Rural hospitals moving into the future
Technological innovations may offer solutions to the challenges facing rural hospital medicine.
Picture a small, rural hospital. Do you envision holograms of specialists meeting with patients? How about robot arms doing ultrasounds? Or hospitalists updating order sets from hundreds of miles away?
Obviously, this is not how most rural hospitals function today. But such technological innovations are in the works and may offer solutions to some of the problems currently facing rural facilities.
Those problems pose an existential threat to small rural hospitals. “One hundred and forty-nine hospitals have closed since 2010, they estimate, and it's well above 200 that are at risk,” said Keith Mueller, PhD, director of the Rural Policy Research Institute and a professor of health management and policy at the University of Iowa.
At the same time, recent events have highlighted the continued importance of these facilities. “The pandemic especially showed all of us how important it was to have these hospitals open. All of us put together didn't have enough beds to take care of these patients,” said Raji Kumar, PT, MBA, CEO of Crescent Regional Hospital, an 84-bed facility in Lancaster, Texas.
The pandemic also proved that more care could be provided virtually than most clinicians and patients previously realized, according to Matthew Sakumoto, MD, FACP, a “virtualist” primary care internal medicine physician with Sutter Health in San Francisco.
“‘You can never assess a respiratory complaint across video; you have to listen to the lungs.’ That's maybe what I would have said in 2019 or early 2020. Clearly, we've done a ton of COVID assessments over video,” he said.
The result is that some rural hospital leaders are looking into telehealth as part of their survival strategy. Dr. Mueller described the thinking: “What is our role in the community? What service lines can we provide here? What are we losing, in terms of people going somewhere else for services that we can provide in a high-quality manner?”
Virtual hospitalists
Hospital medicine is usually one of those key services that a hospital needs to provide, but it can be difficult for rural hospitals to maintain.
“There are many hospitals I've studied, the critical access and rural hospitals, that have a low volume of patients, and therefore, it's really challenging for them to maintain the staffing,” said Jeydith Gutierrez, MD, FACP. “It would be optimal if all those facilities could hire more hospitalists.”
When hospitals can't do that, especially sufficient to have medical staff 24/7, some of them turn to Dr. Gutierrez and her colleagues. She is the director of the telehospitalist service at the Iowa City Veterans Affairs (VA) Medical Center.
“We are the hub of what now is a national telehealth hospital medicine program … working to bridge that gap and bring hospital medicine expertise to those hospitals,” she said.
The telehospitalists typically work with nurse practitioners or physician assistants on the ground in rural areas. “A lot of nurse practitioners and physician assistants are willing to take care of patients in the hospital setting, but they just might not have had the appropriate training and as much experience with it,” said Dr. Gutierrez.
Virtual access to hospital medicine expertise can allow the rural hospitals to keep patients “that are a little more complex than they might feel comfortable caring for if they don't have that extra level of support,” she said.
Keeping patients local can provide benefits for everyone involved, the experts noted. “When patients have to bypass their local hospitals, they have worse outcomes because they delay care of conditions that can be very time sensitive,” said Dr. Gutierrez.
For the distant hospitals that would otherwise take the patients, remote systems can help with volume issues. “If the academic health center is having to turn patients away or put them on really long waiting lists because they're over capacity, they have a lot of incentive to keep the patients that are at lower need local,” said Dr. Mueller.
These telemedicine systems can also be a boon to the physicians who are practicing in rural areas, he added, offering the example of virtual ED coverage, which he said is becoming increasingly common.
“Nurse practitioners and physician assistants can push the big red button on the wall and have an immediate visual interaction with the board-certified emergency doctor,” Dr. Mueller said. “That helps the local hospital stay open because it's covering the ED. And one of the side benefits we found in our work was that it enables them to recruit and retain local physicians, because now the physician doesn't have to be on call 24/7 for the ED.”
Experimental technology
Physicians, including hospitalists, can also be the ones on the receiving end of the remote expertise, noted Ms. Kumar.
“Many of the family medicine physicians in the rural areas that are trying to take care of patients in the hospital, or even hospitalists, don't have the support of specialists they need in order to take care of patients,” she said. “It's nice to have, ‘Hey, I'm admitting this patient but I think I'm going to get into this issue …’ and have a nephrologist or neurologist stand by remotely.”
At her hospital, those remote specialists who provide support are taking on a new form—holograms. Using technology from the Dutch company Holoconnects, patients at rural Crescent Regional are ushered into a dedicated by a nurse or medical assistant and then seen by a holograph of a remote physician displayed in an 86-inch box.
“Many teleconsults are done using an iPad and it doesn't feel to patients like they've had an encounter with a physician,” said Ms. Kumar. “The patients that we have done [hologram] consults on, it's fascinating. They feel like they've seen the doctor. It's quite realistic.”
The remote physician, meanwhile, sees the patient two-dimensionally on a screen but has the ability to substantially adjust the cameras. “If they need to zoom in and look at a wound, or for a postop case, they have to look at the sutures, it's very clear,” she said.
