‘Screen-side manner’

For more than a decade, Betty Lowe counted carbs, attended diabetes classes and faithfully took her prescribed medications, yet she was unable to get her blood sugar under control.

Frustrated, the 59-year-old Hillsville resident readily agreed when her primary care physician suggested a telehealth consultation with a University of Virginia endocrinologist. “I would have tried anything,” she says. “I was desperate.”

Lowe’s virtual appointment with U.Va.’s Dr. Richard Santen took place last December at the Tri-Area Community Health Center in Laurel Fork, nearly 200 miles southwest of Charlottesville in remote Carroll County.

Lowe expected the video consultation with Santen would be impersonal, but she was pleasantly surprised. “He was very warm,” Lowe recalls. “I felt like I was actually sitting in the room with him. As he talked to me and asked me questions, he learned where my lack of knowledge was and filled in the gaps pretty quickly.”

Santen adjusted Lowe’s medication to her lifestyle and gave her a telecare monitor to check her sugar levels. The device runs on cellular signals and transmits the numbers to Santen’s office in Charlottesville. Today, Lowe’s diabetes is under control, and she regularly speaks by telephone with Santen, whom she has never met in person. “I feel like I know my doctor and have a relationship with him,” she says. “He’s not that person four hours away from me. He’s my doctor, and he knows me.”

Lowe is among thousands of rural Virginians living hundreds of miles from specialized care providers. Budget constraints and low patient volumes often limit the ability of community hospitals and medical facilities in less-populated areas to attract primary care physicians. Recruiting specialists, such as neurologists, neonatologists, psychiatrists and cardiologists, is even tougher, meaning patients must travel to distant sites for specialized care.

However, travel time has substantially dwindled as a growing number of health care systems harness broadband and wireless technology to deliver critical medical care to patients regardless of their locations.

Telehealth electronically transports doctors to remote clinics, community hospitals and even patients’ homes, where they can review test results, including radiologic images and CT scans, make diagnoses and recommend treatment. Stroke victims can be quickly diagnosed and administered lifesaving drugs, premature infants can be sent home earlier from neonatal intensive care units, diabetes patients can undergo vision screenings for diabetic retinopathy and psychiatrists and counselors can provide mental health therapies.

According to the American Hospital Association, more than half of U.S. hospitals use video and other technologies to reach patients. That number is projected to grow over the next few years due to increased demand for accessible health care services and technological advancements that make it easier than ever for patients and physicians to connect remotely.

Bridging the miles
“Telemedicine bridges the miles between patients and care,” says Dr. Karen Rheuban, director of the University of Virginia’s Karen S. Rheuban Center for Telehealth, which she co-founded in 1996.

The U.Va. center has served more than 100,000 patients in 60-plus clinical disciplines at 150 sites across Virginia, one-third of which are in rural areas. Rheuban estimates that telehealth has saved Virginia patients more than 20 million miles of driving. 

Initially focused on rural areas, U.Va.’s telehealth program has expanded to wherever there is a shortage of specialists. For example, hospitals in Northern Virginia and Waynesboro, as well as Southwest Virginia, participate in U.Va.’s telestroke program. Through video conferencing, U.Va. neurologists review CT scans of possible stroke patients and talk to the patient and emergency room personnel to determine a diagnosis. One recent stroke patient was diagnosed remotely by U.Va. doctors and received the clot-busting drug tPA within 27 minutes of arriving at a community hospital.

“The longer it takes for a stroke patient to get access to medical treatment, the poorer the outcome,” she adds. “We’ve seen amazing outcomes in more than 10 years of doing telestroke services. Patients are evaluated and treated as quickly as if they had come to the U.Va. emergency department.”

U.Va. recently launched a remote monitoring program to check on patients dealing with heart disease, diabetes and stem cell replacement. “It’s an incredible opportunity to better manage patients outside bricks-and-mortar facilities,” Rheuban says. “We can track their vital signs and intervene before they have a critical situation and have to be admitted to the hospital.”

Remote monitoring also decreases the time premature babies or newborns with health issues spend in neonatal intensive care units. “Ordinarily, they would have to stay in the NICU to gain more weight,” Rheuban says. “But we can monitor infants once they get home using iPads. It’s better for the family and lowers the cost of medical care.”

iPatients
Sentara Home Health, which implemented telehealth about 10 years ago, was the first Hampton Roads health care group to do remote patient monitoring, leading to a decrease in emergency room visits and hospital readmissions. Patients use a laptop computer or iPad to measure their blood pressure, pulse, weight and blood glucose. The results are sent to home care nurses who electronically monitor their vital signs.

