telemedicine and inpatient ambulatory care for rural alaska

Running head: TELEMEDICINE & INPATIENT/AMBULATORY CARE 1

Telemedicine & Inpatient/Ambulatory Care in Rural Alaska

Patrick Williams

Saint Joseph’s University

TELEMEDICINE & INPATIENT/AMBULATORY CARE 2

Abstract

US Health care is organized with a mixed system, changing continuously to fit the needs of care

worldwide. Within this continuum lies inpatient and ambulatory care. Both ambulatory and

inpatient care are utilized to fit the needs of patients, with the best health outcome in mind.

Scientific developments from both medical technology and the pharmaceutical industry have led

to changes in each care network. Health care facilities including critical access hospitals and

rural outpatient networks are finding it easier to offer high level treatment because of discoveries

in applied sciences and information technology. According to Eron (2010), information

technology regarding telemedical use between patient and provider is the future of health care

(p.224). Telemedicine and remote health offer a broad continuum of medical practice within both

ambulatory and inpatient care settings (Clark et al., 2010, p. 261). This research paper will assess

Telemedicine and its effect on ambulatory and inpatient care from the perspective of both rural

Alaskan based hospitals and outpatient networks.


Telemedicine & Inpatient/Ambulatory Care in Rural Alaska

Health care outreach is broad, serving different ethnic groups and cultures across the

world. Uniquely, US health care functions with no governing agency. Currently US health care

functions through a mixture of market and social justice systems (Budetti, 2008, p. 92).Within

this health care mixture is ambulatory/outpatient and inpatient care. By definition ambulatory

care is treatment provided to patients not required to stay in an overnight in a health care facility.

Outpatient care is usually performed in hospital or clinic setting (Shi & Singh, 2013, p.161). In

contrast, inpatient care is a defined as an overnight stay in a health care facility (Shi & Singh,

2013, p.185). Determining whether or not a patient requires inpatient or outpatient care upon

health care staff judgment for positive health outcomes (White & Glazier, 2011, p.58). Most

non-rural health care organizations consist of inpatient and outpatient care within one setting.

Providing health care in rural locations can be a challenge. Many rural communities exist

without large hospitals and specialty health care. The vastness of Alaska and its complexity as a

state creates issues within many remote locations. According to Choudhury et al., 2008, Alaska’s

population density measures one person per mile (p.2). This Alaskan frontier has created

challenges for administration of health care services for many rural outlying communities

(Roberts, 2011, p.10). These barriers for Alaska based communities include: accessibility,

acceptability and availability of services (Mohatt, et al., 2005). Health care institutions in Alaska

are required to utilize alternate routes for health care delivery for provision of appropriate care

for its residents.

Telemedicine

Medical technology is a complex, powerful and costly system that affects health care on

many levels (Williams, 2008, p.38). Medical professionals are trained different than ever before,


because of high level advances in both the medical technology. The fundamental reason why

medical technology changes the way health professionals practice medicine is high outcome and

result expectations by patients receiving the services (Shi & Singh, 2013, p.105). When result

expectations are high, medical professionals are required to provide detailed care by: staying

informed of latest developments/ advances in medicine, following expert clinical guidelines and

staying ahead of competitive pressure placed by newer technologies (Williams, 2008, p.35).

Health care delivery is an objective placed by many health care organizations seeking to increase

organizational strength by accessibility of services. The use of medical technology for health

service delivery is a popular practice for rural areas and isn’t an entirely new concept (Roberts,

2011, p.). Distance health service began in the early 1950’s, two way radios for physician

communication regarding medical terminology (Patrickoski, 2004, p.365). According to Clark et

al., 2010, any electronic device used to transmit clinical health service is considered E-Health, or

telemedicine (p. 261). Currently, telemedicine is a critical component of health care. Studies

reveal that every state has a telemedical program; most involving many outlying hospitals and

clinics (Shah, et al., 2013, p.200). The terms telemedicine, e-health and teletherapy coincide,

each accounting for electronic medical communication (Nelson, et. al., 2012, p.10). E-health

benefits rural communities by providing health care for individuals and groups considered

inaccessible through electronic communication with distant facilities and specialty physicians

(Roberts, 2011, p.10). Telemedicine originated in 1877, when physicians first used phones to

transfer medical advice. Alaska also was the first state to develop the first pilot telemedical

program in 1950. Under the establishment of the Indian Health Service (IHS), village doctors

communicated directly to community health aides for patient evaluations and care procedures.

