Chase County Community Hospital has faced a number of challenges similar to those confronted by many other rural health systems. Chief among them was a growing shortage of physicians, a problem projected to worsen in the coming years.
THE CHALLENGE
Chase is a 15-bed critical access hospital in Imperial, Nebraska. Like many rural healthcare organizations, the facility relies heavily on advanced practice providers – nurse practitioners and physician associates.
State law in Nebraska mandates a physician be available by phone when an APP runs the emergency department. Before the introduction of telemedicine, there were times when Chase had to contract physicians in other towns to be available by phone – even though sometimes a physician may not have been needed.
“Not only was this costly and not sustainable long-term, it was difficult to find physicians to cover, creating additional stress and pressure on our one physician along with the leadership and staff to figure out this coverage,” said Abby Cyboron, CEO of Chase County Community Hospital.
“Another major hurdle we faced was a lack of adequate resources to manage the growing complexity of patient care, particularly during the COVID-19 pandemic,” she continued. “As large health systems became overwhelmed and unable to accept new patients, transferring patients to other facilities became increasingly difficult.”
This forced Chase to retain patients longer than normal, requiring a higher level of care not typically seen in the critical access hospital. Its providers were called on to treat increasingly complex patients, such as managing severe traumas and patients needing ventilators.
Sometimes, these patients remained on-site for days due to transfer delays, putting a significant strain on the medical staff and highlighting the urgent need for a solution to support providers.
PROPOSAL
Chase began looking into telehealth vendor Avel eCare’s emergency service line for the ED after one of the hospital’s APPs came to Cyboron with a video about the technology and service and said they loved the idea of having someone live to help with questions.
“I brought it to the medical staff to gauge their interest,” Cyboron recalled. “We were willing to consider it if our providers thought it would genuinely benefit them and, ultimately, our patients. We were already familiar with Avel, having used its pharmacy telemedicine system for several years.
“The telemedicine system was attractive because it promised to alleviate the physician back-up coverage that we had been struggling with,” she added. “Avel’s board-certified physicians and critical care nurses are available 24/7/365, so our physicians, APPs and nurses can access them immediately for consultation, critical decisions, fulfilling requirements and eliminating the need for high-cost temporary physician contracts.”
Telemedicine would ensure staff members had access to expert guidance, streamlining processes and additional support to provide a higher level of care, if necessary.
MEETING THE CHALLENGE
Chase introduced telemedicine in phases as different needs arose. It began using telemedicine in the pharmacy and later expanded to include emergency and hospitalists. Now Chase is adding behavioral health services to the ED in response to the current mental health crisis.
“The technology is easy to use,” Cyboron noted. “Avel installed secure, interactive, high-definition video and audio equipment and trained our staff. Now, when the need arises, they simply press a button or make a phone call and are immediately connected to the vendor’s team of emergency physicians and critical care nurses for consultations, care planning and critical decision support.
“They function as an extension of our local care team,” she continued. “As part of the technology implementation, we shared information specific to our facility, such as staff lists, contact numbers, medications, supplies and equipment available to them. Avel can provide medical direction, order diagnostic testing and expedite an air ambulance.”
The vendor also can provide specialty emergency consults and offers translation services when necessary. After each encounter, the vendor team faxes the documentation to Chase so it can be added to the patient’s medical record.
In 2024, Avel began providing EMS telemedicine to the Imperial Emergency Medical Service, Chase’s local EMS agency. If they are consulted on a case, the vendor will call ahead to notify hospital staff as to the condition of the incoming patient. This advanced notice allows Chase to get the appropriate staff and equipment in place before the patient arrives, giving Chase a head start during the critical “Golden Hour” in medicine when a patient’s chances of survival are greatest.
“We quickly found that telemedicine benefits all of our providers,” Cyboron said. “Having someone available to consult on a patient is invaluable. Even just to say, ‘This is what I’m thinking of doing, do you agree or would you do something different?’
“One of our providers said before the virtual care emergency services were available, after a code or trauma, they would go home and replay the scenario over and over in their mind, as to what they did, and try to think if they could have done anything differently,” she continued. “Now, with Avel, the providers have a partner on shift with them and can walk away from a case knowing they did everything they could have possibly done.”
The vendor also supports Chase’s nursing staff. Facilities like Chase typically operate with a small team outside normal business hours. That means from 5 p.m. to 8 a.m., the hospital may have one charge nurse and two or three support clinical staff running the hospital.
“Having someone available at a moment’s notice is invaluable during these critical hours,” Cyboron explained. “Whether they need guidance on a complex care situation or simply need a PRN order, telemedicine prevents them from unnecessarily waking a local provider while ensuring patient care continues smoothly.
“In addition, the nursing documentation provided by Avel allows our local nurses to spend more time providing care at the patient’s bedside,” she added. “This kind of immediate, reliable support builds confidence in new nurses and eases the workload for seasoned staff.”
RESULTS
When Chase dove into telemedicine, cost savings was never a driving force. It was always about providing the best medical care in the ER and making sure the facility had appropriate coverage based on the regulations.
“However, unintentionally, telemedicine has actually resulted in significant cost savings,” Cyboron reported. “It has allowed us to have a physician available around the clock, reducing the pressure on our local physician and also reducing the amount of contract physicians needed. This has reduced our expenses while maintaining compliance with regulatory requirements for physician oversight. Now, with one set monthly cost – not per click – we have a physician available 24/7/365.
“The service the vendor provides allows for efficiencies of scale,” she continued. “They can have one physician covering multiple facilities all at the same time. Where we would have to pay one physician to cover only our facility – where there might not even be any support needed during a particular shift.”
The total cost of what Chase pays for the emergency telehealth services for 365 days is comparable to paying for one physician to be available by phone, for back-up support to only the facility, for approximately 45 to 60 days.
ADVICE FOR OTHERS
Cyboron’s biggest piece of advice to a hospital or health system considering a telemedicine system is to get buy-in from providers. She said this is key, and that Chase would not be using – and expanding its use of – telemedicine without the support of its clinicians.
“Healthcare organizations should make it clear telemedicine is a supportive resource, not a replacement for on-site expertise,” she advised. “Communicate to your staff the benefits of telemedicine and the flexibility it allows.
“Think about the technology offered,” she continued. “Is the technology easy to use? Our providers only have to push a button on the wall or make a phone call to gain immediate virtual access to a team of physicians and clinicians representing 15 specialties. The goal is to make the job easier for your providers, not more complicated. Make sure the vendor provides training.”
Healthcare organizations also should consider patient privacy, security and regulatory compliance, she added. The telemedicine providers must be licensed to work in the state and credentialed and privileged to provide patient care in the facility, she said.
“Telemedicine gives me peace of mind,” Cyboron noted. “Before telemedicine, I spent many hours worrying about physician back-up coverage for our ED along with burning out the only physician we had. It was overwhelming.
“Now, I know it is handled,” she concluded. “There is someone available, 24 hours a day, seven days a week, to support our medical staff in whatever capacity they need. Out of all of the responsibilities with my role, this is one of the most important.”
Follow Bill’s HIT coverage on LinkedIn: Bill Siwicki
Email him: bsiwicki@himss.org
Healthcare IT News is a HIMSS Media publication