Editor’s Note: The following is a free Briefings on Accreditation and Quality article from yesteryear! If you like it, check out more of our work covering quality and accreditation!
How one critical access hospital turned to telemedicine to better serve its community
After reading this article, you will be able to:
- Describe the needs a telemedicine program meets at a rural or remote facility
- Identify surmountable barriers to implementation for a telemedicine program using robotic instrumentation
- Identify the types of programs or services a telemedicine link can help a remote facility provide
- Describe the financial benefits, both to the organization and to patients, that come with having a strong telemedicine program in place
- Discuss credentialing challenges that an organization implementing a telemedicine program might face
Tucked away on the far side of mountain passes in northeast Oregon, the 25-bed critical access Grande Ronde Hospital in La Grande provides much-needed care for a populace that can be cut off from larger facilities by a single snowstorm. The hospital provides all that it can for the local population, but, as with every critical access facility, there are inherent limits to the services that can be provided on-site. Certain specialties and medical services simply do not have the demand to draw full-time physicians or other professionals to the area.
Grande Ronde has, however, found a high-tech solution to this issue-one that ensures its patient population can receive services locally rather than traveling hundreds of miles, as might have been necessary in the past.
“We were asked by Saint Alphonsus Hospital in Boise to take part in a grant program,” explains Doug Romer, the hospital’s executive director of patient care services. “Their outreach director got in touch with us and said, ‘I have these robots through a grant. Would you like to try providing telemedicine services?’ “
At the time, Grande Ronde did not have a telemedicine program and was interested in taking part in the process. And so its robot, a nearly human-height, mobile machine with a monitor where the “face” would be, arrived at the facility.
The program is what is known as a hub-and-spoke model-the tertiary hospital, in this case Saint Alphonsus, is the hub, and the rural facilities are the spokes. This model has evolved for Grande Ronde and is now known as a remote presence healthcare network. The network connects Grande Ronde with four states and five cities for specialty healthcare. For example, patients in the Grande Ronde ICU receive telemedicine services from St. Louis.
“The physicians log in, can see our electronic medical records, review images, review labs, review vital signs, and they will come in and visit patients face-to-face [via the robot’s camera and monitor],” explains Romer. “They are able to assist and direct the care of patients throughout the day and through the night when our nurses have questions. They will call ICU doctors in St. Louis and they will make decisions or change therapies as needed.”
Perhaps the most immediate benefit Grande Ronde saw following the start of the program was a reduction in patient transfers. In the first 52 months of the program, the hospital was able to keep 57 patients in-house who otherwise would have been transferred because Grande Ronde didn’t have the necessary on-location intensivist coverage.
The benefits of keeping those patients in-house are multiple. For starters, the hospital averted almost $1.5 million in transfer costs. Because of the location of the hospital, every patient transfer carries roughly $28,000 in travel costs. Thanks to the telemedicine program, the patients did not have to travel and were able to receive care locally-and Grande Ronde was able to keep a significant amount of healthcare dollars in the community that would otherwise have gone to other hospitals.
“That $1.5 million is savings to the system,” explains Romer. “Sometimes it’s private insurance, sometimes it’s people with no insurance who have to mortgage their house to pay for a helicopter ride [to the next facility].”
In addition, there is a benefit associated with keeping a patient local during the healing process, one that’s difficult to define, he says.
“A lot of healing comes from keeping someone local,” says Romer. “It allows them to see loved ones more often, to see familiar faces. The nurses they are being treated by are faces they see in the community, rather than strangers.”
Finally, staying local means that family members who would otherwise not be able to make the trip out of the valley to offer support are able to see their loved ones in person.
All of this being said, Romer notes that simply having access to telemedicine services is not sufficient to ensure quality care. In addition, a hospital absolutely must have top-notch nursing and support staff as well as top-of-the-line equipment to make sure the on-site care matches the quality of the consult.
“You need that bench. You need those resources,” he says.
