Telemedicine is improving patient access to timely care
David Richardson woke up early as usual, between 4 and 5 a.m. He didn't feel well. He nibbled at the breakfast his wife, Karin, made later that Sunday morning, then told her he was going to lie down.
"After an hour and a half I got up, came into the kitchen, and sat down to watch the NFL pregame," said Richardson, 56, a disabled Navy veteran from Fountain Lake, Ark. "That's all I remember until I woke up in the hospital."
Karin Richardson called 911 when she found her husband slumped over in his chair, clutching his left arm, drooling and unable to speak. As a nurse at a long-term care center in Hot Springs, Ark., she recognized the symptoms of stroke.
Within 10 minutes of her call, the ambulance crew was at the door. The emergency medical technicians took David Richardson to St. Joseph's Mercy Health Center in Hot Springs. They'd called ahead to make sure the hospital's stroke plan was in place. Such coordination can be critical to a stroke patient's survival. As Dr. Douglas Ross, medical director of the emergency department at St. Joseph's Mercy, put it, "Stroke patients are like a ticking clock, in that time is of the essence in treating them."
Ready, set, treat
When Richardson was wheeled into the treatment room, a neurologist in Florida was "virtually" in the room waiting for him, ready to examine Richardson and make a diagnosis via a two-way video communications system outfitted with high-resolution cameras, monitors and speakers. The doctor had computer access to Richardson's complete electronic medical record, including test results.
The telestroke technology service at St. Joseph's Mercy began Sept. 1, just 18 days before Richardson's stroke. St. Joseph's Mercy was the first hospital in Mercy's four-state system to launch the telemedicine service. Since then it's gone live at its hospitals in Springfield, Lebanon and Washington, Mo.; Fort Smith and Rogers, Ark.; and Oklahoma City. It will be rolled out to other hospitals, including Mercy's critical access facilities this year and next, until all 31 hospitals are onboard.
Because a relatively short amount of time had elapsed from the onset of Richardson's symptoms, the neurologist gave orders for an injection of tissue plasminogen activator, or TPA, a clot-busting drug that must be administered within four and a half hours following an embolic or thrombolytic stroke. The treatment worked. Richardson was talking by the time he was moved to the intensive care unit. In two days, he was walking. And in less than two weeks, he was home.
The drug likely saved Richardson's life, and it reduced his risk of long-term disability, but it was the instantaneous telemedicine connection with a board-certified neurologist that helped ensure the safe and timely administration of the treatment. Because the drug carries significant risks, emergency physicians often are not comfortable giving TPA without first getting a neurological consult — a service that is not available in some hospitals at all and may not be available around-the-clock where it is offered.
"We struggle in Arkansas as many do elsewhere with very few neurology specialists," explained Ross. "We only have two, and it's impossible for them to cover the ER 24 hours a day, 365 days of the year. With the telemedicine cart, we can have a board-certified neurologist and even a vascular neurologist at a patient's bedside in less than 10 minutes."
Ross said in the year prior to initiating telestroke technology, TPA was used only twice at the hospital. In the first four months of the telestroke service, five stroke patients received TPA, and it worked.
Maximizing patient access
The Chesterfield, Mo.-based system is relatively new to telemedicine. It is in the process of installing technology including fixed-base equipment like wall-mounted cameras in telemedicine rooms and distributing portable, self-contained telemedicine carts to its hospitals and clinics. That investment, which is funded in part by grants, will enable its sweeping vision for harnessing technology to maximize health care access, especially in midsize towns and small rural hamlets that often have a hard time recruiting primary care doctors, let alone specialists.
One of the distinct features of Mercy is that it has major metropolitan hospitals where subspecialists employ state-of-the-art technology; and it has 20- and 25-bed hospitals in towns that may have just one general surgeon, said Dr. Tim Smith. As vice president of research for Mercy's Center for Innovative Care, Smith is charged with implementing Mercy's telemedicine strategy. "We have a need and a mission obligation to extend this state-of-the-art technology to those smaller, rural communities. Telemedicine allows us to do just that," he said.
With telemedicine, Mercy's critical access hospitals will have near instant connectivity with burn specialists and trauma doctors who can direct treatment or triage for transport. Other specialists from throughout the Mercy system will consult on the care of inpatients and treat outpatients remotely.
