# Presentation: 571050

## Telehealth and Rural Practices...the Road Less Traveled

**Kiki C. Nocella**
- University of Southern California
- Keck School of Medicine
- Department of Family Medicine

**Notes:**
This is in Shingletown, California.  Yes, it’s a dead jack rabbit. 

## Rural California

**Notes:**
How many of you have been to California?  How many to Disneyland?

Contrary to popular belief, California is rural

***75% of land mass***

***11% of population***

- 75% i

**75% of land mass and**
**  ****11% of population **
**live in rural California**

## Slide 4

**Notes:**
Describe what exists here
Three healthcare districts
Tehachapi Valley Healthcare District
Muroc
East Kern Healthcare District
One acute hospital
Critical Access Hospital
24 staffed beds (including SNF)
5 acute
19 swing (SNF)
ADC
Acute	1
SNF	19
ER
No OB, Surgery
Four community clinics
Tehachapi
California City
Mojave
Boron
No school based clinics
One ambulance company based in Bakersfield, Tehachapi, California City, and Mojave
2 helicopter services in California City
No formal training programs for healthcare professionals
1 “Care-a-Van” in Mojave

## Tehachapi Valley Healthcare District

**Notes:**
One site of care in the region and the only hospital in the region.

New hospital being opened in 2008 due to state seismic requirements – presented a huge opportunity to address quality and technology
Community passed a bond to fund the building of the new facility – in Calif requires a 2/3 voter approval – indicated that the community was ready to get behind a project such as the planning grant.

## State of the Region....2004

- Had a telemedicine unit since 1998
- JPA Collaborative
- New TVH built by 2008, seismic retrofit

**Notes:**
Once upon a time......

Blue Cross had installed a telemedicine unit in the facility as part of a statewide network.

Unbeknownst to me, they had been threatening to take the unit out
Had a teleradiology unit in the hospital (not in any of the other RHC’s in the region).  Although the hospital thought it was functional, the docs only had complaints about the service – amount of time to obtain wet reads, no available radiologist to read films on weekends and evenings.

Docs weren’t using the telemedicine or the teleradiology systems.  Our first sign that there was a disconnect in perspectives – neither the docs or the hospital understanding the others POV

## 98.7% outward migration for inpatient care!

**Notes:**
Hard to address chronic disease and quality of care when everyone is leaving the region to get their care!  Have to get the care back in the region.

## Support and Success for Telehealth

- Blue Cross of California/Wellpoint
- Funded through State to develop telehealth network for Healthy Families (SCHIP) and MediCal (Medicaid).
- CTEC
- California Telemedicine and eHealth Center
- UC Davis
- ....So why wasn’t it working in SE Kern?

**Notes:**
Wasn’t clear as to why telehealth wasn’t working in SE Kern.  The equipment was there, the training had occurred (again and again and again) and there existed a significant brain trust in the state

## What sites do you think of when you think of Telehealth?

- Rural hospital?
- Rural Health Clinic?
- Academic Medical Center?

-  Physician Office??????

**Notes:**
How many folks here have a telehealth connection?  Where’s it set up?

When it comes to telehealth, we usually don’t think of the individual provider in his/her own office.  We get equipment for the hospital or the RHC and then wonder why the community docs aren’t using the equipment.

## So....what was our process

- Community based planning collaborative
- Networking outside the rural region
- Capacity Building
- Lots of data gathering
- Lots of key informant interviews
- Provider  	-- Ancillary
- Admin		-- Office staff

## How did we get the docs talking?

- Trust building
- Listened, and listened, and listened
- Maintained confidentiality to a level that was virtually painful
- And the ripple effect began – the docs kept talking – to each other and testing the trust

## What the docs said (about telehealth)

- Only possible after much listening and trust building
- Show me what is possible in a way I can get my head around – and I’ll run with it from there
- Will it take revenue out of my practice?
- Will it impact my relationships with my specialists?
- My patients better not get billed anything extra (Translation – I don’t want to hear any complaints)
- What’s in it for me? (Not said, but always there)
- The hospital is just trying to compete with me

**Notes:**
Re “show me what is possible” – they let down their guard enough to say “ I’m interested – if you show me where the road is, I think this is something I can make my own”

Re revenue out of practice – this is the fundamental fear and issue – and ties directly to their belief that the hospital and RHCs were trying to directly compete.

## OK. Got the docs’ attention....but that’s not all of the challenges

## Slide 14

**Notes:**
As we moved into the transition from planning to implementation, had to look at problem issues.

Office of Statewide Health Planning and Development (OSHPD) geocoded their discharge data for all chronic diseases in the region.  Based on this, plus other quantitative and qualitative data, selected DM  as our disease of focus. 

## Community’s 

- Hospital’s business needs

- Community’s
- Health
- Needs

- Physician business needs

- Health Plan Business Needs

_**The “Win-Win” is at the center**_

**Notes:**
We worked to understand the business needs of the doctors, the hospital and clinics, and the health plans.  Each has different incentives and needs.  Until you understand them, you can’t find the solution, which lies in the center.

