As medical director of the telehealth program at University of Washington (UW) Medicine, John Scott, MD, MSc, has witnessed the difference that telehealth can make. The physician and associate professor of medicine at UW has treated rural patients who have taken ferries or planes to see a specialist. Many other patients simply go without treatment because the services they need are not available near their homes.
Health care disparities among rural populations have been documented. The limited availability of physicians and specialty services in rural areas partially accounts for the disparities. People living in rural areas received lower-quality health care and had worse outcomes compared with residents of more populated areas on a number of scores, according to the Chartbook on Rural Health, part of the 2014 National Healthcare Quality and Disparities Report.
But academic medical centers are finding that telehealth is an effective means to reach medically underserved rural populations that may have higher infant mortality rates, higher poverty rates, and a larger population of older adults. Using broadband networks, high resolution imaging, and mobile devices, physicians have been able to improve care for rural residents with tangible results.
ANGELS in Arkansas
In Arkansas, the state’s Medicaid program funded the Antenatal and Neonatal Guidelines, Education, and Learning System (ANGELS) to treat women with high-risk pregnancies and other conditions requiring specialty care. Established in 2003, the program outfitted rural community hospitals, health departments, and some private physician offices with telehealth and broadband equipment to connect rural patients with specialists at the University of Arkansas for Medical Sciences (UAMS) in Little Rock.
UAMS specialists use videoconferencing equipment, computers, servers, broadband connections, and other technology to treat women suffering from complications such as diabetes, obesity, sickle cell disease, and hypertension. Through ANGELS, physicians conduct obstetrical consultations, perform ultrasounds to detect any fetal anomalies, and provide genetic counseling in real time.
With a network of nearly 500 rural sites, the ANGELS program has grown beyond the specialty of maternal fetal medicine to include asthma care, pediatric cardiology, mental health services, and stroke care.
Using broadband networks, high resolution imaging, and mobile devices, physicians have been able to improve care for rural residents with tangible results.
“Every person in Arkansas is within 30 miles of an ANGELS site,” said Curtis Lowery, MD, director of ANGELS and chair and professor of obstetrics and gynecology at UAMS. “Through the ANGELS program, we’ve been able to provide poor people living in rural Arkansas access to the kind of quality care that they never had before our telehealth program began.”
Nationwide, other health facilities are relying increasingly on telehealth to serve medically vulnerable populations. Currently, an estimated 61 percent of health care institutions use some form of telehealth, and between 40 and 50 percent of all hospitals in the United States employ some form of telehealth, according to a 2016 report from the U.S. Department of Health and Human Services that cites data from the Healthcare Information and Management Systems Society.
Telehealth in action
In the predominantly rural Pacific Northwest, Extension for Community Health Outcomes (ECHO) is a telehealth network that uses teleconferencing technology to bring together community-based primary care providers and their university-based specialists to help rural residents.
The ECHO model was developed at the University of New Mexico in 2003 and expanded to include UW in 2009. Through this network, health care providers treat patients with hepatitis C, HIV/AIDS, chronic pain, heart failure, multiple sclerosis, and psychiatric problems. In addition, several doctors that began participating in project ECHO as residents have said they’ll stay in a rural community on the condition that they can participate in project ECHO.
“In the Pacific Northwest, primary care doctors in rural communities are older and retiring in record numbers so there is going to be a huge shortage of doctors in these areas,” said Scott. “We see telehealth as a way to leverage the resources that are in those communities, which might be a draw for new doctors to come out there.”
UW’s participation in ECHO has meant improved patient outcomes in rural areas. Of 1,200 hepatitis C patients whose treatments began in the last three years, over 90 percent have been cured. June 2016 data show that physicians in the UW ECHO program have supported nearly 700 HIV patients at 32 sites and three affiliated pharmacy sites. Additionally, 300 addiction and psychiatric patients and more than 500 chronic pain patients have received telehealth services from UW ECHO physicians and other staff who received training through the ECHO model at an academic medical center.
“Before we started the UW ECHO program, virtually none of these patients were being treated,” Scott said. “Transportation is a huge expense, and there’s a time burden on patients to travel to a specialist. That’s a big hassle just to see a doctor for 15 to 20 minutes.”
“Transportation is a huge expense, and there’s a time burden on patients to travel to a specialist. That’s a big hassle just to see a doctor for 15 to 20 minutes.”
John Scott, MD, MSc
University of Washington Medicine
To push the ECHO and ANGELS programs forward, the governors of Washington State and Arkansas, respectively, recently passed laws requiring health insurance companies to cover the costs of telehealth services. “Tremendous gains are likely to be realized as restrictions are eased,” said Scott Shipman, MD, director of primary care affairs and workforce analysis at the AAMC. “Regulatory restrictions on use and reimbursement for telehealth services have an adverse effect on access to care for populations with inadequate access to needed services.”
Remote patient monitoring is another form of telehealth that is evolving. Advances in technology now enable real-time collection and transfer of large amounts of data about patients’ activities and well-being, said Shipman. “Real-time and asynchronous tools enable health care providers to monitor patient adherence to treatment protocols and improve connection to other members of the health care team.”
The University of Southern California (USC) Center for Body Computing launched a virtual-care clinic in 2016 to enable remote access for patients and their family members. Keck Medicine of USC and partner companies provide the resources. The clinic is designed to bring disease treatment and management options, as well as other services, to patients living in rural communities.
“The virtual-care initiative is one of many projects under the Center for Body Computing that aims to build digital structures to allow us to tackle difficult chronic conditions such as cardiovascular disease, breast and neurologic cancers, retinal diseases, and complications from diabetes. We also have programs around sensors and athletic performance,” said Leslie Saxon, MD, executive director of the center.
Saxon noted that while staff from the USC Center for Body Computing will not diagnose a patient’s condition, they will provide continuous communication, medical content, and education support over mobile applications that include wearables and biosensors.
Telehealth services continue to expand in rural communities across the country. For people living in remote areas, this means convenient and timely access to health care. For hospitals, technology tools are helping to improve patient outcomes and reduce staffing costs. While mobile apps and remote monitoring systems can present new challenges, such as generating large quantities of data to sort through, they also hold the promise of helping physicians reduce health care disparities in rural America.