Telemedicine Relieves Night Gaps, Specialist Shortages

Marcia Frellick

March 29, 2019

NATIONAL HARBOR, Maryland — Hospitals are turning to telemedicine to fill physician gaps in nightshifts, relieve surges, and keep money from flowing out of intensive care units when a lack of subspecialists could mean the transfer of a patient to another hospital.

The model has efficiency benefits for both hospitals and physicians, said Mac McCormick, MD, president and chief executive officer of Eagle Telemedicine, who was one of several experts who made the case for telemedicine here at the Society of Hospital Medicine 2019 Annual Meeting.

Remote physicians can provide backup for onsite nurse practitioners and physician assistants, saving money, he explained. And "physicians working for three or four places can earn the same kind of income they would if they were doing an on-the-ground job, but each hospital is only paying for a fraction of the salary."

Some of the hospitals that Eagle Telemedicine works with have a census below 200, McCormick told Medscape Medical News. About six hospitalists back up nurse practitioners, physician assistants, and overloaded physicians, and specialize in providing night services so that daytime hospitalists do not have to take calls at night.

"Having done that some myself, I hated it," he said.

Telehospitalists can work from home offices and can be hired for a few hours or a whole shift, McCormick said. They have access to the electronic health record and can consult with a provider, admit patients from the emergency department (ED), and order labs and tests.

When a doctor working remotely needs to see the patient, a telemedicine cart is wheeled into the room. The morning hand off to the daytime physicians is also a virtual process. And a system is in place that specifies which onsite person will perform certain procedures, such as the insertion of a chest tube.

Night shifts typically have young, inexperienced nurses, which often leads to numerous calls on status changes, causing the nocturnist to bounce from page to page, said Brian Schroeder, assistant vice president of Atrium Health in Charlotte, North Carolina.

"Being able to offload those calls for cross-cover to a teleprovider allows the nocturnist to focus on the admissions in the ED," he explained.

When subspecialists are not available in the middle of the night, patients could be transferred 20 or 30 miles away, resulting in monetary losses for the hospital and lower patient satisfaction. Having a telemedicine provider address needs of the patient until the day team arrives means that patient can stay close to home, Schroeder said.

More than half of all hospitals in the United States use some form of telemedicine, according to the American Telemedicine Association.

Some hospitals find that telehospitalists can solve problems related to the recruitment and maintenance of full-time nocturnists, said hospitalist Ameet Doshi, MD, from HealthPartners in Bloomington, Minnesota. And flexible hours means that hospitalists working on demand can even fill partial shifts.

Questions to Ask Before Building a Telemedicine Program

In cases in which small hospitals allow EDs or moonlighting physicians to admit patients at night, a telehospitalist can complete that task overnight so that the daytime physicians do not have a backlog of admissions to deal with in the morning.

Several questions should be examined when a practice is trying to determine whether telemedicine, and which specific model, is the right choice, Doshi said.

First, what problems are you trying to fix? "If you're focusing on trying to reduce provider burnout, that's a different set of metrics than if you're trying to improve provider–nurse communication," he pointed out.

Another thing to look at is the strength of the partnerships in your environment, especially between hospitalists, the ED, and the nurses at the bedside. "Without strong partnerships, any telemedicine is going to fail," he said.

Hospitals should also ask themselves what success means in telemedicine. "If it's purely a revenue model, then many telemedicine models won't be to your liking," Doshi warned.

When hiring a telehospitalist, you have to look for skills beyond medical acumen, he added. Telepresenter capability is important because special skills are needed when you are building a connection with a patient without the usual proximity. Telehospitalists also need to be able to work well with the provider at the bedside operating the cart.

There is little research on what works and does not in telemedicine, he pointed out. But already, it means that hospitals can offer all-day, every-day full service, and can add services, such as nutrition and social services, after hours and on weekends.

As for the future, Doshi said that frontline hospitalists could eventually be supported by a host of telemedicine specialists.

But the benefits extend beyond the medical realm, McCormick added.

"There are 900 million office visits a year in America," he said. And "there's inconvenience and expense and global warming that goes along with that."

If just 10% of those visits could be done with telemedicine, 90 million visits, and 90 million car trips, could be eliminated, he said.

McCormick, Schroeder, and Doshi have disclosed no relevant financial relationships.

Society of Hospital Medicine (HM) 2019 Annual Meeting. Presented March 26, 2019.

Follow Medscape on Twitter @Medscape and Marcia Frellick @mfrellick


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