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Wednesday Dec 03, 2014

Long-distance Support: Thoughts on Telemedicine at 2:30 a.m.

"You may want to use propofol," said a deep, gravelly voice that seemed to come out of nowhere.

I was caring for an older woman, and she was doing poorly. It was 2:30 a.m., the witching hour in medicine, and it looked like we might have to put her on a ventilator. I looked up at the two female nurses who were the extent of the medical team. The anonymous suggestion was welcome, but I had no idea where it had come from. It clearly was not either nurse, and I was fairly certain it was not the voice of God or an auditory hallucination.   

"She appears to be decompensating," the voice said.

In rural areas -- like my practice location in Valdez, Alaska -- telemedicine holds potential to help primary care physicians and our patients.

Now, I may not be at my best at 2:30 a.m., but I was pretty sure that I was awake.

"You've given Lasix," the voice continued. "Good. Tell you what -- I'll put in orders for propofol while you're getting ready."  

Despite my confusion, this was good news. We have an electronic health record system that requires us to type in orders before we can get medications, and I had my hands full at the moment.

That's when I noticed the cart in the corner with a camera tracking the action. We had been talking about signing up for Tele-ICU with Providence Anchorage Medical Center, although I had my doubts about its utility. There is no substitute for having a well-trained physician capable of stabilizing critically ill patients in rural communities, but I was interested in trying the system out. I just hadn't realized it was ready to go.

One of the challenges in rural medicine is the feeling of isolation during an emergency and the heightened sense of responsibility that comes with it. This likely is one of the biggest reasons why rural physicians burn out and leave. Sometimes, all it takes is one bad outcome, especially when the physician -- or the community -- thinks the patient could have been saved.

There have been many patients in Valdez who have required all hands on deck, but there is a cost in terms of lost sleep and function when the medical staff consists of only three people. It sure is nice, though, to have another doctor to talk with. Although I have only used Tele-ICU once so far, I have often called a doctor covering the ICU or ER in Anchorage -- or even a colleague in the lower 48 states -- just to discuss a difficult case. I doubt the doctors at the other end know how important those connections have been for me.    

Telehealth is not new technology, although historically, it has been a solution in search of a problem. I have been angered at the money spent on telemedicine carts that could have been better invested in training new rural physicians or increasing physician payment to improve retention. These types of investments improve the rural safety net more than flashy engineering marvels that do not take into account how or why patients are actually seen.

My experience with the Tele-ICU was different. One of the most important aspects of modern medicine is the team approach and the opportunity it offers to discuss how to best to serve a patient. Rural physicians often have no access to the collaboration that occurs in metropolitan areas. So I think one problem telemedicine could solve is not so much how health care is delivered, but rather, how to collaborate at a distance through systems that support the local providers. These include broadband Internet, dedicated specialists who get paid for their work, and an attitude that the best provision of care happens locally.

Telemedicine has many potential benefits but also a number of pitfalls. For critical-access hospitals facing shrinking patient volumes, there is the potential for keeping more patients, rather than transporting them. This may require additional procedural training of rural health care professionals. If medical transportation rates decreased, this would result in significant health care savings.   

Telemedicine has the potential to improve access to specialty care, but how will this affect rural practices? With proliferation of direct-to-patient sites, there may be decreased viability of the local system, and many rural physician practices are struggling as it is. Regulation currently prevents the establishment of national telehealth systems, although there is significant pressure to relax these rules. My fear is that direct-to-patient telehealth could unravel the rural safety net. Telehealth works best when it supports the local physician because there is no substitute for competent hands-on care.    

Telemedicine also could allow specialists to narrow their field of study while empowering family physicians. I have a dream of sitting with my patient in front of a screen discussing her glomerulonephritis with a nephrologist who spends his day performing glomerulonephritis consults via telehealth. For this to work, a system must be in place that allows payment of the specialist and an adequate originating fee for the family physician.

It is too early to see how this will play out, but we are fast approaching a time of rapid change. From a rural perspective, I can see the allure of having another physician at your shoulder in the middle of the night when the patient is crashing. I might have done things a little differently without Tele-ICU and a virtual intensivist, but it was a good experience, and the patient did well.

John Cullen, M.D., is a member of the AAFP Board of Directors.

Posted at 03:09PM Dec 03, 2014 by John Cullen, M.D.

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