System explores telemedicine to improve health care access for urban poor
By JULIE MINDA
Telemedicine has been used in an increasingly wide variety of settings and for many different purposes. But few health care providers have tapped into telemedicine as a means to expand access to medically underserved urbanites. St. Joseph Health System in Orange, Calif., hopes to do just that with a telemedicine network in densely populated Southern California.
Telemedicine is "the future of medicine," said Dr. Elliot Sternberg, St. Joseph executive vice president of wellness and health improvement and head of the telemedicine project. "Five years from now, this will be standard and pervasive."
Sr. Jayne Helmlinger, CSJ, executive vice president of mission integration for St. Joseph, agrees. "If the predictions are correct, we'll need to deliver care differently in the not-so-distant future because we simply won't have enough providers to deliver care in the manner in which we deliver it today.
"We can't shy away from the technology and new ways of delivering care," she said. At the same time, St. Joseph is determined that its efforts to preserve or improve health care not be won by sacrificing healing, human, sacred encounters with patients.
A pivotal concern for the system as it completes the rollout of the telemedicine network that it is calling Health Presence is that the holistic and person-centered nature of Catholic health care be preserved in these high-tech encounters between clinicians and patients, Sr. Helmlinger said.
"Technology is a great tool of connection, but we have all seen how it can run the risk of depersonalization," she said.
"If we allow technology to be an end unto itself, we will fail miserably in our mission to bring healing and hope to all we serve." Technology, Sr. Helmlinger continued, should be viewed "as a conduit and instrument to be used by caring, compassionate health care professionals who engage with patients in body, mind and soul."
Extending the mission
Beginning in late summer, St. Joseph will open pilot "interactive wellness sites" in Southern California. It will expand to sites in Northern California if the pilot is a success. Initially, the telemedicine outposts will open at St. Joseph-affiliated clinics and other medical facilities in Fullerton, San Juan Capistrano and Laguna Beach. There also will be a stand-alone telemedicine kiosk, designed as a private medical exam room, in Apple Valley.
St. Joseph chose the sites to be accessible to low-income people. "That is why we are providing (the telemedicine connections at) community clinics that accept remuneration based on ability to pay," explained Sternberg.
He added that the sites also were chosen because of their convenience — while some of the communities where the sites will be located are relatively affluent or even upper-income, they are still convenient to the low-income patients who work in or visit those communities. At these sites, patients will get, "easy access, in and out," explained Sternberg.
At each of the telemedicine sites, a medical assistant will connect the patient with primary care and specialty care clinicians at other locations via videoconferencing equipment.
At the clinician's direction, the medical assistant may check vital signs and symptoms, transmitting electronic images and data in real time to the clinician. The telemedicine system uses high-definition cameras with zoom lenses and clinicians view the images on high-definition television screens, so they are able to see more detail than they could with the naked eye. The medical assistant and remote clinician both can enter observations and share files including x-rays, lab work and dictated reports in an electronic health record that can be accessed throughout the St. Joseph system and be shared with the patient's primary care provider.
In the future, St. Joseph also will be able to move beyond the fixed telemedicine sites. Laptops and other mobile devices will enable telemedicine to be used virtually anywhere. St. Joseph envisions using it for home health, at skilled nursing facilities and in its mobile health vans.
Sternberg said St. Joseph has dabbled in telemedicine at some of its 14 hospitals and other care sites. It decided to invest in the technology in a comprehensive way with Health Presence because of telemedicine's ability to bypass some key health care access barriers that vulnerable people face. For instance, it's hard or impossible for some patients in St. Joseph's service area who may not live or work within a short commute to their doctors' offices to keep appointments during standard office hours.
To illustrate how telemedicine may overcome such challenges, Sternberg described a study St. Joseph conducted at its St. Mary Medical Center in Apple Valley. That hospital often is at capacity and there are long waits in the emergency department, particularly in the evening. A study of patients who came to the emergency department between 5 p.m. and midnight revealed that most could have been seen in an urgent care location.
So, St. Joseph is locating one of its telemedicine sites in Apple Valley and keeping it open during evening hours for patient appointments and walk-ins in the hope that people will use it and reserve the emergency room for serious emergencies. The plan is to put the kiosk in a high traffic location like a strip mall.
Transportation is often an obstacle for low-income people including non-English speakers in need of specialty care or behavioral health services. Because it reduces geographic challenges, telemedicine holds the potential to open access to a broad spectrum of clinicians and translators.
For all its potential to advance St. Joseph's mission to care for the vulnerable, telemedicine has possible pitfalls.
Before endorsing Health Presence, St. Joseph's President's Council weighed the risk that promoting remote interactions between clinician and patient could sacrifice healing aspects of human-to-human contact.
Too, "telehealth is not for everyone," Sternberg said. Some patients prefer to have a face-to-face encounter with their doctors.
Added Sr. Helmlinger, "As Catholics, we understand that personal presence is at the root of our sacramental experience."
And, yet, technology need not be an automatic barrier to closeness. "Have you ever had a phone call that touched your soul or deeply moved your heart?" Sr. Helmlinger asked. "While not the complete experience, human encounters via technology can be powerful — and precisely because of technology, the human elements ought to be emphasized as central to their use, especially in health care."
St. Joseph is developing curriculum to help clinicians and medical assistants at the telemedicine sites to be attentive to the patient, alert to any discomfort or hesitancy on the patient's part, in order to instill and build trust.
Telemedicine "will be new for most patients and we must be sensitive to their needs, responses and concerns with it when they interact with us in this new venue," Sr. Helmlinger said.
St. Joseph also will be engaging its telemedicine team in the Sacred Encounters spotlighting process (see related story) to determine how to enhance the experience for patients.
"There might be ways in which telemedicine is 'hands-off,' but as we envision its use, it not eyes-off or smiles-off or ears-off," Sr. Helmlinger said. "That is to say that telemedicine, with the impact of high-definition screens, enables caregivers and patients to speak, see, listen and respond in ways that are, of course, human.
"The technology is only there to assist," Sr. Helmlinger emphasized. "It is the human connection between the patient and the caregivers that will ultimately determine the success of telemedicine."
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