26548proof 11/26/02 8:29 AM Page i Rural Health Care Delivery: Connecting Communities Through Technology Prepared by First Consulting Group December 2002 26548proof 11/26/02 8:29 AM Page 1 Rural Health Care Delivery: Connecting Communities Through Technology Prepared for: CALIFORNIA HEALTHCARE FOUNDATION Prepared by: First Consulting Group Authors: Fran Turisco and Jane Metzger December 2002 26548proof 11/26/02 8:29 AM Page 2 Acknowledgments This report was prepared by Jane Metzger and Fran Turisco of First Consulting Group. First Consulting Group is a leading provider of consulting, technology, and outsourcing services for health care, pharmaceutical, and other life sciences organiza- tions in North America and Europe. More information about FCG is available at www.fcg.com. About the Foundation The California HealthCare Foundation, based in Oakland, is an independent philanthropy committed to improving California’s health care delivery and financing systems. Formed in 1996, our goal is to ensure that all Californians have access to affordable, quality health care. CHCF’s work focuses on informing health policy decisions, advancing efficient business practices, improving the quality and efficiency of care delivery, and promoting informed health care and coverage decisions. CHCF commissions research and analysis, publishes and disseminates information, convenes stakeholders, and funds development of programs and models aimed at improving the health care delivery and financing systems. The iHealth Reports series focuses on emerging technology trends and developments and related policy and regulatory issues. The information included in this report is provided as general information and is not intended as medical or legal advice. The California HealthCare Foundation does not, and does not intend to, whether through this publication or otherwise, endorse any product, entity, or person, and reserves the right to alter the content of this report at any time. Additional copies of this report and other publications can be obtained by calling the California HealthCare Foundation’s publications line at 1-888-430-CHCF (2423) or visiting us online at www.chcf.org. ISBN 1-932064-22-2 Copyright © 2002 California HealthCare Foundation 26548proof 11/26/02 8:29 AM Page 3 Contents 5 Executive Summary 7 I. Purpose Problems of Scarcity and Distance A New Range of Technologies Organization of This Report 9 II. Understanding the Technology Technological Developments Technology Equipment Levels of Connectivity Selecting the Right Equipment and Connectivity Option Technology Challenges 14 III. Case Examples of Technology Solutions Email-Based Applications Web Portal Applications Image Capture and Interpretation Applications Real-Time Remote Video Consults Remote Patient Monitoring Supporting Rural Home Care 25 IV. Practical Issues in Getting Started Collaboration Is a Necessity Regulations Funding and Reimbursement 33 Appendix A: Resources 34 Appendix B: Interviewees 35 Appendix C: Representative Vendor Information 36 Appendix D: Additional Information Sources 37 Endnotes 26548proof 11/26/02 8:29 AM Page 5 Executive Summary FOR THE PAST 20 YEARS, HIGHLY PUBLICIZED telemedicine programs used video teleconferencing equipment to address the problems of distance and resource scarcity asso- ciated with rural areas. These grant-funded programs flour- ished during the demonstration period but then struggled after the initial funding ran out. Today, innovations in technology, connectivity, and financing are lowering the barriers for imple- menting technology solutions that improve care delivery in rural communities. With the growing usage of PCs and the Internet by providers and patients, programs are increasingly being developed to support remote diagnosis, care delivery, and communication, as well as provider education. These technology tools are faster, smaller, and cheaper, with more effective connectivity options, than earlier products. At the same time, the financial and organizational challenges of deploying and maintaining technology-based programs in rural health care are becoming more manageable. Advocacy groups, private companies, and federal, state, and local govern- ment programs have provided funding support for new tech- nology programs. Tertiary care centers and other care delivery organizations have created a range of technology offerings that help improve information access, communications, and care services to rural areas. And Medicare and other payers are beginning to recognize the benefits from offering remote tech- nology services and are easing some restrictions on reimburse- ment for professional services by specialists. The solutions being applied in rural health settings today range from basic to advanced. I The Internet and email allow providers to communicate with patients and consult with other providers. I Web portals organize and provide access to general medical and patient-specific information from remote locations. I Scanners and digital imaging technology capture and send images, EKGs, and other materials to remote locations for interpretation. Rural Health Care Delivery: Connecting Communities Through Technology | 5 26548proof 11/26/02 8:29 AM Page 6 I Video teleconferencing, also known as “telemedicine,” utilizes smaller, less expensive systems that can be more readily deployed in hospitals, practices, and patient homes. I Remote patient-monitoring systems supported by regional tertiary care center professionals allow rural hospitals to keep intensive care (ICU) and cardiac services open. As this report illustrates, the common denomin- ator among successful rural technology programs is collaboration among institutional players and individual providers. New possibilities for collab- orative models involve a wide variety of entities— including rural health associations, vendors, government agencies, federal and state associa- tions, advocacy groups, hospitals, and existing telemedicine programs. Implementing successful technology solutions, nevertheless, is not easy. It requires creative use of grant funding, integration with work flow, and effective selection of sup- portive technologies. 6 | CALIFORNIA HEALTHCARE FOUNDATION 26548proof 11/26/02 8:29 AM Page 7 I. Purpose “Americans who live in the Problems of Scarcity and Distance suburbs fare significantly better Challenges facing rural health care include scarcity of local in many key health measures medical resources and distance between patients, physicians, and facilities. Many rural areas have insufficient numbers than those who live in the of primary care practitioners, including physicians, physician most rural and the most urban assistants, and nurse practitioners, while all rural areas have areas.” problems with access to specialty care. — Tommy Thompson, For patients, the need to travel away from home and from HHS Secretary, CDC local providers for medical care results in a range of difficulties: Media Relations press release, time away from work; additional expenses; and the compli- 9/10/01. cations of coordinating care in different locales. The likelihood that information will be missing or incomplete is greater and this may cause delayed or fragmented care. Rural physicians and other care providers are likewise impacted by the problems of scarcity and distance, resulting in limitations on productivity, communications, and ongoing education. Rural providers have much more difficulty commu- nicating with other providers and specialists. They have few opportunities for conferences and training without travel; and limited access to medical knowledge and research work. These factors result in much lower efficiency: more travel time to visit patients in hospitals and nursing homes, fewer face- to-face patient visits, and more time on the telephone with other providers and with patients. Rural Health Care Delivery: Connecting Communities Through Technology | 7 26548proof 11/26/02 8:29 AM Page 8 A New Range of Technologies Organization of This Report Technology solutions for rural health care have The purpose of this report is to provide an been discussed for decades, and early experiments overview of practical technology solutions for with video teleconferencing (telemedicine), rural providers and to help them get started. while demonstrating some real benefits, were In each chapter the discussion begins with the economically unsustainable after initial grant simpler options and moves to the more complex funding ran out. Problems included high costs and/or costly. The information was gathered for infrastructure and software, immature from many sources, including the published liter- technology, lack of reimbursement, and a focus ature, Web sites, and interviews with rural health on technology itself rather than on the health agencies, telemedicine associations and programs, and business problems. health care networks, payers, hospitals, physi- cians, and technology vendors. However, the situation today is different. Wide use of the Internet has spurred the diffusion of The second chapter provides a grounding in the end-user devices and connectivity to most possibilities for technology and connectivity and offices and many homes. A wide choice of tools describes how to determine the equipment and provides better performance and lower costs, connection requirements for a specific technology offering improved access to medical and patient solution. Technology challenges such as broad- information and effective substitutes for face-to- band infrastructure connectivity and integration face visits. These technologies support improved of devices and software are also reviewed. health outcomes, workload and communication The heart of the report is Chapter 3, which efficiencies, and satisfaction with the care exper- uses case examples to explore the wide range of ience for providers and patients. technology solutions found in practice today. Funding for the higher-end investments still These are categorized by their supporting tech- comes mainly from grants. However, new busi- nology (email, Web site, portal, etc.). Chapter 4 ness models and collaborative agreements with introduces a spectrum of successful business different associations, other medical centers, models used in programs for rural providers and vendors, and government entities have created hospitals. Current financial, regulatory, and a range of opportunities for providers who want operational challenges are discussed, as well as to use technology to connect to patients, clinical lessons learned from other organizations. information, and other providers. In addition, Many public and private resources are now changes in reimbursement (federal, state, and available to those desiring further information. other payers) for technology-supported care The appendices provide a guide to those identi- delivery will help to make programs financially fied through this research, listing associations viable over time. (Appendix A), interviewees (Appendix B), repre- sentative vendors (Appendix C), and additional sources of information (Appendix D). This compilation of information about the latest technologies and real life experiences in the field is intended to help rural providers and organiza- tions move ahead efficiently to achieve solutions to their own particular challenges. 