Health aides monitored each patient and contacted physicians via radio for advice and care


related to the patient’s condition (Clark et al., 2010, p.261). Even with these accomplishments,

telemedicine wasn’t accepted nationwide as a beneficial health program. Pilot programs had little

effect because of two factors: absence of appropriate technology and financial instability/cost. It

wasn’t until the US Presidential Reagan administration of the 1980s that telemedicine/e-health

was widely accepted. During that time, telemedicine was used for military and disaster relief

purposes, allowing health care delivery networks across the globe (Clark et al., 2010, p.263).

With continued development of medical technology over the last two decades, applications of

electronic based health care have grown. Telemedicine is now benefiting rural areas by

utilization in: specialty care, patient consultations, remote monitoring and medical education

(Clark et al., 2010, p.263). Benefits of telemedical use include: reduced health care costs,

increased patient access to specialty providers, improved quality/continuity of care, faster/more

convenient treatment resulting in reduction of lost time/travel costs (Clark et al., 2010, p. 263).

This research paper will assess pilot telemedical programs and discuss their effect on rural

inpatient and ambulatory care of Alaska.

Ambulatory/outpatient networks

Use of electronic communication for ambulatory care is improving. Telemedicine is

affecting ambulatory care networks by improving decision-making, remote-sensing and

collaborative arrangements of providers (Clark et al., 2010, p.262). According to Eron (2010),

telemedicine is considered the future of outpatient health care (p.224). E-health can assist in

overcoming barriers linked to ambulatory care by decreasing health care costs and adding

specialty physician reach for limited locations (Eron, 2010, p.224). Rural locations are receiving

health care that was never thought possible through electronic devices (Nelson, et al., 2012,


p.10). Two rural ambulatory/outpatient care networks are provided: primary care telemedicine,

tele-behavioral health/tele-psychiatry.

Primary care. Primary care is defined as the foundation for outpatient services. Primary

care contains integrated accessible services accounting for the majority of personal health care

needs (Vanselow et al., 1995, p.192). Primary care is the largest sector of health care delivery in

the United States (Shi & Singh, 2013, p.).Meeting primary care needs for the growth in an aging

population is challenging for the US (Shah, et al., 2013, p.223). A shortage of primary care

providers and recent increases in the older adult population has both played a role in accessibility

and timeliness of services. Rural locations continue to face difficulties providing primary care

because of accessibility, acceptability and availability of services (Mohatt, et al,. 2005).

Telemedicine delivery offers timely, high quality patient centered health care by improving

quality of life for patients needing primary care services (Shah, et al., 2013, p.223). Rural

locations benefit from the ability to reach specialized primary care physicians not available in

their location. Primary care telemedical pilot programs are currently being evaluated for

increased utilization. The association of primary care and telemedicine has seen an increase in

research documentation and investigation over the past two decades. Many programs offer

exams for people who are cannot access health care on a routine basis. Evidence from pilot

programs reveal telemedicine gives patients a feeling of empowerment, and improves health

outcomes (Shah, et al., 2013, p.229). Veteran’s affairs in Oklahoma City, Oklahoma recently

researched telemedical primary care by examining quality and efficiency in rural locations

(Sorocco, 2013, p.350). The pilot program is considered a success. Patient health improvements

and data collection were shown within a 6 month time period. Documented improvements

include: physical strength, social functioning, decreased caregiver burden and compliance with


treatment programs (Sorocco, 2013, p. 352). A second pilot program, the Alaska Federal Health

Care Access Network (AFHCAN) gave research and projections for primary care via

telemedicine for rural Alaska communities (Patrickoksi, 2004, p. 370). The AFHCAN originated

in 1998 though US Department of Health and Human Services. This projects mission is to

improve health care for Alaskan natives by using sustainable telehealth systems. AFHCAN

generated over 235 sites linked by telehealth to primary care physicians, and improved the

overall health of Alaska natives (Patrickoski, 2004, p. 371). Programs like the AFHCAN

continue to help Alaska move toward an open system, where everyone has access to primary care

services. Studies reveal there are limitations associated with telemedicine and primary care.

