**2. Current programs and their results**

Figure 1 displays the geographic breadth of the Avera *e*CARETM program which is of one of the most comprehensive rural telemedicine programs in the world by geographic breadth, number of sites served, and number of unique telemedicine services operating from one location. It can be noted from the figure that the greatest concentration of activity is along the borders of five states of the North Central region of the United States: South Dakota, North Dakota, Minnesota, Iowa, and Nebraska. However, the greatest recent growth is westward including expansion into the states of Wyoming and Montana.

monitoring further expanded to hospitals outside of the Avera Health system, including those with different medical record or electronic record platforms. Finally, Avera *e*ICU services

Avera *e*CARETM has several years of experience in providing a broad expanse of telemedicine services. Each service has enjoyed similar growth and success. Avera's programs have also experienced similar and unique challenges in implementation, growth, and cultural adapta‐ tion. The expansion of Avera's telemedicine program was born in the success of Avera eICU CARE, and lead to the development and expansion of programs such as *e*Emergency and *e*Pharmacy. Like the Avera eICU CARETM program, these services provide rural facilities access to additional health care services and providers. *e*Emergency and *e*Pharmacy have expanded faster and are more widely distributed than Avera *e*ICU CARETM. This could be the result of several factors, but one could postulate that perhaps these services have been more useful to rural sites of care. Today, a variety of services are being researched, designed and piloted to provide care to an amazing assortment of patients, medical providers, clinics, hospitals, and other health care facilities to be described later. Many of these pilots have been launched and have been well received. The goal of this chapter is to describe the status of the comprehensive Avera *e*CARETM system and to hypothesize the future of this very successful paradigm of care.

As time progresses and needs arise, unique applications of telemedicine supervision are developed. Many of these applications are in the pilot stages of development as part of Avera's comprehensive program. Avera's suite of telemedicine services are now largely sustained without any outside financial support. Avera's telemedicine start-up costs have been off-set, in part, by grants and other funding opportunities. Avera's growing breadth and scope of telemedicine service offerings lead to a decision to bring *e*CARE together as a "Virtual Hospital". With this goal in mind, and generous financial support, Avera has developed a colocated telemedicine center that brings together all of Avera's telemedicine services under one roof, offsite from any traditional hospital or clinic location. Side-by-side, the medical providers, nurses and support staff work toward multidisciplinary success in each patient encounter. This telemedicine center is unique in the practice of telemedicine and is called the Avera

Figure 1 displays the geographic breadth of the Avera *e*CARETM program which is of one of the most comprehensive rural telemedicine programs in the world by geographic breadth, number of sites served, and number of unique telemedicine services operating from one location. It can be noted from the figure that the greatest concentration of activity is along the borders of five states of the North Central region of the United States: South Dakota, North Dakota, Minnesota, Iowa, and Nebraska. However, the greatest recent growth is westward

expanded into multiple states.

124 Telemedicine

*e*HelmTM.

**2. Current programs and their results**

including expansion into the states of Wyoming and Montana.

**Figure 1.** shows the seven states of the North Central United States which receive Avera *e*CARETM services: Wyoming (WY), North Dakota (ND), South Dakota (SD), Nebraska (NE), Minnesota (MN), Montana (MT) and Iowa (IA).

Avera's telemedicine experience initially shows the seven states of the North Central United States which receive Avera *e*CARETM services: Wyoming (WY), North Dakota (ND), South Dakota (SD), Nebraska (NE), Minnesota (MN), Montana (MT) and Iowa (IA).started by using video-conferencing equipment to facilitate medical consultations between primary care providers and patients in rural locations in South Dakota to specialists in a tertiary setting. It now is an active and robust program spanning seven states of the North Central region of the United States. Expansion of the type of programs and number of sites served has pushed Avera's total service area to include more than one hundred sixty-five hospitals and clinics within and outside of the Avera Health system.

The six primary *e*CARE services are shown in Figure 2: *e*Consult, *e*Pharmacy, *e*Emergency, *e*Long Term Care, and *e*Urgent Care in Correctional Facilities.

