**3. The future –A paradigm shift**

The proliferation of different virtual health services in Avera's comprehensive telemedicine program is illustrated in Figure 9. Telemedicine can be used to supplement each phase of the health care continuum. Telemedicine has evolved in the North Central Plains region as a program that supports the entire continuum from primary care, emergency care, critical care, multiple pharmaceutical interventions, and a nascent follow-up program in long term care facilities.

**Figure 9.** illustrates the complete continuum of telemedicine services which now exist and are co-located in a single

Home Care

SNF

**Acute Care**

> OP Rehab

**Recovery & Rehab Care**

IP Rehab

Hospital

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135

hub such as the Avera eHelm which coordinates and enhances patient care.

Retail

Home

health care continuum..

centers.

**Community-Based Care**

Acuity

Pharmacy Physician Clinics

> Wellness and Fitness Center

Diagnostic/ Imaging Center

Ambulatory Procedure Center

> Urgent Care Center

Figure 10 illustrates the important "air traffic control" or back up capability of telemedicine for each phase in the health care continuum.

**Figure 10.** illustrates the important "air traffic control" or back up capability of telemedicine for each phase in the

To this end, Avera *e*CARETM is planning for a

major shift in healthcare delivery in the future.

A paradigm shift in health care delivery is being

driven by the expansion of telemedicine services.

especially in remote areas (rural parts of the United

States, Third World Countries, Emerging Nations),

which cannot develop a full medical infrastructure

The New Doctor's Office, and the New Continuity

on their own, will turn to "The Virtual Hospital,

Service", all expansions of mature telemedicine

The progression of innovation in telemedicine,

**Figure 10** illustrates the illustrates the complete continuum of telemedicine services which now exist and are co-located in a single hub such as the Avera eHelm which coordinates and enhances patient care "air traffic control" model of telemedicine utilization, where telemedi‐ cine providers serve as back up for the other components of the continuum. While this may be the case in some urban settings, rural areas might utilize telemedicine in a formal role in direct patient care, leading a local medical team from a remote location. Remote telemedicine care may actually provide total first line diagnosis and therapies in the near future.

To this end, illustrates the important "air traffic control" or back up capability of telemedicine for each phase in the health care continuum.Avera *e*CARETM is planning for a major shift in healthcare delivery in the future.

A paradigm shift in health care delivery is being driven by the expansion of telemedicine services. The progression of innovation in telemedicine, especially in remote areas (rural parts of the United States, Third World Countries, Emerging Nations), which cannot develop a full medical infrastructure on their own, will turn to "The Virtual Hospital, The New Doctor's Office, and the New Continuity Service", all expansions of mature telemedicine centers.

Update on the Most Rural American Telemedicine Program — The Present and Future http://dx.doi.org/10.5772/56589 135

**2.4. Awards**

134 Telemedicine

Initiative.

facilities.

**3. The future –A paradigm shift**

healthcare delivery in the future.

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

The proliferation of different virtual health services in Avera's comprehensive telemedicine program is illustrated in Figure 9. Telemedicine can be used to supplement each phase of the health care continuum. Telemedicine has evolved in the North Central Plains region as a program that supports the entire continuum from primary care, emergency care, critical care, multiple pharmaceutical interventions, and a nascent follow-up program in long term care

**Figure 10** illustrates the illustrates the complete continuum of telemedicine services which now exist and are co-located in a single hub such as the Avera eHelm which coordinates and enhances patient care "air traffic control" model of telemedicine utilization, where telemedi‐ cine providers serve as back up for the other components of the continuum. While this may be the case in some urban settings, rural areas might utilize telemedicine in a formal role in direct patient care, leading a local medical team from a remote location. Remote telemedicine

To this end, illustrates the important "air traffic control" or back up capability of telemedicine for each phase in the health care continuum.Avera *e*CARETM is planning for a major shift in

A paradigm shift in health care delivery is being driven by the expansion of telemedicine services. The progression of innovation in telemedicine, especially in remote areas (rural parts of the United States, Third World Countries, Emerging Nations), which cannot develop a full medical infrastructure on their own, will turn to "The Virtual Hospital, The New Doctor's Office, and the New Continuity Service", all expansions of mature telemedicine centers.

care may actually provide total first line diagnosis and therapies in the near future.

**Figure 9.** illustrates the complete continuum of telemedicine services which now exist and are co-located in a single hub such as the Avera eHelm which coordinates and enhances patient care.

Figure 10 illustrates the important "air traffic control" or back up **Figure 10.** illustrates the important "air traffic control" or back up capability of telemedicine for each phase in the health care continuum..

capability of telemedicine for each phase in the health care continuum.

To this end, Avera *e*CARETM is planning for a

major shift in healthcare delivery in the future.

A paradigm shift in health care delivery is being

driven by the expansion of telemedicine services.

especially in remote areas (rural parts of the United

States, Third World Countries, Emerging Nations),

which cannot develop a full medical infrastructure

The New Doctor's Office, and the New Continuity

on their own, will turn to "The Virtual Hospital,

Service", all expansions of mature telemedicine

centers.