The boxes are currently quite large, but Ms. Kumar is hoping they will get to a size where they can be brought to the patient instead of vice versa. “I eventually see that, instead of a box, we might just have a built-in system in each room,” she said. “I only saw this as a concept on Star Trek growing up, but I could see this as something we live through, where a specialist can just hop into the patient room.”
Star Trek may be a valid analogy, according to what Dr. Mueller has heard from tech experts working on the future of medicine for the federal government.
“What was fascinating was a lot of research being done on the space station is what's leading them,” he said. “They talk about the ability to miniaturize a lot of the diagnostics and other equipment, so that you could have a mobile unit that could do things like CT scans, MRIs.”
Robots performing ultrasounds is another concept that came from space, according to Steve Seslar, MD, PhD, a pediatric electrophysiologist and cofounder of Dopl Technologies, a startup based in Seattle.
“We basically resurrected a very old idea, originally conceived of by NASA engineers to try to figure out how to do surgery on spacecraft, which is to put a robot somewhere and have an operator somewhere else,” he said.
Their product is a robotic arm with an ultrasound, operated by a remote sonographer, which allows rural hospital clinicians to order any type of ultrasound without an on-site sonographer.
“It's not like [rural hospitals] are under any illusions that they don't want or need ultrasound,” said Dr. Seslar. “They just physically can't get it at this point. … They are trying to hire sonographers, and so we walk in there and say, ‘We're going to bring you sonographers.’”
The remote ultrasound begins with a medical assistant escorting the patient into the room with the robotic arm, then positioning it in the proper spot (e.g., the chest for a cardiac ultrasound). The remote sonographer does finer adjustments and completes the scan, which is read by a remote expert who reports back to the ordering physician.
“Whether they're the inpatient hospitalist or the emergency room doctors or the clinic doctors, they're the ones getting the results back and deciding what to do,” said Dr. Seslar. “There are some interesting opportunities for hospitalists to make use of this, and instead of having specialists meet with patients, they will have consultory interactions.”
It may seem counterintuitive to think virtual care could facilitate more team-based care, but he and other telemedicine advocates believe that could happen.
Dr. Seslar envisions the rural physician responding back to the interpreter of a scan, “‘Hey, I got this ultrasound result. I'd love your comanagement’ … allowing them to function at the top of their license.” He noted that a goal of his company is to group hospitals and remote experts so that all the staff involved become familiar with each other over time.
Similarly, Dr. Gutierrez sees telehospitalists as part of team-based care that makes the most of all participating clinicians' skills.
“We work with the same midlevels on a daily basis. We develop relationships, and we're trying to come up with some kind of program where we can develop their skills,” she said. “A lot of times we see all of their patients if they have not had a lot of experience. … The idea would be that as the program progresses, they could become more independent and we could act as a consultant.”
The remote hospitalists also serve to keep the rural teams updated on best practices. “It's a lot more challenging to keep up to date when you are in a smaller facility without lots of subspecialties giving you input,” said Dr. Gutierrez. “We will develop guidelines in a tertiary center and then just spread them out to other facilities seamlessly.”
Challenges
Of course, Dr. Gutierrez noted, the sharing of expertise, by whatever technological means, is typically less seamless outside of the VA's unified electronic, accreditation, and funding systems. “One of the biggest challenges for telehealth in places other than the VA remains reimbursement,” she said. “There are still questions about how these programs could become financially sustainable.”
The federal government's extension of pandemic telehealth waivers was helpful, noted Dr. Sakumoto, but not sufficient. “The biggest thing holding back health systems from going all in on this, putting the infrastructure in place, is waiting until they know that reimbursement is going to be in place for the long run and not just kicked two years down the road,” he said.
Licensing across states is another issue. “These programs will probably work more efficiently if you could cover several facilities in different states with the same pool of providers,” said Dr. Gutierrez. Conveniently, sonographers are licensed nationally instead of by state, noted Dr. Seslar.
One additional barrier is clinicians' leeriness about this new form of practice, according to Dr. Sakumoto. “Fear of the unknown stops people from doing it, like, ‘Oh, what if this went wrong?’” he said. “Things can go wrong when we're physically in the hospital. As people—patients, nurses, hospitalists themselves, and the specialists—have exposure to it, they say, ‘It's not as scary as I thought’ or ‘We don't miss the things we thought we would miss.’”
Ensuring that their care is high quality is an ongoing concern for telehospitalists, Dr. Gutierrez noted.
“One of the things that we're always really worried about is making sure that we're not providing inferior care. Whatever plan and program we develop, we do it very thoughtfully in working with the local providers and ensuring that we're not just substituting inpatient care with virtual care that's not up to standards,” she said.
There has to be caution involved in these new models of care, but there can also be a lot of enjoyment, she added.
“I am biased, I love it,” Dr. Gutierrez said. “I like to be able to provide the care for the patient where they are when they need it. … And if you haven't worked in a small or rural facility, this is certainly an interesting opportunity. This allows us to have a better understanding of what rural facilities are capable of.”
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