These telemedicine programs are shows the six telemedicine services offered by Avera *e*CARETM to date.designed to benefit rural patients and medical providers by improving the speed of care delivery and helping ensure the highest quality of care is provided locally where the patient resides. For the remote medical provider, Avera *e*CARE services offset a lack of specialists in rural areas affected by fewer resources and limited medical professional assis‐ tance and consultation. In addition, the facilities served may lack access to educational and career growth opportunities. These medical providers often have large patient loads and are required to be available to provide patient care many hours per week2 , 3 . Patients in remote, rural locations are often more elderly and are more likely to suffer from chronic disease than their urban counterparts4 . The cause of this startling statistic may be multifactorial but may include reasons such as greater distances to travel for specialty consultation, delays in seeking care due to higher rates of lacking primary health insurance or being underinsured, and in some cases inclement weather delaying access to care.

patient travel hours and more than 1.8 million patient travel miles. Additionally, access to specialist care via *e*Consult has resulted in a cost savings of more than \$425,970 for rural

> **eConsult Utilization by Specialty CY 2012**

> > Infectious Disease 38%

Other Services 9%

Hepatology 8%

Update on the Most Rural American Telemedicine Program — The Present and Future

Other 11%

"Other Services" illustrates the utilization of telemedicine consultations by specialty over the past twelve months in‐ clude those specialties that average <100 consults/year: Rehab, Internal Medicine, Gastroenterology, Occupational Medicine, Palliative Care, Women's Services, Dermatology, Pediatrics, Neonatology, Otolaryngology, Neurosurgery,

**Avera** *e***ICU CareTM (***e***ICU)** began in 2004 and had accounted for the largest quantum of growth in the history of Avera's telemedicine services until just recently. As stated earlier, Avera *e*ICU CARE provides around-the-clock remote intensive care monitoring of seriously and critically ill patients in the thirty-three hospitals served. With the inception of this program, Avera was able to electronically quantitate the severity of illness for such patients by using an interna‐ tionally known and validated severity adjustment methodology called the Acute Physiology and Chronic Health Evaluation (APACHE) scoring system. Patient data is automatically calculated from the data entered into the electronic medical record to generate APACHE predictions. The system also analyzes quality measures such as the frequency of ordering "best practice" national guidelines. Avera tracks outcomes such as severity-adjusted intensive care unit (ICU) length of stay, severity-adjusted ICU mortality, severity-adjusted hospital mortality,

**Figure 3.** illustrates the utilization of telemedicine consultations by specialty over the past twelve months.

Cardiology 4%

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127

Nutrition 4%

Nephrology 3%

Pulmonolgy 10%

Oncology 14%

Behavioral Health 10%

Neurology, and Endocrinology

5 eConsult Database (2013). Avera eCARE Services.

patients5 .

**Figure 2.** shows the six telemedicine services offered by Avera *e*CARETM to date.

#### **2.1. The Avera** *e***CARETM programs**

*e*Consult allows patients to access scheduled specialty consults at their local facility through two-way video technology. These consults are supported by special telephonic stethoscopes, otoscopes, and examination cameras. Avera first began providing virtual visits in 1993. *e*Consult benefits patients by saving time away from school or work and by saving the expenses of roundtrip travel. Figure 3 illustrates the utilization of this service by specialty over the past twelve months. As can be seen, primary specialties such as pediatrics or mental health are regularly requested. Many rare subspecialties are also utilized monthly. Infectious disease expertise is the single most frequently scheduled telemedicine consult provided to rural medical providers and their patients.

The status of this program is summarized as of May 30, 2013. *e*Consult is live in 109 sites; 76 patient sites and 33 specialty sites. Over a twelve month period, 5,900 *e*Consults were con‐ ducted by 88 unique specialist providers. *e*Consult services have saved an estimated 28,500

<sup>2</sup> Ormond, B., Wallin, S., Goldenson, S. (2000). Supporting the rural health care safety net. The Urban Institute, Occasional Paper 36.

<sup>3 2009.</sup> Rural practice, keeping physicians in. AAFP Position Paper. http://www.aafp.org/online.en/home/policy/policies/ r/ruralpracticekeep.html

<sup>4</sup> Joynt, K., Orav, J., and Jha (2013). Mortality rates for medicare beneficiaries admitted to critical access and non-critical access hospitals, 2002-2010.

patient travel hours and more than 1.8 million patient travel miles. Additionally, access to specialist care via *e*Consult has resulted in a cost savings of more than \$425,970 for rural patients5 .

"Other Services" illustrates the utilization of telemedicine consultations by specialty over the past twelve months in‐ clude those specialties that average <100 consults/year: Rehab, Internal Medicine, Gastroenterology, Occupational Medicine, Palliative Care, Women's Services, Dermatology, Pediatrics, Neonatology, Otolaryngology, Neurosurgery, Neurology, and Endocrinology

