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Robot Helps Save The Day At Rural Hospital

Some small, rural Kansas hospitals are using highly sophisticated medical robots in ways that are helping ease the shortage of specialists in their areas and – in at least one instance – boosting the bottom line.

Hamilton County Hospital here was on the brink of closing little more than a year ago because of financial and staffing problems, but use of a robot has been a key factor in the facility’s dramatic turnaround, according to chief executive Bryan Coffey.

“The reports of our demise are greatly exaggerated,” he said.

First order of business for Coffey when he became the administrator in June 2013 was hiring doctors for a hospital that had none. He recruited a primary care physician and a cardiologist.

Then “we brought in a telemedicine robot and started seeing a 180 (degree change). There’s been a 40 percent increase in (patient) volume and we’re consistently, month over month, 15 percent in growth,” Coffey said.

Coffey since has written a “white paper” on how small hospitals like Hamilton County’s can make the machines, which can easily cost $50,000 or more, a workable investment.

Hamilton County borders Colorado in southwest Kansas and has a population of about 2,700 people. The nearest major regional medical centers are in Denver and Wichita.

The robot now is being used at Hamilton County Hospital for a variety of purposes, including emergency room stroke treatment, dermatology and specialty pediatrics.

Coffey said the latter, done in partnership with Children’s Mercy Hospital in Kansas City, Mo., is “starting to grow hand over fist.”

‘Same page, same time’

The hospital now works with nine remote specialists, “and we’ve really just scratched the surface,” he said, noting that the machines make the sort of collaborative medicine that has been the hallmark of the Mayo and Cleveland clinics a possibility at all sorts of medical facilities, including small, rural hospitals.

“It puts everybody on the same page at the same time,” he said.

The robot connects distant doctors with patients and local medical providers in real time via a high-definition mobile visual display that includes various monitoring and imaging attachments such as a digital stethoscope. The hospital now is able to “beam in big-city care in a rural health care environment, all while saving the federal government money and lowering overall health care costs,” Coffey said, noting that many of the hospital’s patients are on Medicare.

The machine that makes it possible, he said, reminds him of the robot in the 2008 animated film “WALL-E” “but without the googley eyes.”

Tony Nunn at the University of Kansas Hospital in Kansas City, Kan., also is familiar with the robots thanks to a project he is working on with Hays Medical Center in central Kansas and Liberty Hospital, which is northeast of Kansas City, Mo.

KU Hospital stroke doctors will connect with patients via the robots in each of those hospitals, he said, once the new system goes live within a couple of weeks.

‘Like ‘The Jetsons’ on steroids’

The doctors will be available around the clock for remote consultations, he said, and able to link to the robot via iPads or laptop computers.

“It’s like ‘The Jetsons’ on steroids,” he said.

The robots at Hamilton County, Hays and Liberty are made by California-based InTouch Health.

Tim Hulen, the company’s sales representative for the Midwest, said the machines have been used by the military in Iraq and Afghanistan and were used at the Olympics, especially by “smaller countries whose specialists couldn’t make the trip but were still able to confer with their athletes” via the robots.

He said installing the machines and getting staff trained to use them is relatively easy.

“The thing that slows things down is licensing and credentialing,” he said. “We try to help the facility to see that they get everything done for billing and compensation. The device part is not that difficult.”

He said about 20 facilities in Kansas are using the company’s machines and about 10 more are expected to by early July.

But the number of InTouch or similar devices being used in small, critical access Kansas hospitals such as Hamilton County is thought to be low.

Innovation network

About a year ago, Stormont-Vail HealthCare in Topeka put an InTouch robot at Sabetha Community Hospital, which is in northeast Kansas near the Nebraska line.

The Sabetha hospital and Stormont are part of the Health Innovations Network of Kansas, which includes 19 facilities that primarily are small and rural. Stormont is the largest member.

Telemedicine experts say federal and state laws and regulations haven’t kept pace with the rapid changes in technology that now allow doctors to provide a variety of care to distant patients.

