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My first experience in rural healthcare was in 2010 as the CIO of the western region of Montana for Providence Health & Services. In this role, I was responsible for technology and services across all of Western Montana.
Recently, I returned to Montana as the Interim CIO of Benefis Health System in Northcentral Montana. Much has changed but the challenges and opportunities facing rural healthcare are still the same. However, I feel two areas require significant attention, 1)improving access to affordable broadband connectivity, and 2) addressing the physician shortage.
"Getting more medical providers, physicians as well as mid-levels, from both in state and out of state involved will be key to expanding the presence of telehealth services"
When I first began working in rural healthcare, it was eye-opening to see the technological struggles facing rural communities. Affordable broadband connectivity is not readily available in many rural areas, and many days I felt like I was stuck in the 1990s with screaming modems and dial-up connections. Some programs such as the FCC-USAC’s Rural Health Care program have been key contributors in closing the connectivity gap. However, extending the reach of high-capacity wireless cellular service to the far reaches of rural states remains an unmet need.
In addition to the technology challenges, there is a physician shortage in many rural states, especially in key clinical specialties. This often means that existing, in-state providers are already working at capacity. In many cases, the only providers who might actually have additional capacity are those who practice outside of the state suffering from a physician shortage.
This is where I believe telehealth services can be used to improve the healthcare delivery system in rural states. If we could partner with state licensing and privileging boards to streamline the licensing and privileging process and allow these non-local providers to offer telehealth services to the rural areas outside of their home state, we could help provide better healthcare to rural populations. Getting more medical providers, physicians as well as mid-levels, from both in state and out of state involved will be key to expanding the presence of telehealth services.
Here at Benefis Health System, we have already begun to leverage telehealth services to serve our rural state through our REACH Montana Telehealth Network (Realizing Education and Community Health). Many of the Montana counties served by the REACH Network are very rural—so much so that most are designated frontier, with a population density that averages less than three persons per square mile. Livestock outnumber people here by a large margin, and many communities get by fine without traffic lights—but not without adequate healthcare.
Telemedicine services in Northcentral Montana began humbly in 1992 with four rural hospitals sending digitized X-rays by modem to the Montana Deaconess Medical Center (now Benefis Health System in Great Falls). In 1994, with assistance from the Rural Electrification Administration’s Distance Learning and Medical Grant Program, the REACH Network began its telehealth service.
Using televideo technologies over private communication circuits and secure Internet VPNs, today REACH spans a 40,000 square mile, 15-county service area, reaching nearly 230,000 residents in Northcentral Montana, delivering clinical telehealth services including oncology, cardiology, and mental health counseling as well as community health-related education. Since 2003, the REACH Network has saved patients in the communities it serves from traveling 1,540,386 miles. That’s more than 61 trips around the earth at the equator!
Meeting the healthcare challenge of rural Montana sometimes means capitalizing on providers’ talents wherever they exist, and that’s not always in the large tertiary centers. A mental health provider based in at a rural clinic on the REACH Network has extended her practice with once-a-month tele-mental health clinics to two rural communities, 80 and 125 miles from her clinic office. While this innovative addition to her practice proves telehealth’s potential to extend specialty care to under-served areas, it also underscores the limitations: other communities await this same type of service, but this particular provider has reached capacity and cannot add additional patients.
Tele-oncology and genetic counseling are growing telehealth clinical services for Benefis Health System’s Sletten Cancer Institute (SCI). SCI has one of only three genetic counselors working within the state of Montana, and video conferencing via REACH has enabled face-to-face consultations to be extended to multiple Montana communities. Additionally, Benefis has been able to leverage telehealth to provide patient care at the Northern Montana Healthcare campus in Havre, 115 miles away from our main campus, connecting medical and radiation oncologists to their patients while saving travel time and expense.
Extending the specialty care of cardiologists to rural patients is another clinical focus for REACH. One rural VA patient illustrates the positive effect telehealth can have for a patient. This veteran first had to drive 250 miles during the Montana winter for an EKG, and then an additional 400 miles to another VA facility for a stress test. After all that, he returned home to a phone call instructing him to follow up with a cardiologist in Great Falls. This news came just as a winter storm was approaching. The cardiologist who received the stress test results from the VA electronically was able to see the patient in a video conference and hear the heart sounds via a tele-stethoscope. This telehealth session spared this veteran another 220 miles of travel to meet with his cardiologist.
These few examples highlight that telehealth can have a significant impact on rural healthcare delivery; however, there is still a great deficit of providers to meet the needs of individuals living in rural areas in both primary care and various specialties. In Montana alone, there are nine counties without a single physician and 12 counties without a single primary care physician. By improving and streamlining the credentialing, licensing, and privileging processes and expanding telehealth services, we can greatly improve rural healthcare.