Telemedicine opens doors for rural Vermonters

The growing use of telemedicine in Vermont is helping health care providers fill voids in care created by the state’s rural nature. 

With technological innovations having an impact on the health care market, programs like Skype and Facetime are no longer social conveniences, they’re life-saving tools. 

“Lots of people are paying attention (to telemedicine),” said John Olson, chief of rural health and primary care for the Vermont Department of Health. “They’re either excited or frightened.”

Essentially, telemedicine allows patients to receive exams, medication and frequent monitoring without requiring the patient and provider to be in the same room. 

Telemedicine encompasses a dynamic range of practices and can take many forms, including video calls with a doctor or a machine in the home that automatically transmits data to a health center. 

Olson said a chief concern of patients is that they will not understand how to use the technology. 

“Some of these people don’t even understand how to use their cellphone, let alone something that monitors their health,” he said. “Obviously the patient’s life is more important and this can be concerning.” 

Melissa Faignant, community relations manager at the Rutland Area Visiting Nurse Association and Hospice, said the organization’s clients are personally instructed in the use of telemedicine devices.

“There’s not a big learning curve,” she said of the simple machines. 

RAVNAH uses telemedicine to monitor vital information like weight, blood pressure, glucose, oxygen, pulse and heart rhythm. Devices are left in patients’ homes to allow daily monitoring. 

“It gives us 24/7 updates,” Faignant said. “We can see spikes or bad signs that will get us there faster.” 

She said pre-emptive detection at the beginning of the week can save an emergency room visit by the weekend. 

Faignant also stressed that telemedicine was not replacing home visits by nurses, but is being used “in conjunction.”

Telemedicine is also being used at Rutland Regional Medical Center to connect patients with the specialists they need. 

“Currently, RRMC has a teleneurology (inpatient) program in partnership with Fletcher Allen Health Care” said Dr. Baxter Holland, who works with professional support services at RRMC.

With inpatient telemedicine procedures, a telepresenter, or clinical partner, is usually with the patient to operate equipment while the specialist runs the appointment via video monitor. Typically, one to three teleneurology patients are seen per day at RRMC. 

Mark Gorman, a doctor of neurology at Fletcher Allen in Burlington, is just one of the many doctors who treats patients via telemedicine. 

“It is a unique experience,” Gorman said. “Despite the technical challenges (of occasional poor video and audio quality), we have been able to make a solid human connection. Humor carries, concerns are communicated and important details of the problems to be investigated are distinguished.”

“Both patients and providers have been concerned about how remote health will impact the relationship between doctor and patient, but people adapt very well,” Olson said.

Holland agreed. “The feedback from both patients and physicians about the program has been very positive.” 

While Gorman agrees that the relationships with his Rutland patients are well established, he believes the clinical partner is an important intermediary between the patient and doctor. 

“The clinical partners (are) RRMC nurses trained to perform the physical examination together with me. (They) add a bit of zest and help me to interact with the patient and family. Often they will pick up on subtle clues that I am missing, whether it’s related directly to the neurological examination, or related to the interpersonal contact. Following each examination, we take the time to discuss the findings and answer all questions.”

While telemedicine is focused on the convenience of the patient, Gorman said it helps physicians too.

“(The program benefits) physicians caring for patients at RRMC. (They) have greater security in their decisions when they have access to specialist opinion.”

Gorman says the specialists in Burlington also benefit because “the physical findings in neurological conditions often recede or diminish with time, and the telemedicine connections allow us to see what is going on at the time the question arises, rather than at a later clinic visit when (problems) may be absent or have changed.”

While the teleneurology program has been successful, the Rutland and Fletcher Allen hospitals have no more collaborative programs planned at this time.

Veterans Affairs clinics statewide are diving headfirst into telemedicine. The Burlington Lakeside Community Based Outpatient Clinic is one of only two VA clinics in the country to use telemedicine for physical therapy. 

Initial meetings are done at the clinic, but afterwards, machines are installed in the home. Patients video call with their physical therapist while using the rehabilitation equipment. The equipment feeds data to the therapist during the video call. “The patient doesn’t even have to get in the car to receive therapy,” said Naaman Horn, media liaison at the Burlington VA clinic. 

Vermont VA clinics also have a telemental-health program. “Some people might think it wouldn’t be as personal,” said Horn, “but vets like it a lot. There are feelings of greater privacy speaking with someone over video rather than face-to-face.” 

Dermatologists at state clinics are also embracing telemedicine. “Our doctors can often see the skin better with the camera scope than they can with the naked eye,” said Horn.

While the Burlington VA clinic uses telemedicine for a variety of treatments, Rutland Mental Health Services is focusing on using telemedicine to refill medications. “We are very familiar with telepsychiatry,” said Daniel Quinn, president and chief executive officer. “We could use it for a lot of things, but the biggest need (right now) is medical follow up services.”

Psycho-pharmacology is made simpler by telemedicine, said Quinn. Instead of patients having to drive to an office location or have a less-thorough phone conversation to get a prescription refilled, patients can simply conference via video.

A study published in December 2013 in the medical journal “Pediatrics” found that “Medications for patients who received telemedicine consultations had significantly fewer physician-related errors than medications for patients who received telephone consultations.” 

However, Quinn feels his ability to use telemedicine is limited, citing a “geographic restriction” in Vermont’s health policies. Telemedicine can only be practiced by in-state facilities. Out-of-state health services cannot use telemedicine to fill prescriptions. 

Quinn has been collaborating with Frank Reed, deputy commissioner of mental health for the Vermont Department of Health, to feel out potential changes in Vermont policy. 

“I’m open to options that increase psychiatric availability,” Reed said.

However, laws that prohibit out-of-state telemedicine protect small health services from being bulldozed by large, out-of state companies. To stop powerful hospitals from expanding their reach into the territory of small-town physicians, some states continue to hold to legislation preventing out-of-state physicians from practicing telemedicine without holding a state license.

Though a relatively new science, telemedicine is covered by both Medicaid and private insurance in Vermont. Telemedicine services delivered to a patient while in a health care facility are treated as though the consultation were done in person. However, telemedicine communications done at home are typically not covered by insurance, though some providers absorb home costs.