Ellen McGowen, 63, settles into her chair at the Colbert County Health Department in Sheffield, Alabama, looks at the TV on the telehealth cart in front of her, and speaks "face to face" with Eric Wallace, M.D., her nephrologist and University of Alabama at Birmingham assistant professor of medicine.
Wallace is able to give a full checkup to McGowen, a home dialysis patient who lives 115 miles away. With the use of a high-definition handheld examination camera, he is able to check McGowen's legs for swelling, her mouth for signs of dehydration, and her dialysis catheter for redness, drainage or other signs of infection. He even listens to her heart and lungs with his Bluetooth-enabled stethoscope, and a nurse draws her blood to be shipped to a central lab for testing.
"My son who works for NASA is going to be amazed by this," McGowen said.
The next day, the scene repeats itself. This time it is 84-year-old Mary Epp, and she is at the Dallas County Health Department in Selma, 88 miles from UAB.
"My husband was able to go to work today since I didn't have to come to Birmingham for my checkup," Epp said. "I think it's wonderful. I really almost feel like I'm there."
This two-way, real-time interactive communication between the patient and the physician is known as telehealth, or telemedicine, and these visits Wallace conducted with Epp and McGowen are part of a pilot study in a UAB School of Medicine partnership with the Alabama Department of Public Health. They are novel for the state because telehealth is not utilized in any expanded or comprehensive capacity. The visits are innovative for the United States because they are believed to be the first in the country to replace a comprehensive face-to-face visit for the home dialysis patient.
"This pilot program, funded by Baxter Healthcare Corp, is really three years in the making," Wallace said. "And what these dialysis visits mean for Alabama is what I'm most excited about. If I can provide a fully comprehensive telehealth visit for a home dialysis patient -- which is one of the most complicated visits to do -- then I can do this for any patient and virtually any disease. It means that the subspecialty and super subspecialty care that may only be available in a university setting, such as rare diseases, can now be extended to every corner of Alabama, thus increasing the quality of care of patients in Alabama. The gaps in care and education that telehealth can bridge are tremendous and incredibly needed in Alabama."
UAB Health System CEO Will Ferniany says the partnership on this pilot study will show how big an impact telehealth could have in Alabama with the right nurturing.
"With UAB and the ADPH, you have two of the largest health care providers in the state working together for one common goal -- to improve the health of the residents of Alabama," Ferniany said. "The examples of what telehealth can achieve for Alabamians are limitless. The real question is how we organize it in Alabama so it can be successful."
Telehealth rarely covered by insurance in Alabama
One of the obstacles to telehealth in Alabama is reimbursement from insurance companies.
Across the national landscape, most states have very robust telehealth networks. More than half have laws in place requiring coverage for telehealth-provided services, and a telehealth appointment is viewed the same as the patient's presenting in the clinic room with the provider. The provider is reimbursed at the same rate regardless of the type of visit in states with telehealth laws in place.
Border states Georgia, Mississippi and Tennessee have all enacted health insurance parity laws. Alabama has not, and as a result, reimbursement opportunities for providers are almost nonexistent.
Blue Cross/Blue Shield of Alabama began to reimburse for five specific health conditions in December 2015 -- cardiologic and dermatologic conditions, infectious disease, behavioral health, and neurologic diseases, including stroke.
"What Blue Cross/Blue Shield did is a fantastic step in the right direction, but many other patients with other disease processes could benefit from this technology," Wallace said.
ADPH partnership is vital
One of the hardest things to do in telehealth is to find a place in the patient's hometown for them to go to have access to telehealth equipment. This is especially difficult in rural areas.
Knowing how important this could be for Alabama residents, the ADPH began developing a statewide telehealth network at county health departments in 2015 to work with UAB and other medical partners to build an infrastructure that would provide greater access to care throughout the state.
In February 2015, the ADPH deployed four telehealth carts with its first partner, Medical AIDS Outreach. They presently see their clients at six county health department telehealth facilities and are continuing to expand to other ADPH sites.
The partnership with Wallace in UAB's School of Medicine quickly followed, leading to the first dialysis telehealth visits in March of this year. Currently, 13 patients from seven different counties are enrolled in the study with a targeted enrollment of 40.
"We want our county health departments to be a neutral point of entry so patients can come into our facilities and receive services via telehealth facilitated by our nurse and social work staff with specialists around the state," said Michael Smith, director of Telemedicine for the ADPH. "We are breaking new ground in supporting those who are interested and have the support system for home dialysis. Our cooperative agreement with UAB's School of Medicine is a great partnership to further develop our telemedicine network. It's actually a model that's been well-established nationwide."
Smith points to Mississippi's program, which has 6,000 telehealth visits per month and sites across the state beyond county health departments. Some hospitals, schools, primary care centers and other facilities also provide a point of entry for patients.
Currently, there are 10 telehealth-ready ADPH county health department sites in Alabama with 15 more scheduled to come online before the end of 2016.
In Alabama, Wallace wonders what the possibility of the implementation of telehealth on a broad scale could mean for his patient population, which has one of the highest incidents of end-stage renal disease in the United States.
"There are so many patients in our state who have little to no access to subspecialty care like nephrology and have limited access to home dialysis care, and that's the reason we are doing this," Wallace said. "As soon as telehealth carts are deployed, UAB physicians could get to any county in the state. My goal is to have some traditional clinics where I'm in my clinic office, and then connect to 'be in' several county health departments seeing other patients with telehealth. You could be in multiple places within a normal half day of clinic."
Benefit to the patient
One of the factors physicians and nurses take into account when deciding how to best care for their patients are the burdens of disease.
The first burden of the disease is how the disease makes someone feel. But another is the time involved caring for the disease. That includes driving back and forth to and from clinic visits, waiting in waiting rooms, having to take off work and maybe losing pay because of it, and being away from loved ones.
"My hope is that telehealth will provide the patient less time caring for their disease and in turn will improve their quality of life," Wallace said.
Smith says a broad spectrum of counseling and clinical services is possible with telehealth. The ADPH already uses telehealth to provide mental health counseling and AIDS and HIV patient care.
"With a counseling visit, you don't need any peripheral clinical equipment like a stethoscope, handheld exam camera or ultrasound," Smith said. "And counseling on a broad spectrum is possible -- not just mental health counseling. Genetic counseling, diabetes education, weight management and other routine consultations are all possible. And clinical services including maternity care, diabetic retinopathy screening, oral health screenings -- there are many, many health care services that can be facilitated and provided with telemedicine that would provide opportunities for those that wouldn't otherwise see a doctor or a specialist."
The majority of Alabama's medical specialists are located in the state's metropolitan areas, but the majority of the state's population lives outside of those areas. Because of that, Wallace says Alabama's greatest health care need is increasing access to care in these small, sometimes isolated, rural communities.
Wallace estimates up to 25 percent of his patients are driving more than an hour to Birmingham for their visits. Telehealth, Wallace says, can bring many of these patients in contact with the highly specialized care his patients need and dramatically improve the impact of medicine in his home state.
"Alabama is my home," the Anniston native said. "This is my state, and I started doing this to show that this could be done here and could be used as a way to improve the quality of life of patients like Mrs. Epp and Mrs. McGowen. What has come from it is a true collaboration in every sense of the word with the ADPH, UAB and DaVita. Many people have been involved to get this pilot project off the ground. And now that we are showing it can work clinically and be better for the patients, there is so much more that is possible. A statewide telehealth network can serve both the adult and pediatric populations -- and this will help ease the burdens on patients and their families. I hope this is just the beginning for telehealth in our state."
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