Small Town to a Big City — 7 Telemedicine Practices From a Rural Hospital

For patients living in rural areas, access to specialty care can be hard to come by. Cardiovascular, neurosurgical and orthopedic specialists may be separated by miles in rural areas. The separation makes telemedicine services vital for administering specialty care.

Lake Chelan (Wash.) Community Hospital is located in rural North Central Washington State. In the past, LCCH has struggled to employ in-hospital specialists to provide patients with specialty care. Kevin Abel, CEO of LCCH, explains, "The primary motivation was to improve the health of patients in rural North Central Washington. Our hospital is a smaller critical access hospital and there are not as many specialists in the area." Mr. Abel and LCCH's CIO, Ross Hurd, knew that telemedicine services could literally bridge the gap between patients and care.

One of the first areas in which LCCH implemented telemedicine was radiology. Before telemedicine, LCCH shared one traveling radiologist with four other hospitals. The radiologist would spend the day consulting and treating patients, reviewing the images and scans and then reporting the results. "Having one radiologist was taxing on the radiologist but also on the patients and physicians," says Mr. Hurd.

Thanks to telemedicine, LCCH can now route images, ultrasounds and CT scans to Virtual Radiologic, a national radiologic practice which partners with local radiologists and hospitals to provide care. Instead of one radiologist traveling among the hospitals, images are automatically routed to a radiology center outside the hospital. Any number of radiologists can then view the image and make reads. The radiology staff then uploads to the hospital information system, CPSI, and notifies the referring physician. Technically, the radiologist could be anywhere with a stable internet connection. "It used to take the radiologist several days to get around whereas now physicians can receive images and reports within minutes," says Mr. Abel.

Similar telemedicine services have been set up for other departments as well.
LCCH's stroke program uses Swedish Medical Center's telestroke technology and the pharmacy utilizes a telepharmacy service with pharmacists around the world.

The telemedicine services have given LCCH many positive outcomes. Most importantly, patient outcomes have improved. LCCH can offer patients specialty care at quicker rates. Stroke patients have survived strokes because the Telestroke Technology allowed access to physicians in Chelan as well as neurologists in Seattle.

Lake Chelan is not an exception in its telemedicine accomplishments. Other hospitals — in rural or urban settings — can imitate LCCH's success with the following seven best practices.

Apply for grants. LCCH has been aggressive in searching for grants to fund their telemedicine services. In 2003, LCCH received the USDA Distance Learning Telehealth Rural Utilities Service Grant to build a telemedicine service linking radiologists to patients. One grant opened the door to others. The hospital used the outcomes of the radiology service to improve its applications for other grants. They have received the USDA grant every year since 2003. LCCH has continuously researched and applied for grants over the past nine years to receive almost $3 million in funding for Washington State.

Build community support. Mr. Abel believes part of LCCH's success in telemedicine is due to the Chelan community. LCCH received strong community support for one of its services — digital mammography — before the service was fully implemented. When the service was available, LCCH had already educated the community, made them aware of how local mammograms would change and what the value of the digital version would be. The community adopted the digital service with more vigor and LCCH could continue to afford the service due to the high level of activity it saw — 528 studies — a large number by rural hospital standards. "It always seems to fall under the umbrella of 'if you build it, they will come,' and the community did. They really appreciated the digital mammography [once they tried it]," says Mr. Abel.

Create an implementation committee. An internal implementation committee can guide the integration of new services while keeping costs down because with a committee, the need for consultations may be less. According to Mr. Abel, a hospital should create an implementation committee of not just of IT staff or hospital staff but also of physicians. "You need everyone's input and assistance for the best outcomes," says Mr. Abel. "You should also include clinical staff in the design and implementation. Adding telemedicine to a hospital needs to be an enterprise wide effort."

Set appropriate goals. Both Mr. Abel and Mr. Hurd attribute the success of LCCH's radiology telemedicine service to clear and appropriate goals. "Our ultimate goal was to improve patient care through access to specialists," says Mr. Hurd. "The goals guided our implementation and our benchmarks. Achieving each benchmark helped the overall program — through the whole process we knew where it was headed and now we have multiple telemedicine programs." For example, in 2003 when LCCH received its first grant, the steering committee formed at that time did not realize all rural hospitals were without their own local radiologist. Before LCCH could utilize the grant, a system had to be designed to freely route studies between each hospital but not to outside resources. Mr. Hurd had to build a network to connect members and outside resources. "It took a little backtracking and redesign time, but the project continued and is still widely used," says Mr. Hurd. If the committee had begun with the goal of creating a network, instead of receiving funding, Mr. Hurd may have avoided backtracking and redesigning.

Build your own network. Mr. Hurd recommends building a network for the telemedicine service to control costs. "The leading factor for the success of our telemedicine was being able to utilize the radiology network while keeping the [network set-up] affordable," says Mr. Hurd. "Our first network was point to point and it was too expensive. We had one vendor and we had to buy circuits to establish connectivity — it was limiting our speed because we could not afford too much bandwidth." To keep costs affordable, Mr. Hurd started with local hospitals and redesigned cabling, switches and routers to support telemedicine services 24/7. "I wasn't going to be able to drive to each site to resolve network problems, but if built correctly, I could support all the services from the one location," says Mr. Hurd. “Otherwise, the IT team would have to grow to support the services, which would have created too more overhead.”

The next step was networking across the public internet connection using various local service providers. "This is where virtual private network tunnels come into play. The tunnels encrypt the traffic so only the members would be able to see the data. [VPN] creates a very secure network," says Mr. Hurd. Since Mr. Hurd was able to build a network from the ground up, LCCH could provide affordable telemedicine services. Once the design became a common platform that provided critical care, the hospitals contracted with ConnectMD to provide a true 24/7/365 support staff to monitor the internet connections.

Training drills. Mr. Hurd recommends training clinical staff on the telemedicine services so they are informed and are confident operating the devices. "Create simple, clear instructions for the training. When the clinical staff is given time to practice, later issues are more resolvable. Real-time in the hospital is time sensitive so avoiding mistakes is crucial," says Mr. Hurd. "I also recommend training without the IT staff present. They will not be there in real-time. It is best to train in as real of situations as possible."

Disaster practice. LCCH practices mock drills randomly throughout the year to determine if the clinical staff is current in knowledge and training to utilize all the Telehealth and Telemedicine.  LCCH also conducts once-a-year disaster training to prepare for scenarios such as system breakdowns, Internet disruptions or natural disasters. "As [a] service becomes more electronic — more telemedicine based — it is important to go through scenarios. What if you cannot access the hospital's server? If you have to access the back-up system, what will change? You have to prepare for these scenarios so they are not debilitating in real-time," says Mr. Hurd. You cannot prevent disasters or technological issues, but as Mr. Hurd says, you can prepare for them by practicing. "Practice is neither expensive nor difficult. It could save your hospital's telemedicine services down the road."

LCCH's venture into telemedicine created services in radiology, cardiology, mammography, stroke care and other specialties. The hospital maintained a selective business model, worked as independently as possible and remained in the black financially. The hospital achieved success because of the above seven best practices.

Other hospitals, in small towns or big cities, can implement telemedicine within their budgets as well; it just takes focus, clear goals and adherence to best practices.

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