Mary L. Hill, JD, BSN, MA
Vice President of Ethics
Avera
Sioux Falls, SD
"Once we developed telehealth technology, we had an ethical responsibility to use it for the benefit of marginalized persons," said Deanna Larson, CEO of Avera eCARE®. And, with their signature blend of determination, creativity and technological prowess, the Avera eCARE team proceeded to do just that. The result? A multifaceted virtual health ministry which reinterprets Jesus's command "Go and do likewise" by extending services across geographic, socioeconomic and cultural boundaries. Through technology, Avera's mission of positively impacting the lives and health of persons and communities has been realized in new and evolving ways. And Avera's experience is not unique. During recent years, many Catholic systems throughout the country have implemented telehealth programs that provide healthcare services to populations in need.1
Fundamentally, ethics is about fidelity to one's identity, and for Catholic healthcare, this means faithfully embodying "Christ's healing compassion in the world."2 Of particular importance to Catholic identity is the service provided to "those people whose social condition puts them at the margins of society and makes them particularly vulnerable to discrimination: the poor; the uninsured and underinsured; children and the unborn; single parents; the elderly; those with incurable disease and chemical dependencies; racial minorities; immigrants and refugees … and person[s] with mental or physical disabilities."3 Not only has telehealth enabled Catholic ministries to reach these special populations, the technology has provided a number of unexpected advantages for doing so.
Immediate Availability of Colleagues: "I knew I would never be alone."
If, as Scripture scholars tell us, the most oft-repeated phrase in the Bible is God's command, "Be not afraid," God's enduring promise, "I am with you," must be a close second. The promise was first manifested in the Old Testament through God's accompaniment of the chosen people, and later took on special significance with the coming of Emmanuel, "God with us." In the midst of the world's suffering, Jesus was "with" humankind, teaching, healing and ministering. And, at the conclusion of his earthly ministry, Jesus commended the promise to all generations proclaiming, "I am with you always, until the end of the age."4
Telehealth technology enables healthcare providers to "be with" one another, providing technical expertise and moral support, while creating "a community that provides healthcare to those in need of it."5 Hospitals and clinics supported by telehealth have immediate access to board-certified physicians and experienced healthcare professionals from a variety of disciplines. For this reason, many critical access hospitals utilize telehealth in emergency departments to ensure 24/7 provider coverage. A recent survey of Avera's 150 eCARE Emergency sites indicated that in 30 percent of the cases, the local emergency provider was not on site when eCARE was contacted, and that it often took 30 minutes or more for local providers to arrive at the hospital after being called in. Fortunately, the immediate availability of eCARE clinicians ensured that necessary treatment was implemented without delay. The following story from Avera eCARE Emergency bears witness to the power of accompaniment through telehealth.
"We were called by one of our critical access hospitals that was about to receive multiple patients injured in an explosion," said Avera eCARE Emergency Medical Director, Dr. Kelly Rhone. "There were going to be at least five patients, including two who were critically burned and one who had actually been on fire. We knew that the care of these patients would quickly overwhelm that emergency department, so immediately we began calling down their disaster tree and calling in any hospital staff who could lend a hand. At the same time, we dispatched two of Avera's Careflight aircraft in order to provide the hospital with transfer support as well as critical care nurses and paramedics who could assist at the bedside."
"As the patients started to arrive, the ED clinicians put those who were most critical in front of the camera so that the eCARE team could assist the bedside staff with decisions such as where to place an IV in a patient who doesn't have much skin, how to maintain airway support, and the amount of fluid needed for resuscitation. Because we knew that these patients would be transferred to tertiary facilities, the eCARE team notified regional trauma and burn centers about the impending transfers, and the conditions of the patients. This freed up the bedside staff to focus on providing hands-on care."
"A couple months later, we learned that a locum tenens physician who had been working at the hospital during the explosion incident decided to sign a contract with that facility. In explaining her decision, the physician specifically mentioned the 24/7 support available from Avera eCARE stating, 'I knew I would never be alone.'"
Preventing Workplace Violence: "Would you like us to call Nora?"