**Figure 3.** illustrates the utilization of telemedicine consultations by specialty over the past twelve months.

**Avera** *e***ICU CareTM (***e***ICU)** began in 2004 and had accounted for the largest quantum of growth in the history of Avera's telemedicine services until just recently. As stated earlier, Avera *e*ICU CARE provides around-the-clock remote intensive care monitoring of seriously and critically ill patients in the thirty-three hospitals served. With the inception of this program, Avera was able to electronically quantitate the severity of illness for such patients by using an interna‐ tionally known and validated severity adjustment methodology called the Acute Physiology and Chronic Health Evaluation (APACHE) scoring system. Patient data is automatically calculated from the data entered into the electronic medical record to generate APACHE predictions. The system also analyzes quality measures such as the frequency of ordering "best practice" national guidelines. Avera tracks outcomes such as severity-adjusted intensive care unit (ICU) length of stay, severity-adjusted ICU mortality, severity-adjusted hospital mortality,

specialists in rural areas affected by fewer resources and limited medical professional assis‐ tance and consultation. In addition, the facilities served may lack access to educational and career growth opportunities. These medical providers often have large patient loads and are

rural locations are often more elderly and are more likely to suffer from chronic disease than

include reasons such as greater distances to travel for specialty consultation, delays in seeking care due to higher rates of lacking primary health insurance or being underinsured, and in

*e*Consult allows patients to access scheduled specialty consults at their local facility through two-way video technology. These consults are supported by special telephonic stethoscopes, otoscopes, and examination cameras. Avera first began providing virtual visits in 1993. *e*Consult benefits patients by saving time away from school or work and by saving the expenses of roundtrip travel. Figure 3 illustrates the utilization of this service by specialty over the past twelve months. As can be seen, primary specialties such as pediatrics or mental health are regularly requested. Many rare subspecialties are also utilized monthly. Infectious disease expertise is the single most frequently scheduled telemedicine consult provided to rural

The status of this program is summarized as of May 30, 2013. *e*Consult is live in 109 sites; 76 patient sites and 33 specialty sites. Over a twelve month period, 5,900 *e*Consults were con‐ ducted by 88 unique specialist providers. *e*Consult services have saved an estimated 28,500

2 Ormond, B., Wallin, S., Goldenson, S. (2000). Supporting the rural health care safety net. The Urban Institute, Occasional

3 2009. Rural practice, keeping physicians in. AAFP Position Paper. http://www.aafp.org/online.en/home/policy/policies/

4 Joynt, K., Orav, J., and Jha (2013). Mortality rates for medicare beneficiaries admitted to critical access and non-critical

. The cause of this startling statistic may be multifactorial but may

, 3

. Patients in remote,

required to be available to provide patient care many hours per week2

some cases inclement weather delaying access to care.

**Figure 2.** shows the six telemedicine services offered by Avera *e*CARETM to date.

**2.1. The Avera** *e***CARETM programs**

medical providers and their patients.

Paper 36.

r/ruralpracticekeep.html

access hospitals, 2002-2010.

their urban counterparts4

126 Telemedicine

<sup>5</sup> eConsult Database (2013). Avera eCARE Services.

and severity adjusted hospital length of stay. Avera uses these analyses to design strategies to improve the care delivered to seriously and critically ill patients in the *e*ICU CARE system. Avera *e*ICU CARE has also provided education to medical providers across the region concerning this new high quality service by publishing results in the South Dakota Journal of Medicine (2).

ported by sophisticated technology that recognizes and alerts for negative trends in vital signs and abnormalities in laboratory tests is one of the primary reasons for such significant improvement in patient outcomes. The *e*ICU team of intensivists and critical care nurses is alerted to negative trends in patient status and can immediately be present in a patient's room by a two-way interactive televideo system to respond to emergencies. Additionally, Avera *e*ICU CARE supports consistent application of evidenced-based medicine through active rounding on patients, with a focus on ensuring such evidence-based measures are implement‐

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129

Avera *e*ICU CARE currently provides coverage for one hundred thirty-two beds in thirty-three facilities across six states, spanning a geography from Wyoming to mid-Iowa and from North Dakota to Nebraska. The Avera *e*ICU CARE team monitors an average of sixty to sixty-five patients at any time, and averages twenty-two admissions per a twenty-four hour period. *e*ICU intensivist physicians write an average of 1,400 orders per month. This greatly exceeds the average number of interventions for other tele-intensivist programs (4), which attests to the welcome invitation by rural sites for continous coverage when primary providers cannot be

Although the number of ICU telemedicine programs in the United States has continued to grow rapidly, our program has been recognized for its coverage to the least densely populated geographic rural region (5) and to the largest number of critical access hospitals (those

*e***Pharmacy was** developed shortly after the quantum expansion of the Avera *e*ICU CARETM service. Many rural sites experienced long periods of time when a local pharmacist was not available, highlighting a need for this service. Avera's virtual pharmacy service provides remote medication order review and approval before a first dose of medication is adminis‐ tered. ePharmacy uses automated dispensing equipment and remote provider order entry which has led to a reduction in serious safety events related to duplication of medication therapies, allergies, and drug-to-drug interactions. Currently ePharmacy service is provided to forty-six sites. Since its inception in 2009, more than 83,300 patients have been served by ePharmacy. To date more than 1,054,000 orders have been reviewed, and more than 14,200 serious safety events avoided. Each month, the ePharmacy team of pharmacists reviews more than 44,000 orders and documents 800 interventions to promote medication safety and efficacy.

