Telemedicine Revolution Needed In Rural Health Care

MHA finalist for $25 million grant that could cut costs and improve care by linking local doctors to specialists in real time


Telemedicine could save both lives and money in places like Rim Country, where emergency helicopter rides to the Valley can easily result in $20,000 in additional costs that could be avoided if local doctors could get expert advice and diagnosis in real time.

Telemedicine could save both lives and money in places like Rim Country, where emergency helicopter rides to the Valley can easily result in $20,000 in additional costs that could be avoided if local doctors could get expert advice and diagnosis in real time. |

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Dr. Alan Michels can still vividly recall the heart attack patient he saved thanks to the clamor of angels on his shoulder.

Well, not angels exactly — cardiology specialists, actually, who provided all the expert advice in real-time needed to save a patient who had essentially dropped dead.

A former engineer and emergency room nurse, Dr. Michels was then just an intern — with the nerves, but not the knowledge needed to save the patient.

Fortunately, the team of heart experts fed him a stream of urgent commands as they watched him work and assessed test results through a video and voice link.

“I coded him with cardiologists over my shoulder. The patient had essentially dropped dead and the paramedics brought him in.”

Dr. Michels revived the patient, who later underwent successful heart surgery.

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Dr. Alan Michels

That vivid memory helps account for Dr. Michels’ current excitement about the prospects of the huge leap into the future Rim Country doctors and patients will make if the Mogollon Health Alliance lands a $25 million federal grant to establish an integrated telemedicine system in Payson. That system would connect local doctors, nurses and therapists with teams of specialists in far-flung centers.

Even without the grant, the use of digital medical records and real-time links between local doctors and medical centers in Phoenix, Tucson and elsewhere have helped transform care locally — and compensate for the debilitating shortage of specialists in rural areas without the patient base to sustain the practices of neurologists, heart surgeons, cardiologists, rheumatologists and others.

However, the grant could result in dramatic advances, since it would underwrite an effort to not only connect many local doctors with specialist teams — but to convince health insurance plans to change the way they pay for the time and expertise of physicians and other health professionals.

The idea could save both lives and money in places like Rim Country, where emergency helicopter rides to the Valley can easily result in $20,000 in additional costs that could be avoided if local doctors could get expert advice and diagnosis in real time.

One such example was included in the Mogollon Health Alliance grant — which has already made it through two screenings and is now one of 50 finalists nationwide. That case involved a local man who had quit taking his blood pressure medications because he didn’t have a local doctor to renew the prescription. Feeling lightheaded, he took his blood pressure at home only to discover it was extremely high — one side effect of abruptly stopping many blood pressure medications. He went to a local clinic on the assumption a doctor there could renew his prescriptions.

Instead, the EKG at the clinic revealed a sharp spike in the electrical signals generated by the heart, suggesting the man was actually having a heart attack. Acutely aware that Payson lacks a cardiac cath lab or anyone who can perform open-heart surgery, the clinic doctor called in the paramedics who rushed the patient to the helipad for a $17,000 flight to the Mayo Clinic in Scottsdale.

There, doctors did a new EKG and discovered that the EKG in Payson had been miscalibrated, making the diagnostic spike look much higher than it actually was. Some $35,000 worth of medical costs later, doctors concluded the patient wasn’t having a heart attack after all.

The Mogollon Health Alliance hopes that the federal grant will help avert such cases by making it possible to perform a much more definitive and accurate assessment of patients during real-time consultations with experts in other cities before deciding whether to call in the helicopter, said Michels, who helped prepare the grant application.

“Virtually everyone agrees that the current health care and wellness system in rural America is broken,” wrote Mogollon Health Alliance Board Chairman Kenny Evans in the grant application. “The total system cost is exploding out of control and is unsustainable. The difference in the quality of care available in rural versus urban areas is unacceptable.”

The MHA hopes to create a telemedicine hub that will serve a wide expanse of northern Arizona. The grant targets an area covering nine Arizona counties with a population of 612,000. That region suffers from much higher rates of poverty and lack of insurance than either the rest of the state or the nation as a whole. The ranks of the uninsured range from 9 percent to 32 percent, depending on the county. The average income in those rural counties lags 20 percent behind the national average, with a full third of the households making less than $25,000 — half the national average household income. The region also includes an unusually high number of impoverished seniors and women raising children with no husband present — all challenges when it comes to obtaining health care.

Because of the mountainous terrain and long distances between hospitals, the rural counties log 300,000 hours annually of medical helicopter transport. If a comprehensive system could avert just 10 percent of those flights, it would save $750 million annually, the grant application concluded.

