The Doctor Is (Logged) In

The rise of telehealth targets rural patients and preventative medicine

Back Longreads Dec 4, 2018 By Russell Nichols

Michael DeBlasio thought it was really bad stomach cramps, but the pain in his abdomen wouldn’t go away. Even though he considers himself “a healthy guy who doesn’t rush to the hospital,” in July, he drove 15 minutes from his house in Volcano to the local Sutter Health emergency room in rural Amador County.

“They determined it was the onset of a heart attack,” recalls DeBlasio, a 66-year-old former product marketing manager.

The emergency department at Sutter Amador Hospital has doctors who can diagnose and treat heart attacks but for more specialized treatment, patients may need to be transferred to another location for a higher level of care. That was the case for DeBlasio. Physician assistants loaded him into an ambulance and sent him to Sacramento, a 90-minute drive to save his failing heart. The surgery was a success, but his story represents the common struggle for residents in remote areas and underserved communities, where doctors are sparse. These patients typically have to travel tens or hundreds of miles for specialty care.

About 15 percent of the U.S. population lives more than an hour away from a trauma center, and 23 percent of children in the country live more than an hour from a children’s hospital, according to the National Center for Biotechnology Information. The American Heart Association says at least half of adults in the country live more than an hour from a primary stroke center. According to the

Sacramento Area Council of Governments, the six-county Sacramento region is 85 percent rural — home to patients who travel long distances for specialty care. But the rise of telehealth, where virtual checkups and post-surgery care allow the patient and provider to be in separate places, is reshaping ideas of access. This includes telemedicine, remote patient monitoring and other electronic forms of communication. With mobile apps, doctors can monitor chronic conditions, and patients can send real-time health data to specialists regardless of distance.

RISE OF THE REMOTE DOCTOR

For the past two years, UC Davis Medical Center has been increasing its virtual services, expanding from post-surgery visits to routine scheduled visits. In 2017 at Kaiser Permanente, more than half of all patient encounters were virtual, according to a Kaiser spokesperson. Dignity Health sees about 35,000–40,000 patients a year through various forms of telehealth, says Kelly Summers, senior director of Digital Care Transformation at Dignity Health, which has expanded its telehealth services with rural health access to post-acute and ambulatory care.  

In the weeks after his surgery, DeBlasio made sure to stay connected. He bought $100 worth of monitoring devices to track his blood pressure, temperature, oxygen levels and weight. Now, once a month, he drives 15 minutes to the local clinic to see his cardiologist virtually. At his local hospital, an off-site cardiologist can emulate an in-person exam, listening to DeBlasio’s heart through a digital stethoscope connected to a smart tablet. The cardiologist can see and hear high-quality, live streaming of heart and lung sounds in real time. DeBlasio can also see and speak to the cardiologist with a secure video-conference application.

Sutter Health is piloting a cardiac monitoring platform from the Bay Area-based devices company, Eko. This partnership is a powerful step forward in delivering quality cardiac care to patients in remote areas, says Connor Landgraf, co-founder and CEO of Eko. For DeBlasio, the fact that he doesn’t have to travel 50-plus miles to see his cardiologist saves money and time. And he says he doesn’t feel weird about the virtual checkup.

“Reminds me of the old days, back when the doctor used to come and visit you,” he says. “It makes sense. If we can do this in outer space with astronauts, why can’t it be done locally, a couple hundred miles from the hospital?”

ANSWERING THE CALL

At Sutter Health, it was a Northern California firestorm that jump-started the health system’s “video visits” program. In October 2017, wildfires scorched at least 245,000 acres across Napa, Sonoma, Solano and other counties — displacing doctors and nurses, and forcing patients, some with asthma symptoms, into shelters.

“That event brought it home for me,” says Dr. Albert Chan, chief of digital patient experience at Sutter Health. “We had one woman who was pregnant and throwing up, but couldn’t get to a doctor because of the fires. But she got referred to an OBGYN through video visits.”

In March 2018, Sutter Health deployed its video visits to all Sutter Health patients who use My Health Online, the health network’s online patient portal. Patients log in and the site will ask if you have one of the 18 covered conditions, such as ear problems or a sore throat.

In recent years, local tech startups have also emerged to fill the gaps between providers and those who need care. For example, Craig Falk, who operates Craig Cares, a Roseville-based home care provider, began SensorSAFE. The startup uses pressure mats and motion sensors in the homes of seniors to provide 24/7 supervision and monitoring. This type of support could be vital in rural areas where caregivers are not available.

“Just last week I received a request for an in-home caregiver in the Chester area [in Plumas County],” Falk says. “I spent days working my network of senior and caregiver organizations and could not identify any caregiver services in that area.”