8 | CALIFORNIA HEALTHCARE FOUNDATION 26548proof 11/26/02 8:29 AM Page 9 II. Understanding the Technology Researchers are working to Technological Developments make equipment that will fit Practical technology options for rural health care are improving in a small suitcase and include due to: (1) improvements in tools, (2) greater impact of the Internet, and (3) improvements in connectivity. a computer, keyboard, and attached medical instruments Improvements in Tools for use in medically underserved Tools are becoming more powerful, smaller, and less expensive. Work stations that cost $5,000 five years ago are now less communities. than $1,000, as well as many times more powerful and much smaller. Advanced video teleconferencing workstations that filled a room and cost $80,000 per unit several years back now have a price tag around $40,000 and are becoming small enough to be truly portable. A base unit that includes a work- station with a camera costs about $10,000. Taking advantage of these improvements, researchers at the University of Texas at El Paso have formed a partnership with NASA to adopt video teleconferencing equipment currently used on space missions for use in medically underserved communities. Researchers are working to make the equipment smaller and more efficient so it can be transported to com- munities where few residents visit physicians. The $35,000 solution, which will fit in a small metal suitcase, includes a computer, keyboard, and attached medical instruments to monitor vital signs and diagnose health problems.1 Greater Impact of the Internet Personal computer (PC) workstations with Internet access are now basic infrastructure for physician offices, hospitals, and even patients’ homes, leading to the adoption of a variety of Internet-based applications such as email and Web portals for communicating and information-sharing among physicians and between patients and physicians. Rural Health Care Delivery: Connecting Communities Through Technology | 9 26548proof 11/26/02 8:29 AM Page 10 Technology Equipment Federal Support for Rural Connectivity Equipment and devices can be categorized The U.S. Senate approved an appropriations bill in November 2001 that was signed by into four groups of solutions—listed below from President Bush in December to provide over simple to complex—for rural health care $100 million in loans to increase the penetra- applications. tion of broadband and dial-up Internet access in rural areas. Included is some $80 million in PC Workstation with Remote direct loans for the establishment of high- Connectivity Using the Internet speed Internet access as well as $22.5 million For rural health care providers and patients, the to be dispensed through an ongoing telemed- icine and distance learning pilot program. most common applications supported by this technology are: Source: iHealthBeat, 11/16/01, 12/3/01. I Secure email communications—patient to provider and provider to provider; and I Web portal applications that give access Improvements in Connectivity to medical and patient information and The physical connection infrastructure is becom- provide educational services (see Case in ing more widespread and offers a variety of Point 2). options. Services range from low-capacity dial-up arrangements to increased penetration of broad- Image Capture and Transmission band services that include DSL, cable, ISDN, Image capture and transmission (also known and even satellite technology—many funded by as “store-and-forward” technology) are done grants and government loans. through direct interfacing with digital imaging Following is an overview of technology equip- equipment or use of scanners that digitize images ment and connectivity options. (For more and documents. Rural providers use this for: detailed information, see the resource listings in I Remote image interpretation by radiology, the appendices.) pathology, and cardiology specialists located in tertiary care centers (see Case in Point 3); I Medication order review by offsite or on-call pharmacists (see Case in Point 4); I Scanned patient information (scanned photos, copied pages from the paper record) needed for provider-to-provider electronic consults. 10 | CALIFORNIA HEALTHCARE FOUNDATION 26548proof 11/26/02 8:29 AM Page 11 Video Teleconferencing care facilities for cardiac and ICU patients located These solutions support the capture, transmis- in rural hospitals (see Case in Point 7). sion, and receipt of real-time video encounters. They are mostly used to replicate face-to-face Levels of Connectivity encounters (see Case in Point 5). Common applications include: Connectivity refers to the physical connection between two sites that allows data, images, and I Specialist consults for dermatology, text to be sent electronically, using shared or psychiatry, cardiology, and other specialties; dedicated connections. The spectrum of the most I Home health “virtual” visits between common connectivity options, moving from patient and care provider; low-speed to high-speed transmission, includes I Professional ongoing training and phone lines, Integrated Services Digital Network educational courses; and (ISDN), Digital Subscriber Line (DSL), and T1 (see Table 1). I Remote interactive administrative meetings. In addition to the options described below, Remote Real-Time Patient Monitoring wireless and satellite connectivity technologies This technology enables video conferencing with are starting to be used with limited, specific the remote site and viewing additional patient application to rural care delivery. The satellite- information stored in the site’s clinical informa- based telemedicine network in South Carolina, tion system. In the rural setting, this is often used for example, supports remote eye screening.2 for remote monitoring by specialists at tertiary Table 1. Connectivity Options in Order of Increasing Data Transmission Speeds Options Description POTS Plain Old Telephone Service. The worldwide voice telephone service. Once only analog, now mostly digital, except for lines from home and office to the central office. Transmission speeds range from 28.8 to 56 kilobits per second (kbps). ISDN Integrated Services Digital Network. Provides a digital service from the customer’s premises to the dial-up telephone network. It turns one existing wire pair into two channels and four wire pairs into 23 channels for the delivery of voice, data, images, or video. ISDN’s basic service is called Basic Rate Interface (BRI), which can support transport up to 128 kbps. The high-speed service is called Primary Rate Interface (PRI) and bonds six channels together for quality video teleconferencing at 384 kbps. DSL Digital Subscriber Line. Dramatically increases the digital capability of ordinary telephone lines into home or office. DSL speeds are tied to the distance between the customer and the telecommunications central office. There are two types: Asymmetric DSL is for Internet access where fast downstream is required, but slow upstream is acceptable; Symmetric DSL is designed for short-distance connections that require high speed in both directions. Unlike ISDN, which travels through a switched telephone network, DSL is always on. The speeds range from 144 kbps over a distance of 16,000 feet to 6.4 Mbps (megabits per second) over 1,000 feet. T1 A 1.544 Mbps point-to-point dedicated digital circuit provided by the telephone companies. The monthly cost is typically based on distance. T1 lines are widely used for private networks as well as interconnections between an organization’s local area network (LAN) and the telephone company. Similarly, T2 lines offer a total speed of 6.312 Mbps; T3 lines offer a speed of 44.735 Mbps. Source: Tech Web (www.techweb.com). Rural Health Care Delivery: Connecting Communities Through Technology | 11 26548proof 11/26/02 8:29 AM Page 12 Selecting the Right Equipment It is important to note that the Internet is not and Connectivity Option equally effective for all health care purposes. Different connectivity options support specific It is most useful for low-end applications such as ranges of data transmission (measured in kilobits email and Web portals. Using the Internet along per second, or kbps), which in turn must be with virtual private network (VPN) technology matched to the performance requirements and for security has worked very well for applications transmission loads of the desired solution. that send patient data between two locations. For instance, applications like email that send These can include remote interpretation of and receive small amounts of data can operate radiology images and secure email consults. with acceptable response time using low-speed Furthermore, this solution is typically much less connections such as phone lines. Sending images expensive than dedicated lines. or large amounts of data or conducting live video However, video teleconferencing and other encounters requires much higher transmission high-speed transmission services currently are not speeds to be usable in care delivery. A critical well supported by the Internet. Frequent trans- demarcation for the connectivity options is the mission problems with speed consistency and 384 kbps threshold—the minimum requirement quality of service occur when information for quality video teleconferencing. Because crosses multiple Internet service providers (ISPs). higher-speed connections are not always available However, many experts believe that the Internet in rural areas, an early part of program planning will continue to evolve to meet the needs of should be gaining an understanding of what these applications and to become the network of options are actually available in the area. choice. Two current research projects—Internet2 Figure 1 maps the minimum equipment and and Next Generation Internet—are focused connectivity requirements for each rural health on upgrading the Internet’s performance and care technology solution charted on this matrix. security with new and refined protocols.3 The intent of this figure is to provide a starting point for understanding the connectivity and equipment requirements for a given technology solution. Picking a technology solution on the grid and then scanning down and across on the corresponding X and Y axes will identify the hardware and connectivity requirements for that solution. For instance, email for patient communication requires low-speed connectivity (POTS, or phone line), as depicted on the X axis, and a workstation with Internet or other remote access capability, as listed on the Y axis. The case examples in Chapter 3 demonstrate why these represent the minimum requirements and provide details about specific implementations. 