The telemedicine robot was created by In Touch Health. (Note: Video footage of the robot in use can be viewed both at www.intouchhealth.com and on Grande Ronde Hospital’s website, www.grh.org, under the telemedicine link.) At first glance, the robot might not seem not too different from the sort of telemedicine technology hospitals have encountered before-for example, many organizations use wheeled carts with monitors and cameras that allow the physician and patient to see each other. The robot used at Grande Ronde, however, allows the physician to take control remotely by using a joystick (or other technology-it is even possible to use an iPad®) to move through the hallways and navigate to the patient’s room. Once at the destination, those same controls allow the physician to control the robot’s camera and look around the room, such as from the patient to the EKG.
The robot isn’t just a viewport, either; it also offers more complex interactivity. The physician can, through the robot, use an electronic stethoscope to listen to the patient’s breathing or chest sounds. Here, again, is where the importance of skilled nursing staff comes into play: A nurse is in the room at the same time and listens to the patient through a stethoscope; this is done as a precaution to confirm what the physician may detect on the other end of the line.
This teamwork has led to an interesting development-the physicians from remote locations develop working relationships with the nurses, and vice versa, in much the same way medical professionals working together in person would.
In fact, Romer has an interesting story along these lines. “I get a note every time the robot fires up,” he says. (The In Touch technology sends an alert to the appropriate parties when the robot becomes active.) “I wanted to see how things were going. We had a patient who didn’t want to be in the ICU, and [when I went to observe] he was trying to negotiate with the intensivist on the robot. This boy wanted to leave-he’d already tried negotiating with the primary caregiver in our community and with his nurses.”
It was at this point a remarkable moment happened right in front of Romer’s eyes.
“I heard the physician on the robot say, ‘Sir, the reason you are in my ICU is because you have very bad pneumonia,’ ” says Romer.
Not the ICU, he notes. My ICU.
“He wasn’t being arrogant by saying it was his ICU,” Romer explains. “He had treated so many patients in our ICU that he felt like a part of it, that it was his own ICU.” In other words, the technology had provided so clear a personal and professional connection that a physician who was hundreds of miles away felt empowered and involved with an ICU he had never set foot in.
And this was not an isolated incident. Romer shares another anecdote involving an outpatient cardiology patient. The ICU nurse had taken some pulses, and otherwise was acting as the hands of the cardiologist, who was seeing the patient from afar.
“The doctor then said, ‘Okay, you can sit up now,’ ” says Romer. “The man sits up on the side of the bed, kicks his legs over, and starts having a conversation about alternate forms of lowering his cholesterol with the physician. They were looking each other in the eye and having a high-quality conversation about his health.”
This was a level of connectivity that, Romer says, a simple phone conversation cannot provide. “He did see that doctor in person.”
Scope and range
Grande Ronde Hospital will perform more than 500 consults this year with the help of its robotic telemedicine link. The services provided are wide-ranging, including:
- Sign language translation
- Foreign language translation
- Grand rounds
- Pacemaker clinic consults
Teaching and counseling
The pacemaker clinic, in fact, uses the robot for a teaching process-it allows a nurse practitioner to beam in and teach patients prior to discharge. The same practitioner does a series of lectures for the community on diet, medication, and signs to watch for involving congestive heart failure. It’s the sort of education a small community might not otherwise have the resources to provide.
The robot enables consultation for other services, too. “Genetic counseling is another big one,” says Romer. “We have an oncologist here who has done outreach oncology for us. Part of having a full-fledged oncology program is needing to have a full-time genetic counseling service. We can’t afford to have one on staff full-time, but we are able to do that through a telemedicine link. That counseling is paid per click rather than kept on staff full-time.”
Neonatology is another area that has seen significant benefits.
“These are situations where the baby is ill-they might have been premature or had respiratory challenges, and the pediatrician has had to get consults from neonatologists,” says Romer. “Sometimes they call for an immediate transfer.”
More often than not these incidents happen following a cesarean section, and so when the mother wakes up, the baby has already been transferred. Because of the telemedicine technology, in these situations the organization is now able to set up a link and beam in a real-time visit.
“We’re able to beam over to St. Alphonsus with the neonatologist on the other end, who goes through the whole visit with her, explaining the treatment, and the mom can see her husband there with the baby” on the other side of the link, says Romer. “This prepares the mom for when she gets discharged so she already knows her doctor on the other end and is able to visit with her baby remotely. We’ve used these televisits in conjunction with five different hospitals” so far.
