Hospital stays are among the more expensive and inconvenient aspects of health care for patients. People living in remote areas get the added unpleasantness of driving sometimes up to 200 miles to the nearest hospital for that experience. State and local public health agencies seeking to reduce the need for hospital visits might want to look at the progress of the The U.S. Department of Veterans Affairs' Veterans Integrated Service Network (VISN) 19, which provides telehealth services to roughly 1,500 veterans around the Rocky Mountain range.
"We comprise almost 28 percent of the United States, yet we have the third smallest veteran enrollment," said Jeff Lowe, care coordination telehealth manager for the VA Rocky Mountain Healthcare Network. Having such low enrollment due to small populations means the VA can't afford to place full-service medical centers throughout the region. To avoid long commutes for veterans in those areas, the agency reaches patients through three general forms of telemedicine.
One way is to install written communication devices hooked to traditional phones lines in patient homes, enabling patients and doctors to communicate. Patients report symptoms daily or as needed and doctors respond with home-care instructions. When patients type and submit their questions, the messages are routed behind the firewall of a VA office in Austin. A care coordinator -- typically a registered nurse or clinical social worker -- reads the messages and directs them electronically to the appropriate doctors. The system enables coordinators to place higher-risk questions at the top of a doctor's lineup. This way, the doctor responds to the most critical cases first.
"Patient self-management is a huge piece of this. If they're educated about their disease, they're better able to communicate with their clinicians at the medical center, and hospitalization rates go down, significantly," Lowe remarked. "Let's face it. More people want to be out of the hospital."
Lowe said the low-tech nature of the landline connection prevents the digital divide problems that sometimes accompany new technologies. Virtually every veteran with a home has a landline. "A goal of setting up telehealth applications is always to keep the technology out of the way. You want to go as simple as you can because the more complicated it gets, the more in the way it gets, and the acceptance level drops," Lowe remarked.
One might think that since the VA's network involves technology, older patients would be likely to reject it. That hasn't been the case, according to Lowe. He said 85 percent of the patients using it responded positively, and most of them were World War II and Korean War vets.
A second form of remote medicine VISN 19 uses is called "store and forward," which involves photos and the VA's electronic medical records system. The patient visits a remote facility, typically staffed by a nurse and an equipment technician. The nurse takes photos of symptoms and forwards them to a doctor via electronic medical records, which the doctor views at a later time. The doctor might refer to the patient to a specialist, adjust a patient's medication, or any number of other medical decisions.
Third, the VISN 19 offers video telehealth, in which a patient interacts directly with a physician. The VA frequently provides mental health services through the video function, but it supports numerous other forms of treatment as well. For example, the video equipment features a digital stethoscope and other types of medical probes, allowing a remote doctor do conduct checkups. Surgeons use it.
"You can do the meet and greet with a patient to develop a rapport, look at their range of motion and watch them move around the room. This way, they know what to expect in terms of surgery. After surgery, there are always post-surgical follow-ups where [doctors] want to look at the sutures and make sure things are healing well," Lowe explained.
Lowe said one of the biggest challenges of implementing a telehealth program was persuading doctors to use it. "They're very, very busy, and they don't have time to mess around with new things that aren't tried and true," he commented. Lowe found that emphasizing the potential for doctors to treat more patients in a way that added minimal strain to their schedules was the most persuasive case. "Typically, doctors are most concerned about patient welfare and good clinical outcomes."
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