When hospitalist Richard Lapin, MD, admits patients at St. Helena Hospital in Clearlake, Calif., their first questions are not about diagnoses or treatment plans.
Instead, they ask where Dr. Lapin is. “I remember explaining, ‘No, I'm not inside the robot. If I were inside the robot, I'd come out.’ They get over that, and say, ‘It's light in back of you. Where are you?’”
In fact, Dr. Lapin is in Israel, where he lives permanently while practicing as a nocturnist in California. As evidenced by the patients' questions, he works through a telehealth robot. The robot has a video hookup and screen that allow physician and patient to see and talk to each other, as well as a stethoscope attachment for a remote physical exam and wheels and steering to travel around the hospital.
Dr. Lapin and his colleagues in the budding specialty of telehospitalist practice use such technology to provide inpatient care in settings where “in-person” hospitalists are unavailable.
“Nighttime is a really big proportion of it,” said Dana Giarrizzi, DO, national medical director of telehospitalist services for Eagle Hospital Physicians, which is based in Atlanta. But there are a number of other applications, she added. “You can round during the morning, you can round during the day, you can back up nurse practitioners, and you can do surge capacity.”
According to its proponents, telehospitalist practice could be a popular solution to the recruitment and retention challenges facing many hospitals and hospitalist programs today, especially in rural areas. It does face a few challenges first, however, including reimbursement, licensing, and the common clinician response you may be having right now: “Really, a robot's going to do my job?”
What's it like?
Telehospitalist systems vary, from a videoconferencing system on a cart that a nurse wheels into a patient room to a robot that travels the halls of the hospital, stethoscope in hand, almost like a physician.
Dr. Giarrizzi uses the latter. “Besides pushing a button to get the elevator, I have so much independence and freedom, I just do what I need to do,” she said.
The tasks of telehospitalists also vary, from consulting on occasional admissions to working a whole shift just as if they were in the hospital. “I still do cross-cover call. I still do admissions. I still do discharges. I still run codes. I still go to meetings,” said Dr. Giarrizzi.
A telehospitalist can perform all these tasks from anywhere in the world, with a laptop, webcam, and a good Internet connection. This portability is the major appeal of working as a telehospitalist. “You work from home, and when my kid gets sick and needs to be tucked back in bed, I can tuck them back in bed,” said Dr. Giarrizzi. “I can work from a beach house. My partner who I work with lives in Paris, France.”
Dr. Lapin, who is the medical director for OffSiteCare's telemedicine hospitalist service, became a telehospitalist to fulfill his lifelong dream of moving to Israel while retaining his career and income as an American hospitalist, but he had doubts at first.
“I was very skeptical when I first started. I was always a very hands-on physician,” he said.
Telehospitalists say they find workarounds for the absence of their hands. “You have to use other ways to touch somebody. Either you use somebody else's hands, like the nurse, or [you use] your ability to communicate,” said Dr. Giarrizzi. “The physical may be a little different because I don't have my actual hands, but I'm still really doing the same things.”
Not surprisingly, verbal communication becomes a more important part of the patient visit. “You'll stay and talk to them a little more. And you'll talk about personal things that maybe you wouldn't on-site because you're trying to get to know that person in that 5-minute interaction,” said Dr. Giarrizzi. “You can't cut corners like you can when you're on site and in a hurry.”
Telehospitalists also have to ensure that their on-the-ground assistance, usually from nurses, isn't rushed. “My biggest fear was that I was going to be missing something in the physical exam, but if one is persistent enough with questioning and with getting the information that is needed to rule in or out whatever you're looking for . . . there's no reason that the care you provide would be any different,” said Dr. Lapin.
To make sure his exam is thorough, he often asks on-site clinicians to clarify the common finding of “within normal limits,” for example, during an eye exam. “My polite response would be, ‘Thank you very much, but in terms of documentation and being thorough, I really need to know what color you see,’” he said.
Sometimes it's not the telehospitalist who needs reassurance that an exam is complete, but a colleague. “I knew [the patient] had an acute gallbladder. I could tell from the history, the way the nurse had pushed on the belly,” said Dr. Giarrizzi. But because the telehospitalist service was new to the hospital, the nurse wasn't sure how a surgeon would respond to her calling him in.
