The adaptation of telemedicine to resolve access-to-care issues will be better guided by changes in law and government regulations, but the creative use of distance-shortening technology is already going full tilt in Indiana. Program leaders say the recent legislation just gives existing initiatives that much more power to bring needed care to people and situations that previously did without.
Video visits between patients and both primary-care doctors and specialists take the time and miles out of getting diagnoses, consultations and follow-up care. A surge in “tele-stroke” response, in which a highly trained neurologist “sees” a suspected stroke emergency at a community or critical-access hospital, is bringing the state of the art to places that have no specialist or equipment on hand in the ED.
Other initiatives bring emergency specialists into EDs that don’t have them, insert nurse practitioners into the decision-making of school nurses handling a child’s symptoms of sickness and closely monitor homebound patients to get visiting nurses to where they are needed first and most. And quickly emerging as a priority of telemedicine is the addition of behavioral health expertise in primary care, EDs and in ongoing treatment of mental illness.
The impact on the Indiana countryside is considerable. “If we provide these available specialists out to rural communities, not only are those patients getting the specialty care at the point they need to receive it, but critical access hospitals sometimes are the largest economic drivers of these rural communities, sometimes the largest employer in the region,” says Stephanie Laws, director of the Wabash Valley Rural Telehealth Network.
The provision of expertise has the effect of keeping many patients local instead of transported to a larger hospital, an economic benefit not only in retaining inpatients but later in filled prescriptions, outpatient lab and diagnostic tests and other services, Laws says. Families and employers also avoid costs associated with transfers: patients otherwise would need social support from loved ones at the distant facility, and there may be lost work time in addition to transportation and living expenses, she explains.
EXPANDING AND EVOLVING
Union Hospital in Terre Haute is the hub for the network in the Wabash Valley, which has nearly a decade of experience in live-video care delivery. It started in 2007 when a pilot program connected a local community mental health center with the ED for patients in crisis. The program spread to six critical access hospitals in view of a beneficial impact that included shorter stays in the ED. Those patients, if admitted, were being treated more closely to their medical needs rather than being hospitalized for safety reasons, Laws says.
In 2014, Wabash Valley Rural Telehealth Network was one of five programs nationwide to receive a grant from the Health Resources and Services Administration (HRSA) to inform a broad-scale study of the efficacy and efficiency of telemedicine in emergency care.
Special emphasis is on neurological, trauma and behavioral health care needs. The ultimate objective is to overcome temporal barriers to emergency care, says Laws, and enable evidence-based care regardless of locale. With the evolution of technology, Union Hospital is able to connect with and receive from almost anywhere, she says.
Several Indiana hospitals are harnessing that technological flexibility to launch services that use encrypted app downloads to turn laptops, tablets and smartphones into telehealth portals. At Reid Health, Richmond, a mobile- based program launched in late 2014 allows patients from anywhere in Indiana or Ohio to have on-demand access to low-acuity urgent care. A mobile-app service from Indiana University Health, Indianapolis, started July 1 and has more than 2,000 enrollees already.
The IU Health program, piloted first with health system employees and dependents in late 2015, is part of a larger long-term strategy to respond to consumer demand for convenience, high quality and affordability, says Ron Stiver, president of IU Health System Clinical Services.
IU Health and Reid Health were two of five sites involved in a state pilot of telehealth that helped inform the eventual Indiana law on virtual visits. The evidence of benefit goes right to the top, with Reid CEO Craig Kinyon included among satisfied users. Kinyon’s wife had a painful condition following foot surgery that made it difficult to walk, but she was able to be “seen” at home and get a medication that had her up and about within a day.
“When you are really ill and at home, you do not want to get in a car and travel somewhere,” says Melinda Schreiber, director of the Reid program. Schreiber herself said “Aah” to her smartphone camera to upload a photo and give an online doctor the view needed to get specific about a sore throat.
SPECIALTY CARE ACCCESS
A more stationary and sophisticated type of telehealth equipment and connection is powering the availability of specialist expertise between larger hospitals and either smaller hospitals or primary care locations.
Reid is set up for visits between specialty practices and Reid’s five owned primary-care practices, mainly to enable follow-up care in more rural areas without the need for a trip to Richmond, says Schreiber. Carts with video and audio equipment, stationed in the remote practices, facilitate visits in the specialties of oncology, cardiology, pulmonology, rheumatology and psychiatry.
St.Vincent Health, Indianapolis, has a telecardiology program in effect with St.Vincent Clay in outlying Brazil, says Richard Fogel, M.D., chief medical officer. Rather than send a cardiologist there for a day or make patients come to Indianapolis, a nurse practitioner can see a patient first, and if a consultation is needed, set up a telelink with a cardiologist on call, he says.
A crucial level of expertise in neurology, especially for when patients exhibit stroke symptoms, is being made available through a capacity created in EDs to summon a seasoned neurologist to diagnose and quickly treat based on video observation and inquiries with the emergency doctor and patient family.
The most experienced telestroke program, in operation since 2008, brings neurologists from Parkview Health and Lutheran Health Network, both in Fort Wayne, to 25 community hospitals located in northeastern Indiana and bordering the region in Ohio and Michigan. Franciscan and St.Vincent have newer telestroke programs, and Reid is planning to soon add telestroke and inpatient teleneurology consulting to its telehealth lineup.
The Fort Wayne program, called Stroke Care Now, reported handling more than 1,000 stroke alerts in 2015, including more than 100 that resulted in administering a powerful clot-busting drug called tPA. The drug therapy has been proven to save lives and lessen long-term medical consequences, but it requires expertise at the receiving hospital that many of them don’t have, says Rakesh Khatri, an interventional neurologist who directed the program starting in 2011.