Electronic synergies
Mercy is in the final stages of installing an electronic medical record that will be accessible from anywhere within the system. That capability is a rocket booster for its telemedicine service, Smith said, because it allows for the elegant exchange of information among providers at the bedside and those consulting from another locale. "Ten years ago, the EMR did not exist and telemedicine functions would have just been videoconferencing events. Consulting providers at a distance would have a view of the patient but no real-time access to the patient's records, x-rays, lab results, etc.
"Documentation of diagnoses, testing and treatments would have been done the old fashioned way: pen and paper. Having the computerized medical record at our disposal helps providers on both ends of the connection manage medical conditions much more efficiently and accurately," Smith said.
Doctors and administrators at Mercy aren't saying that telemedicine technology is better — or could replace — eye-to-eye, doctor-patient contact, but it may be the best option for patients living in rural areas.
"We have high aspirations for providing lots and lots of services to lots and lots of places," Smith said.
Telestroke is one of 68 telemedicine services and projects that are up and running or in the pipeline within the Mercy system. Mercy SafeWatch, a service providing centralized remote monitoring of 400 ICU beds in 10 hospitals in Kansas, Missouri, Oklahoma and Arkansas, has been operating for a few years and is Mercy's most mature telemedicine service.
Other active services connect individual practitioners with their patients. For example, one afternoon a week, Smith and his partner use telemedicine technology at Mercy Hospital St. Louis to hold a headache clinic at a Mercy outpatient facility 100 miles away in Rolla, Mo. On the other side of the state, a neurosurgeon in Springfield, Mo., connects to the Rolla clinic to check the wounds of his postoperative patients. Psychiatrists, a specialist in high-risk obstetrics, a sleep disorder doctor and an ophthalmologist are among those delivering convenient, remote care in the Mercy system.
Mercy is rolling out a home-based monitoring service for a select group of rural Missouri and Arkansas patients who have difficulty managing their symptoms of congestive heart failure. That technology will feed real-time data to the patients' medical records, which can be set to alert nurses and physicians to any signs of trouble. Eventually home monitoring will be offered systemwide and then expanded to include patients with chronic obstructive lung disease, asthma, hypertension and diabetes.
Needless to say, remote medicine requires a high degree of coordination among human and technical resources. Mercy plans to consolidate much of the required logistics and connectivity at a "virtual care center," a first of its kind, $680 million telemedicine hub, to be located near the system's headquarters in Chesterfield. When it opens in 2014, the building will serve as a locus for data, technology and logistics. It will be an actual base to some of the telemedicine clinicians and a virtual base to other doctors and nurses spread throughout the Mercy system who deliver some telemedicine care.
USDA grants fund expansion of Mercy's telemedicine efforts
Last year, Mercy received two separate telemedicine grants, each for $500,000, from the U.S. Department of Agriculture Rural Development, to provide greater access to health care in some of Mercy's most rural communities in Arkansas, Kansas, Missouri and Oklahoma. Roughly half of Mercy's 31 hospitals in these states are located in remote rural areas.
The first grant supports a three-year tele-home monitoring project targeting patients in six rural communities with congestive heart failure, respiratory disease or diabetes. The grant money is purchasing monitoring devices that allow patients to electronically transmit physiological information such as heart rate, weight or glucose levels from home via a black box, their computers or telephone lines directly to their physicians and separately to a specialty nurse who monitors the incoming data in real time.
The nurse is on guard for early indicators that a chronic condition may be poorly controlled and putting the patient at risk for an acute crisis. The nurse or the patient's doctor can initiate timely interventions such as an adjustment to medications, or a visit from a home health nurse. The timely attention can prevent hospitalizations, said Dr. Tim Smith, vice president of research for Mercy's Center for Innovative Care.
So far about 50 patients with congestive heart failure are using the technology. Heart disease is the program's initial focus. Within a year Smith expects about 1,000 people to be using the technology. Mercy will expand the program to cover patients' diabetes, heart disease and respiratory disease.
Steven Ward, 64, of Bella Vista, Ark., is a fan of the service. He was diagnosed with congestive heart failure two years ago. Today, he uses a scale and blood pressure cuff daily that are tied into technology that transmits the results through his home phone line to his physician. If any reading is outside the normal parameters, his doctor can make necessary adjustments to get Ward back on track.