**eEmergency (eED**) illustrates the types of errors which have been detected by the ePharmacy service line in a single month.has had the greatest success with expansion and requests for service. As of June 1, 2013, seventy-six sites utilize eEmergency services. Figure 6 illustrates the pace of growth of this highly requested program to the rural communities of the North Central region of the United States. The *e*ED provides immediate, two-way video access to a board-certified emergency physician and a core of experienced emergency nurses. They assist in the management of a multitude of medical emergencies such as trauma, acute myocardial

receiving federal pass-through payments for services but limited to 20 beds or less).

Figure 5 illustrates the breakdown of adverse events noted in a single month.

ed and documented in the medical record.

infarction and stroke, to name a few.

available. There are no charges to patients for this service.

From the initial forty beds, Avera *e*ICU CARE has expanded to include smaller hospitals within the Avera system, hospitals out of the Avera system, and even hospitals out of the state. Avera was one of the first in the nation to offer the *e*ICU service to patients in CAHs. Avera studied whether the Avera *e*ICU program had an impact on patient outcomes. Data revealed that after the program was implemented there was reduction in severity-adjusted ICU mortality, reduction in severity-adjusted ICU length of stay, reduction of severity adjusted hospital mortality, and reduction of severity-adjusted hospital length of stay (3). In addition, Avera *e*ICU CARE has improved compliance with best practice guidelines, and has achieved one hundred percent compliance with stress ulcer prophylaxis and DVT prophylaxis in *e*ICUmonitored patients. APACHE data has shown that ICU mortality among *e*ICU patients is an average of thirty to fifty percent below predicted in comparison to the APACHE database. Avera has also reduced ICU length of stay by an average of twenty-five percent. Using APACHE predictions, Avera has calculated the number of lives saved from the difference between observed to predicted mortality. Figure 4 shows those results from initial analysis to the current year.

**Figure 4.** illustrates the number of lives saved quarterly from 2005 to the present.

The around-the illustrates the number of lives saved quarterly from 2005 to the present -clock, direct monitoring of critically ill and seriously ill patients by the intensivist-led team, sup‐ ported by sophisticated technology that recognizes and alerts for negative trends in vital signs and abnormalities in laboratory tests is one of the primary reasons for such significant improvement in patient outcomes. The *e*ICU team of intensivists and critical care nurses is alerted to negative trends in patient status and can immediately be present in a patient's room by a two-way interactive televideo system to respond to emergencies. Additionally, Avera *e*ICU CARE supports consistent application of evidenced-based medicine through active rounding on patients, with a focus on ensuring such evidence-based measures are implement‐ ed and documented in the medical record.

and severity adjusted hospital length of stay. Avera uses these analyses to design strategies to improve the care delivered to seriously and critically ill patients in the *e*ICU CARE system. Avera *e*ICU CARE has also provided education to medical providers across the region concerning this new high quality service by publishing results in the South Dakota Journal of

From the initial forty beds, Avera *e*ICU CARE has expanded to include smaller hospitals within the Avera system, hospitals out of the Avera system, and even hospitals out of the state. Avera was one of the first in the nation to offer the *e*ICU service to patients in CAHs. Avera studied whether the Avera *e*ICU program had an impact on patient outcomes. Data revealed that after the program was implemented there was reduction in severity-adjusted ICU mortality, reduction in severity-adjusted ICU length of stay, reduction of severity adjusted hospital mortality, and reduction of severity-adjusted hospital length of stay (3). In addition, Avera *e*ICU CARE has improved compliance with best practice guidelines, and has achieved one hundred percent compliance with stress ulcer prophylaxis and DVT prophylaxis in *e*ICUmonitored patients. APACHE data has shown that ICU mortality among *e*ICU patients is an average of thirty to fifty percent below predicted in comparison to the APACHE database. Avera has also reduced ICU length of stay by an average of twenty-five percent. Using APACHE predictions, Avera has calculated the number of lives saved from the difference between observed to predicted mortality. Figure 4 shows those results from initial analysis to

**Figure 4.** illustrates the number of lives saved quarterly from 2005 to the present.

The around-the illustrates the number of lives saved quarterly from 2005 to the present -clock, direct monitoring of critically ill and seriously ill patients by the intensivist-led team, sup‐

Medicine (2).

128 Telemedicine

the current year.

