Rural access route: E-health investments and network of support facilities help connect rural residents to high-quality care

If you had an ischemic stroke on Martha's Vineyard, things could get a bit hairy. The life-saving dose of Tissue Plasminogen Activator (tPA) that can dissolve a blood clot-but only within the first three crucial hours of an acute stroke-might not be at your disposal on the island, which only offers a critical-access facility. All that has changed, however.

Through a collaboration between Partners Telemedicine, part of Partners HealthCare integrated health system headquartered in Boston, and Massachusetts General Hospital, stroke victims on the Vineyard now have access to a telestroke service through Martha's Vineyard Community Hospital, as do other smaller hospitals connected to the network.

Healthcare systems, hospitals and health plans are following the advice of the Institute of Medicine (IOM), which provides strategies for addressing the healthcare quality challenges inherent in rural America in its report, Quality Through Collaboration: The Future of Rural Health. According to the IOM, rural communities represent nearly 20% of the population and often have poorer access to high quality healthcare services.

The use of advanced technology-electronic health records, information technology expertise and telemedicine-highlights most efforts, and in most cases, the strategies represent a strong partnership between large urban hospitals and smaller rural facilities. The recipients of these special services run the gamut of prison inmates, to residents of slightly isolated but popular vacation spots, to newborn infants.

RENTING SPECIALISTS' TIME

Lee Schwamm, MD, director, telestroke and acute stroke services at Massachusetts General, says the network is successful because it is recognized at the state level as stroke-centered care supported by evidence-based medicine, but the key is the partnership. Each spoke in the hub, such as Martha's Vineyard Community Hospital, purchases its own telemedicine equipment and does not receive discounted services, avoiding any incentive to refer to Massachusetts General. In essence, the TeleStroke program "rents" the time of neurologists at the large teaching hospital.

When a stroke patient arrives at Martha's Vineyard Hospital, he or she is examined by an emergency room physician supported by a consultation with a virtual neurologist in the program. Although a phone conversation may be sufficient, the case may necessitate a videoconference between the emergency room physician at Martha's Vineyard and the specialist at Massachusetts General to evaluate symptoms, offer a diagnosis and determine if the patient should be transferred to the Boston facility-especially if the patient is not a candidate for tPA. As the program has evolved, specialists can now connect to patients directly from their homes or offices.

Over a two-year period, 75% of eligible stroke patients at Martha's Vineyard Hospital received treatment with IV tPA via the TeleStroke program. In July 2006 alone, there were 28 consultations by phone and three to four videoconferences per week to the 14 affiliated hospitals.

Partners Telemedicine also is involved in a weekly teledermatology program with Nantucket Cottage Hospital on Nantucket Island, which is 35 miles offshore. Besides the many tourists that vacation on the island, it houses about 10,000 permanent residents, many in the tourist industry, along with fishermen and outdoor laborers, whose jobs make them susceptible to the sun's dangerous rays. Although it may seem like a paradise, the community has difficulty attracting specialists, such as dermatologists.

Nantucket Cottage Hospital contacted PartnersTelemedicine, which in turn developed a program in which Nantucket contracts for the services of a consultant dermatologist at Massachusetts General two hours weekly for a flat fee. Joanne Bushong, a nurse practitioner, is the clinical coordinator on the Nantucket end. While closed-circuit television technology provides sufficient information for a virtual diagnosis, she is responsible for facilitating the body scan cameras, which produce high-resolution images, and for conducting biopsies and skin scrapings.

The images can be transmitted to and stored at Massachusetts General.

In the past five years, only about 10 patients out of 600 have left the island for further treatment related to a dermatological problem.