The progression of innovation in telemedicine,

Instead of increased numbers of brick and mortar tertiary centers to which patients travel, now there is the possibility of a virtual electronic hub to provide tertiary hospital services to remote sites as they currently exist. In effect, telemedicine brings the tertiary care hospital to the patient. Reduced costs of transfer of patients, improved patient and family satisfaction, increased access to specialists and especially rare sub-specialist consultation are all the byproducts of a robust and integrated telemedicine program. Implementation of improved wireless (cellular) technology to allow remotely controlled medical machines such as mechan‐ ical ventilators, dialysis equipment, and robotic care is likely imminent as an augmentation of such a tertiary care *e*Hospital. In addition, the challenges of local staffing, supply, and power all need to be addressed as unique challenges.

Another trademark of a highly integrated telemedicine program lies in the doctor's office. In a specialist's office there would be a synthesis of activity which allows more active inclusion of telemedicine into practice. A patient might be seen physically in an exam room next to a telemedicine patient in the next exam room. This seamless integration of telemedicine work stations into the flow of patient care would allow the doctor to see any patients regardless of their location. Physician time could be, and in some cases is, divided equally and seamlessly between time spent with physically present patients and virtual patients. In the future, the physician may also be located remotely seeing patients at all locations via telemedicine.

Electronic continuity services could include nontraditional settings such as long term care facilities, correctional facilities, and expanded telemedicine home-based services. In these new and dynamic locations the goal of telemedicine is to continue to monitor compliance with discharge instructions, meticulously supervise proper medication intake at home or in the facility in which the patient resides, and to ensure timely follow up with the primary medical provider and any needed specialists. This system would be designed to prevent errors, relapses, or delays in follow up which might lead to unnecessary emergency visits, hospitali‐ zations, and premature relapses in medical problems.

at least one Avera *e*CARETM service. At the present 650 providers are served by Avera

**Figure 11.** illustrates a model of global care coordinated by multiple electronic telemedicine programs coordinated by

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

http://dx.doi.org/10.5772/56589

137

The future goals of Avera *e*CARETM includes a plan to create virtual support for hospitals, clinics, long term care facilities and other nontraditional care locations to provide access to care at the same level of quality available in urban settings. In addition, Avera is exploring a robust home monitoring and coaching system of care that enables providers to interact with chronically ill patients in their home environments. These steps will create a virtual support

In conclusion, the success of these multiple diverse telemedicine programs in the rural region of the North Central United States has been a result of trying to meet the needs for health care in this area. Telemedicine has been well received due to many factors, including the remoteness of many communities, the frequently inclement weather which impairs urgent face-to-face health care, the lack of health care resources in the agricultural economy, and the extremely low number of specialty and subspecialty providers located these states. The success of Avera *e*CARE has not gone unnoticed. Many have asked to learn how to duplicate some or all of

eCARETM. The total financial impact has been greater than 55 million dollars.

a core of expert telemedicine caregivers located in a core such as the Avera eHelmTM.

for patient centered medical homes.

Avera models of comprehensive telemedicine.

Finally,**Figure 11** illustrates how such complete telemedicine services may expand beyond health systems and rural neighbors. It could even result in global extension of successful telemedicine systems of medical care. A telemedicine program with multiple services could be located together in a core such as the Avera *e*HelmTM. These hubs could just as easily and efficiently provide telemedicine care to the ends of the earth and beyond as they could in the same city or building. Home care, concierge care, doctor's office care, medical home care, urgent care, emergency department care, behavioral health care, general hospital care, specialty hospital care (behavioral health, cardiac, orthopedic), intensive care, long term hospital care (LTHC), and others could be connected to a core like the Avera *e*HelmTM providing telemedicine care and coordination with its multiple primary care and specialty allied health members, nurses, and physicians.

In summary, to illustrates a model of global care coordinated by multiple electronic teleme‐ dicine programs coordinated by a core of expert telemedicine caregivers located in a core such as the Avera eHelmTM.date more than 153,000 patients have been touched by at least one Avera *e*CARETM service. More than 165 hospitals and clinics across a 495,000 square mile service use

Instead of increased numbers of brick and mortar tertiary centers to which patients travel, now there is the possibility of a virtual electronic hub to provide tertiary hospital services to remote sites as they currently exist. In effect, telemedicine brings the tertiary care hospital to the patient. Reduced costs of transfer of patients, improved patient and family satisfaction, increased access to specialists and especially rare sub-specialist consultation are all the byproducts of a robust and integrated telemedicine program. Implementation of improved wireless (cellular) technology to allow remotely controlled medical machines such as mechan‐ ical ventilators, dialysis equipment, and robotic care is likely imminent as an augmentation of such a tertiary care *e*Hospital. In addition, the challenges of local staffing, supply, and power

Another trademark of a highly integrated telemedicine program lies in the doctor's office. In a specialist's office there would be a synthesis of activity which allows more active inclusion of telemedicine into practice. A patient might be seen physically in an exam room next to a telemedicine patient in the next exam room. This seamless integration of telemedicine work stations into the flow of patient care would allow the doctor to see any patients regardless of their location. Physician time could be, and in some cases is, divided equally and seamlessly between time spent with physically present patients and virtual patients. In the future, the physician may also be located remotely seeing patients at all locations via telemedicine.

