Rural communities offer a tremendous lifestyle — with open land, known neighbors, and a generally more relaxed pace to daily life.  However, timely access to full-service healthcare is usually missing.  While small towns may have a small hospital or clinic, their sparse populations typically cannot support the full range of physicians, specialists, nurses, pharmacists and therapists needed.  One solution is “TeleMedicine.”

TeleMedicine, also sometimes called “TeleHealth,” uses the Internet, telephone and video links to connect a patient with the needed healthcare specialist – no matter where the patient or specialist is located.  Local care providers, including ambulance and fire emergency medical technicians (EMTs), can transmit real-time monitoring of vital signs and receive care from specialists while still at the scene or en route.  Once in the hospital or clinic, both the local caregiver and the patient can talk with specialists on camera through interactive audio and visual tools, providing detailed lab, surgical, and medication consultations. This means that a person, even in a remote area, can be treated by a highly-trained specialist at any time.  Further, telemedicine provides residents with a secure platform that can work with most mobile devices, including cellphones, iPads, or laptops – enabling access to healthcare 24/7 from almost any location.

During my career, I have had the privilege of working with the Veterans Administration (VA) and several rural groups to help them design and build telemedicine networks to provide the medical services they need.  By enhancing the quality of care available, and reducing the time to reach it, the rural groups have greatly improved healthcare and recovery for people in their communities. The following are some popular telemedicine applications they incorporated in their networks.

1. Staffing. Many rural hospitals or clinics have only 10 to 50 beds and very limited staff, including typically only 1-3 physicians, several nurses and fewer pharmacists or therapists.  They are also often the only facility in a 50 to 200-mile radius.  Thus, they provide both basic and emergency medical care for residents and visitors and thus see a wide range of medical needs.  Their staff must be “on call” most of the time – a recipe for “burn out” and difficult recruitment of younger professionals.  To resolve these staffing issues, rural communities use telehealth networks to provide resources and backup support from urban healthcare professionals, especially when the rural staff members are on vacation or ill.  This significantly enhances the work-life balance of the rural healthcare professionals and each area’s medical staff recruitment and retention.
2. Teleradiology. Both rural and urban hospitals have used teleradiology with great success.  Teleradiology sends patient x-rays, CTs, and MRIs to specialists in another location to be interpreted.  It is an effective and efficient way to use expertise such as MRI radiologists, neuro-radiologists, pediatric radiologists, and/or musculoskeletal radiologists who may not be required full-time by any one facility, but can provide invaluable services to several facilities as a shared resource.
3. Emergency Departments. The emergency departments (EDs) in many rural hospitals and clinics have established direct connections to the ED staff in larger hospitals to enable coverage and critical treatment of patients.  Stroke patients, for example, have significantly better outcomes when they receive immediate care, including from a neurologist.  Rural ED staffs can bring that neurological expertise online, using systems such as “tele-stroke.”  Similarly, obstetricians, surgeons, and other specialists are routinely aiding emergency departments hundreds of miles from their normal practice areas.  Other physicians have established “Internet only” medical practices to serve patients in rural areas and those traveling and working overseas — such as missionaries, students, tourists, and those in industries such as gas/oil, mining, logging, etc.
4. TelePsychiatry. Another group of emergency patients who currently benefit from telemedicine is those needing psychiatric care.  Mental health events occur at all hours and most psychiatric patients currently end up in police custody or emergency rooms.  TelePsychiatry can bring a mental health professional into the situation to assist the police and ED staffs, greatly reducing the danger and trauma to all and improving the results.  This has become one of the most important uses of TeleMedicine, in both rural and urban areas.
5. Pediatrics. Children typically require more specialized care than adults, yet 90 percent of pediatric specialists reside in metro areas.  For that reason, states have established TeleMedicine programs that provide video consultations among urban specialists and rural physicians. The programs began when the specialists were asked to provide pediatric consultation to emergency departments – and were so successful that they have expanded to provide ongoing pediatric services through TeleMedicine.
6. On-going care. For patients who need non-emergency, on-going care from specialists – such as for chemotherapy, kidney dialysis, asthma, speech therapy, or monitoring of seizures — frequent travel to receive care is nearly impossible, especially if it is multiple times each week.  TeleMedicine allows patients to be treated locally, with the required oncologist, nephrologist, pulmonologist, or other specialist overseeing their treatment via TeleMedicine.  In many cases, this on-going care is being provided via telemedicine in the patients’ homes, saving both the patients and their caregivers time and travel.  Placing the required equipment in the patients’ homes is relatively easy and enables close care coordination.
7. E-ICU Care. Except for the most complicated cases, telemedicine is also providing advanced care in rural hospitals through connections to intensive care units (ICUs) in larger hospitals.  This is important because patients transferred to a hospital outside of their community face a number of challenges, including the distance to the larger medical facility.  When the closest larger hospital is 50-200 miles away, the several-hour drive to reach it is dangerously long when one is ill, has significant injuries, has recently had surgery, or needs specialized surgery.  Even if patients are transported by air ambulance, the distance makes it difficult for family or friends to accompany them or visit them during the distant hospital stay. The problem is further complicated because: many rural residents are farmers and ranchers, who require someone to care for livestock, etc. while they are away and 55-85 percent of the patient population in many rural areas are elderly.  It is a tremendous asset when patients can receive specialized care locally via TeleMedicine networks rather than having to be transferred to a distant medical facility for care.
8. Follow-up Care. Finally, when transferred patients return home, they still need care, perhaps even long-term care and/or high-level rehabilitation services that do not readily exist in rural areas.  The long distances can turn a one-hour appointment or follow-up treatment into an all-day trip. The TeleHealth networks have brought solutions to these areas, resolving many of these care issues.