“I think eventually we won’t call it telemedicine. It will be just the way we deliver care,” said Morgan Waller of Children’s Mercy Hospital.

Meanwhile, policymakers lag behind the new realities.

“The laws are outdated,” Waller said. “The industry is developing so much faster than our state and federal legislatures can keep up with.”

Stormont bought and put the machine at the Sabetha hospital as part of a pilot project, according to Carol Wheeler, Stormont’s vice president of regional relations.

Stormont hospitalists are available for consultations with patients and providers in Sabetha via the robot.

“It started out being consultations in the emergency room,” Wheeler said, “but that was fairly quickly expanded to include inpatient consults as well. Our hospitalists through their control station are able to call up Sabetha and have a visualization of the patient at the bedside and talk with the (local) physician, the nurse and the patient, if necessary. They are essentially doing a consult as if they were there on the property.”

Wheeler said the machine so far hasn’t been used as frequently as had been hoped but that Sabetha hospital staff have shown interest in expanding its use to include consultations with Stormont’s specialists, which might make it busier.

“The docs out there would really like us to expand the specialty consults,” she said. “So we’re looking at the possibility of doing that as well.”

And other remote services could be considered.

“Some places are using them for psychiatric clinics, and that’s a wonderful possibility,” she said.

Stormont has offered the same arrangement to other hospitals in the network, though any takers in the second round of the initiative would be expected to buy their own robots.

Wheeler said none of the other network members has agreed to do it yet, though it is still early in the process.

“The cost of leasing the equipment is not insignificant,” she said.

Children’s Mercy began using the robots at its regional clinics in Wichita, St. Joseph and Joplin, Mo., to provide specialty and sub-specialty pediatric care. It now also can link in real time to a few other hospitals in Kansas and Missouri, said Morgan Waller, a registered nurse who is the director of telemedicine operations and professional services at Children’s Mercy.

“Beyond our original initiative … we are always looking for and receptive to (critical) access hospitals wanting to partner with us to increase their capacity, and Hamilton County is a beautiful example,” Waller said.

Seeing daylight now

The improvements at Hamilton County Hospital have not been lost on its board of volunteer trustees or others living in the close-knit community, according to Kent Schwieterman, the board chair.

Schwieterman is a former hog farmer who now works to maintain compression engines on the areas gas wells, which are atop a field that has dwindling output.

“Without this hospital (which is a major employer) it would be really hard to see any future” for Hamilton County, he said. “It’s pretty amazing from where we were a year ago or even around January. I was pretty fearful and wasn’t sure which direction we would go. We can see a lot of daylight now. I have a pretty good feeling about it.”

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VA Plan To End Rural Health Program Raises Hospital, Lawmaker Hackles

The U.S. Veteran Affairs Department appears to have no plans to continue a pilot program that it launched three years ago to give rural veterans access to private healthcare, despite calls for its continuance from some providers and lawmakers. Instead, it intends to transition the vets now using the pilot to a different program that some hospitals say puts them at financial risk since it reimburses at rates lower than Medicare’s.

The pilot initiative, known as Project ARCH (Access Received Closer to Home) began in 2011 and allowed some veterans to seek care with a private provider that had contracted with the VA. The pilot was available to veterans in certain areas who resided more than an hour’s drive from the nearest VA healthcare facility providing primary-care services and more than two hours’ drive from the nearest VA facility providing acute hospital care.

The Altarum Institute, a research organization, was hired in 2011 to evaluate the program throughout the pilot, offering tracking information on cost, quality and accessibility of care offered through the non-VA care providers. Depending on its findings, the expectation was the program would expand, the company says. ARCH had a 90% approval rate by veterans, according to Altarum.

But ARCH is coming to an end while lawmakers are working on combining a House and Senate veterans’ health bill that, among other things, would allow veterans to visit private doctors at VA’s expense if they are unable to get an appointment in a timely manner or live more than 40 miles from a VA facility.