Electronic continuity services could include nontraditional settings such as long term care facilities, correctional facilities, and expanded telemedicine home-based services. In these new and dynamic locations the goal of telemedicine is to continue to monitor compliance with discharge instructions, meticulously supervise proper medication intake at home or in the facility in which the patient resides, and to ensure timely follow up with the primary medical provider and any needed specialists. This system would be designed to prevent errors, relapses, or delays in follow up which might lead to unnecessary emergency visits, hospitali‐

Finally,**Figure 11** illustrates how such complete telemedicine services may expand beyond health systems and rural neighbors. It could even result in global extension of successful telemedicine systems of medical care. A telemedicine program with multiple services could be located together in a core such as the Avera *e*HelmTM. These hubs could just as easily and efficiently provide telemedicine care to the ends of the earth and beyond as they could in the same city or building. Home care, concierge care, doctor's office care, medical home care, urgent care, emergency department care, behavioral health care, general hospital care, specialty hospital care (behavioral health, cardiac, orthopedic), intensive care, long term hospital care (LTHC), and others could be connected to a core like the Avera *e*HelmTM providing telemedicine care and coordination with its multiple primary care and specialty

In summary, to illustrates a model of global care coordinated by multiple electronic teleme‐ dicine programs coordinated by a core of expert telemedicine caregivers located in a core such as the Avera eHelmTM.date more than 153,000 patients have been touched by at least one Avera *e*CARETM service. More than 165 hospitals and clinics across a 495,000 square mile service use

all need to be addressed as unique challenges.

136 Telemedicine

zations, and premature relapses in medical problems.

allied health members, nurses, and physicians.

**Figure 11.** illustrates a model of global care coordinated by multiple electronic telemedicine programs coordinated by a core of expert telemedicine caregivers located in a core such as the Avera eHelmTM.

at least one Avera *e*CARETM service. At the present 650 providers are served by Avera eCARETM. The total financial impact has been greater than 55 million dollars.

The future goals of Avera *e*CARETM includes a plan to create virtual support for hospitals, clinics, long term care facilities and other nontraditional care locations to provide access to care at the same level of quality available in urban settings. In addition, Avera is exploring a robust home monitoring and coaching system of care that enables providers to interact with chronically ill patients in their home environments. These steps will create a virtual support for patient centered medical homes.

In conclusion, the success of these multiple diverse telemedicine programs in the rural region of the North Central United States has been a result of trying to meet the needs for health care in this area. Telemedicine has been well received due to many factors, including the remoteness of many communities, the frequently inclement weather which impairs urgent face-to-face health care, the lack of health care resources in the agricultural economy, and the extremely low number of specialty and subspecialty providers located these states. The success of Avera *e*CARE has not gone unnoticed. Many have asked to learn how to duplicate some or all of Avera models of comprehensive telemedicine.

Today and in the future, Avera will continue to leverage technology to connect with our North Central USA population, to engage the people of this rural region in prevention and in provision of care and services on the go and where they live. Finally, Avera will partner with stakeholders who will join in the advancement of innovation, research and policy for teleme‐ dicine practice and reimbursement.

[2] Zawada ET Jr, Kapaska D, Herr P, Aaronson M, Bennett J, Hurley B, Bishop D, Dagh‐ er H, Kovaleski D, Melanson T, Burdge K, Johnson T, Avera *e*ICU® Research Group: Prognostic outcomes after the initiation of an electronic telemedicine intensive care

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

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[3] Zawada Jr ET, Herr P, Larson D, Fromm R, Kapaska D Erickson D: Impact of an ICU telemedicine program on a rural health system. Postgraduate Medicine May (2009). ,

[4] Zawada Jr ET, Gangineni S, Herr P, Heisler M, Deppe S Workload update on the

[5] Lilly, C. M, Fisher, K. A, Ries, M, Pastores, S. M, Vender, J, & Pitts, J. A. Hansen III W: A national ICU telemedicine survey, validation and results. Chest (2012). , 142(1),

most rural tele-intensivist program. Chest (2012). 142(4):548A.

unit (*e*ICU®) in a rural health system. SD Journal of Med 59(9):391-393, (2006).

121(3), 160-170.

40-47.

The Avera *e*CareTM Research Group also includes: Jay Weems, Srivedi Gangineni MD, Scott Deppe MD, David Kovaleski, MD, Sarah Kappel CCRN, Tami Schnetter CCRN, Andrea Darr Pharm.D., Deanna Larson RN, David Erickson MD.
