Telemedicine: A Lifeline for Rural Residents
Connections with distant specialists can be especially valuable for older adults
(Editor's note: This story is part of a special report for The John A. Hartford Foundation.)
It looked like a bad case of shingles. At least that’s what the doctor working at a hospital in rural Virginia thought when he examined a patient who had come in. Still, he wanted to be sure. So he arranged to consult with a dermatologist.
But the specialist was not just down the hall, or even in an office across town. He was hundreds of miles away at the University of Virginia. The consultation would occur over the Internet, with the dermatologist doing a virtual examination of the woman’s damaged skin.
It turned out it wasn’t shingles. The doctor on the other end of the video connection recognized the condition as something much more serious — a flesh-eating strep infection. Immediate, aggressive treatment with surgery and antibiotics was necessary and the woman recovered.
That’s a dramatic example, but one that reflects a trend that’s beginning to transform rural health care in America: the use of telemedicine to compensate for the dwindling supply of doctors in rural communities.
Examining and diagnosing patients remotely is a long, long way from the iconic, hands-on country doctor. But it appears to be the future model for treating those living where stoplights — and specialists — are few and far between. And it is especially needed for rural older adults whose transportation options may already be limited by their inability to drive and lack of public transit.
Less Driving, More Access to Specialists
“A picture may be worth a thousand words, but video is worth a whole lot more,” says Dr. Karen Rheuban, co-founder of the University of Virginia's UVA Karen S. Rheuban Center for Telehealth. “If you’re able to see the patient, communicate with the patient, examine the patient [through videoconference], it’s a far more accurate evaluation.”
Ideally, a doctor would do that in person. But Rheuban knows from her own experience as a pediatric cardiologist who used to drive “all over Virginia” to see patients that it’s no longer realistic for rural residents to have that kind of relationship with physicians.
One of the missions of the UVA telehealth center is to help people avoid traveling long distances to get care. By Rheuban's estimate, it has saved Virginians almost 17 million miles of driving since opening more than 20 years ago.
The center also has greatly expanded its reach, now connecting patients to doctors in more than 60 specialties, from neurology to sleep apnea to mental health. The same is happening at medical schools around the country, as technology opens up more and more online treatment options.
Here are five examples of how telemedicine is becoming a core component of rural health care. Several are in areas that predominantly affect older adults:
Beating the clock on strokes Neurologists have a saying, “Time is brain,” meaning doctors have a limited amount of time — less than three hours — to begin treating a stroke before brain damage begins. First, they must quickly determine if the cause is a blood clot or the result of bleeding into or around the brain. It’s a critical call because treatment for the first — medication to dissolve the clot — could exacerbate the second.
But many small rural hospitals can’t always have a neurologist available. And fewer have neurologists specializing in stroke care. In the past, that would have meant the patient likely was transferred to another hospital, wasting valuable time. Now, telemedicine provides a way to beat the clock.
When a possible stroke victim arrives at an emergency room, the doctor can connect with a neurologist online, who can view and even talk to the patient via streaming video. That expedites a diagnosis and a decision on what to do next.
“We can collaboratively decide about the most appropriate treatment,” said Rheuban, “whether it’s administering clot-busting medicine or whether the patient needs to be transferred or whether there are other tools available.”
In places where wireless broadband is widely available, the process can start even sooner. Emergency crews can reach out to a doctor for help from the back of an ambulance. “That means earlier intervention, which can make a big difference,” said Rheuban. “We feel we’ve leveled the playing field for our rural partners.”
Screening out diabetes blindness Diabetic retinopathy is the leading cause of vision loss in working adults, despite the fact that it’s largely preventable. That’s why the American Diabetes Association recommends people with diabetes get an eye exam every year. Still, only about half comply, and research suggests the percentage is considerably lower in rural areas.
Telemedicine programs around the country, however, have started to tackle the problem. Nurses in rural communities are being trained to use special digital cameras to capture images of the retinas in both of the patient’s eyes. The photos are then sent electronically to an ophthalmologist who analyzes them for any sign of retinopathy. If a problem is spotted, an appointment is made with a specialist to get follow-up treatment.