The system would allow doctors in their offices to consult with specialists — sometimes with the patient present. The specialists can then suggest specific tests or direct the physical examination, saving the patient a trip to the Valley and focusing on just the right tests — rather than a shotgun approach.

Dr. Michels offered examples of the potential savings and improved care, based in part on his work currently in a Movement Disorder Clinic at the Payson Regional Medical Center, where he works to treat and rehabilitate patients with aliments like Parkinson’s disease as part of the University of Arizona’s telemedicine program. The clinic includes a real-time video link with specialists at Banner Good Samaritan in the Valley.

The specialists talk Dr. Michels through the exam and necessary tests to track what the patients need.

“As a result, my ability to recognize conditions has dramatically improved,” said Dr. Michels, who was recognized recently in a poll of Roundup readers as the top doctor in Rim Country.

The Mogollon Health Alliance now hopes to involve many more doctors in such collaborative networks. That could result in a big improvement in patient care — while actually cutting costs.

As an illustration, Dr. Michels offered an example of the complications a general practice doctor in Payson faces when confronted with a patient with shoulder pain, given the area’s lack of a rheumatologist or endocrinologist.

“So I get X-rays and a $4,000 MRI. Then I send you to a specialist. But it takes two months to get in to see the specialist down in the Valley. Turns out, I ordered the wrong kind of MRI. So he gets another MRI. And you go back again. But it turns out that you need a rheumatologist (for an auto-immune problem like arthritis). Well, that’s another two months — and a new set of tests.”

After all of that, the full information on the ongoing treatment might not make it back to the local Payson doctor who must manage the patient’s care in the long term — and worry about the interactions of treatments and drugs for other disorders.

By contrast, the new system would allow the general practice doctor to make the initial assessment and then set up a video conference with a team of specialists. Those specialists will suggest a targeted set of tests that will pinpoint the problem. Once those results come back, the team convenes again by the video link, which allows everyone to examine the test results and decide on the next step. The system would also digitize health records, so everyone on the team could check for the influence of other conditions. That would also make it easy to check potential medications for interactions through increasingly sophisticated computerized screening programs that look for potentially dangerous or confounding interactions.

“We’re talking about reworking how the whole system works,” said Dr. Michels. “It also expands the knowledge base of the local doctor — and probably results in more tests done locally.”

It would also prevent patients from getting shuffled from specialist to specialist — with months of frustrating delay and repeated trips to the Valley between each referral.

The system ultimately depends on also altering the way insurance companies pay doctors — which is why the Mogollon Health Alliance wants to create a pilot program to convince insurance companies to try new rules on a small scale.

“We have some really good ideas. We need some evidence-based medicine to prove this can really be done,” said Dr. Michels.

Currently, the U.S. medical system mostly pays doctors for each office visit, procedure and test. The emphasis on paying for procedures generally means specialists get paid far more than general practice doctors. But that’s only true if the patients go to the office of the specialist or undergo procedures. The system pays little or nothing for the time and expertise of doctors who provide advice and consultation. Therefore, making the telemedicine system work would require insurance companies to pay the out-of-town specialists for the time they spend in the consultation and reviewing the tests. In theory, those payments would save the insurer money in the long run by avoiding the wrong tests or unnecessary medical helicopter rides.

“When you start proving you can find savings, then the insurers will get very interested,” said Dr. Michels.

As an example, he cited a recent Veterans Affairs study of wound care in a rural area. In this mountainous rural area, the VA wound care specialist made house calls on veterans recovering from wounds. Due to the travel times, the specialist could only handle about four cases per day. So the VA trained nurses to make the house calls and check on the wounds using video conferencing that connected them to the wound specialist at the medical center. The nurses had cameras to let the specialist take a real-time look at the wound, to monitor the examination and talk directly to the patient, all mediated by the nurse.

As a result, the specialist could check on 34 patients a day instead of four — with no difference in patient outcomes. That resulted in a major savings, even when the cost of the technology and the nurses’ salaries were taken into consideration.

Dr. Michels said Payson doctors are working toward such improvements in the system, often in cooperation with PRMC. Such expert networks represent the future of rural medicine. If the MHA snags the grant, it will dramatically accelerate the trend.

“We keep having people from urban areas tell us what rural people need. What they need to hear is what does a rural community think would change this system. We’re kind of tired of the same old approach. We need to get all the parties together — and get the insurance companies to make this a special case,” concluded Dr. Michels.

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