Healthcare employees are among the occupations most likely to experience workplace violence, which is perpetrated by patients, visitors, intruders and coworkers. Rates of workplace violence in healthcare are significantly higher than for any other industry, and healthcare accounts for nearly as many workplace-violence-related injuries as all other industries combined.6 Workplace violence results in physical and emotional injury, time away from work, moral distress, burnout, and employee turnover.
During recent years, the Centers for Disease Control and Prevention and Occupational Safety and Health Administration of the U.S. Department of Labor have prioritized efforts to address the rising epidemic of violence against healthcare workers. In 2010, The Joint Commission issued a Sentinel Event Alert, "Preventing violence in healthcare settings" which was updated in 2017. The Joint Commission also sponsors a web portal of resources for workplace violence prevention in healthcare.7 Similarly, the Ethical and Religious Directives address the responsibility of Catholic healthcare organizations to provide "a work environment that ensures employee safety and well-being."8
Because a high percentage of healthcare workplace violence occurs in emergency departments, Avera eCARE Emergency has established a communication code for situations which become volatile or dangerous. The eCARE team will ask the on-site providers, "Would you like us to call NORA?" which stands for "Need an Officer Right Away." If the hospital staff respond affirmatively, the eCARE team notifies local law enforcement about the need for assistance in the emergency department.
Two recent incidents highlight the danger of workplace violence committed by inmates who have been transported to hospitals for medical treatment. On May 13, 2017, an inmate who had been hospitalized at Northwestern Medicine Delnor Hospital in suburban Chicago was unshackled after he requested to use the restroom. While unshackled, he grabbed the attending sheriff's pistol and took two female hospital employees hostage in a treatment area. According to news reports, the hostages were both threatened and beaten, and one hostage was repeatedly raped at gunpoint. During the incident, a section of the hospital was evacuated while hostage negotiators talked for several hours with the inmate. After negotiations broke down, the SWAT team entered the room, then shot and killed inmate. One hostage was struck in the arm by the bullet that killed the inmate.9
Less than a month later on June 7, a convicted murderer was taken to Joliet Presence St. Joseph Medical Center for treatment. While at the hospital, the inmate displayed a makeshift weapon and informed the assigned officer and a nursing assistant that they were being held hostage. The Joliet police responded to the incident, apprehended the inmate, and freed the hostages who were physically unharmed.10
One way to decrease the security threat posed by inmates is to increase the capability for medical treatment to occur within correctional facilities through telehealth technology. During its initial years of its operation, Avera eCARE Correctional Health has reduced the necessity of transporting inmates to outside clinics and hospitals by 50 percent, saving millions of taxpayer dollars. "We're always looking for new and better ways to keep inmates inside our correctional facilities for security reasons. With eCARE's technological capabilities it's now much easier, safer and more secure, and cost-effective to do that while still providing exceptional healthcare," said Kayla Tinker, Correctional Health Administrator for the South Dakota Department of Health. And, because of the safety and convenience of tele-correctional health, more clinicians have been willing to participate in caring for inmates, thus further promoting quality care.11
Although not specifically mentioned as a vulnerable population in the Directives, inmates are disproportionally represented by racial and ethnic minorities, persons who are mentally ill, and the poor.12 Interacting with inmates has been one of the hallmarks of Pope Francis's papacy, beginning with his much-publicized washing of prisoners' feet during a 2013 Holy Thursday Mass, just two weeks into his tenure. Since then, Francis has visited prisons throughout the world, invited prisoners to dine with him, celebrated Mass in prisons, and advocated for prison conditions "that are worthy of human persons."13 Certainly, ensuring that prisoners have access to timely and exceptional healthcare contributes to conditions that foster human dignity.
Creating a Safe Space: "It was the first time I had ever seen the whites of his eyes."
As a psychiatric nurse practitioner serving a sparsely populated multi-state region, John Erpenbach has logged tens of thousands of driving miles during his 35-year career. Therefore, when the opportunity arose in 2015 to join Avera eCARE's Behavioral Health team located in a Sioux Falls facility just 15 minutes from his home, Erpenbach jumped at the chance. Along with psychiatrists, psychiatric social workers, nurses, and counselors, Erpenbach provides psychiatric assessment, medication management, and treatment recommendations for patients in hospitals, long-term care facilities, and community settings throughout the country. As well as saving wear-and-tear on his vehicle and decreasing nonproductive driving time, telehealth technology has eliminated weather and transportation-related appointment cancellations. More importantly, working with eCARE Behavioral Health has allowed Erpenbach to continue caring for three dozen developmentally disabled adults who live in community 75 miles from Sioux Falls.
