Telecommunications technology is driving a quiet revolution in health care, and nowhere is that revolution more evident than in the small hospitals of the American heartland. With the new telehealth systems, providers in rural care centers, who once might have been challenged to handle surges in patients or difficult cases—complex trauma cases from car accidents, for example—can flip a switch to connect their exam rooms, via high-resolution cameras and audio equipment, to highly trained emergency medicine specialists working from urban hospital hubs.
“The technology is at the point where it’s economical, effective, and reliable,” says Marcia Ward, CPH professor of health management and policy, who directs the Rural Telehealth Research Center (RTRC). “The telehealth hub has not only emergency medicine physicians to guide care, but also staff who can research medications and arrange patient transfers. That assistance allows the providers in these small hospitals to focus on giving direct care to the patient.”
Rapid Rural Expansion
One of the largest telehealth companies, South Dakota-based Avera eCare, already serves more than 10 percent of the rural hospitals designated as “critical access” care facilities because of their relative isolation.
“That’s more than 130 hospitals—which is broad coverage for something that’s relatively new,” says Clint MacKinney, CPH clinical associate professor of health management and policy and deputy director of the RTRC. “Just the fact that it’s expanding so rapidly tells you it’s delivering value in rural hospitals.”
The initial rollout of telehealth systems in these hospitals has been helped in many cases by government or charitable grants to fund the installation of cameras and other equipment. But MacKinney says the ongoing cost to new client hospitals seems manageable, at roughly $60,000 per year for Avera’s eEmergency service, for example. “I’m not seeing a lot of pushback on that figure,” he says.
The RTRC, a collaboration of the University of Iowa, University of North Carolina-Chapel Hill, and the University of Southern Maine, is funded by the federal Health Resources and Services Administration to evaluate the extent, outcomes, and challenges of telehealth in America’s more remote care centers. It has been one of the most active and prolific research institutions in this field.
“The part of telehealth that we’ve looked at most extensively is its use in rural emergency departments,” says Ward. She and her colleagues have found evidence that tele-emergency services help patients by increasing overall clinical care quality and reducing the time needed to deliver care.
“Tele-emergency services are used for the most severe trauma cases,” says Nicholas Mohr, UI associate professor of emergency medicine. In one recent study of rural North Dakota hospitals, Mohr and his RTRC colleagues found that “when tele-emergency services were engaged, trauma patients were transferred out of rural emergency departments more rapidly than those for whom the services weren’t used,” he says.
Telehealth also appears to deliver subtler but perhaps no less important benefits to hospitals and caregivers. For example, it can reduce the sense of isolation among providers at rural care centers, making them easier to recruit and retain. Moreover, telehealth allows the management within rural hospitals of many patients who would otherwise have been transferred immediately to larger urban hospitals. That retention of patients can make a big difference to a hospital’s bottom line and its long-term ability to serve its community.
Much like the early Internet, telehealth is now seeing a proliferation of services that can work through its new telecommunications medium. The RTRC’s researchers have recently examined or are now examining new specialty tele-emergency services that help client hospitals diagnose and treat specific acute conditions including sepsis (blood infection), psychiatric emergencies, and stroke.
“In the case of stroke there are clot-busting drugs that can really save the brain if they’re administered in time, but you have to make sure the stroke is from a vessel blockage rather than a bleed,” says Ward. “The idea is that a neurologist at a ‘tele-stroke’ hub who has seen hundreds of these cases can evaluate the CT scan, look at the patient, and help the provider in the rural hospital come to the right treatment decision more quickly.”
Beyond tele-emergency, telehealth companies are now offering services for outpatient clinics, prison medical clinics, school and university infirmaries, long-term care centers, pharmacies, and hospital intensive care units.
Room to Grow
As the RTRC has found in its studies, the spread of these telecom-enabled services has been hampered somewhat by their own novelty, and by factors that complicate American health care generally.
“Issues relating to reimbursement, cross-state licensure, and lack of familiarity all tend to limit expansion,” says MacKinney.
Even so, telehealth still seems to have considerable room to grow. Perhaps the best indicator of its broad potential is the success of the first telehealth service, tele-radiology—the transmission of X-ray, MRI, and other medical imaging data to off-site expert radiologists for interpretation. Tele-radiology was initially based on simple phone and fax-based telecom technology, but expanded rapidly after the introduction of high-bandwidth Internet in the early 2000s. These days it is so much a part of ordinary medical practice that it often isn’t even considered a telehealth service.
“It’s almost ubiquitous now,” MacKinney says.
This story originally appeared in the spring 2017 issue of InSight.
The number of suicides among farmers and farmworkers in the United States has remained stubbornly high since the end of the 1980s farm crisis, much higher than workers in many other industries, according to a new study from the University of Iowa.
The study examined suicides and homicides among farmers and agricultural workers across the country from 1992 to 2010 and found 230 farmers committed suicide during that time, an annual suicide rate that ranged from 0.36 per 100,000 farmers to 0.95 per 100,000. The rate is well above that of workers in all other occupations, which never exceeded 0.19 per 100,000 during the same time period.
The 1992 to 2010 rate is not as high as the 1980s, when more than 1,000 farmers took their own lives because they were losing their farms to foreclosure, but study co-author Corinne Peek-Asa, professor of occupational and environmental health in the UI College of Public Health, says the new numbers still are excessive.
“Occupational factors such as poor access to quality health care, isolation, and financial stress interact with life factors to continue to place farmers at a disproportionately high risk for suicide,” she says.
The survey found farmers in the West were more likely to commit suicide, at 43 percent of total farmer suicides, followed by the Midwest (37 percent), South (13 percent), and Northeast (6 percent).
As in the 1980s, financial issues continue to cause some suicides, especially during economic crises or periods of extreme weather, Peek-Asa says. But farmers face an array of other stresses that put them at high risk for suicide: physical isolation from a social network, leading to loneliness; physical pain from the arduous work of farming; and lack of available health care resources in rural areas, especially mental health care. She says other research also suggests that exposure to chemical insecticides causes depression in some people.
In addition, Peek-Asa says, farm culture dictates that farmers who may have physical or psychological needs should just suck it up and go about their work.
Finally, farmers have access to lethal means because many of them own weapons. The rifle they use to chase off coyotes can easily be turned on themselves.
Peek-Asa says farmers are different from workers in most other fields in that their work is a significant part of their identity, not just a job. When the farm faces difficulties, many see it as a sign of personal failure.
“They struggle with their ability to carve out the role they see for themselves as farmers. They can’t take care of their family; they feel like they have fewer and fewer options and can’t dig themselves out,” Peek-Asa says. “Eventually, suicide becomes an option.”
Peek-Asa says policy solutions would include include improving rural economies, increasing social networks in rural areas, and improving access to health care and mental health services in rural areas.
Beyond that, she says improving the quality of life in rural communities also is important, pointing to UI programs that contribute to that, such as the mobile museum or Hancher’s summer art outreach program that brings arts and cultural opportunities to towns and cities across Iowa.
The study, “Trends and Characteristics of Occupational Suicide in Farmers and Agriculture Workers,” was published in the Journal of Rural Health. It was co-authored by Kelley Donham, UI professor emeritus in the College of Public Health; Marizen Ramirez of the University of Minnesota and visiting associate professor in the UI College of Public Health; and Wendy Ringgenberg of Des Moines University.
(This story originally appeared in Iowa Now)
Additional Media Coverage
Iowa Public Radio River to River
Health Day, US News & World Report
Indiana Ag Connection
Nebraska Radio Network