not otherwise be available in their community,” said Sherilyn Pruitt, Director of the Office for Advancement of Telehealth (OAT). “People are less likely to seek help when they have to incur travel costs, a possible hotel stay and time off from work to travel somewhere else in their region for health care services.”

Telemedicine services can travel to patients, via land—or sea. The nearly 500 residents living on four federally underserved islands off the coast of Maine have no bridge access to the mainland and, Registered Nurse Sharon Daley says, residents are likely to ignore health problems if they have to leave the island for care. But when the 75-foot long Sunbeam V docks at Frenchboro Island, the island’s 75 residents welcome the boat—and its telemedicine clinic—like an old friend. For more than 100 years, the faith-based ministry Maine Sea Coast Missions has sent boats to all four islands providing spiritual and social support systems. Ten years ago, Sea Coast Missions hired Daley and added the telemedicine clinic. Patients come on board for both primary care and specialty appointments with physicians in Maine who, via live teleconferencing, diagnose and treat patients. Daley provides a personal touch and hands-on tasks, such as strep screens and blood draws requested by physicians.

In Georgia and Arizona, outcomes have improved and travel costs have been substantially reduced through telemedicine programs with outreaches targeted at immobile populations.

A wound care telemedicine program for rural Georgia nursing home patients substantially reduced the frequency of patient transfers by ambulance to tertiary centers. Patient outcomes also improved. The incidence of pressure ulcers declined among nursing home patients in five rural counties where Archbold Medical Center in Thomasville, Ga., introduced wound telemedicine.

Sue Sisley

Dr. Sue Sisley, Associate Director for the Arizona Telemedicine Program, demonstrates an otoscope used in telemedicine consultations.

“Wound care specialists are in short supply nationwide and almost non-existent in rural areas,” said Dr. Harriett Loehne, clinical educator at Archbold Center for Wound Management and Hyperbaric Medicine. “Patients in nursing homes are at higher risk for pressure ulcers because they frequently are immobile, immune suppressed and have multiple comorbidities. Traveling is also physically difficult for these patients.”

In Arizona, physicians and psychiatrists see prison inmates via live videoconferencing under the umbrella of the Arizona Telemedicine Program (ATP). The Arizona Department of Corrections (ADC) reports a cost savings of more than $1 million since the program’s inception in 1996. Prior to telemedicine, ADC transported prisoners to hospital facilities for appointments. Now over 8,000 prisoners in Arizona’s 10 rural prisons have seen physicians and psychiatrists via video conferencing. Physicians listen to heart sounds using electronic stethoscopes and examine eardrums with high-resolution otoscopes. Prisoners report satisfaction with the program because it has improved their access to health care. ADC is no longer concerned about possible escapes and public safety, major issues associated with transporting prisoners.

Telemedicine makes education and support services more accessible too. Parenting classes and health education, such as a recent seminar on Lyme disease, link residents on the four Maine islands to each other and to specialists leading the sessions.

Networks and Support Systems Increase Access

Bethany Aldridge

Bethany Aldridge, an associate with the Georgia Partnership for TeleHealth, helps patient, Lea, consult with Dr. Matt Smith, a dentist in Waycross, Ga.

Established networks such as ATP and the Global Partnership for Telehealth (GPT) combine a variety of telemedicine technologies to deliver services throughout their states, and in some cases, across state borders.  ATP links 170 member sites with more than 300 specialists in adult and pediatric medicine. GPT includes 200 rural and specialty sites with more than 175 specialists representing 40 specialty areas. Although Maine Telemedicine Services (MTS), which worked with Sea Coast Mission to develop its floating telemedicine clinic, isn’t a network, it has developed and supported several telemedicine projects, according to Michael Edwards, MTS director of research and evaluation.

Through live videoconferences from Thomasville, Loehne trains staff working in Georgia’s rural nursing homes to better assess and treat wounds. Using store and forward technology, nursing home staff transmits weekly digital photographs of residents’ wounds for Loehne’s review and recommendations. Loehne also travels monthly to each facility for patient consultations and hands-on education.

