At the Health IT Summit in Nashville, Next-Door Neighbor Georgia Offers Lessons in Rural Telemedicine Advances

For every challenge in healthcare delivery, there is some potential approach for improvement; that was a broad theme underlying the message delivered by Suleima Salgado, of the Office of the Chief of Staff of the Georgia Department of Health, on Thursday morning at the Health IT Summit in Nashville, sponsored by Healthcare Informatics. Speaking to an audience at the Sheraton Nashville Downtown, Salgado delivered a presentation entitled “Telemedicine: Improving Population Health through Collaboration and Partnerships.”

The Atlanta-based Salgado sketched a portrait of the state of Georgia that many in Tennessee and throughout the Southeast and Appalachia would find relatable, of a state with vast rural areas that remain underserved for their residents, and in dire need of the benefits of telehealth/telemedicine solutions and strategies. “We have 159 counties in Georgia, and 110 of those are rural,” Salgado noted. “Meanwhile, here in Tennessee, you have 89 rural counties and only six urban counties, according to your state office of rural health. We need to find ways to provide access to quality care for a huge percentage of the residents of our states,” she said. And that involves facing up to daunting challenges of all kinds, from funding to staffing to data and information infrastructure challenges. “The reality at the end of the day is that most of our rural health partners are facing severe data issues,” she said, noting that, just to take one smallish example, “Clinics tell us that they have to schedule their participation in webinars around potential data crashes.” Many rural clinics have fragile Internet connections; what’s more, some have only one active nurse on staff, so if that nurse drives to a live educational session, that particular clinic has to shut its doors for a day.

Of course, every state has its own peculiarities in terms of addressing rural health issues, as well. Salgado pointed out that, while the Georgia Department of Public Health is overseen by one commissioner and one board of public health, and that one commissioner appoints the 18 district health directors who oversee the state’s 18 public health districts, its 159 county governments each have their own county health departments and county boards of health, which are managed independently and which independently implement broad statewide policies. “Our state health commissioner employs the health directors, but has no control over policies implemented at a local level,” she noted. Still, that fact in itself is not necessarily negative, she pointed out. “I’ve worked in a state office and in a county office. And to me, the work happens at the county level. At the end of the day, most of the work and effort come from those county organizations,” she said. So the independence of county health organizations is not in itself a problem; it just adds to the complexity of addressing broad rural healthcare policies, she emphasized.

One positive in the landscape around rural health in Georgia has been around funding, Salgado said. “In Georgia, we’re always looking towards the federal, state, and local organizations that can help us. And Georgia [health] has undergone a dramatic change in the last ten years as a result of increased federal funding, state legislative support and intra-state collaboration.”

The Georgia Telehealth Network

That increased funding has been absolutely necessary to address some disparities around access to quality healthcare in Georgia. “About 60 of our 159 counties don’t even have specialists in certain specialties; people are having to drive four to five hours to see a specialist,” Salgado noted. “So we established a telemedicine network through the state,” she reported, with an initial funding grant of $2.3 million to establish the Department of Health-led network. But, she quickly added that, though that figure sounded large in the abstract, in practice, “when you start figuring in technology, data, and other costs, it wasn’t a lot. Still, it provided a strong start. “The goal of the Department of Health,” she continued, “is to connect patients to providers in their local communities and not extract business/medical services from the local economy. We’re trying to help those counties without specialists in specific specialties. We want to help those counties so that people don’t have to drive to Atlanta or Jacksonville or across the state line to Alabama. It’s not a replacement, and we’re not using it as a medical home.” Indeed, she said, she and her colleagues have emphasized to the local communities they’ve reached out to, that providing adequate telemedicine medical specialty services actually helps local communities, and does not take resources out of communities. In that regard, she said, “Significant inroads have been made with private physicians, local hospitals and other telehealth entities within Georgia to advance towards a cross-collaborative network,” with the goal of the telehealth network “as a means to better communicate between each other and most importantly as a way to provide access to specialty care for our patients.”

Among the key points made in her presentation, which included a slide presentation, were the following:

• It is the goal of DPH to connect patients to providers in their local community and not extract business/medical services from local economy.
• In situations where a provider is not available within the community or through existing DPH referral services, DPH will look to surrounding counties and then eventually to metropolitan areas to find services.  
• DPH also has an agreement with the Georgia Partnership for Telehealth, for access to their telemedicine network, when needed.
• The Georgia Partnership for TeleHealth is a non-profit, Open Access Network, with over 200 specialists and providers that represent more than 30 medical specialties.
• In addition, DPH contracts directly with local, specialty providers to meet the healthcare needs of our patients. 

