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Bringing subspecialists to rural patients via telehealth


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Ninette D  Swanson Rn Bsn Optimized

Ninette D. Swanson, BSN, RN

Living on the North Olympic Peninsula has many benefits: gorgeous mountain and water views, a very temperate climate and many ways to promote healthy living.

Easy access to sub-specialized health care is not one of those benefits. The North Olympic Peninsula is rural with a medium-size rural hospital and two Critical Access Hospitals, which are unable to employ sub-specialists and offer all the specialties typically available in urban areas. The trip back and forth to Seattle for medical appointments is a full-day commitment.

This area also has a significant percentage of Medicare and Medicaid-eligible citizens with limited incomes and access to transportation. Patients requiring disease-specific specialists often need to travel three hours each way to the metropolitan areas of Seattle to receive care.

Through the Telehealth program offered by Olympic Medical Physicians in partnership with Swedish Health Services, patients get access to the Swedish Movement Disorders Clinic as well as the Swedish Lung Cancer Screening/Thoracic Surgery Clinic. Telehealth visits are scheduled for one day each week, alternating between TeleMovement (neurology visit for Parkinson’s disease and essential tremor) and TeleLung (lung cancer screening and perioperative thoracic surgery) visits.

Telehealth presenting is the sparkle to my work week. It gives me the opportunity to use my assessment skills and work closely with the patient and family to ensure a meaningful provider visit. When I am not working with Telehealth, I am an office nurse triaging patient concerns, refilling medications and performing simple procedures like injections and changing urinary catheters.

To prepare for this role, I spent a day shadowing each Swedish Telehealth provider face to face in Seattle so that I could synchronize my assessment skills to match what they would find, as if my hands were theirs. I am using skills that would have remained dormant in my regular job duties.

For Telehealth, I am using a cart containing a computer, monitor, remote microphone and web camera as well as accessories to be used during the exam. These accessories include an exam camera with several lenses and a Bluetooth-enabled stethoscope.

For the TeleMovement visits, I use the exam camera to allow the remote provider to assess patient’s gait and balance. The rest of the neuromuscular assessment involves me being the hands of the remote provider, evaluating the patient’s tone, fine and gross motor skills.

For TeleLung visits, the Bluetooth-enabled stethoscope is used for cardiac and pulmonary assessment. The remote provider wears a similar stethoscope and is able to hear heart and breath sounds as if the patient were in his office. The camera is used to visualize eyes, mouth, hands, feet and incision lines (for the postoperative patients.) The technology enhances the amount of information the remote provider can obtain about the patient’s clinical condition.

One patient stands out from all of the visits: RP, a 45-year-old male who lives 30 minutes from our clinic, was seen through the TeleLung program after his second spontaneous pneumothorax due to severe emphysema. He was still smoking and was told that if he wanted surgery to help his condition, he needed to quit. His first visit was to initiate a smoking cessation program and evaluate his status after his hospital stay. His second visit was 10 days after lung volume reduction surgery. He had been smoke free for two months and tolerated surgery well. It is unlikely that he would have survived without the services provided through Telehealth as he was unable to access the specialized services and frequent follow-up visits that would have been needed if they were in Seattle.

Postoperative visits after thoracic surgery, such as hiatal hernia repair or lobectomy, via Telehealth have significant value for the well-being of the patients. These patients are usually weaker and unable to tolerate six hours of travel time for a 15-minute physician visit in the office.

Most patients seen in our clinic live less than 30 minutes away. They be seen by the remote provider, assessed, have next steps planned as part of the Telehealth visit, and are home again within two hours. Patients can be seen more frequently if needed as the hurdles of travel time and costs to receive care are much smaller.

For patients with advanced Parkinson’s disease, being dependent on others for transportation, requiring assistance to ambulate and often having cognitive changes, the Telehealth visit addresses those challenges by making the provider available in a quiet, relaxed setting. As one TeleMovement patient said to me recently after his first Telehealth visit, “I received a more comprehensive visit via Telehealth than I would have if I traveled all the way to Seattle and met with the doctor face to face.”

Presenting myself confidently to the patient and family eases anxiety and encourages a positive Telehealth experience. I am pleased that Telehealth has become part of my skill set and that I can help provide this important service for patients who might find it difficult, even impossible, to receive that kind of care.