Avera *e*ICU CARE currently provides coverage for one hundred thirty-two beds in thirty-three facilities across six states, spanning a geography from Wyoming to mid-Iowa and from North Dakota to Nebraska. The Avera *e*ICU CARE team monitors an average of sixty to sixty-five patients at any time, and averages twenty-two admissions per a twenty-four hour period. *e*ICU intensivist physicians write an average of 1,400 orders per month. This greatly exceeds the average number of interventions for other tele-intensivist programs (4), which attests to the welcome invitation by rural sites for continous coverage when primary providers cannot be available. There are no charges to patients for this service.

Although the number of ICU telemedicine programs in the United States has continued to grow rapidly, our program has been recognized for its coverage to the least densely populated geographic rural region (5) and to the largest number of critical access hospitals (those receiving federal pass-through payments for services but limited to 20 beds or less).

*e***Pharmacy was** developed shortly after the quantum expansion of the Avera *e*ICU CARETM service. Many rural sites experienced long periods of time when a local pharmacist was not available, highlighting a need for this service. Avera's virtual pharmacy service provides remote medication order review and approval before a first dose of medication is adminis‐ tered. ePharmacy uses automated dispensing equipment and remote provider order entry which has led to a reduction in serious safety events related to duplication of medication therapies, allergies, and drug-to-drug interactions. Currently ePharmacy service is provided to forty-six sites. Since its inception in 2009, more than 83,300 patients have been served by ePharmacy. To date more than 1,054,000 orders have been reviewed, and more than 14,200 serious safety events avoided. Each month, the ePharmacy team of pharmacists reviews more than 44,000 orders and documents 800 interventions to promote medication safety and efficacy.

Figure 5 illustrates the breakdown of adverse events noted in a single month.

**eEmergency (eED**) illustrates the types of errors which have been detected by the ePharmacy service line in a single month.has had the greatest success with expansion and requests for service. As of June 1, 2013, seventy-six sites utilize eEmergency services. Figure 6 illustrates the pace of growth of this highly requested program to the rural communities of the North Central region of the United States. The *e*ED provides immediate, two-way video access to a board-certified emergency physician and a core of experienced emergency nurses. They assist in the management of a multitude of medical emergencies such as trauma, acute myocardial infarction and stroke, to name a few.

treated, over 10,800 transfers have been arranged, and over 980 transfers have been avoided, resulting in a savings of \$7.85 million. Figure 7 breaks down the types of complaints routinely

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131

Figure 7 illustrates the frequency of problems handled by the

**Figure 7.** illustrates the frequency of problems handled by the eEmergency program

the initiation of several quality improvement

The *e*Emergency program has expanded to include

The *e*Emergency program has illustrates the frequency of problems handled by the eEmer‐ gency program expanded to include the initiation of several quality improvement programs with major clinical effect on the region. One example includes what is called the "Chest Pain Initiative." Because the *e*ED is often involved in cases before the local provider has arrived, important diagnostic tests and critical therapies can be initiated that in the past may have been delayed. As an example the program has documented improvement in "door to ECG" times. After implementation of *e*ED project, the median time to ECG has improved and now exceeds the Centers for Medicare and Medicaid Services (CMS) standard of ten minutes as shown in

programs with major clinical affect on the region.

Pain Initiative." Because the *e*ED is often involved

Another component of the illustrates the improvement in median time to ECG for patients with chest pain presenting to emergency departments in the region due to assistance from eEmergency services.Chest Pain Initiative was improvement in aspirin administration. After the *e*ED project was implemented, participating sites were noted to have 100 percent compli‐ ance with established guidelines for aspirin administration. Historically, these hospitals

important diagnostic tests and critical therapies can

be initiated that in the past may have been delayed.

significant decrease in the time to transfer and the increase in use of thrombolytics for care in

. Other important outcomes impacted included

implementation of *e*ED project, the median time to

ECG has improved and now exceeds the Centers

One example includes what is called the "Chest

in cases before the local provider has arrived,

As an example the program has documented

the appropriately screened and eligible candidates. This number is at 100 percent.

improvement in "door to ECG" times. After

for Medicare and Medicaid Services (CMS)

standard of ten minutes as shown in Figure 8.

handled by the *e*ED.

*e*Emergency program

reported compliance as low as 67 percent6

6 Avera Health Quality Department Data (2011).

Figure 8.

Figure 5 illustrates the types of errors which have been detected by the **Figure 5.** illustrates the types of errors which have been detected by the ePharmacy service line in a single month.

ePharmacy service line in a single month.

**Figure 6.** demonstrates the pace of growth of eEmergency services aided by the Helmsley grant to be described be‐ low.

*e*Emergency allows for the demonstrates the pace of growth of eEmergency services aided by the Helmsley grant to be described below.initiation of accurate diagnostic testing before local provider arrival, streamlines emergency transfer arrangements, and eliminates unnecessary transfers. Since inception in 2009 through May 30, 2013, more than 5,900 patients have been treated, over 10,800 transfers have been arranged, and over 980 transfers have been avoided, resulting in a savings of \$7.85 million. Figure 7 breaks down the types of complaints routinely handled by the *e*ED.