Providing easier access to screenings appears to be making a difference. A recent study of almost 1,700 adults participating in the North Carolina Diabetic Retinopathy Telemedicine Network found that once virtual exams became an option, the screening rate among the patients rose from 25 percent to more than 40 percent.
According to Dr. Seema Garg, a retina specialist who led the study, 80 percent of the diabetes patients in the study showed no sign of the condition, and 11 percent had mild to moderate retinopathy. But 9 percent had severe cases that required treatment. Not surprisingly, older patients were more likely to be in the last group.
Managing burn treatment Another area where smaller community hospitals are taking advantage of telehealth is in treating burns. Most ER doctors in rural areas don’t see a lot of burns, so when they do, the tendency is to be overly cautious and transfer the patient to a burn center. Often, that results in a long, needless trip.
The alternative is to enter into a partnership with a “teleburn” program that provides access to specialists at university hospitals, including the Ohio State University Wexner Medical Center and the University of Utah. Doctors at the latter, for instance, consult with hospitals over a large region, including Colorado, Idaho, Montana, Wyoming and Oregon.
One of the more established teleburn centers is at the Lehigh Valley Hospital in Allentown, Pa. Since it opened in 2008, it has provided consultations for nearly 5,000 patients from smaller hospitals in Pennsylvania, Delaware, New York and New Jersey.
The teleburn center is connected to partner hospitals or offices through a mobile app. When a burn patient comes into an ER, a handful of photos are taken of the wound and then uploaded, along with pertinent personal information, and sent through the app. The pictures appear on the iPhones of the teleburn staff no matter where they are, enabling them to provide a timely diagnosis. They get as many as 75 to 80 calls a month.
“We’re able to see the wound, determine the depth,” said Patrick Pagella, a nurse practitioner there. “At the same time, we can determine the body surface area of the burn, which can help us evaluate whether they need treatment at a burn center.”
Easing pain An estimated 100 million Americans suffer from chronic pain — which is pain lasting more than three months — and this results in almost 70 million doctor visits a year. That makes it a prime candidate for telemedicine innovation.
While treating pain usually requires in-person examinations, managing it offers opportunities for using virtual connections. Rural doctors, for instance, are doing video consults with addiction specialists to broaden their knowledge of how to address opioid abuse. One study, in fact, concluded that primary care doctors who consulted with pain management specialists wrote fewer prescriptions for the high-dose painkillers most often tied to addiction and overdoses.
Another study of 250 chronic pain patients using primary care clinics found similar benefits to long-distance counseling. Half of the patients received standard care for a year, while the other half also received regular telephone monitoring. Patients in the latter group reported 30 percent less pain and fewer of them began taking larger doses of opioids.
Recent research involving people 50 and older with knee pain suggests that telehealth can also be an effective way to help people learn to reduce their pain. Half of the study subjects received educational material on dealing with pain, while the other half were provided with a more extensive pain-coping program, including seven Skype sessions with a physical therapist. After three months, the people in the second group reported considerably more pain relief and improvements in physical function.
Providing mental health help Perhaps no aspect of health care has more to gain from telemedicine than mental health therapy. Not only isn’t it necessary for a patient and therapist to meet face-to-face, according to advocates, but in many rural communities, mental health professionals are rarer than doctors.
Rob Marino knows this first-hand. He runs the Free Clinic in Fauquier County, Va., a semi-rural community about an hour west of Washington, D.C. “The number of mental health professionals in this region is pathetic,” he said. “It’s nowhere close to what is needed.”
So since last fall, visitors to the clinic have been able to talk to therapists in other cities. Marino explained that patients go into a private room, and once a staff member sets up the video connection, they are left alone to talk with the therapist.
“They have an appointment just as if they were meeting with that health professional in an office,” he said. “And when they come out, we help them set up the next appointment. We get a summary of what happened in the visit and we share that with their primary care doctor. That doctor and the clinician are part of that patient’s team.”
Marino admits that he wasn’t sure how people would respond to virtual therapy sessions. But he said it’s gone far better than he expected.
“I wondered at first, ‘What are they going to think? They’re talking to a computer screen.’ But I did it myself. After the first few minutes, you don’t even notice the computer anymore.”