Telehealth and Rural Practices…the Road Less Traveled Kiki C. Nocella University of Southern California Keck School of Medicine Department of Family Medicine

Rural California

75% of land mass 11% of population 75% i 75% of land mass and 11% of population live in rural California

Tehachapi Valley Healthcare District

State of the Region….2004 Had a telemedicine unit since 1998 Had a telemedicine unit since 1998 JPA Collaborative JPA Collaborative New TVH built by 2008, seismic retrofit New TVH built by 2008, seismic retrofit

98.7% outward migration for inpatient care!

Support and Success for Telehealth Blue Cross of California/Wellpoint Blue Cross of California/Wellpoint –Funded through State to develop telehealth network for Healthy Families (SCHIP) and MediCal (Medicaid). CTEC CTEC –California Telemedicine and eHealth Center UC Davis UC Davis ….So why wasn’t it working in SE Kern?

What sites do you think of when you think of Telehealth? Rural hospital? Rural hospital? Rural Health Clinic? Rural Health Clinic? Academic Medical Center? Academic Medical Center? Physician Office?????? Physician Office??????

So….what was our process Community based planning collaborative Community based planning collaborative Networking outside the rural region Networking outside the rural region Capacity Building Capacity Building Lots of data gathering Lots of data gathering Lots of key informant interviews Lots of key informant interviews –Provider -- Ancillary –Admin-- Office staff

How did we get the docs talking? Trust building Trust building Listened, and listened, and listened Listened, and listened, and listened Maintained confidentiality to a level that was virtually painful Maintained confidentiality to a level that was virtually painful And the ripple effect began – the docs kept talking – to each other and testing the trust And the ripple effect began – the docs kept talking – to each other and testing the trust

What the docs said (about telehealth) Only possible after much listening and trust building Show me what is possible in a way I can get my head around – and I’ll run with it from there Show me what is possible in a way I can get my head around – and I’ll run with it from there Will it take revenue out of my practice? Will it take revenue out of my practice? Will it impact my relationships with my specialists? Will it impact my relationships with my specialists? My patients better not get billed anything extra (Translation – I don’t want to hear any complaints) My patients better not get billed anything extra (Translation – I don’t want to hear any complaints) What’s in it for me? (Not said, but always there) What’s in it for me? (Not said, but always there) The hospital is just trying to compete with me The hospital is just trying to compete with me

OK. Got the docs’ attention….but that’s not all of the challenges

Hospital’s business needs Community’s Health Needs Physician business needs Health Plan Business Needs The “Win-Win” is at the center

So, what was the solution? Telehealth only part of the equation Telehealth only part of the equation System redesign is the approach we’ve embraced System redesign is the approach we’ve embraced

Providers (Physicians, PAs, and NPs) Basic “talking heads” teleconferencing More as utilization dictates Via “Integrated Technology Association” Rural Hospitals and Clinics Higher cost equipment Telehealth center that integrates with other programs Academic Medical Centers and other specialists Telehealth Solution Teach them “rural” Agree to take all patients Specialties that were not in competition

We’re reforming – but not around the edges! Infrastructure Infrastructure –Give, give, give and then get a little –Provider leadership team –Population based quality improvement –Start with the basics…playing nice and sharing Education Education –Rural residency training –Rural HIT and population health curriculum –E-health alerts –CME/CEU –Some cool pipeline conversations

And reforming Telehealth – meeting the providers’ needs Telehealth – meeting the providers’ needs –“Talking heads” at every provider’s desk Telehealth – meeting the community’s needs Telehealth – meeting the community’s needs –Diabetic Retinopathy –Women’s health issues –Cardiac issues

And reforming! Synergistic and overlapping approaches on technologies Synergistic and overlapping approaches on technologies –PHR –SCDR Capacity building Capacity building

Policy suggestions Focus on the physicians Focus on the physicians Count all costs, not just traditional costs Count all costs, not just traditional costs Implement a reimbursement model that does not further fractionate an already fractionated system Implement a reimbursement model that does not further fractionate an already fractionated system

“Ultimately, the challenge of health care reform is the challenge of building community” Shortell, 1996

Acknowledgements Thanks to Michael and Jami for pinch hitting with no notice! Thanks to Michael and Jami for pinch hitting with no notice! Thanks to AHRQ for giving this community the reason to have this, and other, conversations Thanks to AHRQ for giving this community the reason to have this, and other, conversations Office of Statewide Health Planning and Development – thanks for the maps! Office of Statewide Health Planning and Development – thanks for the maps! Gregg, Lisa, George, Adil, Atif, Julie, Bill – thanks for your wisdom Gregg, Lisa, George, Adil, Atif, Julie, Bill – thanks for your wisdom Residents of SE Kern – thanks for being so open, willing, and dedicated Residents of SE Kern – thanks for being so open, willing, and dedicated Wish I were there 