**Figure 7.** illustrates the frequency of problems handled by the eEmergency program

Figure 7 illustrates the frequency of problems handled by the *e*Emergency program The *e*Emergency program has expanded to include the initiation of several quality improvement programs with major clinical affect on the region. One example includes what is called the "Chest The *e*Emergency program has illustrates the frequency of problems handled by the eEmer‐ gency program expanded to include the initiation of several quality improvement programs with major clinical effect on the region. One example includes what is called the "Chest Pain Initiative." Because the *e*ED is often involved in cases before the local provider has arrived, important diagnostic tests and critical therapies can be initiated that in the past may have been delayed. As an example the program has documented improvement in "door to ECG" times. After implementation of *e*ED project, the median time to ECG has improved and now exceeds the Centers for Medicare and Medicaid Services (CMS) standard of ten minutes as shown in Figure 8.

Pain Initiative." Because the *e*ED is often involved in cases before the local provider has arrived, important diagnostic tests and critical therapies can be initiated that in the past may have been delayed. As an example the program has documented Another component of the illustrates the improvement in median time to ECG for patients with chest pain presenting to emergency departments in the region due to assistance from eEmergency services.Chest Pain Initiative was improvement in aspirin administration. After the *e*ED project was implemented, participating sites were noted to have 100 percent compli‐ ance with established guidelines for aspirin administration. Historically, these hospitals reported compliance as low as 67 percent6 . Other important outcomes impacted included significant decrease in the time to transfer and the increase in use of thrombolytics for care in the appropriately screened and eligible candidates. This number is at 100 percent.

ECG has improved and now exceeds the Centers

for Medicare and Medicaid Services (CMS)

standard of ten minutes as shown in Figure 8.

0

Q4 2009

Q1 2010

Q2 2010

ePharmacy service line in a single month.

Q3 2010

Q4 2010

Q1 2011

provides immediate, two-way video access to a

Q2 2011

**Figure 6.** demonstrates the pace of growth of eEmergency services aided by the Helmsley grant to be described be‐

*e*Emergency allows for the demonstrates the pace of growth of eEmergency services aided by the Helmsley grant to be described below.initiation of accurate diagnostic testing before local provider arrival, streamlines emergency transfer arrangements, and eliminates unnecessary transfers. Since inception in 2009 through May 30, 2013, more than 5,900 patients have been

**eEmergency Encounters by Quarter**

*e***Emergency (***e***ED)** has had the greatest success with

2013, seventy-six sites utilize eEmergency services. Figure 6 illustrates the pace of growth of this highly requested program to the rural communities of the North Central region of the United States. The *e*ED

Figure 5 illustrates the types of errors which have been detected by the

**Figure 5.** illustrates the types of errors which have been detected by the ePharmacy service line in a single month.

expansion and requests for service. As of June 1,

Q3 2011

Q4 2011

Q1 2012

Q2 2012

Q3 2012

Q4 2012

Q1 2013

500

low.

1000

1500

130 Telemedicine

improvement in "door to ECG" times. After implementation of *e*ED project, the median time to 6 Avera Health Quality Department Data (2011).

challenging. Several states in which *e*CARE services are provided participate in the Nurse Licensure Compact. In these states, licensure in one participating state covers the nurse when he or she is working in other participating states. South Dakota, Iowa, Nebraska, and North Dakota are all compact members. Separate full, unrestricted nursing licenses are needed in Minnesota, Montana, and Wyoming. Nursing staff is not required to apply for any privileges

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133

Two different processes are used for credentialing and privileging, the traditional process that has been in place for many years, and a newer telemedicine application process. Approxi‐ mately fifty percent of hospitals receiving *e*CARE services have adopted the telemedicine credentialing/privileging process. The other fifty percent have chosen to continue with the traditional route for a variety of reasons including preference for the existing method and the

The *e*Pharmacy staff of hospital-trained pharmacists are licensed in each state where *e*Pharmacy services are provided. Licensure is highly regulated by each state's Board of Pharmacy. Most of these states require a separate written exam before granting a license.