Some of the roadblocks or challenges faced by the rural communities in developing their TeleMedicine networks include:

1. Regulatory Requirements. The licensing of medical persons is managed by each state and the credentialing of staff is managed by each facility.  While important for quality control, these regulations make the provision of TeleMedicine services across state and county lines difficult.  To accommodate the current TeleHealth solutions, cooperative agreements have been drafted and approved by all entities.  The “Internet” medical practices are also changing this.
2. Reimbursement. Accessing medical specialists clearly impacts the cost of healthcare for the patient, the rural facility, and the urban facility.   The specific impact depends on factors such as the type of care required, the seriousness of the event, and whether the cooperative agreement between the medical facilities is “on-demand” or “on-going.”  “On-demand” means that specialists are called only “as needed.”  It is less capital-intensive because the specialists are involved for shorter times, but it does not develop the sense of camaraderie and cooperation built between the facilities with the “on-going model.  The second model, “on-going,” provides constant patient monitoring by the specialist watching via monitors and reviewing data, such as with the e-ICU service.   The Return on Investment (ROI) for each facility also depends on whether that medical facility is “non-profit,” “for-profit,” “critical access hospitals,” or “Medicare Prospective Payment System” hospitals.  For the patient, telemedicine depends on whether he/she has medical insurance, what type, and whether the services are “in-network” or not.  For example, Medicare limits the geographic and practice areas where beneficiaries may receive services, the types of services that may be provided via telehealth, and the types of technology that may be used.  This is outdated and needs to be updated.  What is known is that telemedicine saves money and significantly increase the level of care in much less time.
3. Infrastructure. A third hurdle is that not all rural communities and patients have the needed communications infrastructure to make TeleMedicine work.  Many rural areas still lack sufficient Internet bandwidth, cable, and phone service to support TeleHealth, especially as more services “go to a cloud.”  However, since federal, state, and local agencies have become aware of the significant benefits of TeleMedicine, various programs have been established to improve rural communications infrastructures.  These include, but are not limited to: the Rural Development Program run by the Rural Utilities Service (RUS), the Rural Development Telecommunications Program run by the United States Department of Agriculture (USDA), and the Rural Health Care Program, funded by the Federal Communications Commission (FCC), that have partnered with hundreds of telecom providers across the US “to fund broadband infrastructure to meet the TeleMedicine needs of rural communities.”  On June 19, 2018, the FCC voted unanimously to increase the funding for the Rural Health Care Program by $171 million – from $400 million to $571 million.   The program’s previous funding cap of $400 million was set in 1997 and current costs have outpaced that cap.  The new cap adjusts for inflation and will apply to 2018 funding so that rural health care programs can expand.  Any unused funds can be carried forward to future years.  The American Hospital Association (AHA)’s Executive Vice President Tom Nickels stated that, “This funding is critical to improve the lives of rural Americans, now more than ever, since innovations in healthcare demand connectivity for TeleHealth, remote monitoring, patient engagement and daily operations.”