“I closely follow every patient,” Loehne said. “This is phenomenal technology for nursing homes where pressure ulcers are always a concern. The wound care software creates a folder that lets me see the wound in chronological order over time and the whole continuum at one time. So we absolutely know what progress we are making.”

ATP pioneered the use of videophone technology for ostomy care. More than 100 cancer patients living in isolated areas have direct access to ostomy-certified nurses at tertiary centers. Using a special close-up lens, nurses can examine the patient’s ostomy site and make recommendations. Previously, these patients traveled long distances regularly to the tertiary center for ostomy care.

Maine, Georgia and Arizona all have a high demand for telepsychiatry. Four mental health providers associated with Arizona’s Regional Behavioral Health Authorities (RBHA) offer telepsychiatry services in every county. Previously, psychiatrists were spending thousands of hours driving long distances to rural areas. Telepsychiatry has resulted in more than 4,700 patient services and approximately $106,000 in cost savings through reduction of psychiatrists’ travel expenses and time.

Maine Sea Coast Mission patients’ most requested services have been mental health, and drug and alcohol abuse counseling, Daley said, adding, “If you’re anxious and depressed, you’re even more unlikely to leave the island to get help because that’s anxiety producing in itself. I’ve seen such improvements in the way people are functioning now that they are getting psychiatric help.” Island residents are also able to attend AA meetings via the technology.

Telemedicine’s growth means rural providers need training relative to its use, said Rena Brewer, director of the Southeast Telehealth Resource Center (SETRC). This summer, SETRC—in collaboration with California Telemedicine and E-Health Center (CTEC) and HomeTown Health University —is rolling out its National School of Applied Telehealth. Students will complete online classes to become certified as telemedicine clinical presenters, telehealth coordinators and telehealth liaisons.

Assistance AIDS Advances

OAT, which is under the federal Office of Rural Health Policy, promotes the use of telehealth technologies for health care delivery, education and health information services. OAT’s functions include coordinating telehealth grant programs and providing technical assistance to communities that are beginning new telehealth programs or enhancing existing ones.

Despite noteworthy advancements, telemedicine coverage is still spotty or unavailable in many rural areas, Pruitt said. Broadband connectivity, often essential to provide the full range of clinical services, isn’t available countrywide. Telephone systems limit scope of services. State laws limiting cross-state licensure and credentialing complicate efforts to advance telemedicine across state borders. Lack of reimbursement can make a program unsustainable. (Medicare reimburses telemedicine nationwide in non-metropolitan areas but private payers’ reimbursements vary from state to state.)

“If there’s no reimbursement, specialists aren’t going to add telehealth into already full schedules,” Pruitt said. “And in rural areas, these clinicians are so busy in their day-to-day practices that they don’t know how or feel they don’t have the time and money it takes to start telemedicine services. There is a lot of upfront work.”

Rural providers also grapple with costs not only of funding new technologies but also upgrading technologies as they advance, Edwards said. The technology on the Sunbeam V is already considered outdated and providers are working to equip the islands with technologies that will alleviate the need for a boat to bring telemedicine services to the islands.

“When states can pull together statewide and regional networks, they improve efficiency and coverage,” Brewer said. “Positive telemedicine legislation is a foundational requirement in establishing a successful statewide telehealth program. Georgia’s experience has been that a statewide, nonprofit network levels the playing field and enables telehealth entities to work together. That improves access to everyone.”

SETRC, which is one of nine regional OAT-funded TeleHealth Resource Centers (TRC), continues to serve Georgia through GPT and has begun working with South Carolina, Florida and Alabama. TRCs provide free technical assistance to rural communities interested in starting or enhancing a telehealth program. OAT also works with state telehealth leaders to help them understand their respective state’s laws and the regulatory changes necessary to successfully implement services.

“We have a passion for helping others with telemedicine,” Brewer asserted. “We’re thankful we can share our experiences in Georgia. The bottom line here is that we want all families in rural America to have access to the kind of expertise that telemedicine provides. We want to take the lessons we’ve learned in Georgia into other states.”

Telemedicine is already dramatically changing the way Americans view the delivery of health care. Within the next 10 years, Pruitt predicted, telehealth will become a major component in the way rural health systems throughout the United States deliver care.

Back to: Summer 2011 Issue