Avera Health member hospitals and clinics have long been financially supportive of the telemedicine mission. Through the innovative thinking of Avera leaders, telemedicine has been considered a strategic part of Avera's future and has been budgeted for accordingly. In addition to internal financial support, various granting agencies have provided funding for the implementation and growth of many *e*CARE programs. These agencies have ranged from the local, state and federal government, foundations of publicly traded companies, as well as private local and national foundations. Without this generous support, telemedicine expansion on such a broad scale would have been difficult, if not impossible. We will summarize some

The United States Department of Agriculture (USDA) has funded seven grants exceeding \$2.7 million to expand various Avera *e*CARETM programs. In addition, private foundations focused on rural healthcare have provided financial resources to operationalize some a variety of *e*CARE programs. One particular grant from a private foundation has allowed for greater collaboration between individual Avera *e*CARETM services. *e*CARE services that were once scattered across a large medical campus are now able to function as a fully integrated virtual hospital, housed in a state-of-the-art building miles from any traditional hospital walls. This new location allows Avera to provide telemedicine based care in a much more cohesive and supportive manner. This new super-hub is called the Avera *e*HelmTM. The *e*Helm serves as an incubator for new and innovative telemedicine programs and services by allowing and

In 2012, an Avera community hospital was awarded a grant from the Health Resources and Services Administration (HRSA) Office of Rural Health Policy to expand the *e*Long Term Care

unsure nature of state and federal survey teams' reception of this new process.

Credentialing and privileging is not required for pharmacists.

of *e*CARE's past grant awards and funding opportunities below.

facilitating dialog and cross-fertilization of existing telemedicine experts.

program to an additional sixteen centers.

in any of the hospitals currently served.

**2.3. Funding Sources**

Figure 8 illustrates the improvement in median time to ECG for patients **Figure 8.** illustrates the improvement in median time to ECG for patients with chest pain presenting to emergency departments in the region due to assistance from eEmergency services.

with chest pain presenting to emergency departments in the region due to assistance from *e*Emergency services. Another component of the Chest Pain Initiative was improvement in aspirin administration. After the *e*ED project was implemented, participating sites were noted to have 100 percent compliance with established guidelines for aspirin *e***Long Term Care (***e***LTC)** has developed as an outgrowth of *e*ED, and uses telemedicine technologies to improve long term care staff and residents' access to providers and specialty services in a manner that is high quality, convenient, and low cost. The goal of the program is to provide urgent care services to residents of long term care facilities in an effort to prevent emergency department visits and hospital admissions. This program was launched as a pilot project in January 2012 at four sites, and is currently available in six sites. In the first year of pilot, 120 residents were seen by the eLTC provider. Of these, 30 percent (36 encounters) resulted in an avoided a transfer to the emergency department or clinic. As an additional component of the service, specialist care via *e*Consult is available to residents in participating facilities. Grant support to be described below has assisted in innovating in this branch of telemedicine.

administration. Historically, these hospitals reported compliance as low as 67 percent6 . Other important outcomes impacted included significant decrease in the time to transfer and the increase in use of thrombolytics for care in the appropriately *e***Access in Correctional Facilities** has also developed as an outgrowth of *e*ED. In this program, telemedicine technology is used to provide physician-directed urgent care services to inmates, resulting in a reduction of unnecessary and costly transfers. This pilot was launched in May 2012 at four sites. In the first twelve months of service, 372 patients have been served, with thirty-two percent of those encounters resulting in an avoided transfer. The distribution of complaints handled by the virtual physicians was similar to one shown above for the *e*Emergency program as a whole.

#### screened and eligible candidates. This number is at 100 percent. **2.2. Major lessons learned and challenges**

6 Avera Health Quality Department Data (2011). Credentialing and licensure for all these telemedicine services requires considerable amount of time and perseverance. Avera *e*CARETM medical providers are licensed in every state where *e*CARE services are provided. In addition, medical providers must apply for, and be granted, medical privileges in each hospital in which services are provided. Nursing licensure is no less challenging. Several states in which *e*CARE services are provided participate in the Nurse Licensure Compact. In these states, licensure in one participating state covers the nurse when he or she is working in other participating states. South Dakota, Iowa, Nebraska, and North Dakota are all compact members. Separate full, unrestricted nursing licenses are needed in Minnesota, Montana, and Wyoming. Nursing staff is not required to apply for any privileges in any of the hospitals currently served.

Two different processes are used for credentialing and privileging, the traditional process that has been in place for many years, and a newer telemedicine application process. Approxi‐ mately fifty percent of hospitals receiving *e*CARE services have adopted the telemedicine credentialing/privileging process. The other fifty percent have chosen to continue with the traditional route for a variety of reasons including preference for the existing method and the unsure nature of state and federal survey teams' reception of this new process.

The *e*Pharmacy staff of hospital-trained pharmacists are licensed in each state where *e*Pharmacy services are provided. Licensure is highly regulated by each state's Board of Pharmacy. Most of these states require a separate written exam before granting a license. Credentialing and privileging is not required for pharmacists.