Issues include technical problems associated with bandwidth capabilities, reimbursement from

3rd party sources and legal challenges for primary care (Shah, et al., 2013, p.229). Resolving

issues will ensure utilization of primary care telemedicine services. Programs like AFHCAN

work to limit barriers by bringing different organizations together to form coalitions. These

groups serve as AFHCAN project officers, to ensure compliance and limit barriers associated

with telemedicine projects. Project officers also carry out day to day management of primary

care telemedicine issues (Patrickoski, 2004. p. 371).

Tele-behavioral health. Behavioral/mental health is a significant issue in most locations.

The terms behavioral health and mental health can be used interchangeably. Mental health is

defined by the World Health Organization as psychological well-being, or the absence of a

mental disorder or illness (WHO, 2001, p.1). Behavioral health continues to be a significant

challenge in rural locations. It is estimated that nearly 60% of rural America is underserved

regarding mental health services (Roberts, et al., 2011, p.10). Communication between large

health organizations and rural locations is common to deliver behavioral health care service to


those without accessibility. Applications like two way Skype equipment offer new innovative

ways for accessibility (Nelson, et al., 2012, p.10). Outpatient behavioral health telemedicine can

involve screening, assessment, primary treatment and after-care. This application can also

provide accessible treatment for those who have barriers related to location, shame, guilt and

stigma (Nelson, et al., 2012, p.10). Pilot programs for behavioral health telemedicine originated

in Alaska during the 1950’s, utilizing health aides for communication between the patient and

physician (Clark et al., 2010, p.261). Because of its vastness and rural location, Alaska stands as

a forerunner in telemedical use for behavioral health (Nelson et al., 2012, p.10). Currently, pilot

and training programs for mental health telemedicine in Alaska are managed by Alaska Rural

Behavioral Health Training Academy (ARBHTA). This program trains professional utilization

techniques for telemedical equipment and decreases barriers associated with rural telemedical

care in Alaska (Nelson et al., 2012, p.14). Telemedicine has also transitioned into psychiatry.

AtlantiCare Regional Medical Center located in New Jersey initiated one of the first pilot

programs for tele-psychiatry (Clark et al., 2010, p.265). This program utilizes real time visual

and audio teleconference effects in clinical settings, with nurse monitoring of patient vital signs.

The model adopted by AtlantiCare Regional hospital serves as a solution for potential specialty

provider shortages in many locations (Clark et al., 2010, p. 265). Rural Alaska locations

including: Gateway Mental Health and State of corrections have also started small programs to

facilitate provider shortages. Programs like this offer distinct and needed psychiatry level care

for communities with no access (Patricoski, 2004, p.381). Barriers for telemedicine and

behavioral health include: cultural attunement, apprehension of technology, reimbursement rates

and technology adaptations (Nelson et al., 2012, p.14). In Alaska, ARBBHT commits much of

its time focusing on increasing cultural attunement or “cultural humility” for Native Americans


(Nelson et al., 2012, p. 11). Secondly, ARBBHT focuses on training participants and health

professionals for utilization of telemedical practices. Clinical supervision trainings happen

regularly, developing health care professional telemedical skills for program efficiency (Nelson

et al., 2012, p.11). Alaska Telehealth Advisory Council (ATAC) developed in 2009, also seeks to

limit barriers associated with telemedicine. ATAC helps with developing tele-psychiatry

standards for the state, resolving reimbursement issues and limiting technological limitations

(Patricoski, 2004, p. 372). Resolving barriers will ensure success for tele-behavioral/tele-

psychiatry health programs in both Alaska and other locations.

Inpatient care/Critical Access

Technology use within inpatient care facilities continues to grow. New ideas continue to

raise consumer expectations; leading greater demand for the best care a facility can offer (Shi &

Singh, 2013, p.106). Telemedicine leads technology benefits by allowing patients and provider’s

ways of communicating needed information and facilitating virtual visits between specialty

physicians and clientele (Shi & Singh, 2013, p.109). Two rural inpatient care networks are

assessed: chronic medical conditions and stroke/neurology.