12 | CALIFORNIA HEALTHCARE FOUNDATION 26548proof 11/26/02 8:29 AM Page 13 Figure 1. Rural Health Care Technology Functions Mapped to Hardware and Connectivity Requirements Hardware/Access Requirements Functionality Remote patient monitoring, video Remote teleconferencing and monitoring Complex computer access services Video teleconfer- Specialty consults and direct encing with data care visits collection Video teleconfer- RH, RHome care virtual visits encing Educational conferences Image capture Remote imaging interpretation solutions with services remote access Workstation with Remote access: Email: Store- Email: Store-and-forward: Internet access plus home care data and-forward: high resolution data collection collection low resolution devices Workstation with Email: Patient Remote access: Simple Internet or other communication Clinical application access remote access Internet: Health information Connectivity Requirements POTS ISDN DSL T1 T3 Low Speed High Speed Technology Challenges Integration of devices and software is a problem Two big technology issues for rural health care with the more advanced technologies such as are the availability of broadband infrastructure video teleconferencing. The lack of connectivity connectivity and the lack of technology inte- standards for devices and the incompatibility gration. Some progress has been made with the of devices with different server operating systems infrastructure issue in the past year. Private can make these implementations cumbersome companies are broadening their service options and ultimately not usable for caregivers. Trade into rural areas, and government programs now organizations are working toward standards that offer funding and low-cost loans to spur further will minimize these issues. However, the results development. However, these efforts are not will take time to appear in practice. For the time coordinated and the lack of a central focus on being, organizations will be responsible for instal- the connectivity issue leaves no clear path today lation and testing of new data collection devices to widespread success across rural areas. It will be (e.g., camera, scanner, medical equipment) and several years before some remote rural areas will the associated software to ensure adequate hard- have connectivity options beyond phone lines. ware resources, compatibility of the software, and acceptable response time. Rural Health Care Delivery: Connecting Communities Through Technology | 13 26548proof 11/26/02 8:29 AM Page 14 III. Case Examples of Technology Solutions THE EXTENSIVE LITERATURE SEARCH AND INTER- views conducted for this project revealed broad activity in the area of rural health-care-related technology. This chapter presents the range of solutions from the most basic to the most complex, in terms of technology and connectivity, as shown in Table 2 (see next page). Email-Based Applications Email-based solutions securely link patients and providers for purposes of communicating and accessing information (text, data, images, and video clips). They require a PC workstation, Internet access, and a low-speed connectivity option. Email supports both patient-to-physician and physician-to- physician communications. For physician and patient email communications, physicians can use secure messaging offered by a number of commercial vendors. Some medical societies also offer secure email as a value-added service for membership. These solutions supply the communication infrastructure for patients to ask health-related questions, request appointments and prescription renewals, and obtain referral authorization using email instead of phone communications or coming into the office. Rural care providers can use secure email to collaborate with specialists. They can also attach patient-specific data to the message as a preliminary screening for a possible referral, to ask questions about a specific disease, or to provide referral paper- work for a specialist consult. Typically, electronic consults include structured forms for the specialist to document the clinical analysis and recommended plan for care, and then send back to the referring primary care physician. 14 | CALIFORNIA HEALTHCARE FOUNDATION 26548proof 11/26/02 8:29 AM Page 15 Table 2. Technology Solutions and Requirements Application Technology Requirements: Basic to Complex Email for communications and consults Internet-accessible PC workstation; low-speed connectivity Web portals for medical information, patient data access, and education Image capture applications for remote consults and Internet-accessible PC workstation/server—interfaced interpretations to image capture technology; low- to medium-speed connectivity Real-time remote video consults Video teleconferencing stations; high-speed connectivity Remote patient monitoring Remote patient monitoring stations, including live video capabilities; high-speed connectivity These solutions overcome the problem of Percent of Physicians Who Use Email geographic distances and allow for more effective to Communicate with: patient-physician communications through the Professional colleagues 55% use of structured templates for requests, referrals, Support staff 34% consults, and questions. Given the busy schedules Patients 13% of most physicians, one of the biggest benefits Health plans 9% of email is the ability of providers to respond at their own convenience, avoiding constant inter- Source: “Physicians expand use of Web, email” in Internet Health Care, April 2002. ruptions to answer phone calls, find faxes, and sort through paper mail. Finally, clinical email messaging systems can pro- vide a record of the information exchange, which Case in Point 1 can potentially reduce liability. Email-based ACCESS TO SPECIALISTS applications are increasingly being adopted as a THROUGH CLINICAL MESSAGING means to enhance communication and provide A primary care physician in Watsonville, California, better service. (For detailed information about uses a clinical messaging system for physician- patient-physician email, see E-encounters, pub- to-physician email, patient-to-physician email, labor- lished by the California HealthCare Foundation.) atory test results, x-ray data, consultations, referrals, and authorizations. The biggest benefit that the system has provided is access to specialists. There are no rheumatologists in Watsonville, for example, so the physician’s practice has developed a relation- ship with rheumatology specialists in Santa Cruz. Source: Personal communication with Dr. Robert Webber, Family Doctors, Watsonville, CA, April 2002. Rural Health Care Delivery: Connecting Communities Through Technology | 15 26548proof 11/26/02 8:29 AM Page 16 Web Portal Applications Medical Education and Training Applications based on Web portals connect Using the Internet to provide professional con- rural providers and patients with patient-specific ferences and training sessions for continuing data, medical information, and remote educa- medical education has started to take hold. tional opportunities. They require only a PC These eliminate the need for rural physicians and workstation with Internet access and low-speed allied health care professionals to travel long connectivity. These portals offer a broad range distances for training and education. Most Web- of applications and are typically sponsored based programs are still heavily weighted toward by hospitals, academic medical centers, library text versions of journal articles, with only 20 service providers, and training centers. percent providing interactive learning, leveraging videos, audio, and immediate feedback. How- Patient Access to Medical Information ever, although only 4 percent of CME credits are Of patients already on the Internet, 45 percent earned via Internet connections with programs, rate retrieval of health-related information for significant growth can be anticipated with themselves and family members as a top activity.4 increased deployment of higher-speed connect- Given the huge amount of information available ivity options.7 on the Internet and the challenge of differentiat- ing what is reliable, some hospitals and physician Access to Patient Information practices offer focused information from vetted For rural providers who need to review their sources as a service to their patients and the patients’ hospital or specialist information, community. Visitors to the Web site can learn the problem of access to paper records can be about specific medical conditions and see aggravated by distance and transportation costs detailed information about the organization’s for records. One solution is a centralized Web- resources for the given condition. In one exam- based health record to which both the hospital ple, Sharpe Medical Center’s eSharpe site had and patients contribute information that can nearly 3 million visits in 2000, which resulted in be accessed by physicians (see Case in Point 2). 75,000 physician referral transactions.5 Provider Access to Medical Information Physicians can locate and print out medical information to answer practice-related clinical questions using library service functions, Web sites (e.g., Medline, Intelihealth), and a number of commercial vendors (e.g., UpToDate, Cline- Guide). However, the key to successful use of these medical services is to integrate health refer- ence links with the provider’s other applications such as prescription writing tools, electronic medical records, or email communication vehicles. One study reported that there was “limited use” of stand-alone access to full-text journals, text- books, and decision-support tools made available through a Web portal.6 16 | CALIFORNIA HEALTHCARE FOUNDATION 26548proof 11/26/02 8:29 AM Page 17 Case in Point 2 Image Capture and Interpretation Applications WEB-BASED SYSTEM COVERS WIDE DISTANCES IN MAINE Providing access to remote specialist services is The results of a study done in 2000 to understand one of the most successful uses of technology to spiraling health care costs showed that many support rural health delivery. With up to 90 per- citizens of Maine are unable to access needed cent of specialty physicians practicing in urban health care services and information. areas, diagnostic specialists such as radiologists, In response to the study, Eastern Maine Health- pathologists and cardiologists are in short supply care (EMH) created a Web-based solution called in rural areas.8 This shortage is particularly diffi- MyOnlineHealth that allows participating Maine cult for radiologists, who must rotate through residents to engage in secure communication with on-call times for after-hours coverage for the their health care providers, take risk assessments emergency department and emergency surgeries. and receive feedback, and use the personal health record. EMH, which covers two-thirds of the state Fortunately, many academic medical centers geographically but only one-third of the population, and independent radiology practices in urban has many patients who are more than 30 miles areas have extra capacity for reading images. away from their provider. Technology can play an important role in con- Patients can use the system to communicate with necting the demand to the supply with several their physicians, request an appointment, view business models. Using digital diagnostic equip- laboratory test results, or obtain a prescription refill. In addition, they can complete online health risk ment or digitized scanned images, diagnostic assessments and receive feedback both on healthy specialists can read images from multiple sites behaviors and areas for attention. The risk assess- and send back interpretations electronically in a ments link to health content; in addition, physicians matter of hours. can push health information tailored to the particular patient’s needs. One example is the Cleveland Clinic’s e-Radio- logy Service Department established within The