Some lawmakers want ARCH to continue because they fear vets now using it could see a lapse in care before any new program is put in place as a result of congressional action. Even if a deal on a bill can be reached, and it passes both houses and is signed by the president by early July, the subsequent rulemaking process to implement the law could be lengthy.

The VA is concerned about its ability to handle the administrative burden of implementation of the non-VA provisions in the House and Senate bills, Philip Matkovsky, assistant deputy undersecretary for health for administrative operations at the Veterans Health Administration, testified Wednesday at a House Veterans’ Affairs Committee hearing.

ARCH was limited to five pilot sites: Billings, Mont.; Farmville, Va.; Flagstaff, Ariz.; Pratt, Kan.; and northern Maine. Had the program expanded, as many as 3.2 million rural veterans now enrolled in the VA healthcare system could have potentially benefited.

The program will end Aug. 29. The VA is creating individual transition plans for each veteran in the pilot, Matkovsky said at the hearing Wednesday. The agency did not release data on how many vets are currently in the program or the amount of money spent on ARCH to date.

The VA feels that an initiative it launched late last year, known as Patient-Centered Community Care, or PC3, will largely fill the void left by ARCH. PC3, among other provisions, provides rural veterans coverage for inpatient and outpatient medical and surgical specialty care. The agency however, is still investigating how to best help those relying on ARCH for primary care, as that’s not currently covered in the PC3 program.

Under PC3, the Veterans Health Administration contracts with managed healthcare organizations Health Net and TriWest to develop and oversee a network of providers who deliver specialty, mental health and limited emergency care.

However, some of the hospital participants in ARCH contend switching to PC3 could hurt their bottom lines. During the Wednesday hearing, Kris Doody, CEO of Cary Medical Center in Caribou, Maine, said that her facility has thus far declined to become part of PC3 because of its low reimbursement rates.

She preferred ARCH, she said, because in it a hospital contracts directly with the VA and receives Medicare equivalent rates. Health Net, which is overseeing PC3 in her area, is offering payments below Medicare rates. Lawmakers anecdotally had heard concerns that this was happening in other parts of the country.

Since Maine already has Medicare rates lower than many other states, it wouldn’t be financially feasible to accept Health Net’s offer, Doody said. A report released earlier this month by the CMS revealed that Maine’s total Medicare expenditures per capita were 17% lower than the national average.

Doody had relayed similar concerns to Sens. Susan Collins (R-Maine) and Angus King (I-Maine), who in turn sent a letter (PDF) June 9 to acting Secretary of Veterans Affairs Sloan Gibson asking that he extend ARCH. Early indications are that PC3 is not being used in Maine, they said.

“PC3 has been operational in Maine for two months, but statistics show that it is not meeting the needs of highly rural veterans who are most in need of this program,” the lawmakers say. “According to the VA’s own data, in the first month of its operation not one veteran in Maine had used PC3 during this time period. We are concerned that the low rate of reimbursement offered by Health Net could preclude PC3 from being an adequate successor to ARCH.”

Collins and King sent another letter a few days later co-signed by Sens. Jerry Moran (R-Kan.) Jon Tester (D-Mont.) and John McCain (R-Ariz.) also pushing to continue ARCH.

“For reasons we do not understand, the VHA is choosing—at VHA’s own initiative—to end this successful program,” the letter (PDF) reads. “All along, the VHA gave us the impression that it was waiting on analysis about the success of ARCH to inform its decision about extending the program. We are deeply disappointed by this breach of trust because those who suffer from this recklessness are veterans.”

Hospital CEO Turnover Hits Record High

The churn rate for hospital CEOs fluctuated between 14% and 18% for a decade, but spiked to 20% last year, the American College of Healthcare Executives says.

One-in-five hospital chief executive officers churned through the job in 2013, a record rate of turnover, according to the American College of Healthcare Executives.

