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Focus on Rural Health

Connect and Engage

Critical Access Hospitals in North Dakota use telehealth to meet the needs of their rural patients.

By Stacy Kusler on

Eric Johnson, MD
Eric Johnson, MD

Telemedicine connects—and re-connects—patients to health providers in a variety of ways. Years ago, Dr. Eric Johnson, associate professor in the Department of Family & Community Medicine at the University of North Dakota (UND) School of Medicine & Health Sciences (SMHS), provided mentorship at a diabetes summer camp to help kiddos learn how to manage life with diabetes. Fast forward years later, and the same children from that very camp have sought out Dr. Johnson as adults when they learned they could “see” him in Rugby, North Dakota, without traveling all the way to Grand Forks.

According to Dr. Johnson, who also maintains a family medicine practice at Altru Health System, it's this type of connection that is changing rural healthcare for the better in countless ways.

Diabetes at a Distance

Altru Health System in Grand Forks works in partnership with Heart of America Medical Center (HAMC) in Rugby by providing psychiatry, dermatology, cardiology, and diabetes care through telemedicine. For the past four years, a diabetes telemedicine clinic facilitated by Dr. Eric Johnson has been offered twice monthly. Patients from HAMC with Type 1 or Type 2 diabetes are able to receive care remotely through this clinic, saving time and improving their health. In addition to Rugby, Dr. Johnson provides similar telemedicine clinics to Carrington and Devils Lake.

Although Dr. Johnson is located in Grand Forks, he is assisted by Kathy Brandt, a certified diabetes educator and dietitian serving as the telemedicine nurse at HAMC. Brandt meets with patients in person, taking vitals and updating the electronic medical record (EMR) so that Dr. Johnson has all the information he needs for the visit.

“If the patient is wearing an insulin pump, I'm able to generate reports and upload them to the EMR, and I can also scan blood sugar logs so Dr. Johnson is able to review them as well,” Brandt said.

This makes the visit virtually identical to an in-person visit—and arguably even more effective. According to a 2016 study by Dr. Johnson, “Delivery of Diabetes Telehealth Services to a Rural Clinic,” patients at HAMC who experienced telemedicine visits showed improved A1C scores (a test that indicates average blood sugar levels), and in some cases better patient satisfaction, relative to patients who had done traditional in-clinic visits only.

You need someone on the other end to facilitate the conversation, and that's where the provider in Rugby, for example, really helps with keeping the patient engaged.

To ensure patients are comfortable during the exam, the provider at the distance site, where Dr. Johnson is, and the nurse or dietitian at the originating site, where the patient is, work together to deliver care and to coordinate any follow-up patient education or appointments. Still, he says delivering care effectively through telemedicine can take some time to learn.

“It often doesn't work to simply put a patient in the room with a camera,” Dr. Johnson said. “You need someone on the other end to facilitate the conversation, and that's where the provider in Rugby, for example, really helps with keeping the patient engaged.”

Virtual E.R.

Another service helping rural North Dakota meet the healthcare needs of its patients is eEmergency services, provided by Avera Health in South Dakota. Brought about by a grant from the Leona M. and Harry B. Helmsley Charitable Trust, Avera eEmergency made its way into North Dakota in 2009 and is now present in the emergency rooms of 29 of the 36 Critical Access Hospitals around the state. Nikki Johnson, CEO for Cooperstown Medical Center (CMC) in Cooperstown, North Dakota, appreciates the comfort Avera eEmergency provides both providers and patients.

We have a small staff, and eEmergency helps keep the E.R. service open in our community and helps our providers manage care better.

“We have a small staff, and eEmergency helps keep the E.R. service open in our community and helps our providers manage care better,” Nikki Johnson said.

Avera eEmergency works by simply pushing a button located in the emergency room. If a rural provider pushes the button in the E.R., a certified emergency room physician located at a hub site in Sioux Falls, South Dakota, pops up on a monitor mounted in the room. The board-certified emergency physician and her team are then able to assist in any way the providers in Cooperstown need.

Sometimes the rural providers just need the distance physician to observe and chart the visit. At other times, the rural providers need advice, consultation, and guidance on how to best treat the patient. The Avera eEmergency team will even assist in making transfer arrangements.

Johnson says this is not only a helpful tool in patient outcomes; it helps with recruitment of new providers too.

“Rarely do we have a job candidate that doesn't ask if this is available,” she says of eEmergency. “Providers feel more comfortable knowing they have board-certified physicians available to help them deal with complex medical conditions at the push of a button.” Johnson added that providers are encouraged to use eEmergency to discuss difficult patient conditions outside of the E.R. as well. “Without eEmergency, we would lose the ability to recruit, which of course would impact the care we provide our surrounding communities,” she said.

While telemedicine is already filling a few key areas of need throughout the state, the trend is clear: care delivery in this manner will only increase. In a recent study conducted by the UND Center for Rural Health, telemedicine is being implemented in each of the 36 critical access hospitals in the state; on average, the top three telemedicine services being used are e-emergency, radiology, and dermatology. The telehealth services these rural hospitals say they are most interested in adding are behavioral health, speech therapy, asthma management, and oncology.

UND medical students
UND medical students on both sides of the camera work on the "webside manner" at the School of Medicine & Health Sciences.

Whether it's by computer screen or personal cell phone, the wave of the future will be providing virtual care. And North Dakota is already working hard to ensure that future physicians are being prepared to enter the telemedicine environment post-training.

“In Rugby, we're saving patients about a 300 mile round-trip drive,” concludes Dr. Johnson, noting his use of the virtual stethoscope. “On the patient's end the nurse has something that looks like a regular stethoscope that you can put to the patient's lungs, and we both have headphones so we can listen. The sound quality is very good, so 200 miles away I can be listening to somebody's heartbeat. So, It's fairly comprehensive.”

This article originally appeared in the Summer 2018 issue of North Dakota Medicine.

Stacy Kusler Stacy Kusler is the connection between rural healthcare facilities in North Dakota and qualified health professional job seekers. As the workforce specialist, she assists rural facilities to attract medical providers and other health professionals to their communities by sharing job opportunities. Through her position, Stacy is working to reduce the healthcare workforce shortages throughout the state.