How Mercy is raising the national bar on telemedicine
The groundwork was laid at community roundtables, held in various Mercy markets in the Greater St. Louis area and beyond.
Over the last few years, and confirmed at recently held roundtables, residents in rural areas voiced a consensus: they wanted to stay close to home to receive care from specialists and subspecialists in larger communities for their families. With feedback in hand, hospital administrators made the decision early on: even if reimbursement wasn’t forthcoming, Mercy would invest heavily in telemedicine.
“It started with us thoughtfully looking around to ask ‘what can Mercy do for you?’ and then to see if we were in a position to match what we were able to do with what residents wanted,” said Timothy Smith, MD, vice president of research for Mercy’s Center for Innovative Care (CIC), who also treats migraine patients via telemedicine from the Mercy Clinic Headache Center in St. Louis. “Telemedicine is an obvious solution, and a range of options became an automatic success story for us.”
Smith helped Mercy, which serves 3 million patients annually, land roughly $2.5 million in grants to launch the telemedicine pilot project, with the bulk coming from USDA’s Distance Learning and Telemedicine grants for Mercy’s most rural communities in Arkansas, Kansas, Missouri and Oklahoma.
“Mercy is the ideal health system for employing telemedicine technology because we have a large geographic footprint and an interesting mix of large metro hospitals with subspecialists and rural health clinics and small critical care hospitals in remote areas,” said Smith.
SafeWatch, an electronic ICU (e-ICU) monitoring program started in 2006, is Mercy’s most mature telemedicine operation. From one center, 450 ICU beds are monitored throughout four states.
“It wasn’t the first program of its kind, but it’s the largest in the country,” said Smith.
Mercy now operates 72 distinct telemedicine pilot programs, projects and fully developed operations. Among them: cardiology, dermatology, neonatology, ophthalmology, pathology, pulmonology, psychiatry, radiology, and stroke.
“And we haven’t even built the Virtual Care Center yet,” said Smith. “That’s how ambitious this project is … to improve service delivery through telemedicine.”
Tom Hale, MD, director of Mercy’s CIC, pointed to the early and sustained success of SafeWatch for the impetus of hospital leaders deciding to invest heavily in telemedicine.
“The real testament to the program’s success is that we’re 12 percent below the anticipated APACHE (Acute Physiology and Chronic Health Evaluation) score for hospital mortality for critically ill patients by putting this program in place,” he said.
Hale also noted that Massachusetts, which enacted its own healthcare reform law in 2006, has experienced such positive response for its e-ICU monitoring pilot programs that the state plans to expand it statewide.
“It’s not there yet, but our hope is that this type of program will expand significantly,” Hale said.
Challenges and Benefits
Sufficient bandwidth remains one of few limitations to aggressive expansion of telemedicine.
“We’d like to not have any limits on what we can deliver,” said Smith. “For example, we want to extend mental health coverage to small town emergency rooms and clinics because rural areas don’t have psychiatrists and psychologists to cover emergency presentations or hospitalized patients. Also, we have some work centered on maternal-fetal medicine for high risk pregnancies, where maternal-fetal medicine specialists can connect with patients in rural areas and transmit obstetrical ultrasound pictures to specifications … perform measurements and give expectant mothers feedback on their developing babies.”
Hale agreed the perinatology telemedicine program’s partnership with a St. Louis OB/GYN group that delivers nearly 12,000 babies annually has eased the minds of many moms-to-be in rural communities. “The nurse practitioner does the ultrasound while the patient has a two-way consultation with the specialist,” he explained. “An immediate emotional connection is often made then. The patients absolutely love it, and mothers with high-risk pregnancies do very, very well.”
- Mercy has enough in-house specialists and subspecialists for telemedicine programs except neurology. As a result, Mercy has partnered with Miami-based NeuroCall to cover episodes of care for the Telestroke program, guaranteed to provide a callback from a board-certified neurologist within 15 minutes of initial contact. (NeuroCall contracts with neurologists around the country, not only Florida.)
“We have neurologists within Mercy who perform stroke consults, but we don’t have enough to cover the full range of needs just yet,” said Smith.
- The looming physician shortage has hampered the nation’s healthcare community from adequately covering specialties and subspecialties, making telemedicine an important component of a health system’s offerings to maximize talents.
“There’s an assumption that there are enough specialists and subspecialists for the population at least in larger cities, but I can tell you that across America, there aren’t enough physicians, period,” said Hale. “When we covered St. Louis patients with the Telestroke program, we had enough neurologists, but when we expanded over four states, we didn’t. Part of our goal is to bring specialists to communities that don’t have specialists and use them in a more efficient manner so we can tap into that very precious resource in the best way possible. You’ll see more health systems collaborating with companies like for-profit NeuroCall.”
- Public universities should be primary collaborators on telemedicine projects.
“Frankly, I’m flabbergasted at their resistance,” said Hale.
- Telemedicine hasn’t taken off nationwide because some health system administrators find it too challenging to provide telemedicine services over a large geographic footprint.
“Many health systems can’t provide telemedicine because there can be many administrative complications,” said Smith. “For example, our doctors have to be licensed in the states we operate, and also credentialed with the 30 hospitals in the system.”
- Another stumbling block for implementing a telemedicine program: even though it overall decreases costs and increases quality, there’s almost no payment methodology.
“Our health leadership, especially (Mercy CEO) Lynn Britton, has been courageous in his mission to push us forward because it’s the right thing to do for patients and will overall decrease costs,” said Smith. “For example, we’re looking to next year when Medicare and Medicaid won’t pay for preventable readmissions. If we can prevent the patient with congestive heart failure from being readmitted, then we’ve saved wasted dollars the healthcare system wouldn’t be reimbursed for. These devices are relatively inexpensive, and fairly cost-effective even without reimbursement from payers or the government.”
- Mercy’s e-hospitalist program for critical care hospitals doubles as a doctor retention program in rural areas.
“Some areas only have one doctor, supported by nurse practitioners, and having an e-hospitalist available via telemedicine helps keep the primary care physician at home and asleep at night,” explained Smith. “Telemedicine is allowing us to move into all kinds of applications.”
The Big Picture
In fact, telemedicine is similar to a virtual multidisciplinary clinic, said Smith.
“We’re aiming for that environment in our emergency rooms, clinics and maybe patients’ homes,” he said. “Hospice or homebound care is a perfect example. For example, if a patient in a rural community has congestive heart failure and that patient is getting on the scale every morning, along with the other vitals being monitored, our team may notice the patient’s body weight going up from water retention and call the patient to see what’s going on. Are they taking their medications? Does a nurse need to go by their home? We’d rather be proactive instead of waiting for the patient to become critically ill and end up in an ambulance to the emergency room. We can reach out to them earlier, and keep them healthier at home.”
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