**1. Introduction**

#### **1.1. Review of previous experience and accomplishments**

As previously published (1) the Avera Health system launched its telemedicine program by offering consultation by video connectivity from the main tertiary hospital in the largest city of the multi-state North Central Region of the United States to some of its smallest partner clinics and hospitals. Between 1993 and 2004, medical providers and patients learned what it was like to practice medicine and receive care via a telemedicine connection. A major growth spurt in Avera's rural telemedicine program came in 2004 after the initiation of a virtual ICU service staffed by intensivist physicians and critical care nurses; Avera *e*ICU CARETM1. Since 2004, Avera has initiated and rapidly expanded multiple other telemedicine programs to meet demand for additional services and coverage. These around-the-clock, always available services are unique as stand-alone programs, but combined provide one of the most robust telemedicine platforms on the planet.

In the previous report, the goals, expectations and consequences of the Avera *e*ICU CARE program were described. Avera *e*ICU CARE initially started with the system's tertiary hospital, Avera McKennan Hospital & University Health Center, serving as the hub location for the provision of twenty-four hour per day remote patient care and monitoring of seriously ill patients in three medium-sized rural hospitals. Over time it evolved to include several more hospitals of that size called "Rural Regional Hospitals." Additionally, remote Critical Access Hospitals (CAHs) began to request *e*ICU coverage. Intensivist-led medical supervision and

<sup>1</sup> Avera eICU CARE is a registered trademark of VISICU, Inc.

© 2013 Zawada Jr et al.; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2013 Zawada Jr et al.; licensee InTech. This is a paper distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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 expanded into multiple states.

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 *e*HelmTM.

**Figure 1.** shows the seven states of the North Central United States which receive Avera *e*CARETM services: Wyoming

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

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

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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

The six primary *e*CARE services are shown in Figure 2: *e*Consult, *e*Pharmacy, *e*Emergency,

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

(WY), North Dakota (ND), South Dakota (SD), Nebraska (NE), Minnesota (MN), Montana (MT) and Iowa (IA).

within and outside of the Avera Health system.

*e*Long Term Care, and *e*Urgent Care in Correctional Facilities.