Grande Ronde’s size enables it to do this sort of thing impartially, in comparison to the competition factor that might be present at larger facilities. “We’re small. We don’t have a dog in the fight,” says Romer. “In a big city, it’s unlikely the hospital would allow you to visit your loved one by telemedicine link. We’re like Switzerland in this matter.”
And these links are not just used for the beginning of life. A local woman’s grandfather was very ill at another facility, too far away for her to get to his bedside. That other facility was part of Grande Ronde’s remote presence healthcare network. The woman approached Grande Ronde and made an appointment, and both facilities agreed to help. The remote location brought its robot to the grandfather’s bedside, and the woman sat in Romer’s office to talk with her grandfather.
“I left them for a little while to give them some privacy, did some work down the hall,” says Romer. Both facilities let the conversation go on longer than initially expected. When they were wrapping up the call, the woman told her grandfather she loved him; unable to speak because of a tracheotomy, he responded by mouthing that he loved her back.
“Following that display, I got an email from the other organization,” said Romer. His counterpart there was amazed. “He said that was the most spectacular event he’d ever seen, and that even his hardened ICU nurse was in tears afterward.”
Time and distance
It isn’t just the emotional or human side of telemedicine that makes it such a boon for Grande Ronde. Due to the hospital’s remote location, its patients have, in the past, had to travel vast distances for services that were not available locally. Take endocrinology, for example. The nearest endocrinologist is 86 miles away. This physician had a good working relationship with the hospital, but also had a high no-show rate. With a three-hour drive there and back, minimum, the chances of a patient and his or her family deciding to cancel an appointment last minute, whether due to health issues, weather, or other unforeseen circumstances, were very high. “People are not going to drive over snow in a situation that is not life or death,” says Romer.
Now, the endocrinologist holds a remote clinic one afternoon a week through the telemedicine link to see the patients rather than asking them to make the 86-mile drive.
“Because of this, people are getting the preventative care they need,” says Romer.
As mentioned earlier, the interactions between on-site and remote staff have built a solid foundation and repertoire for these teams. Though some have never met face-to-face or shared the same building, they are as much colleagues as they would be if they worked in the same office.
Of course, that level of familiarity wasn’t achieved overnight. “It’s all about communication. There haven’t been any big challenges, but it did take a little time to get used to,” says Romer.
The medical staff struggled a bit with the technology at first, but after they had a couple of wins-a few situations that really demonstrated the power of the telemedicine link-they became fully invested in the system.
The nurses have even developed a knowledge of the peculiarities of the remote doctors, the way they would with their own in-house physicians. “They know which ones want to drive the robot, which ones want the [picture archiving and communication system] images up already, which ones won’t log into the electronic medical record but rather talk through it with the nurse directly,” says Romer. “It’s been nothing short of spectacular.”
Financially, use of the telemedicine link is a net win for the hospital as well. It pays the consultants, but is able to retain patients who might otherwise be sent elsewhere for treatment. Patients, in turn, avoid large transport costs, repeated tests, and traveling to new facilities. Telemedicine has furthered Grande Ronde’s commitment to providing access to high-quality healthcare.
Telemedicine and credentialing
Anyone who has been in healthcare during the advent of telemedicine knows that credentialing and privileging remote physicians has been a learning process for the industry. In the case of Grande Ronde Hospital and Oregon, specifically, this was a unique chance to change the process for the entire state.
When the telemedicine link was first established, the hospital went through all the hoops to get 17 remote physicians fully credentialed at its facility. They were fingerprinted and had complete background checks-t’s crossed and i’s dotted.
But when Grande Ronde filed this information with the state, the physician licenses came back as inactive. It turned out Oregon had a law prohibiting the practice of medicine unless a physician first conducts a face-to-face visit with the patient.
“This may have been a way to prevent online prescribing of drugs, but we don’t know for certain,” says Romer.
So Grande Ronde went to the state medical board and pleaded its case. The hospital did a complete demonstration of the process with a volunteer patient, and showcased how the service would provide care and options that were otherwise unavailable in its geographic region.
The perseverance paid off. The next day Grande Ronde received a call from the state medical board saying that a temporary rule would be put in place to allow the hospital to begin its program, and that during the following year a change would be forthcoming to allow telemedicine credentialing permanently.