## So, what was the solution?

- Telehealth only part of the equation
- System redesign is the approach we’ve embraced

## Telehealth Solution

- Providers (Physicians, PAs, and NPs)
-  Basic “talking heads” 	teleconferencing
-  More as utilization 	dictates
-  Via “Integrated 	Technology Association”

- Rural Hospitals and Clinics
- Higher cost equipment
- Telehealth center that integrates with other programs

- Academic Medical Centers and other specialists

**Telehealth Solution**

-  Teach them “rural”
-  Agree to take all patients
-  Specialties that were not in     	competition

**Notes:**
Little blue circles are the docs – just as much cogs in the system as the others.

Putting the basics, at no cost, in the docs offices. 
Developing infrastructure – a vehicle to legally organize the providers, provide equipment, and conduct population based health studies   We’re calling it an “ITA” – integrated technology association.  Like an IPA but better!

Rural hospitals and clinics – we’re putting the more expensive equipment at these sites.  Eg retinal camera at 25k – docs quickly realized that they don’t have the capital or the volume to have a decent ROI for this – so are ok with the hospital or RHC purchasing it.  It doesn’t hurt their existing referral patterns since there is a shortage of ophthalmologists in the urban areas. Currently, the docs aren’t getting any followup reports when their patients do go to an ophthalmologist.  With this system, everyone wins – the doc, the patient, the community, and the hospital....and no one loses.  The docs like that!

Re AMC’s – have to “teach” them rural – at least in California.  Even with those that think they know rural.

## We’re reforming – but not around the edges!

- Infrastructure
- Give, give, give and then get a little
- Provider leadership team
- Population based quality improvement
- Start with the basics...playing nice and sharing
- Education
- Rural residency training
- Rural HIT and population health curriculum
- E-health alerts
- CME/CEU
- Some cool pipeline conversations

**Notes:**
So here’s what we’re doing:
Focus on infrastructure,  Lots of individual providers and nothing linking them.  Add to that a culture in rural providers of being fiercely independent – have to develop a structure that is “theirs” that gives them purchasing power, negotiating power, integrated systems, etc.  Need a leadership team of providers to make that work – starts with your physician leader(s).  Sometimes your wisest decision is to keep your friends close and your enemies closer.  Have to start with the basics – sharing (of data) and playing nice with each other.  Have to give them what they’re asking for, and keep giving.  We plan to give them computers and software and cameras and connectivity, and, and, and......in exchange we expect that they will collectively use the data to identify, analyze, and address specific community health issues.
Education – have to raise the water level, through education, so that everyone’s boat floats just a little higher.  Ideas come from IOM’s “Health Professions Education: A bridge to quality”   Plan to develop a curriculum that will show health professionals how to address rural quality issues through HIT, how to build infrastructure, select and install systems, and most importantly, query those systems to develop population health interventions.

## And reforming

- Telehealth – meeting the providers’ needs
- “Talking heads” at every provider’s desk
- Telehealth – meeting the community’s needs
- Diabetic Retinopathy
- Women’s health issues
- Cardiac issues

**Notes:**
Re partnering with another academic institution – there is enough here for everyone – if USC isn’t the right partner for something, then Loma Linda is.  For another, UC Irvine is making the most sense.  

Re telehealth – meeting communities needs

DM Retinopathy – data supports a focus on DM.  Have certified diabetes educator (CDE) in the community – provides a great launching off point. California Hospital Association will fund the development of FollowMe PHR for DM, which will then overlap with provider and patient education which will then overlap with telehealth strategy.  
Re women’s health issues – Kern County is 2nd worst in state for Chlamydia. No Ob-Gyns in region, nor Family Docs who do OB.  Phase 2 of our telehealth strategy focuses on this.  Phase 3 is on cardiac issues – another health challenge that our data has highlighted, 

## And reforming!

- Synergistic and overlapping approaches on technologies
- PHR
- SCDR
- Capacity building

**Notes:**
As mentioned earlier, everything we’re doing overlaps with telehealth initiatives.....eventually, everywhere you turn you will bump into the telehealth system until it becomes a normal part of every docs practice.
Capacity building.  I’m not moving to the region (though I only live an hour and 20 minutes away. Neither is Michael...though we have hopes for Jami.   We are building capacity as we work there – providing coaching, support and counseling. We are very careful not to establish unhealthy dependencies or paternalistic relationships (which academic entities often excel at!). We are partners – each with different skills and strengths.  I’ve learned more from my rural partners than I’ve given them and I truly value all they have to offer.  My job is to give them the best of me in a sustainable way, and then leave.

## Policy suggestions

- Focus on the physicians
- Count all costs, not just traditional costs
- Implement a reimbursement model that does not further fractionate an already fractionated system

## “Ultimately, the challenge of health care reform is the challenge of building community”Shortell, 1996

## Acknowledgements

- Thanks to Michael and Jami for pinch hitting with no notice!
- Thanks to AHRQ for giving this community the reason to have this, and other, conversations
- Office of Statewide Health Planning and Development – thanks for the maps!
- Gregg, Lisa, George, Adil, Atif, Julie, Bill – thanks for your wisdom
- Residents of SE Kern – thanks for being so open, willing, and dedicated
- Wish I were there 

**Notes:**
This is Route 58 right outside of Mojave