Chronic medical conditions. In an overall study of mortality and disability causes in the

US, chronic medical conditions (CMC) rank number one (Rajan et al., 2013, p.127). CMC is

defined as a long term illness or condition with no current cure. Examples of CMC include:

Alzheimer’s, heart disease, obesity, Parkinson’s, chronic obstructive pulmonary disorder and

cancer (CDC, 2015, para. 1). Treating CMC can be challenging in rural locations. It is estimated

that 50% of individuals in the US have at least one CMC (Ward et al., 2014, p.1 ). With needs

unmet nationwide, rural locations suffer lack of coordinated care surrounding accessibility

(Rajan et al., 2013, p.128). Telemedicine provides rural locations accessibility to specialized


CMC provider care. Similar to other telemedical based programs, CMC utilizes video based

electronic communication to link physicians and patients over distances (Rajan et al., 2013, p.

128). Utilizing telemedicine for CMC patients increases stability by limiting time spent in

healthcare settings and by increasing independence from the burdens associated with CMC. Pilot

programs are currently being developed to improve CMC service and for continued research in

viable locations. Mercy Home Health system (MHHS) in Philadelphia, Pennsylvania recently

initiated a CMC pilot project allowing patients with a CMC treatment from remote locations,

instead of continually visiting their physician (Clark et al., 2010, p. 264). This program serves

several conditions including: congestive heart failure, chronic obstructive pulmonary disorder,

hypertension and diabetes. Telemedicine enables those with CMC freedom from periodically

visiting the hospital for care (Clark et al., 2010, p.264). There are also pilot programs more

specifically linked to specific CMC. SK Yee Medical Foundation in Hong Kong conducted one

of the first pilot programs that are currently researching the details telemedicine with

Alzheimer’s disease. Evidence from data revealed in this program revealed that telemedicine is

an effective way to treat and diagnose Alzheimer’s disease. Increasing services like SK Yee in

Hong Kong would improve accessibility of Alzheimer’s treatment in locations lacking specialty

care (Poon et. al., 2005, p.286). Programs like SK Yee Medical Center of Hong Kong, would

allow rural locations access to Alzheimer care needed. There are however, deficiencies

associated with the use of telemedicine for CMC services. MHHS’s home health project has

difficulties associated with technology for administering telemedicine within the outlying

locations. Pilot program evaluation reveals there are issues regarding monetary funding and

internet connection/video technology capabilities (Clark et al., 2010, p. 264). Care for those with

Alzheimer’s disease by telemedicine suffers from lack of research and limited pilot programs.


Pilot programs like SK Yee Medical Center in Hong Kong are few, especially if searching within

the US (Poon et. al., 2005, p. 286).

Tele-stroke/Tele-neurology. One of the more popular uses for e-health inpatient care is

tele-stroke. Cerebrovascular disease or stroke is considered the fifth leading cause of death in the

US (Mozzafarian et. al., 2015, p.229). Stroke is defined as a clot in your brain limiting cells to

their destination, eventually causing irreversible tissue death. Cases of stroke can end with

hospital treatment and physical limitations (Crespi et al., 2013, p.1083). Stroke patients require

efficiency and time sensitive care. National recommendations for patients suffering from acute

stroke conditions concur that receiving specialty care within three hours of symptoms limits

negative impacts from the disease process (Clark et al., 2010, p. 266). Rural locations struggle

with access to neurological providers extending time sensitive aid for those patients having

stroke complications. Barriers include location, lack of medical professionals, and cost of

specialty care (Clark et al., 2010, p.266). Rural locations benefit from telemedical neurologist

access. It also offers a cost-effective treatment for patients seeking care near home without the

requirement of travel. Telemedicine can offer primary care physicians a stroke network to offer

help and guidance in times of need. AntlantiCare of New Jersey piloted a neurology tele-stroke

program offering remote services to extended locations needing guided care (Clark et al., 2010,

p. 266). This program allows physicians the ability to access instrumental care from specialists

and save stroke related tissue death in their patients. This program offers full-spectrum care for

individuals who need pre-stroke consultation and after-stroke care (Clark et al., 2010, p. 266).