"It was the first time I had ever seen the whites of his eyes," said Erpenbach, of Richard (not his real name), a patient whom he has been treating for the better part of two decades. "Richard is severely autistic and when we used to meet in person, he would look down at the floor during the entire appointment. However, since our first telehealth meeting, Richard has consistently made eye contact with me. Communicating through the video camera has provided a level of comfort he didn't experience when we were in the same room." Erpenbach has noted a similar dynamic with several other of his severely autistic patients.
In addition to creating a safe space for persons with autism, tele-behavioral health has enabled greater anonymity and confidentiality for persons seeking mental health and addiction treatment. Rather than being seen entering mental health or addiction treatment clinics — which identify the conditions for which they are being treated — persons may avail themselves of telehealth services at locations where a wide variety of healthcare services is provided.14 Addiction researchers have suggested that the availability of telehealth — and even the use of avatars in a virtual space — has positively impacted client engagement in the recovery process.15
Supporting Aging in Place: "Doc in the Box"
During the early years of telehealth, questions arose about whether technology could mediate personal presence sufficiently to establish and maintain a therapeutic provider-patient relationship. Healthcare has always been a high-touch endeavor, and through the centuries it has also become an increasingly high-tech one. Despite advances in technology, the relationship between patient and care provider remains central. "The Church's moral teaching on healthcare nurtures a truly interpersonal professional-patient relationship [italics added]."16 And, although close physical proximity between a provider and patient may facilitate interpersonal interaction, a therapeutic relationship and effective communication are possible even in the absence of such proximity.
Personal "presence is frequently treated as consisting of spatial or physical presence, and social presence. The former is 'the sense of being in a virtual place,'…ways in which our perceptions and actions create a sense of space;' the latter is 'the sense of being together with another.'"17 Researchers agree that personal presence falls along a continuum. The degree to which personal presence is experienced depends upon the degree of physical presence combined with the degree of social presence.18 Physical presence may be engendered by being bodily in the same room as another person, as well as through the mediation of technologies such as interactive online forums and videoconferencing. Social presence implies interaction between persons. Activities such as in-person dialogue, phone conversations, and "interaction with a virtual or remotely located communication partner"19 ostensibly facilitate a sense of social presence.
Also, the degree to which persons intend to be and are present to one another is directly proportional to their experiences of personal presence. In other words, the more a person is paying attention to, emotionally engaged with and responsive toward another person, the greater the degree of personal presence being mediated. The fact that persons are not within close physical proximity of one another does not preclude a significant experience of personal presence. Technologies like videoconferencing — by which both verbal and "non-verbal communicative clues, such as gaze, direction or posture" are conveyed — have the potential to mediate a high degree of personal presence.20 Conversely, persons who are in close physical proximity but who are ignoring one another may experience a very low degree of personal presence.
In order to facilitate personal presence and therapeutic communication on the part of eCARE staff, Avera enlisted the expertise of a former television news reporter who assisted in developing a training video about on-camera presentation that is used for new employee orientation. Topics covered include facial expressions, tone of voice, body language and empathetic communication techniques. Staff are also trained in the use of two-way video cameras with an emphasis on safeguarding patients' dignity and privacy. The consistently high eCARE satisfaction ratings from both patients and providers attest to the effectiveness of telehealth to facilitate therapeutic interactions.
Because today's senior citizens did not grow up with virtual technology, presumably they might have more difficulty adjusting to telehealth than younger generations. "In my experience, seniors have been very adaptable to telehealth," said Michele Snyders, LCSW, who serves in Avera's eCARESenior program. The program provides the expertise of board-certified geriatricians and geriatric-trained nurse practitioners, pharmacists, nurses and social workers to long term care facilities in a multi-state region. Residents of these facilities have affectionately dubbed the telehealth technology "doc in the box" because the eCARE clinicians appear on a large flat screen monitor mounted to a wheeled cart. The mobility of the cart enables telehealth encounters to occur in the privacy and comfort of the resident's room, as well as in other locations throughout the facility. "One time I had pneumonia and the staff was able to wheel the equipment right in my room so I could see the provider," said a resident. "I can see how this impacts quality because of the access to knowledge and how quickly they can come up with the medication needed. It makes healing faster because you don't have to wait to get into the doctor's office."