“We really view telehealth as a way to improve quality, improve service and help lower costs, thus increasing the value of the service we deliver,” says Jordan Asher, senior vice president and chief physician executive for Sentara Healthcare.

With Sentara MDLIVE, a cloud-based software platform, patients can have virtual appointments with physicians and therapists without leaving home. Another service, MyChart, lets Sentara hospitals, doctors’ offices, and other health care sites have secure, electronic access to patient medical records.

“We look at telehealth as a way of solving logistical issues,” Asher adds, noting that MDLIVE has about 100 visits per month, while 413,000 users access MyChart. “We think about it as how do I keep you well and how do I take better care of you when you’re really sick. It gives patients options.”

Ellen Powers used MDLIVE when she could not get in to see her primary care physician for what she feared was a recurrence of impetigo, a highly contagious skin infection. “I would absolutely do it again,” says the Virginia Beach resident, who works with babies at risk for developmental delays. “Speed is what made a difference to me and why I so appreciated it.”

Technology also helps Sentara treat nearly 10,000 of its sickest patients in ICU beds annually through eICU. Intensivists and specially trained nurses working at a central location use high-resolution cameras, monitors, alerts and two-way communication links to check vital signs, X-rays and lab results and communicate with physicians, hospital staff, patients and family members. 

A growing number of telehealth services also focus on mental health. The Steven A. Cohen Military Family Clinic at The Up Center in Virginia Beach offers virtual counseling for individuals, couples and families, and telehealth group therapy may be added in the future. “Some people feel more comfortable being in their own home,” says Iman Williams Christians, the clinic’s director. “It makes them more willing to enter therapy.”

Telemedicine has also alleviated the scarcity of psychiatrists in rural areas. “Telemedicine extends psychiatrists’ reach,” says Steve Morgan, chief medical information officer for Roanoke-based Carilion Clinic. “A rural patient’s primary care doctor initiates a psychiatric consult over telemedicine. It’s a learning opportunity for the primary care doctor in treating mental health.”

Etiquette lessons
Carilion implemented telemedicine in 2016 and has expanded it to include skilled nursing facilities, telestroke and pediatric specialties. “This is a way to extend care in a more collaborative way to our communities and patients,” Morgan says, noting that most U.S. health systems place digital health among their top three priorities. “It saves travel times, and communities are starting to ask for this service.”

To bring physicians up to speed on technology and virtual etiquette, Carilion has begun teaching how to practice medicine on-screen, via video. “It’s a learned skill to some degree,” Morgan says. “The folks who do this more frequently teach others.”

Telehealth education has not been required in any medical or nursing school curriculum, notes Tina Gustin, director of Old Dominion University’s Center for Telehealth Innovation, Education and Research. “Most people realize that’s a problem. You have practitioners suddenly using telehealth who have never been trained in it. Everybody is scrambling to catch up.”

Health care students from ODU, Eastern Virginia Medical School, Virginia Wesleyan University and Hampton University participate in interprofessional education at the center, learning telehealth etiquette — or what Gustin refers to as “screen-side manner.”

That includes wearing neutral colors, engaging in small talk with patients and refraining from shuffling papers or looking down. “We remind students that they are not text-chatting with friends,” she says. “Little movements are incredibly distracting on telehealth.”

Along with etiquette, ODU also teaches state policies governing telehealth. “The policies and regulations are changing rapidly,” Gustin notes. “New graduates and providers in the community need to know them.”
Connectivity is also an issue in many rural areas. More than 600,000 Virginians do not have broadband internet service in their homes, says U.Va.’s Rheuban, adding  that the Federal Communications Commission has a $100 million Connected Care Pilot Program to help defray costs of bringing broadband technology to selected rural areas. “We think this will be a transformative opportunity for us to evaluate the delivery of remote monitoring tools in homes for underserved populations.” In addition, the Virginia General Assembly created the Broadband Infrastructure Loan Fund to help remote communities improve their broadband availability.

Earlier this year, the legislature passed a bill requiring insurers to cover remote patient monitoring. State employee health plans have included telehealth coverage for years, notes Gene Raney, director of the Virginia Department of Human Resource Management’s Office of Health Benefits. Two of the state’s three self-insured plans contain telehealth options. “The only challenge is to help people understand it’s available in a way they will recall and try when they are sick,” he says. “A lot of times for something like this, it’s a matter of a co-worker trying it and having good success.”

For Betty Lowe, who was able to have brain surgery for a malformation after getting her sugars under control, that success was lifesaving. “I’m doing awesome,” she says. “Telemedicine saved my life.”