Written by Rod Moore

Covering 261,797 square miles, a state the size of Texas would seem readymade for the promise of telemedicine. Approximately 3,061,090 residents (or 11 percent of the state's population) live in rural areas, according to the U.S. Department of Agriculture’s Economic Research Service. Yet, the state is becoming more and more urban. As regulators clear the path and remove impediments that have long stymied telehealth’s growth, hospitals are now venturing into the territory.

While telehealth carts and associated equipment are rolling out across the state at higher frequency, no single business model has emerged as an overall solution. A state as large as Texas means a variety of patient needs are exhibited in different communities. The range of needs are significant and include consideration for margins in many service lines, areas with high uncompensated care and departments with physician recruitment gaps.

Naturally, patients and employers have been advocating for more access to telemedicine without burdensome restrictions. However, striking a balance between rules protecting patients and broadening access to care has been challenging.

In 2017, the Texas Medical Board repealed two telemedicine regulations, which allowed more hospitals to begin or expand on various telehealth models and ways of integrating telemedicine within the framework of hospital’s traditional, in-person care.

Many of the questions that once existed are gone. The initial skeptisism around the technology has given way as telehealth carts become commoditized. Today, the differentiation of one telemedicine partner over another comes down to a hospital’s desired business model. While the virtual urgent care models of MDLive and Tela- Doc tend to get more visibility because of their direct-to-consumer focus, it is lesser- known enterprise-level models that are taking hold in hospitals. Many of those are initiatives taken on by leadership teams. Others are launching telemedicine programs with partners.

To address the variety of needs in the Texas market, Access Physicians, a Dallasbased multispecialty physician group and one of the largest providers of acute inpatient telemedicine, builds telemedicine programs respective to the needs in a given hospital and its geography.


Gallagher

“We have a custom approach to every hospital in terms of meeting their needs and working with existing resources from a personnel and infrastructure standpoint, to develop really low cost, but clinically effective, programs,” said Chris Gallagher, M.D., CEO of Access Physicians.

In many cases, the primary driver for implementing telemedicine in hospitals is a concerted effort to expand or supplement a specialty need or to augment emergency care in the emergency room. In others, however, Access Physicians is working with hospital leaders to identify where opportunities for eliminating out-migration might exist. In 2013, Michael McAndrew, then CEO of what was Hopkins County Memorial Hospital before becoming CHRISTUS Trinity Mother Frances – Sulphur Springs, relented to requests from staff to consider telehealth opportunities to keep patients from having their higher acuity care needs provided by surrounding urban providers.


McAndrew

“I was excited about the prospect of doing something like that at my hospital,” said McAndrew, who now works for Access Physicians. “I was losing patients to the more urban markets. Like a lot of rural hospitals, we had a lot of patients with significant health needs like critical pulmonary issues.”

McAndrew’s team established a series of solutions using the Access Physicians platform that utilized doctors available remotely. Other hospitals, however, are using the telehealth carts as underlying technology. In either form, Access Physicians said, the solutions are driven by internal hospital leaders in collaboration.

“We were able to take care of a lot of sick patients without having to send them to other places,” McAndrew said, underscoring how telemedicine also addresses major physician recruitment challenges that come with not being able to lure physicians away from urban living options. “That means families aren’t having to travel. They aren’t having to get hotels. They stay right there in their communities.”

Homegrown Solution Emerges in Austin

Leaders of Austin-based St. David’s HealthCare began a modest telehealth program five years ago to better connect physicians to patients among their region’s seven hospital locations.



Layton

“Once we had some experience and realized the benefits—such as reduced burden of travel for the patient, as well as physician efficiencies, given the geographic region they were able to cover—we determined that we could help other hospitals outside of our healthcare system,” said Wendy Layton, director of the telehealth program, St. David’s HealthCare.

St. David’s elected to partner with InTouch Health to provide the technology platform needed to connect their physicians to other facilities. Now, St. David’s HealthCare’s homegrown telehealth model reaches over 25 hospitals in remote parts of the state. 

