Telemedicine another tool working to improve access to specialists for rural residents
A patient recently came into Samaritan Medical Center’s Emergency Department presenting with symptoms of a possible stroke. Although a CT scan was done to rule out other causes, the physician treating the patient was still not completely convinced that stroke was the correct diagnosis.
Not wanting to administer any unnecessary medication that could cause serious side effects if the patient wasn’t experiencing a stroke, the physician turned to the hospital’s new telemedicine service, which was just introduced in June.
Samaritan is one of several north country hospitals which have begun using the service, which connects the local physicians in the emergency departments with neurologists at Upstate University Hospital in Syracuse, who specialize in diagnosis and treatment of stroke patients.
The technology allowed that SMC physician to share patient data, such as the CT scan results, while communicating through a portable videoconference system with the Syracuse neurologist. The equipment was moved into the patient’s room, so the neurologist could see and speak with the patient as well.
The telemedicine connection had been made within minutes, which is critical because there is just a three to four hour window of time from the onset of a stroke when a patient can be administered intravenous tPA, a drug that breaks up blood clots and restores blood flow to the brain, said Dr. Sarah Delaney-Rowland, SMC emergency department physician.
But it’s just as important to determine if the patient is not having a stroke, because administering this type of medication to a patient who is not actually undergoing a stroke be dangerous, even fatal in some cases, she said.
In the case of the SMC patient, the emergency department physician was able to use the services of the Syracuse neurologist to determine that patient, in fact, was not suffering a stroke. Instead, the patient was diagnosed with a “complicated migraine” and was not administered the intravenous tPA, said Dr. Delaney-Rowland.
Other north country hospitals participating in the telemedicine service with Upstate University Hospital include Carthage Area Hospital, River Hospital in Alexandria Bay and Claxton-Hepburn Medical Center in Ogdensburg.
“Within minutes, a physician in the emergency department can connect with the stroke-attending physician in Syracuse,” said Dr. Delaney-Rowland. “The telemedicine allows the patient, if possible, to speak directly with the stroke doctor as well because the telemedicine equipment is brought into the exam room on a portable cart.”
The telemedicine technology allows the physicians to have collaboration, “make the diagnosis more accurate and decide on the best therapy,” she said.
Some patients may not seek care at a hospital right away after experiencing stroke symptoms at home, so by the time they get to a hospital, that three-to-four hour time frame in which a life-saving drug can be effectively administered has been shortened, Dr. Delaney-Rowland said.
“It’s very unlikely to get a stroke patient transported to a specialized center in that time frame, particularly if they have remained at home for awhile,” she said. “But this allows for faster treatment if called for and may also result in the patient staying at Samaritan, if possible.”
If a stroke patient is stabilized at Samaritan and still must be transported to the Syracuse hospital, the stroke-attending physician who had been using the telemedicine service with the emergency department physician will already be familiar with the patient’s case, said Dr. Mario Victoria, Chief Medical Officer at Samaritan.
“A stroke specialist is involved from the beginning, and if there is a need to transfer the patient, then that physician is already familiar with what the patient has experienced and does not have to run all initial tests,” he said.
The telemedicine service allows hospitals outside of large metropolitan areas, such as Samaritan, to “be a part of the specialized coverage for stroke patients” that is not typically available, Dr. Victoria said.
Upstate is the only Comprehensive Stroke Center in the region as delegated by DNV Healthcare, a national hospital accrediting body. It is also a state Department of Health-designated primary stroke center.
The partnership allows physicians at the four participating hospitals to reach and consult with a neurologist 24 hours a day, seven days a week.
“The telemedicine allows the patient to receive a higher level of care without traveling,” Dr. Delaney said.
The Fort Drum Regional Health Planning Organization, 120 Washington St, assisted in providing each hospital with necessary equipment for the partnership with Upstate Medical Center.
The agency has worked to provide telemedicine access to many hospitals and health care agencies throughout the north country. FDRHPO had worked with the Development Authority of the North Country several years ago to establish a large fiber network to support telemedicine services.
Some of the top users of telemedicine have included Lowville Medical Associates, Lowville; Child and Adolescent Wellness Clinic, Watertown; St. Regis Nursing Home, Massena; Community Clinic of Jefferson County, Watertown; and River Hospital, Alexandria Bay, according the FDRHPO data.
The number of health care providers participating in telemedicine is expected to increase significantly this year as a result of state legislation that now requires all commercial insurance companies, along with government-subsidized health care plans, to cover telemedicine services, said Denise K. Young, FDRHPO director.
“This is a huge step forward,” she said.
Although the legislation went into effect on Jan. 1, many providers are still waiting for the state to release the official telemedicine coverage rules and regulations later this year before implementing the coverage, Mrs. Young said.
“We have been long-time advocates of growing telemedicine in the north country,” said Mrs. Young. “But one issue that has been a problem is not having it covered by all health insurance companies.”
