• Case Study: Bringing Needed Care to Rural Patients

    Apr 28, 2011

    When Herb Saloum, MD, a family practitioner in Tyndall, S.D., is off duty and one of his patients goes to the hospital emergency department (ED) with chest pain, the ED nurse knows to push the red button that will connect her with a physician immediately.

    "Within 10 seconds, there is an emergency physician and staff on the screen," says Saloum. "The nurses in the ED start taking care of the patient and, by the time I arrive 15 minutes later, they will have already done the initial EKG, started the IV, drawn blood, and be waiting for the results."

    The emergency physician calling the shots is not in Tyndall, a town of about 1,200 people, but rather 90 miles away in Sioux Falls, S.D. The care is provided through two-way video technology that allows around-the-clock eEmergency coverage to 26 hospitals in South Dakota, Iowa, Minnesota, and North Dakota.

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    The eEmergency program is one of a growing suite of Avera eCARE™ services provided by Avera Health, a regional health system based in Sioux Falls. The telehealth services provide the right expertise to patients in their home communities just when they need it.

    At the same time, the services are breathing new life into rural hospitals that otherwise might not survive the transition to a value-based healthcare delivery system.

    "Any time we can allow a patient to be treated locally, we are supporting a critical access hospital's ability to stay vital and open," says Deanna Larson, vice president of quality initiatives at Avera Health. "We can never underestimate the importance of local access."


    Increasing Access to Inpatient Care

    Avera Health first introduced Avera eICU® CARE™ services to rural hospitals-organizations affiliated with Avera and those outside the system-six years ago.

    System officials estimate that, among the more than 29,000 patients who have been monitored by Avera's remote critical care team, 631 lives have been saved. In addition, about 16,000 ICU days have been avoided (as compared to the length-of-stay predictions based on a severity-adjusted scoring system), saving hospitals more than $25 million. Moreover, a 30-month study of eight critical access hospitals found that the service has saved the health system-meaning providers, payers, and patients, not just Avera Health-roughly $1.7 million in helicopter costs and $350,000 in ground ambulance costs.


    The eICU success prompted Avera to look for ways to expand remote care delivery. "This has been a visionary quest," says Larson. "The question became, 'If the backbone of the telehealth network worked for eICU, why wouldn't it work for other types of inpatient care as well?'"

    In addition to critical care, the system's eCARE services include the following.

    eEmergency. Since it started in late 2009, eEmergency has served more than 900 patients in 26 hospitals. In the first 15 months of operation, the service kept 190 patients in their home communities and saved nearly $2.4 million in emergency transfers.

    eStroke. Piloted at the 25-bed St. Michael's Hospital in Tyndall, eStroke is an extension of eEmergency. The service allows neurologists to evaluate whether patients are appropriate candidates for the crucial tissue plasminogen activator treatment that must be administered within three hours of stroke onset.

    ePharmacy. This service allows every medication order to be reviewed and approved before it is administered to a patient. More than 2,000 medication occurrences from drug-drug interactions, allergies, wrong dosages, and other problems were avoided in the first two years, saving hospitals an estimated $320,000.

    Remote neonatology coverage. This service supports rural hospitals that have no obstetric practices or those that are not equipped to handle a premature delivery or a critically ill newborn.

    While eICU services use proprietary technology from an outside vendor, Avera has developed the other eCARE services on its own. Several IT vendors support the systems, including those that provide video-conferencing equipment, electronic health record technology, auto-dispensing cabinets, order management systems, and various picture archive and communication systems, says Mandy Bell, eCARE development director.

    Increasing Access to Specialists

    Avera's most popular eCARE service is eConsult, which gives rural patients access to infectious disease specialists, behavioral health services, dermatologists, pulmonologists, and other specialists via two-way video technology at their local hospitals. The service is available in 42 sites and provided nearly 5,000 consults in 2010.

    The average patient satisfaction scores for the eConsult service typically exceed 95 percent. Big screens make it seem as if the specialist is in the room with the patient, and nurses at the rural hospitals use special cameras that allow remote physicians to examine patients in close detail, says Saloum.

    The main patient satisfier, Saloum says, is that patients and their family members do not have to make the lengthy trek to Sioux Falls. "The question I always look at is, 'Would you rather have a telehealth visit or travel?' And 97 percent of patients prefer the telehealth visit just because they don't have to travel," he says.

    Indeed, Avera estimates that eConsult visits eliminate $46,000 in patient travel expenses each month. But the more important statistic applies to physician access. "Through our customer service surveys, we have learned that up to 30 percent of the patients who are receiving specialty services would not drive the 150 miles one way to get that service," says Larson. "They would just not do it. They would not get the specialty consult."

    Benefiting Rural Hospitals

    One benefit to local hospitals is financial because eICU patients can be treated in their home communities.

    "Our hospital is able to keep the revenue of the hospitalization and all the associated labs and X-rays that otherwise would have been done up at Sioux Falls," says Saloum.

    But other benefits might be even more important. For one thing, the eCARE services make it easier for rural practices to recruit new physicians because they have the same level of support they would receive from a tertiary care hospital.

    In some cases, that extra support serves as a source of physician education that leads to better patient care. For example, through the ePharmacy program, a physician's medication order is sent to an Avera pharmacist who evaluates it for appropriateness, potential interactions, allergies, and other factors. Before the first dose is administered to a patient, the pharmacist either approves the order or intervenes with a recommendation that the order be changed.

    "We find that when a hospital first starts with ePharmacy, there will be quite a few interventions-that's what we call suggestions for changes-but after a while, the number of interventions as a percentage of all written prescriptions drops because physicians learn from their mistakes," says Saloum.

    Saloum, the chair of Avera Health's board of directors, believes telehealth will be key to allowing rural hospitals and physician practices participate in the move toward value-based care.

    "If critical access hospitals and independent physicians in rural areas want to survive in the healthcare environment that is coming, they are going to have to look at clinically integrating with a large accountable care organization," he says. "An electronic record and all of these telehealth programs that we have allows for a high level of communication, so we are going to be able to deliver value-based care."

    Making It Work

    Hospitals pay a subscription fee to Avera Health for eEmergency, eICU, and ePharmacy services, and the fee provides unlimited access to the services.

    Avera Health is looking for ways to further expand its eCARE program by adding new services-a remote psychiatric program is under consideration-and adding more hospitals. While hospitals as far away as Alaska have expressed interest in participating in the eCARE program, Avera is weighing whether that is feasible.

    Telehealth programs require careful implementation, including site visits and relationship-building between local providers and the specialists who work in Avera's telehealth hubs, says Larson.

    For eEmergency, for example, quarterly site visits are needed to allow the eCARE team members to understand how each hospital is set up so that its services can be most effective. The cost of those site visits increases in relationship to the distance from Sioux Falls.

    For the time being, Avera Health's target market is South Dakota and bordering states. Rural hospitals pay a subscription fee to Avera Health for eCARE services, and a critical mass of participating hospitals is needed to make a telehealth program financially viable.

    The eICU program is self-sustaining, but most of the other services rely on grant funding until more hospitals sign on, says Larson. While the system aspires to eventually break even on providing eCARE services, Avera Health's pioneering work in eCARE services is mission-driven, she says.

    "If you close a hospital in these small communities, you're losing a lot of jobs and a lot of tax base. Maintaining health care-not only from an access and quality perspective, but also for the economic stability of those communities-is really who we are at Avera, and certainly eCARE fits right into that," she says.