Dr. Giarrizzi's solution? “I went down and had the ER doc come up and put his hands on and be like, ‘Yup,’” she said.
Suspicion is a common response of clinicians to telemedicine. “Medical staff don't necessarily believe it until they actually see it,” said Dr. Lapin.
Patients, on the other hand, tend to respond favorably to their first encounters with telehospitalists, according to both satisfaction surveys and anecdotal experiences. “The patients love it. They're like, ‘I'm on TV,’” said Maureen Ideker, RN, MBA, director of telehealth for Essentia Health in Duluth, Minn.
Sometimes patients even request telehospitalist care. “I've had nurses call me and say, ‘I know this patient was seen before you came on, but the family sees you motoring into all these patients' rooms and they asked me about it. They wanted to know if you're going to come and see them,’” said Dr. Giarrizzi. “They feel like they're getting something: ‘A big city doc is coming to see me.’”
Where it makes sense
Most current telehospitalists practice in rural hospitals. “Rural hospitals and smaller facilities are primary targets for telemedicine, primarily because of their location and historic recruiting pitfalls,” said Richard Sanders, MPH, vice president of telemedicine services for Eagle. “You have facilities out there that maybe have been looking for hospitalists to come to their community for years and just haven't been able to get them.”
Telehospitalists can be used in a number of ways to remedy hospitalist shortages. For one, physicians can work in a high-need area while living in the city of their choice. Dr. Giarrizzi entered telemedicine when the hospitalist company she liked working for left the area where she lived.
But telehospitalist practice, especially night coverage, can also resolve shortages by facilitating recruitment of on-site hospitalists. “[Recruiters] can say, ‘You don't have any night call responsibility. You can work your standard daytime shift, a week on, a week off,” said Mr. Sanders. “Otherwise, what they're selling is ‘Come work for us, you can work 24/7/365,’ which scares a lot of people away.”
Other rural hospitals with coverage problems have opted to staff their wards with nurse practitioners and physician assistants. Essentia Health uses telehospitalists to oversee these clinicians. “If a nurse practitioner admits a patient, then they need to be seen by a physician within 24 hours, and so the telehealth visit is set up,” said Ms. Ideker.
Small hospitals that successfully recruit hospitalists may find that they don't have enough work to keep them busy. That's how Swedish Medical Center in Seattle got into the telehospitalist business. “We needed to level out our nocturnist resources at night. We have 3 campuses,” said Jose Gude, MD, a telehospitalist with Swedish.
The nocturnist at the system's less busy hospital would often go to one of the other hospitals to help out. But when there was a nighttime admission back at the small hospital, he or she would have to turn around and head back. “It would take hours for the hospitalist to go back and evaluate the patient,” said Dr. Gude.
Now, when a patient needs to be admitted at the hospital where the nocturnist isn't, “we go to a telemedicine station, we log on, we connect with the telepresenter at the other end, which is usually a nursing supervisor,” said Dr. Gude. “You can diagnose and initiate care with a little bit more confidence [than giving orders on the phone].”
Leveling out care so that each physician has the right amount of work is a theoretical benefit of telehospitalist care, but it doesn't always work out in practice, according to Steve G. Cervi-Skinner, MD, chief medical officer of Apogee Physicians, a hospitalist company based in Phoenix.
His company tried offering telehospitalist services but eventually discontinued them. “We had good doctors on call and they would take call 24 hours a day, 7 days a week to provide higher-level assessment and planning,” Dr. Cervi-Skinner said. However, the hospitals didn't have enough work to keep the telehospitalists busy.
“The only way to have some success with that is to scale it, so that the doctor who is being paid to be on is covering multiple facilities and is busy enough to justify a full shift,” he said. “You still have to pay the doctor who is on telehealth coverage about what you'd pay a physical doctor.”