The new legislation states that insurance companies must cover medical services provided via telemedicine to the same extent as the services would be covered if provided in-person.
Since January, there have been 21 active telemedicine programs established in the region, but there are an additional 91 health care sites preparing to implement telemedicine services once the state regulations are released, Mrs. Young said.
“Our goal is to help get everyone up and running” with telemedicine, she said.
It’s difficult for some patients who need specialized care to drive a long distance to receive it, and telemedicine “gets rid of that barrier,” she said.
The FDRHPO has provided telemedicine access to numerous hospitals and health care agencies in the north country during the past several years.
“The patients feel very comfortable,” Mrs. Young said. “The providers are very engaged, they are looking at the patients and giving them their full attention.”
The same type of telemedicine service for stroke diagnosis is being used at Claxton-Hepburn Medical Center in Ogdensburg.
“We are excited to begin this partnership with Upstate to provide more advanced stroke care in our emergency department to our patients,” Nate H. Howell, CEO of Claxton-Hepburn Medical Center, had stated earlier.
Mr. Howell also added “now we are able to provide a quicker diagnosis, which decreases a potential delay in treatment. Thanks to this technology in the treatment of stroke patients, our rural location is less of a barrier to care.”
Staff at the Ogdensburg hospital has already utilized the stroke telemedicine system for several patients who have come to the emergency department with symptoms, said hospital spokeswoman Laura Shea.
Claxton-Hepburn is also in the process of establishing a telepsychiatry service for its patients in the future, Mrs. Shea added.
Samaritan has been utilizing telemedicine services in some other areas as well, said Dr. Victoria. These include pediatric cardiology in the neonatal ICU, which allows physicians to consult directly with specialists.
The hospital is also using telemedicine services for elderly residents at Samaritan Keep Home and Samaritan Summit who have a diagnosis of some type of movement disorder, such as Parkinson’s disease, he said.
The Movement Disorder Center in Rochester is partnering with Samaritan, and the service offers the advantage of observing patients in their own environment, which makes “the accuracy of diagnosis much better,” Dr. Victoria said.
Telemedicine services are also being used by north country physicians outside of the hospital settings.
Dr. Steven Lyndaker of Lowville Medical Associates has been using telemedicine for a few years to offer both his adult and pediatric patients the services of a psychiatrist from St. Joseph’s Hospital Health Center, Syracuse.
He also serves as medical director of the FDRHPO and its sister organization, the North Country Initiative, a clinically integrated network.
Dr. Steven Lyndaker of Lowville Medical Associates has been using telemedicine for a few years to offer adult and pediatric patients psychiatric services from St. Joseph’s Hospital Health Center, Syracuse.
“Telemedicine really levels the playing field,” he said. “There is no reason if you live in Lewis County that you can’t see a highly skilled subspecialist. You should not be restricted geographically.”
Dr. Lyndaker started offering telemedicine for psychiatry, also called telepsychiatry, for both adults and children who were not responding to initial treatments of medications and/or counseling.
“If a patient was not responding at that point, we would ask for help from a psychiatrist,” he said.
The majority of patients referred for telepsychiatry have been dealing with the more serious cases of depression and/or anxiety, Dr. Lyndaker said.
“Getting patients to see a psychiatrist has been challenging” in the past because there have often been long waiting lists for appointments, he said.
“Historically, about 15 to 20 percent of psychiatric referrals are no-shows,” Dr. Lyndaker said. “But people are more inclined to keep an appointment if they can be seen quite a bit sooner.”
Since implementing telepsychiatry services at his office, the wait has been decreased for both adults and children who need an appointment with a psychiatrist, he said. The waiting time ranges between two to four weeks, with the majority of patients being seen closer to two weeks from their referral date, he said.
“Scheduling a time for the telepsychiatry session is not difficult,” Dr. Lyndaker said.
The patient schedules the telepsychiatry appointment through the Lowville office, then returns for the therapy session at the same office. The Skype session between patient and doctor is conducted on 17-inch television screen in a private room.
“It’s high quality Skype,” Dr. Lyndaker said. “It’s encrypted and secure. For some patients, it’s actually less intimidating than meeting in person.”
It also saves people a significant amount of travel time that would be required to meet with a psychiatrist in person at St. Joseph’s in Syracuse, he noted
“Kids find it fascinating,” he said. “We had one child who did not want to be seen in person, but agreed to telemedicine”
The technology also benefits the physician, because it allows for better consulting on patient cases, Dr. Lyndaker said.
“It’s been a team approach,” he said. “The communication between myself and the psychiatrist is significantly better because we can also consult over the encrypted network. As a result, I receive very timely feedback.”
Norah Machia is a freelance writer who lives in Watertown. She is a 20-year veteran journalist and former Watertown Daily Times reporter. Contact her at firstname.lastname@example.org.