ACHE tracking data released this week put CEO turnover at 20% in 2013, the highest rate since ACHE began analyzing the numbers in 1981. In the decade before 2013 the turnover rate had fluctuated between 14% and 18% and was at 17% in 2012. ACHE’s CEO turnover rates are based on leadership changes organizations report to the American Hospital Association.

Deborah J. Bowen, president/CEO of Chicago-based ACHE attributes the record-high churn to a combination of factors. “Turnover happens because people can leave for better positions, turnover happens when hospitals close, turnover happens when hospitals consolidate and changes are made in leadership,” Bowen said in a telephone interview. “There are demographic reasons too, with people who are just retiring and exiting.”

Bowen added that “there is a lot going on in the industry right now” and that some executives might not have the enthusiasm to contend with the sweeping changes mandated under the Patient Protection and Affordable Care Act, continuing Medicare reimbursement challenges, various performance measures, along with complex mandates around healthcare IT interoperability.

“We are seeing it reflected in the turnover,” she says.

Bowen says she doesn’t know if this high hospital leadership turnover is a temporary blip or the new normal. “I don’t have a crystal ball about the future,” she says. “We will have to see, but this is a challenging and dynamic time in healthcare, so obviously we are going to watch this with interest.”

Either way, the turnover suggests that hospital leadership and trustees should evaluate their succession planning, she says. “Executives need to be thinking about not only the short-term problems they have today but the sustainability of the organization.”

“If I were trying to take away the lessons learned here obviously boards and senior leaders want to pay close attention to succession planning and things like that because when you have a lot of churn in senior leadership that is not necessarily a good thing for hospitals. Any change management strategy usually takes a minimum of three and more like five years, and with tenure we are seeing the incremental range sliding down too. So if tenure is going to be about four years and that change management strategy takes about five years, then that could lead to more disruption than is ideal for long-term planning.”

Alaska’s 37% adjusted turnover rate for hospital CEOs was highest in the nation in 2013.

Technology Widens Care Options for Rural Hospitals

Rapidly advancing technological developments are helping rural hospitals save patients—and themselves. Throughout the country, hospital leaders are looking at ways they can strengthen their bottom line using technologies that better serve their communities and keep patients closer to home.

In Michigan, urban surgeons perform complex procedures at small Critical Access Hospitals (CAHs). Robotic surgery expands physician and hospital capabilities in Minnesota. And in Washington, medical robots place remote physician specialists at the bedside of critically ill patients.

“Ten years ago, what we’re doing wouldn’t have been possible,” asserts Michigan Rural Healthcare Preservation (MRHP) CEO Ethan Lipkind. “There have been astronomical strides in medical technology that have improved engineering, and advancements that have made it possible to provide sophisticated procedures in settings that were previously impossible. And we can do all of it in an exceptionally safe environment that benefits both patient and hospital.”

Today’s patients are smart and savvy, and they request best practice options such as robotic surgery, according to Joy Johnson, chief operating officer at Sanford Bemidji Medical Center (SBMC) in Bemidji, Minn. Patients want to stay close to home for care but they will travel long distances for best practice surgical options, Johnson said, adding that rural hospitals must be proactive technologically to maintain a solid bottom line.

“The old paradigm was that a hospital’s purpose was to aggregate all the professionals in one place and bring patients there,” says Tom Martin, CEO at Lincoln Hospital in Davenport, Wash. “Now that ability is changing to us bringing the professionals to where the patients are.”

Increasing Treatment Access

Lipkind knows of no organization similar to MRHP, a nonprofit network created in 2010 to help remote rural hospitals remain operational by developing environments that offer patients the advantages of the latest technologies. MRHP collaborates with CAHs in Deckerville and West Branch to operate a surgical program where four urban surgeons travel to the CAHs to do neurosurgery, complex urology, spine and orthopedic surgeries, fusion procedures and advanced pain care management.

“The traveling surgeons are the lifeline of this arrangement,” Lipkind commented. “Patient outcomes have been stellar. In these small rural hospitals, the focus is on one individual patient at a time. So these patients get more individualized care.”

