Telemedicine Brings Much-Needed Specialty Care to Rural Hospitals

If you cannot recruit specialists to your rural hospital, the next best thing may be bringing them on board remotely.

Hopkins County Memorial Hospital in Sulphur Springs is working with a group of physicians and a medical technology firm 80 miles west in North Texas to leverage real-time specialist consultations to increase quality of care.

US Medical IT, based in an incubator on the University of Texas at Dallas campus, supplies a cart with two monitors, one of which is the electronic medical record while the other is focused on either the patient or monitoring equipment. The screen’s resolution allows the physician to examine the patient almost as if he or she is onsite. Physicians from Access Physician: Global Telemedicine Solutions (AP Global) use FDA-approved telemedicine equipment such as stethoscope, ophthalmoscope, and peak flow monitor to examine patients.

After a pilot test, the technology has been a fixture at the hospital since November. AP Global offers cardiology, pulmonary and emergency-medical consultations. It plans to expand the service to include neurology.

AP Global has contracts pending at three long-term acute care facilities, a surgical center, and three other acute-care hospitals.

Chris Gallagher, MD, AP Global president and cofounder, and Eduardo Vadia, a pulmonologist and assistant professor of internal medicine at UT Southwestern, say the services most in demand at rural hospitals are the three they currently offer, as well as neurology and psychiatric care. AP Global and US Medical IT plan to offer all those services.

Stephen Cracknell, US Medical IT chief executive officer, said the technology challenges were affordability and reliability. The hospital rents the cart for about $1,000 a month, which costs about $30,000 to build. Cracknell said the cart could be operated by a wireless connection, a 4G card, or can simply be plugged into a wall. He said the hospital servers recently went down and the telemedicine connection was undisturbed.

The physicians working with the Sulphur Springs hospital are doing so part-time. However, AP Global officials believe the company’s growth will allow it to hire full-time physicians in multiple facilities in the near future.

Robb Sexton, registered nurse in the hospital’s intensive care unit, said telemedicine has been a boon to the facility. He said the hospital previously relied on weekly visits from a pulmonologist, and frequently had to transfer more complicated cases to hospitals in Dallas or Tyler. He said telemedicine has allowed the hospital to keep those cases and allow convenient patient access for families.

Sexton said patients seem to like telemedicine, although many are too sedated to know the difference. He said he recently had a family raving about the service because the patient previously was transferred out of town for care.

Sexton said AP Global’s intensivists have especially improved care in the emergency department (ED). He said local physicians on-call had up to four hours to respond to the hospital. He said the cart usually is set up and the telemedicine intensivist is present by the time the patient is wheeled into the ED.

Only about 10 percent of physicians practice in rural America despite the fact that it contains nearly one-quarter of the U.S. population. Rural Americans also have greater health and socioeconomic challenges. They tend to be poorer, have more chronic conditions, rely more on food stamps, are less likely to have employer-sponsored insurance, and less likely to have prescription drug coverage, compared with urban dwellers. In Texas, some rural counties have uninsured rates as high as 50 percent.

Texas rural hospitals provide access to routine and emergency health care for 15 percent of the state’s population, but cover 85 percent of the state’s geography, according to the Texas Organization of Rural and Community Hospitals. There are areas in Texas that are more than 100 miles away from the nearest hospital. Texas rural hospitals are also shedding jobs because of government insurance reimbursement cuts.

As of 2010, there were 32 Texas counties without a family practice physician, 27 with one family practice physician, and 12 counties with physicians, physician assistants, or nurse practitioners. There were also 40 counties with one or no pharmacists. About three-fourths of the 2,050 rural counties in the U.S. include a primary care health professional shortage area. Nearly one in 10 rural counties has no primary care physician.

The shortage is even more acute for specialists. Rural areas have about 40 specialists per 100,000 residents, compared with 134 per 100,000 in urban areas. The more highly specialized the physician, the less likely he or she will settle in a rural area.

Death and serious injury accidents account for 60 percent of total rural accidents versus only 48 percent in urban areas. One reason for the disparity is that in rural areas, prolonged delays can occur between a crash, the call for emergency medical services (EMS), and the arrival of EMS personnel. Many of these delays are related to increased travel distances and personnel distribution across the response area. National average response times from motor vehicle accident to EMS arrival in rural areas was 18 minutes, or eight minutes greater than in urban areas.

One answer to provider shortages has been telemedicine, which has spread rapidly within the last decade. The number of patients cared for through the technology has risen to about 10 million people in rural as well as urban settings, according to the American Telemedicine Association.

Market analyst IHS expects U.S. telemedicine spending will grow eight-fold by 2018 to about $2 billion.

A new lobbying group, the Alliance for Connected Care, was announced in February to advocate for federal and state policy changes to encourage the industry’s growth. The group is led by former U.S. Senate Majority Leaders Tom Daschle, Democrat from South Dakota, and Trent Lott, Republican from Mississippi. The group’s members include health care and technology giants Verizon, WellPoint, CVS Caremark, Walgreens, and Dallas-based Teladoc.

Counties with 75,000 or fewer residents are considered rural. Hopkins County has about 35,000 residents. About half of U.S. rural hospitals use telemedicine to close gaps in specialist care. Thirty-five state Medicaid programs reimburse for telemedicine, including Texas. Texas is also one of a handful of states that mandates private insurers reimburse for telemedicine. Texas Insurance Code generally requires healthcare coverage providers to treat telemedicine consults as if they had occurred in a face-to-face environment.

Steve Jacob is founding editor of D Healthcare Daily and author of the book Health Care in 2020: Where Uncertain Reform, Bad Habits, Too Few Doctors and Skyrocketing Costs Are Taking Us. He can be reached at