#### **2.3. Funding Sources**

Figure 8 illustrates the improvement in median time to ECG for patients with chest pain presenting to emergency departments in the region due to

*e***Long Term Care (***e***LTC)** has developed as an outgrowth of *e*ED, and uses telemedicine technologies to improve long term care staff and residents' access to providers and specialty services in a manner that is high quality, convenient, and low cost. The goal of the program is to provide urgent care services to residents of long term care facilities in an effort to prevent emergency department visits and hospital admissions. This program was launched as a pilot project in January 2012 at four sites, and is currently available in six sites. In the first year of pilot, 120 residents were seen by the eLTC provider. Of these, 30 percent (36 encounters) resulted in an avoided a transfer to the emergency department or clinic. As an additional component of the service, specialist care via *e*Consult is available to residents in participating facilities. Grant support to be described below has assisted in innovating in this branch of

**Figure 8.** illustrates the improvement in median time to ECG for patients with chest pain presenting to emergency

Another component of the Chest Pain Initiative

the *e*ED project was implemented, participating

sites were noted to have 100 percent compliance

important outcomes impacted included significant decrease in the time to transfer and the increase in

*e***Access in Correctional Facilities** has also developed as an outgrowth of *e*ED. In this program, telemedicine technology is used to provide physician-directed urgent care services to inmates, resulting in a reduction of unnecessary and costly transfers. This pilot was launched in May 2012 at four sites. In the first twelve months of service, 372 patients have been served, with thirty-two percent of those encounters resulting in an avoided transfer. The distribution of complaints handled by the virtual physicians was similar to one shown above for the

use of thrombolytics for care in the appropriately

screened and eligible candidates. This number is

Credentialing and licensure for all these telemedicine services requires considerable amount of time and perseverance. Avera *e*CARETM medical providers are licensed in every state where *e*CARE services are provided. In addition, medical providers must apply for, and be granted, medical privileges in each hospital in which services are provided. Nursing licensure is no less

. Other

with established guidelines for aspirin

administration. Historically, these hospitals reported compliance as low as 67 percent6

was improvement in aspirin administration. After

assistance from *e*Emergency services.

departments in the region due to assistance from eEmergency services.

at 100 percent.

*e*Emergency program as a whole.

Avera Health Quality Department Data (2011).

**2.2. Major lessons learned and challenges**

6

telemedicine.

132 Telemedicine

Avera Health member hospitals and clinics have long been financially supportive of the telemedicine mission. Through the innovative thinking of Avera leaders, telemedicine has been considered a strategic part of Avera's future and has been budgeted for accordingly. In addition to internal financial support, various granting agencies have provided funding for the implementation and growth of many *e*CARE programs. These agencies have ranged from the local, state and federal government, foundations of publicly traded companies, as well as private local and national foundations. Without this generous support, telemedicine expansion on such a broad scale would have been difficult, if not impossible. We will summarize some of *e*CARE's past grant awards and funding opportunities below.

The United States Department of Agriculture (USDA) has funded seven grants exceeding \$2.7 million to expand various Avera *e*CARETM programs. In addition, private foundations focused on rural healthcare have provided financial resources to operationalize some a variety of *e*CARE programs. One particular grant from a private foundation has allowed for greater collaboration between individual Avera *e*CARETM services. *e*CARE services that were once scattered across a large medical campus are now able to function as a fully integrated virtual hospital, housed in a state-of-the-art building miles from any traditional hospital walls. This new location allows Avera to provide telemedicine based care in a much more cohesive and supportive manner. This new super-hub is called the Avera *e*HelmTM. The *e*Helm serves as an incubator for new and innovative telemedicine programs and services by allowing and facilitating dialog and cross-fertilization of existing telemedicine experts.

In 2012, an Avera community hospital was awarded a grant from the Health Resources and Services Administration (HRSA) Office of Rural Health Policy to expand the *e*Long Term Care program to an additional sixteen centers.

#### **2.4. Awards**

Avera's telemedicine efforts have been recognized by several national health organizations looking to reform and improve health care. In 2009, Avera was awarded the American Telemedicine Association's President's Institutional Award for leadership in telemedicine. Avera has received thirteen "HealthCare's Most Wired" awards from a consortium that includes McKesson, AT&T, and Care Tech Solutions, in cooperation with the College of Healthcare Information Management Executives, the American Hospital Association, and Health and Health Network (H&HN) magazine. Avera also won one of three 2011 & 2012 "Most-Wired Innovator" awards and was recognized for this accomplishment at the 2011 and 2012 American Hospital Leadership Summits. Avera *e*CARE was recognized as a finalist for the Monroe E. Trout Premier Cares award in January, 2012, and was nominated for a Catholic Health Association of the United States award in 2013. *e*CARE has also been recognized internally for its impact on quality of care, and has received three Avera Quality Congress awards; one for *e*Pharmacy, one for *e*Emergency and another for the *e*Emergency Chest Pain Initiative.