With the neurologist mobilizing remotely, and the ability of a community to keep a tPA supply on hand because it has access to an expert in evaluating its appropriateness, fewer patients end up being transferred to Parkview or Lutheran for specialized response, says Khatri. About 40 percent stay local, and the hospital retains the care, payment and rehabilitation services.
IMPROVED RURAL CARE
Efforts by groups supporting telehealth expansion, along with the legal approvals advanced in the new law, are helping to move the remote-care approach into additional geographic areas as well as opening up new uses to address demonstrated needs.
The Indiana Telehealth Network, a division of the Indiana Rural Health Association (IRHA), is building on more than five years of providing subsidies to create the broadband network foundation for telehealth, offering resources to plan and build regional initiatives. It’s now getting into network-building itself, fostering the movement of health services into rural schools via virtual visits, says Don Kelso, IRHA executive director.
A federally funded pilot in 2010 paid 85 percent of construction and installation costs for getting high-capacity cable into areas without it, helping to wire 71 health care entities and generate 85 percent broadband penetration in the state, says Allison Orwig, project coordinator. A successor program offering a 65 percent subsidy, called Healthcare Connect Fund, drew more than double the original participation.
IRHA also supports the operation of the Upper Midwest Telehealth Resource Center, one of 12 such centers around the country funded by HRSA that acts as a cross between a Consumer Reports and a Match.com between providers and either area health care facilities or suppliers of the necessary tech equipment, says Orwig. “A lot of what we do is connect, network to other people that can either share success stories or possibly have solutions for what a provider is looking to do,” she explains.
The association is getting more involved with equipment decisions and implementation in a school telehealth program. It received two HRSA grants, one for planning and the next for purchasing the equipment to operate a telehealth network, Kelso says. The objective is to create the links to school buildings, especially in areas of health care professional shortage, over which local providers can help school nurses decide what to do with medical problems that crop up in students, he says. The program includes both medical and behavioral aspects.
A hospital may provide a pediatrician or nurse practitioner, and the association contracts with a mental health care provider serving the particular school district. If the nurse decides to initiate a visit, parents already have signed a waiver permitting such intervention. A parent has the option to be present, but they typically prefer not to leave work unless necessary, says Kelso.
Ultimately the school service can expedite care and prevent escalation to the ED or a hospital stay. And the new law will help make the program more successful, says Becky Sanders, director of the telehealth resource center. If the provider sees an ear infection, for example, an antibiotic can be prescribed right there. Or the provider can instruct the nurse to swab a throat for strep, get a lab test the same day and have the antibiotic prescribed, she says. All the parents need to do is pick up the prescription at a pharmacy at the end of their work day.
PROGRESS IN BEHAVIORAL HEALTH
Someone showing up to an ED might not only be in need of medical care, but may also be edgy or seriously withdrawn, perhaps talking about doing harm to himself or others. If it’s the ED at King’s Daughters’ Health in Madison, Decatur Memorial Hospital or a few other hospitals in Indiana, a behavioral therapist from a distant psychiatric hospital can be “beamed in” to make an assessment and recommend next steps.
This free level-of-care assessment service from Bloomington Meadows Hospital helps to spread mental health care far beyond its seven-acre campus at the northern edge of Bloomington. It also integrates behavioral health services into the larger health care environment, taking some of the differentness out of it, says CEO Jean Scallon.
Telehealth technology can be loaded onto smartphones as well as installed in pediatric and psychiatric clinics where Bloomington Meadows performs and bills for remote consultations. The technology is giving therapists a great way to integrate into a health system. “It’s not threatening; we’re just another avenue to help.”
Remote technology simply has to be ramped up for behavioral health coverage, says John Wernert, M.D., secretary of the Family and Social Services Administration, and a practicing psychiatrist. About half the state’s licensed psychiatrists live in the five-county area around Indianapolis, and that expertise somehow has to be spread statewide, he says.
St.Vincent Health has concrete plans to move into behavioral health within the next few months, offering psych consultations from its Indianapolis location, says Richard Fogel, M.D., chief medical officer. For the patient in a rural ED with depression, “The ability to have a psychiatrist or psychologist assess that patient is really critical. Do we need to admit this patient? Do we need to start him on medication? Do we need to set him up for an outpatient counseling session?”
Reid Health has behavioral health providers linked up with the ED of Rush Memorial Hospital, Rushville, in addition to scheduling individual visits between psychiatrists and patients at the five primary care locations that have telemedicine service via specially equipped carts, says Melinda Schreiber, director of the Reid telehealth program. Ultimately the health system would like to add behavioral health access to the mobile app service it operates for scheduled or on-demand visits, but it’s not there yet, she says.
In addition to the presence in critical access EDs, Bloomington Meadows has agreements with over 60 schools. Through a secure link called Zoom, interaction with children in a school can take place in an office, a classroom or wherever the therapist has to seek out a child in crisis, via a tablet or other mobile device, Scallon says.
At the leading edge of telemental health services, the $120 million Neuro-Diagnostic Institute and Advanced Treatment Center, a new state psychiatric hospital under construction on Indianapolis’ east side, will have 10 telepsych suites, enabling doctors at the institute to have continuing follow-up with their patients who return to their communities, says Wernert.
There are six state hospitals across Indiana, and institute psychiatrists will be able to manage a large volume of patients right from these suites. That’s a more efficient and feasible alternative to trying to replicate in every geographic area a standalone medical staff, Wernert says. “It’s a nightmare trying to staff these. But I can recruit people here in Indianapolis, so we can actually have the same number of doctors—they’re just physically located centrally and delivering care remotely.”