primary benefits for patients include: the Division of Radiology. To connect with • Better access to health information; Cleveland, a physician group or hospital needs • Avoiding appointments and the hassle of travel; only an acquisition device such as a CT scanner, • Avoiding the anxiety of waiting for test results; x-ray, or MRI. The e-Radiology Service provides and all other equipment and infrastructure. Besides • Keeping their health information from multiple supplying off-hours radiology coverage, services sources (primary care physician, hospital, den- like this can provide subspecialty expertise that tist, herbalist, etc.) in one place. rural hospitals can’t attract.9 Source: Personal communication with Mike Peterson, E-Business Director, Eastern Maine Healthcare, April 2002. Rural Health Care Delivery: Connecting Communities Through Technology | 17 26548proof 11/26/02 8:29 AM Page 18 In another example, University of Iowa Hospitals Case in Point 4 is trying to assist the many Iowa communities PHARMACY SERVICES AROUND THE CLOCK whose radiologists are retiring or leaving the area. In 2001, some 6,000 of the 170,000 diagnostic Sacred Heart Medical Center in Spokane, Washing- ton, has built a technology infrastructure of standard radiology services performed were teleradiology computer applications and many programs support- services sent from six small community hospitals ing a network of about two dozen hospitals serving around Iowa.10 The university also has a pediatric the small farming communities east of the Cascade echocardiogram network that supports rural Mountains. Using this foundation, Sacred Heart has areas. Findings from a research study of the effort developed a program to provide remote pharmacist indicated that diagnostic quality of interpreta- coverage to these hospitals to support 24-hour review of medication orders to identify potential tions was excellent and the speed to diagnosis contraindications, improper dosing, and duplications. was enhanced.11 Although the process started by using a standard Besides connecting to a regional tertiary hospital, fax, Sacred Heart will soon use an image scanning another avenue for obtaining radiologist services product to capture the handwritten order electroni- is to connect to an independent radiology cally. Nurses at the rural hospitals transmit a copy of practice, which could be located anywhere in the handwritten order to the remote pharmacist at the world. The case example below describes a Sacred Heart. The pharmacist compares the order image with the electronic order entered by the unique benefit due to the significant time differ- nurse or pharmacy technician to identify possible ence between Australia and the United States. issues. As in any pharmacy department, policy Besides using this technology for radiology and and standard procedures govern the pharmacist’s response when a problem is identified. Sometimes pathology services, rural hospitals are also turning it is appropriate to telephone the physician or nurse; to imaging to maintain 24-hour coverage of in other cases the pharmacist modifies the electronic pharmacy services (see Case in Point 4). order, sending a handwritten order sheet back for inclusion in the patient’s medical record. Telecon- Case in Point 3 ferencing via cameras at the top of each workstation can also support conversations between pharma- REMOTE RADIOLOGY READING cists and nurses at the rural hospitals. EXPLOITS 12-HOUR TIME DIFFERENCE Source: Personal communication with Dr. Larry Bettesworth, NightHawk Radiology Services in Sydney, Australia, Sacred Heart Medical Center, Spokane, WA, July 2002. provides night coverage for rural hospitals and physician practices in the United States. Images, compressed by an application at the rural site where the images are obtained, are sent to Sydney using virtual private networks (VPNs) supported by the Internet. If the radiology equipment at the rural site is not digital, the images are digitized on a scanner first. Within 30 minutes of receipt of the complete exam, the preliminary report is sent back to the originating hospital or practice. For significant posi- tive findings, the service has a policy of providing a verbal report to the ordering physician in addition to the written report. Source: Personal communication with John Berger, Vice President, NightHawk Radiology Services, Coeur d’Alene, ID, March 2002. 18 | CALIFORNIA HEALTHCARE FOUNDATION 26548proof 11/26/02 8:29 AM Page 19 Real-Time Remote Video Consults Robotically controlled microscopes allow Video teleconferencing for specialist consults pathologists to render diagnoses with (telemedicine) is the most commonly known use the same accuracy they would if they were of technology to support rural health delivery. For these visits—both initial consults and follow- actually on site. up visits—the patient and specialist communicate in real time using interactive video equipment; The major benefactor for electronic consults is they can also use diagnostic equipment such the patient, who does not have to travel to get as stethoscopes, blood pressure monitors, digital specialist care. Numerous studies have quantified cameras, and dermascopes. The patient is typi- the time and money savings from these visits cally seen with a clinical assistant who controls and have also concluded that the technology does the equipment and assists with patient care. not artificially increase the number of consults— In some situations, the primary care physician a major concern of some payers.16 also participates. Telemedicine consults have direct benefits for Telemedicine consults are most common for der- local providers, too. For some specialties and matology, mental health, cardiology, emergency medical conditions, these consults, when attended triage, and orthopedics.12 For example, the Blue by the rural primary care physician, provide Cross of California Telemedicine Program reports “on the job” education and training that decrease that 40 percent of their consults are in derma- the need for future consults.17 A University of tology.13 The University of Missouri-Columbia Washington study showed that local providers School of Medicine’s telemedicine program were able to treat 72 percent of the patients reported that the top three patient encounter themselves after the telemedicine consult. These specialties during 1995-1999 were psychiatry, der- providers indicated that at least 47 percent of the matology, and cardiology. Together these made patients would have been referred to non-local up almost 90 percent of all encounters, with psy- consults if the technology solution had not been chiatry contributing more than 50 percent.14 in place.18 Electronic psychiatric and mental health consults Although there is a lot of attention given to tele- have proven to be a particularly effective solution medicine in the press, studies have shown that in rural areas, where the shortage of behavioral growth in telemedicine programs has recently health specialists is severe. Many patients like slowed. In fact, growth did occur from 1999 to this type of care because the program maintains 2000 but cooled off in 2001, with fewer consults patient confidentiality in small towns. Interest- and fewer patients seen. Reasons cited for the ingly, a professional at one site noticed that chil- slowdown include reimbursement and opera- dren appear to be more honest with behavioral tional issues that are discussed in Chapter 4.19 health professionals using video teleconferencing services than in face-to-face visits.15 Rural Health Care Delivery: Connecting Communities Through Technology | 19 26548proof 11/26/02 8:29 AM Page 20 Case in Point 5 Remote Patient Monitoring REMOTE DIAGNOSTIC SERVICES AND Intensive care services in rural hospitals are at risk REAL-TIME SPECIALIST VISITS of being closed down when qualified specialists The Department of Veterans Affairs (VA) Medical (physicians and/or technicians) are not available Center in Iron Mountain, Michigan, has combined for 24-hour patient care monitoring and services. remote diagnostic services with real-time remote For some rural hospitals, this can represent specialist visits. With the retirement of local pathol- the difference between staying in business and ogists, there was a critical shortage of expertise closing the doors. for Michigan’s Upper Peninsula and northeastern Wisconsin. Supported by the VA’s wide area net- Technology can connect the monitoring equip- work (WAN), patients at the Iron Mountain facility ment from the rural hospital to remote specialists can be examined in real time by medical experts who can provide the continuous monitoring located in the Milwaukee or Chicago clinics. “Robotically controlled microscopes allow patholo- needed. Telecommunications options such as gists to render diagnoses with the same accuracy dedicated telephone lines and pagers allow nurses they would if they were actually onsite.” X-rays, to be alerted to problems within seconds of CT, fluoroscopy, and ultrasound images can also a monitor alarm sounding. When a physician be sent over the network, enabling specialists to is involved in the remote monitoring, video capture images and consult in real time. teleconferencing may also be used to support The key to making the system work well is provid- communication between the intensivist and the ing sufficient connectivity bandwidth. In addition to caregivers in the local ICU. the equipment and infrastructure at their own facili- ty, the medical center also supports several satellite The two case examples that follow demonstrate clinics in even more rural areas. Originally funded how remote monitoring technology can support through a grant, the system is maintained by sharing a sustainable business relationship in which both the costs for major capital expenditures on equip- parties benefit from the collaboration. ment and infrastructure with other facilities in the service network. Early concerns about patients not wanting to use the technology did not materialize. Patients adapted to the new technology with ease—they save driving time of at least four to five hours, receive high- quality care more quickly, and are able to have their family members with them. Sources: Customer Profile: Providing Real-Time Virtual Medicine, U.S. Veteran’s Administration, May 2001; personal communication with Dr. Joseph Larschen, Chief of Clinical Support Services, Iron Mountain VA Medical Center, Iron Mountain, MI, April 2002. 