Another pilot program developed by Phillips health care has developed tele-stroke capabilities

for pre-hospital admission Emergency Medical Services (EMS) Personal. The objectives of tele-

stoke capabilities for EMS is to catch a potential stroke early, limiting tissue death and negative


side-effects (Bergrath et. al., 2012, p.1). This program offers physician guidelines via wireless

video technology for EMS personnel treating those with stroke symptoms. Program evaluation

revealed pre-hospital teleconsultation for stroke is feasible (Bergrath et. al., 2012, p.1).

Deficiencies associated with tele-stoke pilot programs are limited. The Atlanitcare tele-stroke

project included technology based limitations in their post analysis, detailing issues regarding

rural internet capabilities. Phillips health care also evaluated technology as the lead barrier for

routine use in pre-hospital tele-stoke equipment. Technological growth and improving broadband

capabilities of the future will ensure development of tele-stoke programs are a broader level

(Bergrath et. al., 2012, p.8).

Conclusions and Future Study

Telemedical studies provide research for possible productivity and advancements in

health care delivery. According to Choudhury et al., (2008) telemedicine is an effective way to

deliver health care services to remote regions (p. 1). Alaska is classified as officially having a

health service shortage, promoting the reason why telemedicine programs are vital (Choudhury

et al., 2008, p. 1). Each pilot program addressed above lists both strengths and weaknesses to

consider in development of future programs in both rural and urban locations. Predominant

evaluation measures are summarized below: (1) Telemedicine develops primary care by allowing

needed patient exams in a more economic and accessible manner (Shah, et al., 2013, p.229).

With telemedicine, primary care can increase patient quality of life by improving: timely health

care checkups, social functioning and treatment capabilities (Shah, et al., 2013, p.229). (2) It is

estimated that rural locations are underserved in mental health services by 60% (Roberts, et al.,

2011, p.10). Telemedicine expands behavioral health by providing needed screenings,

assessments, treatment and after care for those with inaccessible mental health issues (Nelson et


al., 2012, p.10). (3)Treatment of Chronic Medical Conditions (CMC) is a continued burden for

rural health care. According to Rajan et al., (2013), over 140 million individuals have at least one

chronic condition, and by 2030 it is estimated that 50% of Americans will have at least one

(p.127). Telemedicine improves treatment of CMC by increasing patient stability and

independence from current conditions (Rajan et al., 2013, p. 128). (4) Neurological complication

management is also improved by telemedical operations. E-health offers stroke patients fast

time-sensitive care for those in rural locations (Mozzafarian et al., 2015, p.229).

In conclusion, limited amounts of telemedial studies provide research for possible

productivity advancements in health care delivery. Ehealth provides an effective and promising

outlook for health care but deficiencies linger regarding evidential lack and inconsistency within

studies and performance evaluations (Ekeland et al., 2010 p.740).Currently, limited amounts of

pilot programs offer narrowly focused research, leaving uncertainty for major corporations and

lenders that desire to improve rural health care development (Ekeland et al., 2010, p. 739).

Developing rural health telemedicine projects should answer questions of concern regarding

development in: gender specific complications, service configuration and patient

satisfaction/experience (Ekeland et al., 2010, p.742). While there are limitations and deficiencies

associated with limited pilot programs, telemedicine does offer a persuasive outlook for the

future. According to Eron (2013), telemedicine is the future for health care, making it an

essential component of a healthy nation initiative (p.224).Telemedicine has transitioned into a

nationwide health improvement goal regarding information of dexterity and physician

involvement (Ekeland et al., 2010, p. 739). With growing involvement and positive pilot

program initiatives, e-health has the opportunity to improve rural health care on a broad level,

unseen today (Choudhury et al., 2008, p. 1). According to Williams (2008), the future of


telemedicine will be exciting, challenging and important for worldwide health care improvement

and (p.39).


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telemedicine and inpatient ambulatory care for rural alaska

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