Another Voice for Difficult News: "I lost my words."
Telehealth provides an extra set — or more — of eyes on the patient, as well as the expertise of board-certified and experienced clinicians who can remotely monitor vital signs and lab values, screen for high-risk conditions, research diagnoses, evaluate and recommend pharmaceutical interventions, and assist with communication and patient transfers. The geographic distance that often exists between telehealth clinicians and the patients they support undoubtedly allows for greater objectivity on the part of these clinicians. Indeed, patients are less likely to have personal relationships with telehealth clinicians located in another town or state, than they are with healthcare providers who work locally. Within smaller communities, it is not uncommon for providers to care for their own neighbors, friends and even family members.
The relative objectivity of telehealth clinicians may enable them to break bad news to the patient more readily than providers who live in the patient's community. Studies have suggested that the length of the provider-patient relationship is a variable affecting the accuracy of mortality predictions; the longer the relationship, the more likely that the provider's prediction will be overly optimistic.21 Avera eCARE clinicians have experienced this situation in emergency department and ICU cases. On more than one occasion, the eCARE clinicians have diplomatically broached the subject of mortality when the local provider seemed reluctant to do so. After one such case, the local provider later called the eCARE clinicians to express gratitude for their candor. The local provider explained that she had a longstanding relationship with the patient and his family which made it very difficult to raise the issue of mortality. "I lost my words," she said.
eCARE Senior Care is another telehealth program in which discussions about mortality frequently occur. Avera utilizes admission reviews to identify long term care residents who are at higher risk of hospital readmission and/or death. Once identified, a resident is closely monitored and managed according to established protocols. In order to foster appropriate treatment, the medical record is reviewed to ensure that advance directives are documented, and that they accurately reflect the resident's current condition and wishes. Also, eCARE clinicians provide continuing education and support to facility staff who assist residents and their healthcare surrogates with advance care planning.
Managing High Risk and Chronic Conditions: "It was like having a big sister looking over my shoulder."
With the shift to population health management, telehealth enables ongoing monitoring, support and treatment of high-risk and chronic conditions in patients' homes, workplaces, and other community-based settings. One such condition is gestational diabetes mellitus, which affects 7 percent of pregnant women nationally and increases the risk of serious perinatal complications including premature delivery, large for gestational age infants, respiratory distress syndrome, brain injury, fetal demise and serious maternal complications. Infants who do survive are at increased risk of chronic disease later in life, as are women who have had gestational diabetes. Like Type 2 diabetes, the condition disproportionately affects women of color.22 Fortunately, with early identification and tight blood glucose control, many of these risk factors can be mitigated and even eliminated.23
To effectively manage gestational diabetes, evidence-based protocols suggest that a certified diabetes educator (CDE) and/or registered dietitian work concurrently with the patient's obstetrician or primary care provider to monitor blood glucose on a regular basis, provide nutritional counseling, and recommend medication if dietary modifications are not sufficiently effective. However, many women don't have ready access to specialty healthcare providers due to geographic isolation, lack of financial resources, transportation issues, and a shortage of qualified healthcare professionals. In collaboration with the Health Resources & Services Administration (HRSA), Avera eCARE launched the eGDM Program in November 2016 aimed at managing gestational diabetes mellitus through telehealth technology.
Women newly diagnosed with gestational diabetes are connected within one business day to a coordinated team of eGDM Program specialists (maternal-fetal medicine nurse practitioner, CDE who is typically a registered nurse, and a registered dietitian) via a smartphone, tablet or computer. Patients who don't have such devices are provided with cell phones funded from the HRSA grant. The grant also funds glucometers and test strips which the patient is trained to use for blood glucose monitoring four times per day. Results are uploaded via Bluetooth to a cloud platform checked daily by eGDM clinicians who immediately contact the patient in the event of three elevated readings. "It was like having a big sister looking over my shoulder," said one patient. "I was very motivated to eat healthy because my blood sugars were being reported to the team every day."
