The Boise, Idaho-based Saint Alphonsus Health System has developed multiple applications for telemedicine among its four-hospital, 714-bed integrated healthcare system that have, as of January this year, saved the system $1.7 million in medical transport (life flight or ambulance) costs and has allowed more patients to be treated in their local communities.

Close to five years ago, Saint Alphonsus began developing its telemedicine network from a Telemedicine & Advanced Technology Research Center (TATRC) grant, funding a program to deliver nursing education to rural communities. The program grew organically from there. “We wanted to develop multiple applications for a single technology so we didn’t have a piece of equipment that wasn’t being used very frequently, and so the project would be more sustainable,” says Tiffany Whitmore, director of system development and telemedicine, Saint Alphonsus Regional Medical Center (SARMC).

Saint Alphonsus now has 16 video conferencing devices (from the Santa Barbara, Calif.-based InTouch Health) in 12 sites that provide a broad swath of medical and social inpatient and outpatient specialty services that include telepsychiatry, maternal fetal medicine, oncology, dermatology, wound management, orthopedics, endocrinology, sign language interpretation, and even genetic counseling.

“We’re in a rural area in Idaho and eastern Oregon, so a lot of the hospitals don’t have access to specialists that are available in an urban center,” says Whitmore. “So we’re using technology to extend that specialty expertise and try to keep care local when possible.”

Beyond the $1.7 million in medical transport savings, Saint Alphonsus’ telepsychiatry program has saved patients 587,932 miles in travel through December 2011, which equates to $293,966 dollars in savings (calculated at $.50 a mile to the nearest in-person provider).

Saint Alphonsus has grown its telemedicine organically keeping with its mission of providing the services its patients need. Doug Romer, executive director, patient care services, Grande Ronde Hospital (part of the Saint Alphonsus system), says that there were services that Saint Alphonsus could not provide, which spurred Grande Ronde to look elsewhere. “We’re not just developing these programs because we can,” says Romer. “If there are patients who need the service, and we can find the provider, and we can prevent them from traveling, that’s how we grow the service.”

Intensive Care Consults
Grande Ronde Hospital is a 25-bed critical-access hospital in northeast Oregon that has won the ECRI Institute Health Devices Achievement Award for its five-year-old telemedicine program that cares for 450 patients a year through 17 service lines.

“We’re not doing risky new procedures via remote presence, but a continued expansion of services that have been shown to benefit patients, benefit to the community and provides a standard of care consistent with other onsite care services,” says Romer.

One of Grande Ronde’s most successful programs is its intensive care consult program, which has provided 237 remote presence consults to 76 patients. The program is staffed by 17 ICU intensivists from Advanced ICU Care in St. Louis, Mo. In 42 months, the program has saved close to $1.3 million in transfer costs for 51 patients that would have been flown via helicopter to a tertiary care center.

“In keeping those patients here, we have kept $1,115,331 in revenue in our community, and additional patient days [in our ICU],” says Romer. “A patient is going to get a lot more healing if they are home in their own community.”

Emergency Specialist Program
The Emergency Specialist Program (ESP) initiative, with funding from a grant from HRSA’s Office for Advancement of Telehealth, includes SARMC as the hub tertiary acute care hospital and 11 EDs. The American College of Emergency Physicians has ranked Idaho 46th in the U.S. for care of critical patients, based on capacity deficits, access barriers (less than 50 percent of residents live within 60 minutes of a Level II Trauma Center), and a pronounced shortage of health professionals. ESP supplies physicians and physician extenders to rural and outlying EDs, with real-time guidance for the assessment, treatment, and potential transport of critically ill and injured patients through consults from hub-based specialists.

As of last month, 138 patients have been served by the ESP program, and utilization continues to increase. Of patients receiving consultations, 11 percent were able to remain in their local community following consultation rather than being transferred.
 
Telestroke
Stroke is the fourth leading cause of death, according to the CDC, and a leading cause of long-term disability. SARMC has been a Joint Commission-certified stroke center since 2007 and the only tertiary referral center for stroke in Idaho.

“We wanted to provide a service to that would help decrease the death and disability from stroke and getting treatment sooner is a proven way to decrease death and disability from stroke, so that was really our primary goal to treat more patients quickly,” says Nichole Whitener, health system research administrator, stroke center director, SARMC.

Before the telestroke program began last November, patients were seen in the ED and transferred to SARMC without the benefit of early treatment.

“Treatment is time dependent, so we want to make sure that patients who are candidates for treatment get that treatment as soon as possible,” says Whitener. “That’s really what telemedicine has allowed us to do, and allowed us to extend our primary stroke center out to other hospitals.”

Whitener says it is easy for a neurologist to assess a patient from a distance and identify candidates for treatment. The neurologist uses the robotic video conferencing device for different assessments: to zoom in on the patients pupils to see dilation, to relay instructions to a patient to lift their arms or squeeze the hand of the onsite clinicians, to direct a patient to repeat sentences to check for slurred speech, and to check brain cat-scans for signs of bleeding. If a stroke has occurred, then Alteplase, a drug that is typically ordered to treat stroke, can be prescribed in the recommended one to three-hour treatment window.

Three neurologists (soon four) are a part of this program and use an encrypted laptop to perform their consults. If the patient stays at the local facility, the Saint Alphonsus physician dictates into that rural hospital system’s dictation line, which is transcribed and input into the electronic health record (EHR). But if the patient is transferred to Saint Alphonsus, the physician dictates into the Saint Alphonsus system and copies the referring site. However, communication is still a challenge.

“One limitation to telemedicine is that it is difficult for remote physicians to be the admitting physician, so they have to communicate very clearly to the physicians who are going to be admitting that patient,” says Whitener. “We just need to make sure that all information is communicated.”