20 | CALIFORNIA HEALTHCARE FOUNDATION 26548proof 11/26/02 8:29 AM Page 21 Case in Point 6 At each care location, a nurse connects the patient to a portable monitor that is slightly bigger than a COLLABORATION ENABLES REMOTE deck of cards and gets patient information and the TELEMETRY AT SMALL HOSPITAL monitor number. Technicians continually monitor For Allen Memorial Hospital in Moab, Utah, the lack telemetry information and communicate with local of skilled technicians to support patient monitoring sites through alphanumeric pagers and with remote resulted in a majority of cardiac patients being trans- sites through telephone systems. If there is a prob- ferred to other facilities. This caused hardship for lem with the signal, for example, they page/call the the patients, who had to travel at least 100 miles to patient care technician to fix the lead on the moni- the closest tertiary hospital, as well as for the tor. If there is an unusual—but not life-threatening— 38-bed hospital, which was losing patient revenue. signal, the technicians page or phone the nurse. When the system identifies a potentially lethal A solution was to collaborate with St. Mark Hospital arrhythmia, technicians review the data to decide in Salt Lake City. Monitoring equipment in the ICU if it is a real problem. If so, they page nurses on a transmits data to a centralized telemetry center dedicated pager so they can immediately assess the at St. Mark, where technicians watch the data patient’s condition. Throughout the entire process, streams, validate alerts, and contact Allen Memorial data are continuously documented and can be print- ICU nurses immediately via pager or phone. The ed immediately for physician review. Physicians can transmission of real-time continuous data enables access the system online from the office or home physicians and technicians at St. Mark to provide using a clinical browser application. 24-hour, seven-day surveillance. In addition to the positive effects that the centralized Source: Davis, C. “Heart Link: Real-Time Telemedicine Helps Keep Small Utah Community Hospital Open,” Healthcare telemetry system has had on cardiac monitoring, Informatics, February 1999. physicians are beginning to realize that they can benefit from increased access to data. With the clinical browser application, physicians can get diag- nostic information by accessing the system online from the office, home, or while traveling. Case in Point 7 Source: Personal communication with Andrea Ernst, LOCAL AND REMOTE CARDIAC Manager of Marketing, and Beth Lee, Director of Patient Care MONITORING Services, Cardiovascular Surgery, Mid America Heart Institute of Saint Luke’s Hospital, St. Luke’s–Shawnee Mission Health Mid America Heart Institute of Saint Luke’s Hospital System, April 2000. of Kansas City is part of the Saint Luke–Shawnee Mission Health System. A dedicated staff of techni- cians supports both local monitoring at Mid America Heart Institute and remote monitoring for the sys- At each location, a nurse connects the tem’s rural facilities. Before installing the centralized monitoring program, technicians located on the units patient to a portable monitor that is conducted a variety of patient care and administra- slightly bigger than a deck of cards. tive duties such as greeting patient families and looking up information for other staff—tasks that could be performed by other employees. With a centralized monitoring program for remote hospitals now in place, technicians have more focus to their work, have each other for consultation, and see a broader mix of cases. The remote facilities also reap the benefit of cost-effective coverage by experi- enced technicians. Rural Health Care Delivery: Connecting Communities Through Technology | 21 26548proof 11/26/02 8:29 AM Page 22 Connecting rural physicians with physicians in Supporting Rural Home Care tertiary medical centers has been equally success- Patient homes will become an important venue ful. For instance, UC Davis has IT links to for technology-supported services as technology Mercy Medical Center-Redding to provide advances, prices for equipment and connections 24-hour, seven-day pediatric intensivist services. drop, adoption of PC/Internet services increases, For specific questions about dosing and other and technology-friendly reimbursement schemes pediatric questions, Redding pediatricians become available. All these factors are making and adult intensivists can communicate using a strong business case for using technology to real-time audio and video with the university’s supplement face-to-face home visits. With a pediatric intensivists.20 growing aging population, home care is expected Similarly, Sentara Health System in Norfolk, to play an important role in care delivery. Using Virginia, has started a remote IT-supported technology to support home care could be par- intensivist program using computers and ticularly helpful for overstretched rural providers, telemonitoring equipment to support three who must travel in order to assess the patient’s hospitals; it is considering adding more hospitals condition as well as to collect data. For patients in rural Virginia. A study done before and after deemed appropriate, equipment is set up in the implementation showed a decline in the the home for one or both of the following types average length of stay for the ICU from 5.19 to of applications. 4.36 days and a similar decline in vascular ICU from 2.92 to 2.43 days. Overall, Sentara had a Data Collection positive per-case savings from the reduction in These applications can include medical devices stay and from fewer tests and supplies.21 such as a blood pressure cuff connected to a workstation. Patient measurements from the devices and other clinical data entered by the patient are sent to the provider using a modem Key Statistics on the Elderly over phone lines or other connection. These • People 65 and older account for nearly solutions work well for diabetes and pain man- 13 percent of the total population, but 69 percent of home health care patients. agement. • In rural areas, the elderly account for Video Teleconferencing 22.5 percent of the population. • The size of the elderly population will These solutions build on the data collection double in the next 30 years. application by adding video teleconferencing. Most often, virtual visits are scheduled—parti- cularly for visits using video-conferencing; but patients may also upload physiological data at various times, as well as access the system whenever they feel there is a problem. The patient data can connect the home, provider, and tertiary care center or home health agency. In all cases, the technology-supported services reduce but do not totally replace the need for face-to-face visits. 22 | CALIFORNIA HEALTHCARE FOUNDATION 26548proof 11/26/02 8:29 AM Page 23 These applications offer a number of benefits Case in Point 8 for providers, potentially impacting productivity LOW-TECH, LOW-COST HOME CARE and satisfaction. For example: Connectivity is an issue for home health providers I Care providers can increase the number of using technology for “virtual visits. The 2000 ” patients they see, since time spent traveling Census showed that rural households were less is reduced. likely to have Internet access than the rest of the country (32 percent of rural households compared I Costs are reduced, which is why home to 42 percent nationally). Additionally, according to health care agencies often pay for the census figures, 6 percent of households did not equipment and connectivity. have telephone service in 1999. An in-home moni- toring device made by HomMed LLC is sensitive to I Length of visits is reduced, increasing these realities and sends data over a telephone productivity. According to a study at Kaiser modem or by digital two-way pager. Permanente, the average tele-homecare visit The home tele-monitoring system measures a range was 60 percent shorter than a of vital signs, and then communicates this clinical traditional visit.22 data trended over time for review by medical per- sonnel. The system also collects subjective data— I Visits to the emergency room and hospital- how the patient feels, fatigue levels, etc. The moni- izations are reduced.23 tor and its peripheral devices can gather data for many different patient conditions, including conges- Benefits from an outcomes and patient tive heart failure, pulmonary disease, diabetes, and perspective include: other chronic conditions. If any of a patient’s vital signs falls outside of the parameters set by the I No need for patients to wait until the next physician, or if any of the patient’s answers to the scheduled visit. (Even if patients don’t need subjective questions indicate a problem, the moni- to call the home care nurse at 2 a.m., they toring nurse can immediately respond. The system like to know that they could.)24 is easy to use and promotes patient self-manage- ment, resulting in a 98.2 percent compliance rate. I More continuous monitoring capabilities Source: Personal communication with Herschel “Buzz” and more immediate response to changes Pedicord, President and CEO of HomeMed, LLC, April 2002. in patient condition. I Increased compliance with treatment and medication regimens.25 I Greater patient involvement in care and greater patient satisfaction.26 I Improved outcomes. (For example, an Illinois wound care telemedicine program generated a 100-percent healing rate for Stage II wounds, compared to 41 percent prior to the program.)27 Rural Health Care Delivery: Connecting Communities Through Technology | 23 26548proof 11/26/02 8:29 AM Page 24 IV. Practical Issues in Getting Started PROVIDERS AND PATIENT ADVOCACY GROUPS HAVE a growing interest in technology initiatives designed to meet rural health care needs. In addition to technology advances, there is now a better understanding of how to fashion sustain- able operational models. Reimbursement, a long-standing barrier, is improving—but there is still a long way to go. Health care organizations with technology programs in place are increasingly business-savvy and have found other uses for the technology to cover costs. Today’s models differ from those of the past 20 years in that they are based on practical, collabo- rative solutions that are designed to serve all parties’ interests over time. Collaboration Is a Necessity As many of the case examples in this report illustrate, collabo- ration is fundamental to the success of technology solutions in the rural health care sector. Programs underway around the country reflect every possible mix of participants, ranging from a simple partnership between a hospital and local physicians to regional or statewide efforts with an umbrella organization providing infrastructure and support. For those interested in exploring collaborative possibilities, partners can be found in a wide array of organizations: rural health associations, vendors, government agencies, federal and state associations, advocacy groups, hospitals, other health care organizations, funding groups, existing networks, and telemedicine programs. The starting place for building a partnership is to identify organizations with common interests and goals for solving a particular health delivery problem. These could be organi- zations in the region that could benefit from cost sharing; vendors who offer products and services that meet your organization’s requirement; or groups involved in statewide initiatives to deploy technology on a large scale. 