Virtual hospitalists bring expertise to rural hospital

A telemedicine program connected hospitalists with advanced practitioners and nurses at a rural facility.


Background

The University of Iowa Hospitals and Clinics in Iowa City ranks as one of the top hospitals in the U.S. for accepting outside transfers. However, incoming patients are often wait-listed for days, and some transfers don't actually require acute inpatient admission, said ACP Member Ethan F. Kuperman, MD, MS, a clinical associate professor of internal medicine at the university's Carver College of Medicine. The concept of a virtual hospitalist “seemed like the only way to solve those two problems,” he said. “It's very difficult to make triage decisions or evaluate patients based solely on a phone conversation with an external provider.”

How it works

The virtual hospitalist program, which launched in November 2016, allows University of Iowa hospitalists to connect with local advanced practitioners and nursing staff at Van Buren, the pilot site located nearly two hours away. They can converse over video and share the same electronic health record (EHR), said Dr. Kuperman. “Without changing my context, I can directly access the charts of the patients I'm caring for, whether they're in Iowa City or Keosauqua, Iowa,” he said. Most of the time, Van Buren clinicians place the orders.

Two computer tablets were placed at Van Buren for use either in clinician conference rooms or in patient rooms. Twice a day, the virtual hospitalists and on-site clinicians reviewed the status and treatment plan for all admitted patients over video. The virtual hospitalists also used the tablets to interview all patients on the morning after admission and at other times as needed.

Results

During the six-month pilot program, transfers from the Van Buren ED to the University of Iowa decreased from 16.6% to 10.5%, leading to an overall drop in transfers from 17.3% to 11.9%, according to results published in the November 2018 Journal of Hospital Medicine. Van Buren's daily census, length of stay, and transfers after admission remained the same. On average, virtual hospitalists reported spending 35 minutes per patient per day and 92 minutes per day, total, on EHR data review and entry, conferences with Van Buren staff, and the aforementioned virtual patient encounters.

“We were pleased that we were able to increase the number of patients requiring acute admission that could be admitted locally, and that was really our principle aim,” said Dr. Kuperman. “I think our biggest surprise, and perhaps a shortcoming of the program, is that we weren't able to increase the inpatient census at Van Buren the way that we had hoped.” This may be because the virtual hospitalists were sending patients home who might've otherwise been observed and admitted, he noted.

Challenges

“Making sure the local providers in Van Buren County were comfortable with it and making sure my colleagues were ready to assist and do this as well were both pretty major challenges,” said Dr. Kuperman. There were also logistical challenges, such as poor network connections and limitations in patients' hearing and vision.

A level of trust among the clinicians was also essential to success. While leadership was on board because the program solved the financial and recruiting challenges of full-time hospitalist coverage at a small rural hospital, “It took a long time before the nurses and physicians felt comfortable approaching us and asking us questions and understood that we weren't there to just take over and take away their autonomy and independence,” Dr. Kuperman said. He added that Van Buren's advanced practitioners were dedicated to learning and expanding their clinical skills. “Without that commitment, I think we would've struggled a lot more.”

Lessons learned

The most important lesson learned was to be ready to listen, he said. “We came in thinking that we were going to provide a very different set of services to what our partners at Van Buren actually needed. It was only by going down there and meeting with them and listening to them that we were able to create a system that made sense for our institutions,” Dr. Kuperman said.

Next steps

In 2019, Dr. Kuperman's goals are to increase the census at Van Buren and expand to more critical access hospitals in Iowa. “We're Iowa. We have no shortage of them,” he said. “I want to expand to more institutions and start providing them the same service and improving care at those institutions.”