Mary Ann*, a patient with a lumbar disk injury, terms her surgical experience “fantastic.” Dr. Gerald Schell, a board certified neurosurgeon with Michigan Clinic Neurosurgery in Saginaw, performed Mary Ann’s multilevel spinal fusion in the Operating Room of the 15-bed Deckerville Community Hospital (DCH).

“I was treated like family from walking in the door until being discharged,” Mary Ann said. “The staff went above and beyond the call of duty.”

According to DCH Chief Financial Officer Valerie Bryant, the surgical program has stabilized DCH financially, improved employee morale and been embraced by patients. DCH’s upfront investments included equipment upgrades and staff training.

“It takes additional nursing and clinical staff because we need all hands on deck the days these surgeons come in,” Bryant said. “We have to take care of our patients in the hospital and put more staff in the OR. But the benefit has definitely outweighed our additional expenses.”

MRHP is expanding surgical options at these network hospitals and has begun working with two more rural hospitals to develop programs specific to their needs. Lipkind said MRHP is also affiliated with physician offices, the Field Neurosciences Institute and Central Michigan University College of Medicine.

Robotic Surgery Offers New Options for Rural Patients

Dr. Benjamin Roy, a board certified general surgeon trained in robotic surgery at Sanford Bemidji Medical Center in Bemidji, Minn., shows a potential patient how the robotic system gives a view inside the body.

Sanford Bemidji Medical Center in Bemidji and Essentia Health-St. Joseph’s Medical Center in Brainerd are two rural Minnesota hospitals that have installed the da Vinci Surgical System, the first robotic surgical system approved in 2000 by the FDA. The system has a camera that provides a multi-dimensional view inside the patient’s body and a minimally invasive robotic arm with a pivoting wrist that can manipulate microscopic instruments in tiny areas inside the body. The surgeon navigates all aspects of the surgery from an exterior panel.

Currently, both hospitals are offering robotic procedures in the areas of general surgery, urology and gynecology. Difficult surgeries that couldn’t have been done in the past at Essentia Health have become common procedures because of the minimally invasive technology using the robot, according to Essentia Health Urologist Dr. Scott Wheeler.

“Robotics take the minimally invasive world one step further,” commented Dr. Hal Leland, an Essentia Health obstetrician/gynecologist who performs robotic surgery.

“Robotic surgery is significantly less invasive with less trauma to the body than there is even with minimally invasive surgeries,” Johnson concurred. “Patients want robotic surgery because it means shorter hospital stays and faster recoveries for them. New physician surgical grads are trained in robotic surgery and they want to use those skills. If patient retention and physician recruitment are negatively impacted, that can impact a hospital’s bottom line.”

SBMC, which has 90 acute care beds, is at least 150 miles from the nearest tertiary centers so patients were traveling or being transferred long distances for critical services. Four years ago the board of directors adopted a strategic plan to improve patient care and safety by developing SBMC as a regional referral center. In addition to the robotic program, other high-tech improvements since then include a new cardiac program with 24-hour STEMIservice, and a cardiac catheterization laboratory and a chronic wound program that includes hyperbaric oxygen therapy and advanced wound care.

“Hawkeye” the Robot Brings Specialty Care to Local Hospitals

According to the Washington State Hospital Association, the state’s 38 CAHs are the healthcare cornerstone in rural communities, and their viability is threatened. Among the CAHs implementing innovative approaches to stabilize their operations is Lincoln Hospital, the first Washington CAH to use a robot to manage care for patients who have had strokes.  Lincoln soon extended the program to include hospitalist management for all complex care patients. Within the first year of Lincoln Hospital adding the robot (which they call “Hawkeye”) to its staff in 2010, patient transfers decreased by 24 percent and admissions increased by 21 percent, representing a $1 million increase in revenue. Martin said other benefits include shorter patient hospital stays, fewer patient hospital readmissions and improved post-discharge patient management.

