SIOUX FALLS, S.D. — “Can you lift your arms?” physician Luke Van Oeveren asked.
An elderly woman stared blankly at him from the back of an ambulance, where she sat strapped onto a stretcher. After a moment, she complied, but when Van Oeveren added another instruction to the cognition test, she became confused.
“Close your eyes and lift your arms up,” he said.
The two EMTs by her side repeated the request, lifting their arms and closing their eyes in demonstration. The patient smiled, but could not follow the instructions.
The woman had just had a stroke in rural Minnesota. But Van Oeveren was evaluating her by video from the next state over, in Sioux Falls, S.D., where telehealth company Avel eCare operates its emergency response hub.
The COVID-19 pandemic accelerated a shift to telehealth as doctors and hospitals limited in-person care and as Congress flooded the country with trillions in federal aid. But lingering questions about cost, quality and access have stalled broader adoption, with lawmakers hesitant to approve a permanent expansion of telehealth coverage under Medicare.
Federal pandemic aid also helped slow the rate of rural hospital closures. But as facilities contend with lingering inflation, workforce shortages and declining populations, the pace of those closures is picking up again.
Telehealth offers a chance to bridge the gap in hospital deserts.
COVID-19 aid infused millions more into an effort that already claims extensive taxpayer resources for equipment, technology and broadband access. A March 2021 COVID-19 relief law sent $350 billion to states and localities with broad flexibility in how they use the money.
A number of states, including Avel’s home base of South Dakota, have funneled a portion of that cash to virtual care.
Avel launched its ambulance service in November 2022. Gov. Kristi Noem, a Republican, announced a statewide EMS partnership with the telehealth company that same month, funded by a mix of COVID-19 relief money and state general funds. The $1.7 million project aims to connect 60 ambulance agencies by next spring.
Covering the distance
There’s a saying in emergency care that “time is tissue,” and it’s more urgent in rural areas, where ambulances might have to drive two hours round trip to retrieve a patient. The longer it takes to treat a patient, the more likely it is they’ll suffer lasting damage
In Minnesota, the EMTs dialed Avel even before putting the stroke patient in the ambulance. Nurse Cindy Pirrung answered the call, prompting the light lining the top of her cubicle to flash from green to white.
As the vehicle started toward the hospital, Pirrung and Van Oeveren could see in Avel’s system what drugs the ambulance and hospital had on hand, as well as the scope of licenses of the EMTs on the scene. Pirrung also began inputting information into the patient’s electronic health record.
In a cubicle to the left of Pirrung’s, physician Tyler Price jumped on a call with an elderly Colorado man with a dislocated shoulder. The physician assistant was considering sedating him until Price used nurse Kayla Snoozy to demonstrate the “Park method” of popping it back into place. The man was ready to leave the hospital about a minute later.
In the right corner of the hub, nurse Angela Scott opened a new patient record when an elderly man walked into a Montana hospital after a lengthy fall. The six-person team onsite relayed the man’s vital signs and medications to Scott as she documented their work and delivered requested reminders.
Within two hours, Avel clinicians had treated patients across a span of more than 1,600 miles.
A partner for providers
Telehealth can bolster the amount of knowledge in the exam room, since rural hospital staff can have limited experience with complicated medical situations. First-responders are often volunteers with nonmedical backgrounds, and many rural clinicians don’t always encounter uncommon cases in the small populations they serve. Avel doctors can also help cover overnight shifts, or just serve as a simple backup to a hospital’s lone physician.
“Because they’re on an island by themselves,” Van Oeveren said, “they don’t have a partner to talk with.”
Avel offers a number of subscriptions to rural providers, including inpatient monitoring, pharmacy support and mental health aid on police calls. The price is based on the overall patient volume and is around the cost of a nurse’s salary, according to the company.
More traditional telehealth hookups are also expanding as broadband improves. Horizon Health Care, a South Dakota community health center with 26 locations around the state, started investing in telehealth around 18 years ago with the help of grants from the Department of Agriculture and a state rural broadband initiative.
Horizon has a number of clinics with only one doctor and nurse onsite in communities with as few as 300 people. Before the pandemic, the health system mostly used telehealth to connect patients with outside specialists and behavioral therapists. But COVID-19 prompted a wholesale expansion.
The technology also helps with medical emergencies before an ambulance arrives.
“We don’t act as an emergency room,” CEO Wade Erickson said. “But our providers have to address everything that walks in our door.”
Still, uptake is spotty. Nearly a quarter of rural Americans lack broadband coverage, according to the Department of Agriculture, and more than a quarter of tribal residents lack coverage.
The technology isn’t necessarily expensive. Mark Woodring, an assistant professor at the University of Oklahoma Health Sciences Center, recently conducted a pilot that connected Tillman County ambulances to Oklahoma State University Medical Center via Zoom and AT&T’s first-responder network, FirstNet. The total cost for six months was $5,000, and connectivity exceeded expectations, Woodring said.
But when surveyed, physicians and EMTs involved with the pilot said audio and video quality was clear only 62 percent to 87 percent of the time. Woodring is currently surveying rural EMS agencies across the state to identify other barriers to expansion.
“These communities certainly have a lot of workforce challenges,” he said, “and adding one more thing to their plate certainly takes local champions.”
There are other downsides to telehealth. Skeptics worry that an increase in virtual care will worsen access to in-person care that underserved communities already lack.
Congress lifted restrictions on telehealth under Medicare during the pandemic, allowing enrollees to use telehealth in their homes. But most of those flexibilities expire at the end of next year — with the exception of mental health, which was permanently expanded — and concerns about increased costs and worsening disparities have not been resolved.
One such dispute centers around whether doctors should be paid less for a virtual visit than an in-person visit. Telehealth can make health care more efficient, but doctors argue the cost of their employees and the necessary technology remain the same.
“We gotta have the reimbursement to make the numbers meet for us at the end of the day,” Erickson said.
Workforce issues like burnout also still threaten telehealth’s promise. The physical distance for telehealth clinicians doesn’t always lessen the emotional toll.
Avel typically only fields what Vice President and General Manager of Emergency Services Rebecca Vande Kieft called the “knee-deep, all-hands-on-deck” situations.
Pirrung is a former flight nurse who responded to medical emergencies in air ambulances. But the lack of control from behind a video monitor is frustrating. The Avel team needs a space to decompress, she said.
“We need a place to vent,” she said. “To grieve, to holler.”
Lawmakers on both sides of the aisle are interested in expanding telehealth in spite of the hurdles. Members have requested funding for a number of telehealth projects in their districts since Congress lifted the ban on earmarks in 2021.
Virginia Democratic Sens. Tim Kaine and Mark Warner, for example, secured $375,000 in the fiscal 2023 omnibus appropriations law to establish a network of telehealth pods located next to rural post offices.
Sen. Brian Schatz, D-Hawaii, the sponsor of a bill to permanently remove telehealth restrictions under Medicare, believes the momentum from COVID-19 will propel an expansion through Congress.
“Telehealth is no longer the future. It’s the current state of health care,” he said. “We can’t go back.”
This reporting is supported by a fellowship through the Association of Health Care Journalists and funding by the Commonwealth Fund.