"This tele-home monitoring system gives me a certain level of comfort," said Ward, who is semiretired from his job at a moving and storage company. "I feel as if I have someone looking over my shoulder every day, checking on me. And my doctor's office likes it. It gives them the chance to be on the offensive rather than the defensive in treating me."
According to Mercy, extensive research shows health behaviors change and compliance improves when patients know someone is tracking their health status. Just tracking hypertensive patients nationwide with remote blood pressure monitors could potentially save $100 billion a year in unnecessary health care costs.
"With our integrated electronic health record, we can track patient care across four states 24/7 whether they are in a hospital, clinic, ER or at home with monitoring devices," said Smith. "By regularly tracking glucose levels, blood pressure, oxygen levels and more, our patients reap the benefits."
He added that eventually the goal is for all Mercy patients with particular chronic diseases, not just those in rural areas, to have access to the home monitoring equipment.
Mercy matched the second $500,000 USDA Rural Development grant it received at the end of 2011, so that $1 million will be spent to outfit 12 rural critical access hospitals with telemedicine technology. The hospitals are in towns with populations under 5,000 residents: Berryville, Ozark, Paris and Waldron, Ark.; Columbus, Kan.; Cassville and Mountain View, Mo.; and Healdton, Kingfisher, Marietta, Sulphur and Tishomingo, Okla.
"This grant will allow us to hardwire these facilities with telemedicine technology so we can provide round-the-clock emergency coverage, access to hundreds of Mercy medical specialists and even greater access to primary care," Smith said.
Virtual care center will be telemedicine service hub
Mercy is in the early design phase for a facility it describes as the nation's first virtual care center.
The $90 million facility to be built on 38 acres near the system's headquarters in Chesterfield, Mo., will be the mother ship for telemedicine services delivered throughout Mercy's four state region. It will house $590 million in technology and the back office functionality needed to link clinicians scattered throughout the Mercy system with their telemedicine patients.
Mercy serves more than 3 million patients a year through its 31 hospitals and more than 200 outpatient facilities in Arkansas, Missouri, Oklahoma and Kansas.
"Before we started all of this, our leadership had the foresight to go to the communities we serve, suburban, urban and rural, and through community roundtables, ask these communities what they want from Mercy. How can we be of better service?" explained Dr. Tim Smith, vice president of research for Mercy's Center for Innovative Care.
"One answer that came back loud and clear to our leadership is that they want to manage health care in their own communities and not have to drive two to three hours to see a physician. This (virtual care center) seems to be a solution to that."
The virtual care center will house the intensivists and specialty nurses of SafeWatch, Mercy's mature intensive care monitoring service; as well as its planned teleradiology and telepathology services. One day, small rural hospitals might send all their radiology and pathology work to the center while larger facilities could use those services in off hours and to fill coverage gaps. "It helps you get economies of scale," Smith said.
"These radiologists, for example, would receive images from multiple hospitals every day, read them and provide instant feedback to doctors and nurses in small communities," said Smith.
The center also will be a hub for telestroke, Mercy's remote emergency stroke medicine program.
That service launched last fall with physician coverage supplemented by board-certified neurologists employed by NeuroCall, a private company based in Coral Gables, Fla. The long-term goal is to have all Mercy neurologists on the Telestroke response team at all Mercy hospitals using telemedicine.
Those Mercy neurologists will connect to the emergency Telestroke consults using technology suites at hospitals or through home or office computers equipped with cameras. They'll have remote access to the patient's electronic medical record, including test results. Some Mercy neurologists already have the equipment installed in their homes.
The center will support Mercy's budding home monitoring system, technology that allows clinicians caring for patients with chronic illness to more closely track and manage their patients' health statuses. Some of the nurse specialists who will be tasked with assessing that data and looking for trouble signs in patients' weight or blood sugars, for example, will be based at the new building.
Mercy also anticipates having primary care doctors at the center to deliver telemedicine care to rural patients in markets with too few physicians. Additionally, the center will house the staff of a nurse call line for patients throughout the Mercy system.
Mercy's current telemedicine technology:
- Pre- and postop follow-up
- Remote disease management/home monitoring
- Tele-ICU — acute and subacute care
- Telestroke and teleneurology services
- Retinal screening
- Tele–headache
- High-risk pregnancy
- Psychiatric and mental health services
On Mercy's drawing board:
- Virtual radiology
- Palliative care
- Direct online access to primary care services
- Pediatric pulmonology and cardiology