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.