24 | CALIFORNIA HEALTHCARE FOUNDATION 26548proof 11/26/02 8:29 AM Page 25 California has a number of programs that are The following case example shows how one already up and running. One of the most well community health network collaborates with known and one of the country’s largest is the multiple partners, including UC Davis, to solve Center for Health and Technology (CHT) a patient care issue unique to the Central Valley at UC Davis, started more than ten years ago. region. Initially 100-percent internally funded by UC Davis to extend the reach of medical research and Case in Point 9 education, the center has branched out to pro- CONTINUITY OF CARE FOR MIGRANT vide a variety of education, information access, WORKERS THROUGH COLLABORATION and medical care services, and is now supported Central Valley Health Network (CVHN) comprises 50 percent internally and 50 percent from 12 community health centers and 81 licensed external funding. Diversification has been the community clinics in California’s Sacramento and key to sustainability, as the center has learned to San Joaquin Valleys. Together they service 400,000 leverage different funding sources and a single patients, primarily migrant workers who travel throughout the area and are seen at multiple health technical support staff in support of the follow- centers and clinics. More than 1.5 million visits ing programs: are conducted by CVHN each year. I Distance education. Web-based training, To enable care continuity, CVHN implemented an streaming and interactive video for physi- electronic medical record application and infrastruc- cian and nursing continuing education and ture to store and access patient data as well as patient education. conduct telemedicine encounters from any site. A large initial investment was needed for the IT I Medical resources for physicians. Medical infrastructure, equipment, software, training, and informatics consulting, Web hosting, implementation. In addition, expertise was needed application development, access to medical for the infrastructure and site equipment as well as ongoing maintenance. To support the initiative, information, links to other Internet CVHN partnered with a number of organizations: resources. • The Bureau of Primary Health Care and the I Telemedicine. Critical care and outpatient Tides Foundation are the primary funding medical care for patients at more than 80 partners. sites, supporting 30 medical specialties. • Blue Cross of California is funding some connections to support its members in the I Telemedicine Learning Center. One region. of the few comprehensive telemedicine training programs, the center offers a • UC Davis Telemedicine program is the multidisciplinary hands-on approach to the connector for the sites. clinical, technical, and operational aspects Three sites are piloting the EMR application, which of technology-supported care services. To will be followed by a full rollout. The goals for the date, more than 500 people have attended system are to track and manage patient primary the program. care information and to improve health status. Source: Personal communication with Yvonne Bice, Executive Director of Central Valley Regional Health Network, March 2002. Rural Health Care Delivery: Connecting Communities Through Technology | 25 26548proof 11/26/02 8:29 AM Page 26 To build an effective collaborative model, the parties must address the health and technology Easing into Hi-Tech Solutions needs, as well as the human factors: roles and For one community network implementing responsibilities, relationships, communications, video teleconferencing for specialist consults, the key to success was to have a dedicated and ongoing support. For many organizations site coordinator who would look at each putting together a program, the biggest chal- referral request and determine if it could be lenges are around organizational issues, not done using technology or required a face- technology. In fact, nontechnology barriers such to-face visit. This practice eased the adoption as inadequate leadership, lack of buy-in, resist- of technology until it became routine for ance to change, and lack of technical expertise all practitioners. can be overwhelming. Source: Personal communication with Bridget Cole, Blue Cross of California Telemedicine Program, March 2002. Building Success “Successful programs need to have both the I Understand the benefits of implementing relationship infrastructure and the technology the solution for all parties—the rural knowledge. The former is a greater stumbling provider, the patient, and the specialist. block, since you can buy the latter.” Ask “How will technology improve the —Ellen Friedman, Tides Organization services we can already deliver or improve Source: Personal communication with Ellen Friedman, a relationship we already enjoy?”28 Vice President, Tides Foundation, April 2002. I Emphasize the delivery of care or connect- ing with patients and providers, not technology. Organizations are much Lessons learned from some of the pioneering more likely to be successful in technology organizations to overcome many of the nontech- implementation when there is a clear nology issues include: understanding of why and how the solution I Spend enough time in the early planning benefits the physicians, the patients, and phases to understand how the technology the organizations. will impact care practices. Mapping out the I Be prepared for technical difficulties and new processes and clearly identifying the delays. Typical issues cited: nonfunctioning roles and responsibilities for physicians, software, lack of skilled technical support nurses, and administrative staff will solidify staff, loss of a technology collaborative expectations and increase adoption once the partner, delays in getting new equipment, technology has been installed. problems with connectivity, and trouble integrating devices with the technology. It is useful to schedule time for some technology delays and work closely with technology providers to secure contracts that have firm due dates and include a substantial commit- ment to technical assistance during the projects’ early stages.29 26 | CALIFORNIA HEALTHCARE FOUNDATION 26548proof 11/26/02 8:29 AM Page 27 I Take small steps before big ones when Regulations introducing technology. Document success- Since the basic premise of providing health care es and failures to develop better strategies to rural locations begins with care delivery over for future projects.30 distances, there are many examples where the I Realize that training never stops. Typically, patient and the care provider are in different users are trained prior to the implementa- states. Although the technology can bridge this tion, with some on-site support during the gap, interstate care delivery has been the subject first week or two. Because help may be of longstanding debate concerning legal and miles away, training must be ongoing for reimbursement issues. The current requirements use of the application and for support of stipulate that physicians rendering care for the technology. This training may be in the patients in a state must be licensed in that state, form of classes or scheduled times when with a few exceptions, whether or not they trainers will come to the site. practice in that state. Several states have enacted legislation that allows out-of-state physicians to The lessons learned and best practices from receive a special-purpose license or certificate many grant-funded programs are a rich source of to perform telemedicine consultations without information for anyone considering rural tech- requiring a full license. (Refer to the Telemedicine nology solutions (see NLM Final Reports at Information Exchange Web site or individual www.nlm.nih.gov). state government sites for specific requirements.) Familiarity with a variety of practical consider- For hospital-based services such as radiology ations, including regulatory and financial issues, interpretations, the remote physician must also is important for organizations and individuals be credentialed at the remote hospital sending embarking on technology programs geared to the images for interpretation. The lack of univer- rural health care. They are briefly reviewed in the sal licensure in the United States adds adminis- following sections. trative overhead to the process of providing care across states. Other than state and federal regulatory require- ments, there are other external factors that affect technology-supported care. One example of this is the work of the Leapfrog Group, a consortium of private employers and other large public and private sector health care purchasers working to mobilize employer purchasing power to improve the safety and overall value of health care. One of the practices they are promoting is the presence of an intensivist physician to cover hospital ICUs every shift (www.leapfroggroup.org). They created guidelines (see box) that allow for the standard to be met using technology and remote providers. Rural Health Care Delivery: Connecting Communities Through Technology | 27 26548proof 11/26/02 8:29 AM Page 28 Funding and Reimbursement Leapfrog Group Requirements for Remote Monitoring Initial Funding • An intensivist who is physically present in Capital funding gets programs started and reim- the ICU performs a daily comprehensive bursement for services maintains them. Gener- review of each patient and establishes or revises a care plan. ally, both are required to make today’s business • models work. The availability of funding sources, A tele-intensivist is available whenever an on-site intensivist is not. changes in regulations for professional services • A tele-intensivist has immediate access to reimbursement, and other payment options have key patient data, including medications, opened the doors for many rural organizations bedside monitor data, and lab orders and and providers eager to use technology. results. Initial capital purchases can include the network • Data links between tele-intensivists and the infrastructure, computer equipment, software, ICU are reliable and secure. medical devices, and teleconferencing equipment. • Audiovisual support is clear enough for tele- Funding to cover or offset some of the cost intensivists to assess a patient’s breathing pattern and communicates with on-site is available from a number of sources: research personnel at bedside. projects, federal and state governments, trade • Written standards for remote care are associations, statewide initiatives, and private established, including credentials and certifi- funding groups. cation in critical-care medicine as well as explicit policies on roles and responsibilities. For rural practices and hospitals in California, • a good place to start is the California Telehealth Tele-ICU care is proactive, with routine review of all patients at a frequency appro- and Telemedicine Center (CTTC). Founded priate to the severity of illness. in 1997, its mission is to make California a • A tele-intensivist’s workload permits “state where location is not a barrier to receiving completion of a comprehensive patient the commonly accepted standard of care,” and assessment within five minutes of a request to that end it has funded programs across the for assistance. patient care continuum. Key activities for • A written process of communication is CTTC include: established between a tele-intensivist and an on-site care team. I Assist in the development of new technolo- • A tele-intensivist documents patient care gy (telehealth and telemedicine) projects; activities, and documentation is incorporat- I Educate health care providers and govern- ed in the medical record. ment officials; Source: C. Becker, ”Remote Control,” Modern Health- I Monitor legislation and public policy; care, February 25, 2002. I Expand funding for programs; I Serve as an information resource through their Web site; and I Disseminate information to local, state, and national media. 