Telemedicine has long been touted as a cost-efficient way to provide care to people in rural areas with limited access to health professionals. But an unsung benefit of providing medical advice over a video feed is the tremendous cost-savings achieved by avoiding unnecessary air and ground ambulance rides.
Officials from Oregon Health & Science University in Portland estimate their telemedicine program has saved at least $14 million in transport costs since 2010 by keeping patients at their local hospitals.
“Kids will get transported because somebody wasn’t comfortable on the end of the phone line, so the default easy thing to do is just transport,” said Dr. Miles Ellenby, a pediatric intensivist who heads the OHSU telemedicine program. “Well, the default easy thing is very expensive.”
Ellenby said it costs at least $9,000 to transport a patient to OHSU by ground ambulance, and for those who are more than a two-hour drive away, $24,000 to transport by air. OHSU has conducted more than 2,000 video consults with patients in 14 hospitals in Oregon and southwestern Washington. Nearly half of those patients were able to stay in their community hospitals.
Since 2013, OHSU has consulted on 36 critically ill children at St. Charles Bend, helping doctors decide on appropriate treatment and whether the children needed to be transported to OHSU for more complex care.
St. Charles can also connect by video with doctors at Randall Children’s Hospital at Legacy Emanuel in Portland. Randall has conducted at least 525 video consults with six Oregon hospitals since 2012, including pediatric critical care consults and neonatal resuscitation. All three pediatric intensive care units in Oregon are located in Portland.
OHSU provides telemedicine for pediatric intensive care cases, adult stroke evaluation and newborn resuscitation.
In the past, doctors who needed such support had to call OHSU by phone and describe the patient’s condition to a specialist. That depended on the doctor’s ability to correctly assess the patient as well as the ability to accurately describe what was happening.
“Oftentimes you can hear the stress in their voice as they’re trying to describe things,” Ellenby said. “Based on that information, we’re making decisions on the initial treatment and whether or not to transport based on a limited data set.”
With telemedicine, on the other hand, the specialists in Portland can see the patient and make their own assessments. The video feed is provided via a robot that is wheeled into the patient’s room and then controlled remotely. The specialist can reposition the robot, zoom in to get a better view, or listen to a heartbeat or breathing via stethoscope.
“There’s so much value in the visual and the live-streaming component where now we can be part of the team and really see what’s going on at the bedside,” he said.
‘Facetime with a doctor’
Two years ago, just before Thanksgiving, Ellie Hoffman, a 12-year-old girl from Bend, was admitted to St. Charles Bend with breathing problems. She had a history of asthma, but had also contracted a viral infection. Unable to get her oxygen levels up, doctors moved her from the pediatric wing to the ICU and called OHSU for a telehealth consult.
“They were debating next steps,” her mother, Erin Hoffman, said, “whether she needed to go to Portland or not.”
But the OHSU doctors confirmed that St. Charles pediatricians were already doing everything doctors in Portland could do for her.
“There really wasn’t any magic pill that OHSU had that St. Charles didn’t have access to,” Hoffman said. “If they wouldn’t have had telemedicine, they would have had to send her, and it might not have been necessary.”
That likely saved the family thousands of dollars in transportation costs, something they were prepared to pay if need be, but were happy to avoid.
“It definitely did cross my mind,” she said. “But at that point, you don’t say no if they say that’s what’s necessary.”
Dr. Suzanne Mendez, who heads the pediatric hospitalist program at St. Charles Bend, said most of the telehealth consults involved children with respiratory issues, severe asthma or diabetic crises.
“We tell families, it’s like Facetime with a doctor,” she said.
Unlike Facetime or Skype, the telemedicine connection is fully compliant with federal privacy laws. If patients do need to be transferred, they’ve already met the doctors via video and know what to expect once they arrive in Portland.
Sometimes the weather is too bad to fly, and the telehealth providers can help local pediatric hospitalists and adult intensivists care for children in the ICU at St. Charles. And other times, particularly during flu season, the children’s ICUs in Portland have no available beds.
“This last winter, we had a lot of kids who went there,” Mendez said. “Sometimes, they’ll say, ‘You’re doing fine, keep doing everything you’re doing.’ But because it was such a bad viral season, most of them ended up going.”
Mendez said the pediatric hospitalists would like to have the ability to consult with other types of pediatric specialists by telehealth, and to have video connections with the smaller rural hospitals that send their patients to St. Charles.
“Just being able to see them makes such a difference in the assessment of the child,” Mendez said, “maybe someday in the future.”
The hospital has two robots sitting side by side, one from OHSU and one from Randall. Under federal anti-kickback laws, if a hospital purchases its own telemedicine robot, it can connect to anyone. But if the robot is provided by the telehealth provider, it can only be used to connect to that provider.
Meanwhile, some rural hospitals don’t have any robots, because their patient volumes are too low. It’s hard to justify the cost of a robot for two to three cases a year.
OHSU will also provide back-up stroke coverage for St. Charles. While Bend has neurologists that can accurately assess whether a patient is having a stroke and whether clot-busting drugs are appropriate, those doctors are not always available. The telemedicine service can fill in. If the patient is a candidate for a clot retrieval procedure and no doctor is available in Bend, patients can be flown to OHSU and taken directly to the procedure room, bypassing the emergency room. That time savings improves their odds of a functional recovery.
But even in stroke care, many patients can avoid being transported. Local hospitals are more adept at caring for adults than children, and in many cases, the telehealth service can rule out a stroke after a video consult.
Several years ago, OHSU neonatologists assisted by video with the resuscitation of a newborn in Silverton. After an emergency C-section, the child was not breathing, and it was up to a family medicine doctor and local nurses to try to revive the child. While doctors practice that technique on mannequins, it’s not something they’re often called on to do in real life.
The neonatologist in Portland could see that while a nurse was trying to ventilate the baby with an anesthesia bag, she was not getting a good seal around the baby’s mouth. The doctor recommended they make that a two-person job, with one person working on opening the airway and getting a good seal, and the other manipulating the bag. That did the trick.
“The fact that she was able to see what was going on and provide that corrective coaching made all the difference in the world in that baby surviving, or at least surviving without neurologic injuries because those are critical moments,” Ellenby said.
OHSU is launching a new service to provide more routine pediatric specialty visits via telemedicine. Children with diabetes, for example, should see a pediatric endocrinologist every three months to ensure their condition is well-managed. For most that means a drive to Portland.
“That’s the kind of visit that can happen over video with a patient that you already have a relationship with, where you don’t need a full physical exam,” Ellenby said. “It’s mostly a cognitive visit.”
Despite the potential cost-savings, health care regulations around telemedicine present plenty of barriers to wider use. Doctors need to have privileges at the community hospital to consult via telemedicine, but not by phone. OHSU specialists must go through a credentialing process with each of the 14 hospitals they serve. Neonatologists who provide newborn resuscitation support to a hospital in Longview, Washington, also need to be licensed in that state.
“Bureaucratically, it’s a bit of a headache,” Ellenby said. “I like to say, we have 21st Century medicine with 20th Century regulation.”
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