When diet alone isn't sufficient to control blood glucose, the patient is scheduled for an appointment with the MFM nurse practitioner. Insulin is often the first choice when medication is indicated, and insulin education is provided via Avera's virtual platform. In addition, patients meet virtually with the eGDM clinicians on a weekly or biweekly basis for a 10-15-minute appointment. These virtual appointments can occur at times and locations — such as home or workplace — that are convenient to the patient and don't require travel or time off from work. Patients also have access to brief (1-3 minute) educational videos about diet, exercise, breastfeeding, and healthy habits that can be viewed at the patient's convenience.
Such ongoing monitoring and timely intervention facilitate the tight blood glucose control necessary to minimize and avoid serious complications. Results from the eGDM Program's first year of operation indicate significantly lower rates of maternal and neonatal complications as compared to historical baseline data, and very favorable patient satisfaction ratings. Efforts are currently underway to expand the use of this technology to other aspects of obstetric care.
Fostering a Culture of Encounter: Influencing the Healing Profession
In light of current and impending healthcare professional shortages, an aging population, and evolving reimbursement paradigms, telehealth is able to deliver high quality care that is often more affordable and accessible than traditional in-person delivery models. Also, as has been demonstrated by Avera eCARE, opportunities to practice virtually may increase the productivity of healthcare professionals who previously commuted long distances between practice sites, extend the careers of those nearing retirement age, and encourage more clinicians to consider treating marginalized populations, such as inmates.
Because many of the hospitals, clinics and prisons supported by Avera's telehealth programs are secular, collaborations with these entities have created opportunities for Avera "to witness to [its] religious and ethical commitments and so influence the healing profession."24 Staff at local hospitals have commented about the compassion and support experienced from eCARE clinicians, and have asked clinicians to pray with and for them during particularly challenging cases. After such cases, Avera has arranged for counselors to provide critical incident debriefings to local staff, as well as chaplains who provide spiritual and emotional support.
Throughout his papacy, Francis has called the Church to foster "a culture of encounter" that reflects "Jesus' encounter with his people; the encounter of Jesus who serves, who helps, who is the servant, who lowers himself, who is compassionate with all those in need"25. Virtual technology has enabled Catholic healthcare organizations to foster such a culture by extending the healing ministry of Jesus in new ways across geographic, socioeconomic and cultural boundaries. In many circumstances, virtual technology may be the only means whereby persons can encounter Catholic healthcare and, perhaps, any form of accessible healthcare. Finally, collaborations in which Catholic ministries provide telehealth support to secular entities "can help implement the Church's social teaching, …realign the local delivery system in order to provide a continuum of health care to the community; [] witness to responsible stewardship of limited health care resources; and [] can be opportunities to provide to poor and vulnerable persons a more equitable access to basic care."26
1 Health Progress, Telemedicine, Jan-Feb 2015, Vol. 96, No. 1, Catholic Health Association, St. Louis, MO. pp. 5-55.; Christopher Veremakis, MD, "Virtual Care Supports The Common Good," Health Progress, Nov-Dec 2016, Vol. 97, No. 6, Catholic Health Association, St. Louis, MO. pp. 55-8.; Steve Lindquist and Brian Erickson, "A Network Touches the Hard-to-Reach," Health Progress, Jan-Fen 2018, Vol. 99, No. 1, Catholic Health Association, St. Louis, MO. pp. 23-7.
2 Ethical and Religious Directives for Catholic Healthcare Services. Fifth Edition. United States Conference of Catholic Bishops, Washington, DC, 2009 Conclusion, p.16.
3 Ibid. Directive 3, p.5.
4 Gospel of Matthew 28:20.
5 Ibid.
6 Occupational Safety and Health Administration, Caring for our Caregivers, Preventing Workplace Violence: A Road Map for Healthcare Facilities, U.S. Department of Labor, Washington, DC, December 2015. https://www.osha.gov/Publications/OSHA3827.pdf
7 The Joint Commission, "Preventing violence in the healthcare setting," Sentinel Event Alert, Issue 45, June 3, 2010, Addendum Feb 2017, https://www.jointcommission.org/workplace_violence.aspx