At UC Davis, Dr. Jim Marcin, director for the Center for Health and Technology, helps to oversee several telehealth initiatives, including one focused on homecare for those with chronic conditions. Another program connects specialists to more than 80 remote clinics in Northern California communities without access.

“Now it’s more and more about delivering the care to where the patient is,” Marcin says, “whether at home, the workplace, schools and day care centers for children, or long-term care facilities for those requiring care around the clock.”

Telehealth hopefully helps to prevent hospitalization. It’s about being more proactive as opposed to reactive.” Dr. Jim Marcin, director, UC Davis Center for Health and Technology

One of the biggest advantages of telehealth is availability. If the patient has a nonemergency question, a phone call or video chat can connect the patient to the provider, bypassing the process of an in-person visit, he says. In general, the copay is the same as for seeing a patient in person — depending on where the consultation takes place and the service provided — but in other telehealth cases, there is no copay, Marcin says.

In previous decades, only the big health systems had the equipment and ability to communicate electronically, but these days, even the smallest clinics can connect with patients in various places. With smartphone apps, wearable devices and health sensors, primary care physicians can track patients with diabetes, hypertension and epilepsy, among other conditions.

“Telehealth hopefully helps to prevent hospitalization,” he says. “It’s about being more proactive as opposed to reactive.”

THE COST OF CARE

In its aims to be proactive, telehealth also presents a financial paradox. For the most part, doctors get paid to treat illnesses and take care of people, not necessarily to keep patients healthy.

Take, for example, an endocrinologist — a doctor who treats diseases that affect the glands and hormones, such as diabetes. If the endocrinologist can check insulin with a blood glucose monitoring device, the patient may not need to visit the hospital as often, Marcin says.

“We get paid only when we treat patients in a clinic or hospital setting and not when we treat the patient when they are at home,” Marcin says, speaking generally. According to the Centers for Medicare & Medicaid Services, the “home” is not included in the list of originating sites, which are locations of a Medicare beneficiary eligible for telehealth services, such as hospitals and rural health clinics.

“But it’s a tough sell to insurance companies,” Marcin says. “We’re saying, ‘Hey, pay me to monitor and treat these patients when they’re in their homes, and I’m going to save you money.’ I really believe that we can save the system money using telemedicine, but health plans are slow to jump into that game without really good data.”

Private insurance companies typically follow the lead of federal and state insurances when it comes to adopting health payment protocols, Marcin says. With telehealth, however, many insurers have stepped up to pay for services like remote patient monitoring before federal and state insurances. That’s never happened before, Marcin says. As financial incentives align, he adds, more health systems will be able to realize the benefits of care that uses technology to help keep patients out of hospitals.

“We have to get out of this volume-based, treat-me-only-when-you’re-sick-and-I’ll-pay-you world,” Marcin says. “Your bottom line will be better if you keep patients healthier.”

THE FUTURE OF HEALTH

From telepsychiatry sessions to online consultations, advances in technology will continue to create more options for the delivery of health services for underserved communities. UC Davis has started researching the use of automated translation tools to communicate with patients who do not speak English.

These and other high-tech tools could bridge the divide in health care, but that also hinges on access to broadband internet. Only 43 percent of California’s rural population has internet access equivalent to urban areas, according to Valley Vision, a Sacramento-based nonprofit economic development agency. Sacramento is currently deploying a new high-speed 5G network, which officials claim will boost internet connectivity more than ever. In the foreseeable future, 5G will connect people with limited mobility and access living in urban and suburban areas to, for example, virtual health clinics in underserved, poorer neighborhoods. Eventually, the technology may help rural areas get better connected, according to city officials.

“It is early on in the technology,” says Maria MacGunigal, chief innovation officer and IT director for the City of Sacramento. “We have not had enough time to see any strong indicators in any one area, but our ambitions are high.”

Dr. Peter Yellowlees, a psychiatrist at UC Davis and former president of the American Telemedicine Association, imagines a future where telehealth isn’t just used to administer care, but to facilitate understanding of various conditions as well as educate health professionals. He’s experimented using the online virtual world, Second Life. In his “virtual hallucinations project,” he wanted to educate people on what it feels like to have schizophrenia. A user’s avatar walks through a building and gets bombarded with negative audio messages like, “You’re a worthless human being.” Another model simulates a bioterrorism attack to help health professionals figure out how to get antibiotics to thousands of people quickly. Yellowlees sees virtual reality as one of the innovative technologies transforming health care.

“It’s unusual stuff, and it’s hard to get grant funding to do things like this, but these platforms could be very good for the future,” Yellowlees says. “Anyone with broadband access and an attached device, phone or computer can benefit from these technologies, so this is a great way of leveling the playing field for patients who live in rural areas or underserved communities.” 

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