Tuesday Sep 10, 2019
Telemedicine Filling Gap for Rural Community
Telemedicine has experienced rapid growth in health care market share and reach in the past decade. From the boom of Web-based care such as that offered by Roman or Keeps(www.nytimes.com) to extremely sophisticated use of cameras and WiFi-enabled stethoscopes in the ICU, telemedicine is able to reach patients and expand access to care for patients in places where more traditional office- and hospital-based practices and services are less readily available.
Telemedicine especially has the potential to offer much-needed access to subspecialist services in rural areas. My rural community hospital did not have a full-time pulmonologist for two years. Until earlier this year, we routinely had to transfer patients with complex pulmonary and critical care needs from our ICU to larger medical centers for subspecialty care.
Based on the hospital's previous struggles with retaining subspecialists, everyone from its administration to primary care physicians like me knew that recruiting a solo pulmonologist (who would be on call 24/7) would be impossible. So, our hospital partnered with the University of Alabama at Birmingham Hospital, which had already developed a tele-intensivist program with another hospital in our state. This collaboration allowed me and other physicians who round at our hospital to consult an intensivist at UAB on any patient we need extra assistance in managing, 24/7, via a small cart we roll into patients' rooms. This helps us to better manage complex patients, and local physicians are more comfortable managing such patients knowing we have backup just a click away.
The collaboration means fewer patients need to be transferred from our hospital. Allowing patients to receive care closer to home significantly reduces their costs and is much more convenient for them and their families. Many times, patients' families struggle to afford the costs associated with travel to and from the larger medical centers such as UAB, which is an hour and a half away. And when a patient does need an ICU-to-ICU transfer, the intensivist helps facilitate it.
This program made it easier to recruit a new pulmonologist, who will be able to offer inpatient consults and in-person critical care in our hospital. It means he will not have to be on call 24/7, which should enhance our ability to retain him. Although it was a group recruiting effort, all the primary care doctors in the community pushed the importance of addressing the lack of a pulmonologist. We now are exploring the possibility of expanding telemedicine services to our outpatient clinics to provide subspecialty services such as rheumatology.
Although telemedicine has expanded access and improved care for patients, we have to ensure that we don't forget that face-to-face, personal patient care is still the best way for us to care for patients when possible, especially when difficult news must be delivered. Earlier this year, a patient in an ICU at a California hospital was being seen by a physician via a telemedicine platform. He and his family were told by the remote doctor that his lung condition was terminal,(www.fastcompany.com) there was nothing that could be treated effectively and the family should consider hospice care. The family and patient had a difficult time understanding the doctor, and he had to repeat himself several times. When that patient needed personal, face-to-face care the most, the system failed him.
The AAFP supports the use of telemedicine in appropriate settings to expand patients' access to needed subspecialty care, but it should not replace the personal relationship that patients experience with their family doctor.
As family doctors, we have to be aware of the reach of telemedicine platforms for our patients. I recently saw one of my patients in the office, and after my nurse updated his medicine list, I noticed that he was now taking Truvada. I had not prescribed this medicine for him, so I asked him where he got the prescription. He told me he got it from a doctor he talked to through an app on his phone. We had a discussion about this medicine, and I told him I could prescribe it for him (as I do for many other patients). He was glad to know that I could provide that service for him but admitted he'd assumed I couldn't because we are in a rural town in Alabama.
As we move forward in transforming the delivery of health care in an ever-more technologically complex world, we have to always balance the need for expanding access and services with the need for continuous, personal relationships with a primary care physician and the need for face-to-face care when we deliver difficult news to patients. We need to make sure that telemedicine allows us to give our patients the best care we can as family physicians, not simply care that's more convenient.
Posted at 01:43PM Sep 10, 2019 by Tate Hinkle, M.D.