Unlike on-site physicians, telehospitalists aren't going to bring in much, if any, insurance reimbursement for their visits. “CMS will not reimburse professional fees for telehospitalist visits,” said Mr. Sanders. “Other payers may say that they reimburse for telemedicine visits just like in-person visits. However, our limited experience with pursuing that reimbursement has not been successful.”
The financial case for telehospitalists can be made in other ways. When providing vacation coverage for on-site hospitalists, they're certainly less expensive than locum tenens. “[Hospitals are] not only paying less because I'm working other places as well, but you're not paying someone to fly there, to have a hotel, to sit around,” said Dr. Giarizzi.
If a telehospitalist visit can eliminate the need for a patient to be transferred from a smaller hospital to a bigger one, it can financially benefit both parties. “What we're really trying to do is help the rural hospitals, the Essentia critical access hospitals, keep more patients in their own beds, so they're not sending them,” said Ms. Ideker. The rural hospital gets the admission, and the busy hub hospital keeps a bed open for another new patient.
Telehospitalists practicing within their own health system avoid some of the other major obstacles to telemedicine: licensing and credentialing. “If I was going to be covering telehealth. . . with a small hospital in Colorado and another one in Wyoming and another one in Nevada, I'd have to be licensed in those 3 states and I'd have to have credentials in those 3 facilities,” said Dr. Cervi-Skinner. “That's doable, but it's expensive, it's cumbersome, it takes time.”
Both Congress and the Federation of State Medical Boards are looking at simplifying the process of interstate licensing, but the outcome and the applicability to hospitalists are still uncertain.
There are other challenges to practicing in multiple, unrelated hospitals, according to Dr. Giarrizzi. “You've got to be better at CPOE [computerized physician-order entry] and electronic health records, because you'll be logged on in Virginia where they're doing Epic and you'll get off there and push the next button and you'll be in Kentucky where they don't have CPOE at all and everything's on a chart,” she said.
Although it does allow you to work from home or the beach or Paris, telehospitalists say their jobs can have disadvantages compared to normal practice, from adapting to a new computer system to being lonely. “I am, for a 12-hour shift, pretty much bound to my computer,” said Dr. Lapin. “I do miss the in-person interactions.”
To have face-to-face contact with patients and clinicians, he works in an urgent-care center and volunteers in a clinic for refugees. Most of Eagle's telehospitalists also “moonlight” with in-person practices, Mr. Sanders said.
Once everyone involved is used to the technology, however, interactions through the robot can get pretty close to the real thing, according to Dr. Giarrizzi. “People say, ‘Hey, Dr. Giarrizzi, we're ordering pizza tonight and we didn't want to eat in front of you.’ Lots of times I'll go get something to eat and say, ‘OK, I'll eat with you.’”
On-site clinicians become more welcoming of their remote colleagues when they understand their role. “A proportion of the medical staff feel threatened to some extent that we're taking their jobs, which is not true at all. We're happy to help out and take shifts that are left over, after they get their pick,” said Dr. Lapin.
Night coverage, especially, tends to turn on-site hospitalists and nurses into fans of telehospitalists. “[Hospitalists] feel confident and can go to sleep knowing that their patients are being taken care of,” said Dr. Giarrizzi. “Nurses on at night used to think, ‘Dr. So-and-so was on all day. He has to come back and work the next day. Do I really need to call him on that rhythm change? I just called him on the blood sugar and the a.m. labs are going to come back in an hour. Maybe I should just wait.’”
A nocturnist telehospitalist, however, only has to push a few buttons to check on the patient, so nurses aren't afraid to alert her to minor changes. And if the telehospitalist happens to be located on another continent, he's wide awake.
“California nights are my early morning and day. Physicians and nurses who call me don't have to think twice about waking somebody up,” said Dr. Lapin. “Our goal is actually to build the [telehospitalist] service in Israel, or at least in an area where there is a time difference. I think everybody would agree that as a day job, it's more attractive.”
How attractive physicians and hospitals will ultimately find telehospitalist practice is an open question right now, but even skeptics of the model think it's here to stay. “I think telehealth absolutely has a place in hospitalist medicine, but there's still a lot of work to do to sort out the value equation,” said Dr. Cervi-Skinner.