Contrary to the administration’s fears that patients and staff might react negatively to a robot, Hawkeye was an immediate hit. “It’s really amazing to watch Hawkeye at work,” Martin commented. “These remote specialists basically see everything in the patient that a doctor in our hospital does. And the stethoscope quality is so good that there isn’t any deterioration transmitting heart and lung sounds.”

A 25-bed critical access hospital in a CMS-designated frontier location, Lincoln Hospital simply didn’t have high enough patient volumes to justify hiring a full-time critical care specialist. But an outside review indicated that 38 percent of patients transferred to Spokane over a six-month period could have remained at Lincoln if critical care management was available.

“Our doctors are very competent but they weren’t getting that inpatient exposure and skills usage that urban specialty doctors do, so they didn’t always feel comfortable keeping complex patients here,” Martin explained. “As they started using Hawkeye, they agreed it was extremely beneficial to have another set of eyes on their patients. With this additional clinical support, they have the ability to care for more patients here.”

Currently, 14 rural hospitals in Washington state use TeleStroke, and three are developing TeleHospitalist. Critical care specialists or hospitalists at Providence Health Care (PHC) in Spokane provide 24-hour support to the rural physicians and hospitals. According to PHC Telehealth Program Coordinator Denny Lordan, PHC is developing TelePediatrics, TeleMental Health and TeleCritical Care. PHC also assists the rural hospitals with implementation to assure adherence to standard practice guidelines.

“Having subspecialists that we can make available to partner hospitals in the region elevates the level of care that rural patients receive in their own communities and helps to keep care local,” Lordan said. “When we keep appropriate patients in their own communities, we also free up higher acuity beds at Providence for patients that need that level of care.”

While these administrators are enthusiastic about high-tech solutions, they also agree that success won’t happen without community education and support, a financial investment, and willingness to partner or network with other healthcare providers.

“I think as rural hospitals we have to realize if we are going to grow and use our facilities to the fullest extent, it’s essential that we bring specialists into that mix,” Martin said. “Newer technologies offer opportunities that rural hospitals should be evaluating. Clearly, we have to be willing to become part of a system of care where integrating clinically with large systems using this technology affords us the ability to remain independent. Technology affords us a new perspective. We’ve stopped looking at our feet and started looking at the sky.”

What Happens When a Town’s Only Hospital Shuts Down?

What Happens When a Town’s Only Hospital Shuts Down?

A combination of health care economics, political forces and demographic trends have triggered a quiet epidemic of hospital shut downs throughout the country.

The problem stretches from rural areas to hard-hit urban communities.

The cornerstones of every modern health system, the total number of hospitals nationwide has steadily declined during the last decades. According to the American Hospital Association, there are about 5,700 hospitals in the country, but they tend to be unevenly distributed: only 35 percent are located in rural areas.

According to the federal Office of Rural Health Policy, researchers at the University of North Carolina have determined that there are 640 counties across the country without quick access to an acute-care hospital — roughly 20 percent of the nation’s 29,000 residential areas.

When the towns only hospital shuts down

All across the country, nonprofit hospitals dedicated to serving the poor and uninsured in exchange for tax breaks and federal subsidies are closing money-losing facilities and setting up in more affluent communities where patients are more likely to have health insurance.

“Unfortunately, health care remains a commodity that’s bought and sold on the open market,” and hospitals largely decide what the market will bear,” Smedley said. “There’s reason for concern that the trend will escalate.”

That not only means longer emergency response times for gunshot or car-crash victims, the chronically ill elderly or critically injured children, but little or no access to health care for residents who can’t afford insurance and often rely on so-called “safety net” community- or government-run hospitals for primary care. Many of those hospitals — required by law to treat the indigent — have chosen to avoid an impossible equation: caring for the urban or rural poor as the cost of that care increases and government reimbursements shrinks.

Read the full article here: By Joseph P. Williams