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Virtually Ideal: Avera’s Expanding eCare Empire

Jun 21, 2016 09:55PM ● By MED Magazine

By Alex Strauss


A 42 year old Parkston, South Dakota area man is having dinner with friends when he suddenly develops the classic signs of a stroke. He becomes week, half of his face droops, and he loses the ability to talk. His wife rushes him to the nearest hospital, Avera St. Benedict Health Center in Parkston, where his friend, family physician Jason Wickersham, MD, is waiting.


Dr. Wickersham, who has worked in Parkston for 12 years, is not unfamiliar with stroke and has had experience using clot-busting drugs in the treatment of elderly heart attack patients, but this is a different scenario. In a larger health center, he and his patient would likely be surrounded by colleagues who could weigh in on the situation. Here, he is on his own.


Until, he presses a button on the wall of one of the two ER rooms.


Within seconds, the high-definition screen on the wall fills with the image of an ER physician at Avera’s eCare hub in Sioux Falls and he and Dr. Wickersham are collaborating on the case, working in tandem as physicians are trained to do. Within a short time, the two are joined by a neurologist, who helps walk Dr. Wickersham through a series of tests with the patient to confirm the diagnosis they all suspect: acute ischemic stroke.


“I knew about clot-busting drugs but I also knew that very few patients meet the criteria for using them, and we don’t give them very often,” says Dr. Wickersham. “I knew that this was serious and it made me a little nervous. It was great to have both the ER physician and the neurologist agree with me.”


As a team, the three agreed that Dr. Wickersham should administer the clot-buster. It was the right call. By the time the helicopter arrived to transport the patient to Sioux Falls (a process that was also sped up by the eEmergency system), he had begun to move and was able to speak.


“Today, you wouldn’t know that anything had happened to him,” says Dr. Wickersham. “That was my first really great experience with eCare.”


Since then, Wickersham and his colleagues in Parkston have had many great experiences with Avera’s suite of telemedicine services, which also include ePharmacy, for comprehensive oversight of drug administration when a pharmacist may not be on site, eICU, to monitor critical care patients in real time, eConsult for specialty visits, and four other services (see sidebar).


Answering the Call


Through eCare, even the most geographically remote or understaffed facilities can connect with an ER physician 24/7, for everything from a quick second opinion to assistance with a complex procedure. At 120 sites and counting, eEmergency is second only to eConsult as the most popular eCare service.


“It is truly amazing,” says Sioux Falls emergency medicine specialist Brian Skow, MD, medical director of both eEmergency and eCare. Skow has logged more than 8,000 hours in front of a camera and a 50-inch high definition monitor, working alongside rural doctors like Wickersham from a distance.


“We have had some amazing cases in trauma where we were able to help bedside providers places chest tubes or needle decompression of a tension pneumothorax,” says Dr. Skow. “We recently helped with a cricothyroidotomy by putting a handheld camera right above the neck and had a great outcome. The patient was flown to a trauma center and was discharged a few days later without complication.”


While the physicians consult, an eEmergency nurse can be documenting critical patient data, freeing up the nurse on the ground - who may be the only nurse there - to attend to direct patient care. eEmergency providers even have data on the storage location of every tool in the room, saving bedside providers from having to search for something  when time is critical. When transfer is needed, they can facilitate that, too.


Multiple Service Lines


Avera eCare comprises eight different service lines designed to support rural patients and providers as well as providers in other situations  - such as schools, prisons, and long term care facilities - where current staffing levels may be insufficient. The idea is to improve access and outcomes while simultaneously lowering costs and enhancing the stability of the local workforce.


“Our real skill here in telemedicine is that we have gotten very adept at integrating specialty 

 trained physicians - both in the consult world where you have one patient and one doctor in a scheduled visit, and in the critical care or emergency arena - with local providers,” says Deanna Larson, Chief Executive Officer of eCare.


“We like to say ‘We come to them, we don’t make them come to us.’”


In fact, through eCare, more than 100 types of Avera specialists in areas such as critical care, infectious disease, pulmonology, cardiology, neurology and others now provide care in ten percent of the nation’s critical access hospitals across ten states in the Midwest and the Northeast.



eCare Evolution


What began in the early 1990s as an outreach service heavily funded by the Helmsley Charitable Trust has evolved into a self-sustaining business with new sites coming on board every few months. More than two-thirds of these sites are non-Avera facilities.


“Ten or twelve years ago, we were faced with the questions of how do we maintain access to healthcare in those communities where physicians are leaving, places where it is hard to recruit and hard to retain,” says Larson.


“We began to see that the answer was to work in collegiality with partners. Otherwise, in some communities, you may have two providers who are on call 24 hours a day, every other day. Pretty soon, a physician in that situation just can’t provide the highest level of healthcare.”


In the same building where an eEmergency doctor and nurse are standing by 24/7, a pharmacist is also on hand to provide ePharmacy services, reducing the risk of medication errors and keeping prescribers up to date on current medication practices. An estimated 28,000 adverse drug events have been prevented by the service.


Critical care nurses and an intensivist, either in Sioux Falls or at another facility with whom Avera contracts, continuously monitor 100 ICU beds in 30 sites. This service has been found to reduce length of stay, decrease transfers, reduce complication and mortality rates, and decrease provider burnout.


Through eConsult, Avera specialists have provided more than 10,300 virtual visits saving 2.7 million driving miles and an estimated $1.12 million dollars.


Virtual Relationships


As Avera’s eCare services have expanded, so has its need for doctors, nurses, and 

 pharmacists willing to step up and put themselves out there in a whole new way. Dr. Skow, who says he is beginning to recognize the regional accents of distant providers with whom he works, says the virtual environment offers some unique advantages over the “real” ER.


“One of the joys of working over the camera is that you are getting providers who are reaching out to you for help or consult, and patients who want your help,” says Skow. “You don’t always get that in the main ER. You’ll get drug seekers, abusive patients, etc. You really don’t get that over the camera.”


But not everyone is up to the challenge of providing healthcare in a virtual environment. No one is forced to work in eCare and not everyone who wants to is a good fit. As Dr. Skow puts it, “This isn’t Burger King. You can’t have it your way. Some people are used to that, but that doesn’t work here.”


“We are very aware that they can hang up on us on their end,” says Larson. “So we look for people who not only have good camera presence but who can establish and maintain relationships. When that happens, you see people beginning to work together seamlessly. The fact that they are on video becomes nothing more than a glass between them in the same room. It’s just magic.”


And the magic is likely to continue to grow. Avera has plans to expand its eSchool Nurse services into more schools and eventually offer eHospitalist services to support those caring for non-critical hospitalized patients.



Avera eCare

Service            No. of Sites

eConsult                      157

eICU                              30

ePharmacy                    70

eEmergency                120

eLongTermCare            34

eCorrectional Health       4

eSchoolHealth                 9

AveraNow       3,000 enrolled