Partnerships Pave the Way for Streamlining Care

Starting in 2015, The Dallas Children’s Health TeleNICU program began providing the Childress Regional Hospital neonatal intensive care unit 24/7 access to the specially trained, nationally recognized, board-certified neonatologists at the Children’s Health Level IV NICU. The primary reason Childress began using a telehealth partnership was to triage patients so that only infants requiring Level IV care are transferred to Children’s Health.

The connection to Children’s is made through a mobile equipment cart that includes medical-quality videoconferencing, secure data transfer and a specialized stethoscope and camera for the physical examination.


Perry

Tamara Perry, senior director operations of virtual health and innovation at Children’s Health said the joint partnership with Childress has been successful because of strong relationships and trust between program champions and the clinical team.

“For the overall vision, the most important internal champion is executive leadership,” Perry said. “And clinical leadership is important to make sure the program is operational and engaging.”

Since the partnership began, more than 300 newborns have received high-level neonatal consultation using the technology in place, half of whom received the advanced care needed without having to be transferred.

“This (partnership) helps to build the sustainability of rural hospitals in Texas,” Perry said. “Children’s Health values relationships like these with rural hospital partners as we meet our mission of making life better for all children.”

Solutions From Far Away Places

Another comprehensive telehealth solution comes from Avera Health, a nonprofit provider in South Dakota that has become proficient helping hospitals with shortages in physician staffing through high-definition audio-visual connections right in the ER.

Brian Skow, M.D., chief medical officer, said Avera Health developed its telemedicine program 25 years ago with the initial focus on rural communities within their own local footprint.


Skow

“We have high definition audio visual connections that are hardwired into each emergency department room. And with our cameras we can zoom in up to 20 times so we can literally do a pupil exam,” said Skow.

Because eCARE is set up as a subscriptionbased service, hospitals can access the service as many times as they want. Additional remote services offered by Avera eCare include: pharmacy, hospitalists, behavioral, specialty clinic, ICU, senior care and more.

Hospitals find the peer-to-peer consultation attractive since physicians practice in isolation in many rural communities. Another component of eCARE’s service that hospitals find attractive is nursing documentation so that bedside nurses can focus on caring for the patient.

To date, six Texas hospitals have installed Avera’s monitors in their emergency rooms. Gayla Quillin, administrator at Parmer Medical Center, a critical access hospital in Friona, said Parmer's partnership with Avera eCARE has been in place since the summer of 2018. “What I liked about Avera is it wasn’t limited to one diagnosis; they are trying to give a broader spectrum of telehealth, particularly to small hospitals when we need many things,” Quillin said.


Quillin

“We average about 190 patients every month in our ER and out of those they probably access the (eCARE) service on a minimum of half of the patients, sometimes more,” Quillin said. “We’ve got access to board certified emergency room doctors who not only are helping us with our patients, but they’re helping to educate our nurse practitioners and physician assistants.”

Naturally, Skow said, it’s vital to have not only physician champions in hospitals, but nursing champions as well. “Without that initial engagement and (identifying) a champion, typically the retention of the site is not going to last.”

Aside from reimbursement, which can be the biggest barrier to telemedicine (see sidebar), Skow said other barriers are engaging the staff, including nurses and physicians, and familiarizing them with the technology.

Sidebar: Who Pays for Telehealth?

Given the promising potential of cost savings through telehealth for both providers and payers, the most significant impediment has been reimbursement and payment responsibility. Medicare has recently relaxed regulations around telehealth reimbursement approval and many states have also embraced the telehealth trend.

To avoid the complexities of reimbursement, telehealth models like Avera eCare and Access Physicians are set up as subscription- based, which allows hospitals the freedom to choose how to absorb costs.

"We chose to not make that (payment) an issue at all because we don’t transfer costs to our patients,” said Gayla Quillin, administrator, Parmer Medical Center, who chose a partnership with Avera eCare. “Plus, it was really about adding another layer of expertise and allowing for retention, quite frankly, for us.”

Access Physicians has agreements with all major Texas payors, which gives hospitals the option to cover the costs of their services through three options: pay-perclick encounters, hourly rates, or billing and reimbursement.