Meanwhile, the list of clinical areas involved is wide. Salgado noted the following areas:

• Administration
• Asthma/Allergy—pediatric
• Audiology—pediatric
• Behavioral Health counseling—pediatric
• Dermatology—pediatric
• Diabetes Education—adult and pediatric
• Dental Services (School Based)—pediatric
• Emergency Preparedness-
• Endocrinology—pediatric
• Genetics/Developmental—pediatric
• Infectious Disease—specialty clinical care for HIV/AIDS patients
• Interpreter Services—health department clinical services
• Lactation Support/WIC—adult
• Maternal Fetal Medicine—adult
• Nephrology—pediatric
• Neurosurgery—pediatric
• Nutrition/WIC—adult and pediatric
• Sickle Cell —adult & pediatric

“What does telemedicine look like in Georgia?” Salgado asked. “Private providers use their own platforms, but we’re Cisco-based with a Cisco suite, and a full telemedicine backup,” in terms of telecommunications and medical equipment. Often, the telehealth applications involved are not necessarily purely medical in the strictest sense; in fact, she noted, nutritional counseling and behavioral health services are two key telehealth services that have been broadly helpful. For example, she noted, “In many cases, there is one nutritionist serving four rural counties. In the past, that single nutritionist might have been driving across four counties to deliver health-related services. Now, she can see people everywhere.” The same goes for the expanded access to behavioral health afforded by the state’s statewide network.

Among other strategies to maximize resources, Salgado reported, “We realized and leveraged the fact that the FCC [Federal Communications Commission] has telecommunications funding to give you reduced cost per circuit for these kinds of projects. So we decided to put our hub in the third most rural county in Georgia, Waycross County, to get that discount. And we leveraged existing teams that had already created and were maintaining technology in various places. And now we’re running our network.” She cited a cost of $800,000 so far in terms of the cost of running the network. “But we did well,” she said. Initially, at least, she noted, “We couldn’t do a cloud-based infrastructure, we had to do traditional T1 lines. And everything coming back to the hub” in Waycross County. “We’re changing the model over time, and eventually moving to cloud-based. But keep in mind that five rural counties still have no Internet connectivity.”

One very concrete example of resource savings and gains over past dislocation has been around clinician education, Salgado noted. “The Department of Health had been offering a two-day refresher course in Macon for nurses who treat STDs. IN the past, that involved local healthcare provider organizations having to pay for lodging and travel costs, which figured out to about $500 per nurse. And some of those clinics are so rural that they have only one nurse on staff, so they would have to shut down their local clinic to send their nurse to that course.” Providing the educational course via weblink eliminated those costs and dislocative elements.

Meanwhile, the need for ongoing development of telemedicine and telehealth services remains absolutely crucial, Salgado emphasized. “Fifty-two counties in Georgia do not have OB/gyns who can support high-risk pregnancies. That means that for many pregnant women in rural areas, it requires a four-hour drive each way in order to be seen by a physician who can meet their medical needs.” Telemedicine offers an incredible advantage for those women in terms of accessing the specialized medical care they need.

Similarly, she reported, there is a huge need for teledermatology and teledentistry. In the case of teledentistry, the statewide telemedicine program has sent dental hygienists into schools to provide cleaning, fluoride treatment, x-rays, and dental education in schools. Dentists can remotely view the x-rays that the hygienists administer, and can communicate with them regarding potential treatment for the children. That program has been very popular with schoolchildren, she added.

The work will continue to evolve forward in this program, Salgado said, but the advances already made are proving heartening for all involved, and demonstrate what can be done collaboratively to improve healthcare access and quality to rural residents.

Among the many partner organizations in this program include the Georgia Partnership for TeleHealth, the Georgia Department of Behavioral Health and Developmental Disabilities, the Georgia Department of Community Health, the U.S. Department of Agriculture, the Georgia Department of Juvenile Justice,  Voices for Georgia’s Children, Children’s Healthcare of Atlanta, Georgia Regents University, the Augusta University Medical College of Georgia, and the University of Florida College of Medicine-Jacksonville.