28 | CALIFORNIA HEALTHCARE FOUNDATION 26548proof 11/26/02 8:29 AM Page 29 CTTC funded five demonstration projects in I The Southern Governors’ Association is 1998, and, as the result of a grant from The calling for the creation of a 16-state California Endowment, has awarded $6 million telemedicine network that would serve as a for 91 demonstration projects in its current model for a national system. The proposal, grant cycle. Programs supported by these projects sent to the Health and Human Services include remote cardiac and fetal monitoring, (HHS) Secretary and the Homeland tele-ophthalmology screening for Indian health Security Director, calls for establishing stan- clinics, telemedicine dental consults, community dards for capturing medical data so all the health Web sites, video teleconferencing behav- participating organizations would have a ioral health consults, access to the Internet for common platform for sharing data.31 educational materials, and home care monitoring I Idaho State University’s Institute for Rural and remote care delivery. In partnership with the Health is awarding $1.7 million in grants to University of California, Davis Medical Center, fund technology projects aimed at improv- the CTTC has established the Telemedicine ing recruitment and retention of rural care Learning Center, which opened in 1999. providers.32 The Tides Foundation’s Community Clinics Ini- I Funding can be found for smaller projects. tiative is another California resource that funds For example, Virginia’s Bland County information technology and infrastructure. This Medical Clinic received $25,000 from program is focused on “bridging the cultural HHS’ Office for the Advancement of transition” to successfully integrate the use of Telehealth to establish a telemedicine information technology into clinic operations service connecting the clinic with the and to transform how they do business. University of Virginia Hospital in Funding for technology-supported health initia- Charlottesville. It is one of 16 telemedicine tives can come from a variety of sources. Listed facilities in southwest Virginia, all of which here are a few recent funding announcements: were supported by federal funds.33 I The National Library of Medicine Appendix A includes potential funding sources. announced in March 2002 that it is awarding $40 million for building health information networks over the next three years to improve the transfer of medical and patient information among hospitals, clinics, and physicians during a crisis (www.nlm.nih.gov). Rural Health Care Delivery: Connecting Communities Through Technology | 29 26548proof 11/26/02 8:29 AM Page 30 Ongoing Operational Support Help with connectivity fees. Typically the Funding the ongoing operation of technology biggest ongoing technology-related expense is to support rural health care has been more prob- line connections. To help with these costs, the lematic than funding the initial capital required. FCC earmarked $400 million annually to sup- Some programs, such as remote radiology read- port access for rural health care providers under ing and remote monitoring generate revenue the Telecommunication Acts of 1996. Under to cover costs. Technologies such as email com- these rules, eligible nonprofit and/or public rural munications or email consults require a small health care providers are able to purchase certain technology and communications investment. high-speed telecommunications services at rates These can be absorbed into the operating budg- comparable to similar services in the nearest ets for most practices. urban area of the state.34 One area that remains a financial challenge is fair But the program has not been well used. In the reimbursement for video teleconferencing for first 18 months, rural health providers received specialist services. A disincentive exists in today’s only $3.4 million in long-distance subsidies. reimbursement structure because the costs are Following some reforms, the next 12 months borne by the provider while the patients enjoy provided funding for $6.1 million and up to $10 the benefit of not traveling for the specialty con- million in the following year.35 Factors in the sult. To cover the ongoing costs there are several slow adoption include: options that can be used alone or in combina- I Connecting the high-speed telecommunica- tion. These include Medicare reimbursement for tion fiber network to the rural site—the professional services, Federal Communications “last mile”: There is little incentive for local Commission (FCC) program for connection telecommunications companies to invest in costs, and other uses of the technology to defray these connections since the lines will have costs. Only in a few instances have payers recog- low volume utilization, resulting in little nized that these services have differentiating value revenue. in the marketplace and are starting to pay for both the professional service and the technology. I There is a heavy burden of paperwork to apply for reimbursement and yearly reappli- Current provisions from Medicare, the largest cation is required. source of reimbursement for these services, eased some restrictions on geography and the need I There is a one-year delay in getting the for a physician to be present at the remote site. reimbursement. However, except for a $20 facility fee, Medicare’s I Service does not cover ISDN lines. reimbursement is for the specialist’s professional fee. It does not include ongoing costs for infra- I There is a lack of reimbursement for some structure connectivity, usage, equipment replace- care settings, such as nursing homes. ment, technical support, or ongoing training. 30 | CALIFORNIA HEALTHCARE FOUNDATION 26548proof 11/26/02 8:29 AM Page 31 The Northern Sierra Rural Health Network, a Case in Point 10 nonprofit organization serving rural health care CREATIVE, ENERGETIC FUNDING SAVVY providers in Northern California, has successfully used the program to fund the T1 connections The Eastern Montana Telemedicine Network (EMTN) has almost ten years of experience using between ten provider sites to support their video two-way video teleconferencing to bring medical teleconferencing/telemedicine services. Even services and medical education to patients and though the Network completes a large amount of physicians in rural Montana. Energetic funding and the paperwork on behalf of each provider reimbursement efforts support this premier site, the efforts are well rewarded since the reim- program, including: bursement covers over 80 percent of the cost of • Originally funded with grant monies, EMTN the telecommunications lines. Northern Sierra’s continues to take advantage of private and pub- reimbursement represents 90 percent of the lic funding opportunities to expand its network. funds disbursed to California sites for the past • Each of the facilities, including EMTN’s urban three years.36 hub, the Deaconess Billings Clinic, provides financial support in the form of personnel, Creative payment solutions. Organizations that transmission, and operational costs. have video teleconferencing equipment for • Each of the facilities promotes the program consults and care delivery encounters often use within the community. Some 94 percent of them also to provide educational services to care patients who received care over the network providers and to host administrative meetings were retained in their local community and between remote sites. This helps pay for the 96 percent of their providers indicated the ongoing costs of operation. For example, the patient would have been referred elsewhere Telemedicine Center at East Carolina University if the network had not been available. has conducted more than 10,000 distance learn- • EMTN saves providers money: Educational ing and CME activities since 1992.37 For the activities conducted over the network represent Midwest Rural Telemedicine Consortium, cost a savings of $530,082 annually in travel costs savings of avoided travel and time away from and lost wages. work associated with these “secondary services” • Administrative activities save participating keeps the telemedicine program up and running. members $182,342 each year. The percent of time the network is used for • EMTN leverages their technology and gener- patient care is small; the biggest uses are for edu- ates $22,487 in revenues from telebusiness. cational programs and administrative services.38 • Finally, EMTN has used its clout in the state to secure reimbursement for telemedicine activities from both public and private payers. Source: Eastern Montana Telemedicine Network Web site (www.emtn.org). Rural Health Care Delivery: Connecting Communities Through Technology | 31 26548proof 11/26/02 8:29 AM Page 32 Fortunately, some private insurers understand The program provides both live video specialty the benefits of providing access to specialty serv- encounters and store-and-forward encounters. The reimbursement scheme is aimed at being cost- ices that only video teleconferencing solutions neutral to the provider sites, using these guidelines: can bring to rural areas. They have started programs that fairly spread costs and benefits • Live video encounters mirror Medicaid reim- bursement, covering a primary care office visit among all constituents—patients, physicians, and a specialist consult visit; allied health professionals, and payers. Results • Store-and-forward coverage includes the pri- have been good. Today, California has one of the mary care office visit and a second opinion fee; 18 state Medicaid programs that reimburse for • In addition, Blue Cross allows the site that initi- telemedicine services. ates the call to file a claim for the time spent connected to the other site to cover the cost Case in Point 11 of the telecommunication line; BLUE CROSS OF CALIFORNIA NETWORK • Blue Cross also offers a discount program for LINKS MULTIPLE SITES the permanent line charge to help minimize With the help of six grants, Blue Cross of California the connection costs. has established a telemedicine network working Overall, Blue Cross believes the program is success- with clinics, practices, and providers. Blue Cross ful and sees it as a differentiator for the organiza- funded the purchase of equipment, computers, and tion. Here are a few key indicators of performance: infrastructure at these sites to create a network of 40 primary care centers and five specialty centers. • The number of visits has been steadily increas- To participate in the program, sites must: ing each year, with approximately 1,000 to 1,500 per year. • Have adequate telecommunications connec- • Patient survey results indicate that more than tions or capability to have them installed; 85 percent are satisfied with the program. • Have access to secure email; • Only 8 percent of the cases required a face-to- • Have a designation of rural status as defined face follow-up visit. by the state of California; Source: Personal communication with Bridget Cole, • Be located in a specialty shortage area (as Blue Cross of California Telemedicine Program, March 2002. defined by California); and • Have the administrative support to sustain the program. 