8 Ethical and Religious Directives, Directive 7, p. 5.
9 http://www.nbcchicago.com/news/local/More-Nurses-Join-Lawsuit-After-Hostage-Situation-at-Suburban-Hospital-425913003.html ; http://wgntv.com/2017/05/25/nurses-file-lawsuit-over-delnor-hospital-hostage-standoff/ ; http://www.chicagotribune.com/suburbs/aurora-beacon-news/news/ct-abn-delnor-nursesl-hostage-lawsuit-kcso-st-0525-20170525-story.html
10 http://www.wsiltv.com/story/35612226/inmate-takes-hostages-at-will-county-hospital
11 Betsy Taylor, "Avera Health's telemedicine reaches patients in South Dakota prisons," Catholic Health World, CHA, Oct. 1, 2016; https://www.chausa.org/publications/catholic-health-world/archives/issues/october-1-2016/avera-health's-telemedicine-reaches-patients-in-south-dakota-prisons
12 The Color of Justice: Racial and Ethnic Disparities in State Prisons, http://www.sentencingproject.org/wp-content/uploads/2016/06/The-Color-of-Justice-Racial-and-Ethnic-Disparity-in-State-Prisons.pdf ; https://www.nami.org/Learn-More/Public-Policy/Jailing-People-with-Mental-Illness
13 Pope Francis: "Prison conditions must be humane," Catholic Herald, Jan 1, 2017, http://www.catholicherald.co.uk/news/2017/01/04/pope-francis-prison-conditions-must-be-humane/
14 Todd Lawley and David Lopez, MD, "Mental Health Services Extend to Pipeline Towns," Health Progress, Jan-Feb 2015, Vol. 96, No. 1, Catholic Health Association, St. Louis, MO. pp. 29-31.
15 Todd Molfenter, Mike Boyle, Don Holloway and Janet Swick, "Trends in Telemedicine Addictions Treatment," Addiction Science and Clinical Practice, (2015) 10:14, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4636787/pdf/13722_2015_Article_35.pdf
16 Ethical and Religious Directives, Introduction to Part Three, p. 8.
17 Lucia Reno, "Presence and Mediated Spaces: a Review." PsychNology Journal 3, no. 2 (2005). http://www.psychnology.org/File/PNJ3%282%29/PSYCHNOLOGY_JOURNAL_3_2_RENO.pdf (accessed September 3, 2014), citing F. Biocca, C. Harms, & J.K. Burgoon, (2003). Towards A More Robust Theory and Measure of Social Presence: Review and Suggested Criteria. Presence: Teleoperators and Virtual Environments, 12 (5), 456, 459.
18 Wijnand Ijsselseinjn and Riva Guiseppe, "Being There: The experience of presence in mediated environments." In Emerging Communication – Studies in New Technologies and Practices in Communication, edited by Guiseppe Riva, et. al., The Netherlands: Ios Press, 2003: 7-8.
19 Ibid. 7-8.
20 Ibid. 8.
21 Nicholas Christakis and Elizabeth Lamont, "Extent and determinates of error in doctor's prognoses in terminally ill patients; prospective cohort study," BMJ, Vol. 320, Feb. 19, 2000, pp. 469-472. http://nicholaschristakis.net/wp-content/uploads/2015/03/041-Extent-and-Determinants-of-Error-in-Doctors----Prognoses-for-Terminally-Ill-Patients-Prospective-Cohort-Study.pdf
22 Wilfred Fujimoto, MD, Raynald Samoa MD, and Amy Wotring, "Gestational Diabetes in High-Risk Populations," Clinical Diabetes, 31:2 (2013), pp. 90-4.
23 Bonaventura Mpondo, Alex Ernest and Hannah Dee, "Gestational diabetes mellitus: challenges in diagnosis and management," Journal of Diabetes and Metabolic Disorders (2015) 14:42, https://jdmdonline.biomedcentral.com/track/pdf/10.1186/s40200-015-0169-7?site=jdmdonline.biomedcentral.com
24 Ethical and Religious Directives, Introduction to Part Six, pp. 14.
25 Pope Francis, "For a Culture of Encounter," Morning Meditation in the Chapel of Domus Sancte Marthae, Libreria Editrice Vaticana, Tues, Sept. 13, 2016,
26 Ethical and Religious Directives, Introduction to Part Six, pp. 14-15.
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