32 | CALIFORNIA HEALTHCARE FOUNDATION 26548proof 11/26/02 8:29 AM Page 33 Appendix A: Resources Organization and Web Site Type of Resource American Telemedicine Association www.atmeda.org IT Association of Telehealth Service Providers www.atsp.org IT California Rural Health Policy Council www.ruralhealth.ca.gov RH, F, R California State Rural Health Association www.csrha.org RH, F, R California Telehealth and Telemedicine Center www.cttconline.org H, IT Center for Technology and Health—UC Davis Telemedicine Program http://cth.ucdavis.edu H, IT U.S. Health and Human Services, Health Resources and Services Administration (HRSA): – Bureau of Primary Health Care/Community Access Program www.bphc.hrsa.gov/cap RH, F – Federal Office of Rural Health Policy http://ruralhealth.hrsa.gov RH, R – Office for the Advancement of Telehealth http://telehealth.hrsa.gov/grants/preview.htm H, IT, F National Association of Rural Health Clinics www.narhc.org RH, R National Library of Medicine, National Telemedicine Initiative www.nlm.nih.gov/research/telemedinit.html H, IT, F National Rural Health Association www.nrharural.org RH, R Northern California Grantmakers www.ncg.org H, F Northern Sierra Rural Health Network www.nsrhn.org RH, IT Rural Healthcare Division of the Universal Service Administrative Company www.rhc.universalservice.org RH, F Rural Information Center Health Service www.nal.usda.gov/ric/richs/funding.htm RH, F Sierra Health Foundation www.sierrahealth.org H, F Telemedicine Research and Information Exchange H, IT, F – Telemedicine Information Exchange www.tie.telemed.org – Telemedicine Research Center www.trc.telemed.org H, IT The California Endowment www.calendow.org H, F The California Wellness Foundation www.tcwf.org H, F The James Irvine Foundation www.irvine.org H, F Tides Organization/Community Clinics Initiative www.tides.org H, F H – Health focus RH – Rural health focus IT – Health information technology F – Funding information R – Regulatory/government information Rural Health Care Delivery: Connecting Communities Through Technology | 33 26548proof 11/26/02 8:29 AM Page 34 Appendix B: Interviewees Speranza Avrim, Director Dr. Joseph Larschen, Northern Sierra Rural Health Network Chief Clinical Support Services Nevada City, CA Veterans Administration Iron Mountain, MI John Berger, Vice President NightHawk Radiology Services Beth Lee, R.N., B.S.N., C.C.R.N. Coeur d’Alene, ID Director, Patient Care Services, CV Surgery Mid America Heart Institute of Saint Larry Bettesworth, M.D. Luke’s Hospital Sacred Health Medical Center St. Luke’s–Shawnee Mission Health System Spokane, WA Shawnee Mission, KS Yvonne Bice, Executive Director Joseph Middleton, Central Valley Regional Health Network Vice President of Facilities Management Sacramento, CA Bassett Healthcare Andrea Ernst, Manager of Marketing Cooperstown, NY and Public Relations Laura Paoli, Executive Director Mid America Heart Institute of California Rural Health Association Saint Luke’s Hospital Sacramento, CA St. Luke’s–Shawnee Mission Health System Shawnee Mission, KS Herschel “Buzz” Pedicord, President and CEO HomMed LLC Ellen Friedman, Vice President Brookfield, WI The Tides Foundation San Francisco, CA Mike Peterson, e-Business Director Eastern Maine Healthcare Bridget Hogan Cole, M.P.H. Bangor, ME Manager, Business Development— Telemedicine Blue Cross of California, Holly Russo, R.N., M.S. CE’s State Sponsored Programs Home Care Technology expert Wellpoint Health Networks Frank E. Seidelmann, M.D. Camarillo, CA Franklin and Seidelmann, Radiology Practice Jana Katz, Director, Chagrin Falls, OH Chief Administrative Officer Robert Webber, M.D. Center for Health and Technology, Family Doctors UC Davis Health System Watsonville, CA Davis, CA 34 | CALIFORNIA HEALTHCARE FOUNDATION 26548proof 11/26/02 8:29 AM Page 35 Appendix C: Representative Vendor Information Technology Products by Category Vendor Contact Information Web Sites/Portals/Communication Secure email for physician-patient MDHub.com www.mdhub.com communications Medem, Inc—messaging, consult and library services www.medem.com Axolotl’s Elysium clinical messaging www.axolotl.com Online training for physicians, MedCases Inc. www.medcases.com nurses, and allied professionals HealthStream’s Healthcare Learning Center www.healthstream.com Medical knowledge/library services InteliHealth www.intelihealth.com e-cure me www.ecureme.com UpToDate www.uptodate.com ClineGuide www.clineanswers.com Send/Share Data Collect/send data Health Hero—Health Buddy— home health data www.healthhero.com HomeMed home monitoring system www.hommed.com Motion Media Technology— remote data capture instruments using phone lines www.motion-media.com Send/Share Images Remote radiology interpretation NightHawk Radiology Services 250 Northwest Blvd. #202, service Coeur d’Alene, ID 83814 Virtual Radiologic Consultants www.virtualrad.net Remote pharmacy order review Pyxis Corporation—Pyxis Connect www.pyxis.com Teleconferencing/Video Teleconferencing equipment/services Polycom (Picture Tel) www.polycom.com AMD Telemedicine—medical devices for telemedicine consults www.amdtelemedicine.com Cyber-Care Inc—Electronic House- Call ® system—Products and services for health management for providers, patients, and payers www.cybercare.net American TeleCare—home telemedi- cine services www.americantelecare.com Remote Monitoring ICU monitoring Visicu’s e-ICU remote ICU monitoring technology and service www.visicu.com Rural Health Care Delivery: Connecting Communities Through Technology | 35 26548proof 11/26/02 8:29 AM Page 36 Appendix D: Additional Information Sources I Report to the President: Transforming I 2001 Report on U.S. Telemedicine Activity, Healthcare through Information Technology, Association of Telehealth Service Providers President’s Information Technology Advisory I Telemedicine Information Exchange: Committee, Panel on Transforming Comprehensive information resource on Healthcare, February 2001 telemedicine and telemedicine activities I National Library of Medicine, Research (www.tie.telemed.org) Programs: Digital Computing and Communications, (www.nlm.nih.gov) I Federal Telemedicine News (www.federal- telemedicine.com) I 2001 Report to Congress on Telemedicine, U.S. Department of Health and Human Services, Health Resources and Services Administration, and the Office for the Advancement of Telehealth (http://telehealth.hrsa.gov/pubs/ report2001/main.htm) 36 | CALIFORNIA HEALTHCARE FOUNDATION 26548proof 11/26/02 8:29 AM Page 37 Endnotes 1. “UTEP Partners with NASA to Adapt 10. “Teleradiology in Iowa.” Case study. Telemedicine Equipment for Use in Clinics.” Medical Imaging, February 2002. iHealthBeat, June 10, 2002. 11. Kienzle, M. “Rural-Academic Integration.” 2. “IBM, Hughes to Offer Satellite Broadband to Iowa’s National Laboratory for the Study of Rural Communities.” iHealthBeat, May 6, Rural Telemedicine.” National Library 2002; “Wireless Broadband Networks Seen of Medicine Contract NO1-LM-6-3548, Emerging as Solution to ‘Last Mile’ Problem.” March 31, 2000. iHealthBeat, June 4, 2002; “Satellite Network 12. Dahlin, M., G. Watcher, W. Engle, and Will Support Remote Eye Screenings in Rural J. Henderson. Report on U.S. Telemedicine South Carolina.” iHealthBeat, July 2, 2002. Activity: Desktop Reference for a Rapidly 3. “Providers Show Some Backbone.” Evolving Industry. Association of Telehealth Health Data Management, March 2000. Service Providers (ATSP), Portland, OR, 2001. 4. Jupiter/The NPD Group, Inc., Individual 13. Personal communication with Bridget Cole, User Survey. U.S. Online Activities 2002, Blue Cross of California Telemedicine May 2002. Program, March 2002. 5. Reeder, L. “Telemedicine: Is There a Market 14. School of Medicine, University of Missouri- Somewhere Out There?” Healthcare Leadership Columbia. Final Report: Rural Telemedicine and Management Report, 9(12), December 2001. Evaluation Project. January 2000. 6. National Library of Medicine Contract 15. Personal communication with Sharon Avery, Number: NO1-LM-6-3545. Bench to Bedside Director, California Telehealth and Final Report. University of Washington, Telemedicine Association, March 2002. December 8, 2000. 16. School of Medicine, University of Missouri- 7. Bazzoli, F. “Now Class, Turn on Your Com- Columbia. January 2000. puters.” Technology in Practice, March 2002. 17. Personal communication with Sharon Avery, 8. American Medical Association. Physician March 2002. Characteristics and Distribution in the 18. National Library of Medicine. Bench to U.S. 1999. Cited by Rural Health Statistics Bedside Final Report. (www.nal.usda.gov/ric/richs.stats.htm). 19. Dahlin, M., G. Watcher, W. Engle, and 9. Phipps, J. “Distant Dollars: Physicians J. Henderson. Report on U.S. Telemedicine Try to Improve Telemedicine’s Profitability.” Activity: Desktop Reference for a Rapidly Modern Physician, November 2001. Evolving Industry. Association of Telehealth Service Providers (ATSP), Portland, OR, 2001. “JAMA Paper Considers Slow, Uneven Adoption of Telemedicine.” iHealthBeat, July 25, 2002. Rural Health Care Delivery: Connecting Communities Through Technology | 37 26548proof 11/26/02 8:29 AM Page 38 20. Personal communication with Jana Katz, 29. Personal communication with Sharon Avery, Chief Administrative Officer, Center for March 2002. Health and Technology, UC Davis Health 30. Stumpf, S., R. Zalunardo, and R. Chen. System, March 2002. “Barriers to Telemedicine Implementation.” 21. Becker, C. “Remote Control.” Modern Healthcare Informatics, April 2002. Healthcare, February 25, 2002. 31. “Telemedicine Network Proposed for 16 22. Johnston, B., L. Wheeler, J. Deuser, and States.” HIMSS e-News, April 3, 2002. K. H. Sousa. “KH: Outcomes of the Kaiser 32. “Idaho State University to Fund Telehealth Permanente Tele-Home Health Research Programs for Rural Care Providers.” Project.” Archives of Family Medicine 2000, 9: iHealthBeat, November 7, 2001. 40-45. 33. “Rural Virginia Clinic Gets Federal Grant for 23. Dansky K., L. Palmer, D. Shea, and Telemedicine Link to UVA Hospital.” K. Bowles. “Cost Analysis of Telehomecare.” iHealthBeat, June 5, 2002. Telemedicine Journal and e-Health 2001, 7: 225-231. 34. Schneider, P. “FCC Defines Future of Rural Telemedicine.” Healthcare Informatics, 24. Johnston, B., et al. “KH: Outcomes of July 1997. the Kaiser Permanente Tele-Home Health Research Project.” 35. “Report: Barriers Remain—but Lessen—for Telemedicine.” Health Data Management, 25. Friedman, R. H., L. E. Kazis, A. Jette, June 22, 2001. M. B. Smith, J. Stollerman, J. Torgerson, and K. Carey. “A Telecommunications System 36. Personal communication with Speranza for Monitoring and Counseling Patients Avrams, Executive Director, Northern Sierra with Hypertension: Impact on Medication Rural Health Network. Adherence and Blood Pressure Control.” 37. Reeder, L. “Telemedicine: Is There a Market American Journal of Hypertension 1996, 9: Somewhere Out There?” Healthcare 285-292. Leadership and Management Report, 9(12), 26. Demiris G., S. Speedie, and S. Finkelstein. December 2001. “Change of Patients’ Perception of 38. Stammer, L. “Getting Ready to Take Off.” TeleHomeCare.” Telemedicine Journal and Healthcare Informatics, January 2002. e-Health 2001, 7: 241-248. 27. DiCianni, J., and L. Kobza. “A Chance to Heal.” Health Management Technology, April 2002. 28. Kienzle, M. “Rural-Academic Integration.” 38 | CALIFORNIA HEALTHCARE FOUNDATION 26548proof 11/26/02 8:29 AM Page 42