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How Nighttime Telehealth Services Can Improve Overnight Care

The use of telehealth services has the potential to fill in the gaps in inpatient care.

Source: Thinkstock

In hospitals across the country, the image of the solitary doctor making midnight rounds is changing, thanks to telemedicine.

That doctor now sits in front of a tablet, laptop or desktop computer, perhaps at home or even in another country. And he or she can be connected to several hospitals via a telemedicine network, helping night shift nurses with whatever needs to be done during those long, not-always-quiet hours between dinner and breakfast.

Welcome to the world of the telenocturnist.

At CHRISTUS Mother Frances Hospital in Sulphur Springs, Texas, some 90 miles northeast of Dallas, night shift nurses can instantly access a doctor via video through a partnership with Dallas-based Access Physicians.

Chris Gallagher, MD

Chris Gallagher, MD

Source: Xtelligent Media

“The immediacy of access from a nurse’s perspective is huge,” says Terri Bunch, RN, the 96-bed hospital’s Chief Nursing Officer. "For these patients, it's time — how quickly we can get things done and stable impacts their outcomes for life. Having access to these physicians — their knowledge — for us, it has raised the bar."

“We have someone that comes in overnight and in critical condition that requires a physician's immediate attention — with telemedicine we can get that immediately,” adds Susan McGrady, the hospital’s ICU director and a 38-year veteran in the industry. “Before, we would have to transfer. But now we're in contact with that doctor in Dallas; he's there on the monitor in the room, taking care of the patient immediately.”

The hospital’s Chief Medical Officer, Chris Gallagher, MD — who also co-founded Access Physicians — sees the telemedicine platform serving different needs in different environments. In rural settings, it gives hospitals instant access to physicians and puts off the need to transport a patient to a distant hospital with a larger night staff. In urban areas, it enables hospitals to reduce their off-hours staffing needs and choose from a larger talent pool.

“If a hospital needed a doctor to be at the hospital (overnight), a lot of times they’re at the whim of what’s available to them,” he says. “This (platform) gives hospitals instant access to care. This is true medicine. This is providing true care to patients.”

Changing the Night Shift Model

Nocturnists — the name was first coined by Seattle physician John Nelson — began to appear in hospitals in the late 1990s. At that time they were often interns, overworked residents or single or retired doctors who didn’t mind working off hours.

By 2008, following a series of studies by the American Medical Association and others which found that patients admitted after hours stood a statistically higher chance of dying, more and more health systems were looking to add an experienced doctor to their night and weekend staffs by hiring a hospitalist at a higher salary or with extra benefits.

By 2011, roughly 1,500 hospitals had at least one nocturnist on staff, according to The Washington Post; more recent surveys say roughly half of the nation’s health systems now have some sort of nocturnist program. A typical hospital carries three or more nocturnists, each working three 12-hour shifts per week. It’s an expensive position to fill, but the consequences of not having a doctor available at all hours were much worse.

Telemedicine is changing that concept.

“For too long, hospitals just had to accept that nights were really hard or really expensive or both,” says Talbot “Mac” McCormick, whose eight-year-old company, Atlanta-based Eagle Telemedicine, deploys 20 telenocturnists to 15 health systems across the country. “Only recently has that started to change.”

Talbot

Talbot "Mac" McCormick, MD

Source: Xtelligent Media

For many hospitals, a telenocturnist program can strike the right chord financially. Having a real, live doctor on site overnight can run $150 to $175 an hour or more. A telemedicine doctor, meanwhile, can demand $50 to $75 an hour, and that cost is spread out across several hospitals, who pay either a flat rate for access to the service or a per-consult fee.

According to McCormick, one healthcare provider reduced staffing costs by some $40,000 a year by using a telenocturnist program.

“I can have one doctor cover three different facilities (during an overnight shift) without any difficulty,” says Eduardo Vadia, MD, co-founder of Access Physicians, which runs 66 programs in nine states. “We’re talking serious dollars saved for these” health systems.

The position does have its nice qualities. New Jersey-based TalentCare recently ran this online ad for an open telehealth nocturnist position:

“You enjoy having the freedom of most weekdays free and every other week off entirely. You like to work from the comfort of your home office. While most work during the day, you will be enjoying the sunshine. No overhead, no billing and no insurance headaches!”

That said, McCormick points out there’s no CPT code for telenocturnist services yet.

“It’s a problem that has not been fully addressed by [the Centers for Medicare & Medicaid Services] and by payers,” he says. There are many benefits, “but unfortunately [the service] is not being consistently reimbursed.”

Rural healthcare providers “operate on serious, serious budgets,” adds Vadia. “There’s not much left for a program like this … unless you can prove the benefits. You have to sit down with them and do a needs assessment. You have to be able to create a clinical program that can scale through technology … and give them what they really need.”

To McCormick, a successful program isn’t one that is just dropped in front of a hospital, to be used when needed and stored in the closet when it’s not required. Hospital staff have to be comfortable working with the platform, he says, and interacting with clinicians at the other end of a video screen.

“An essential best practice is to assign telenocturnists in pods or small groups for a particular hospital or geography,” he says. “In this way, they get to know the hospitals to which they are assigned, and the hospital clinical teams get to know them on a first-name basis. The goal is for the remote physicians to develop tight working relationships with onsite staff, and for the staff to consider them colleagues.”

"Telemedicine fills in these gaps. We have already seen it in the hospitals where we work: Patients demand physician care for their treatment, and this is an excellent way to provide them with the care they deserve."

“Telemedicine physicians must be good communicators,” he adds. “Their warmth, sincerity and concern must project across a computer screen. If they’re sincerely interested in their patients, and confident in using this innovative form of technology, they do fine.”

Lest anyone think that telenocturnists just sit around at night waiting for the phone to ring, McCormick points out that they often have busy workloads.

“[T]elenocturnists are all experienced in providing night coverage in the hospital setting,” he says. “They understand the process of diagnosing and admitting patients from the emergency department. They work well with nighttime nurse practitioners, physician assistants and nursing staff. They’re collaborators, not dictators. They are flexible, moving seamlessly from handling ED admissions to handling cross-coverage calls on the floor with patients whose daytime doctors are home asleep. In large metropolitan hospitals, these cross-coverage calls are often the main function that telenocturnists perform, while night physicians onsite deal with admissions in the ED.”

Like any other telehealth program, telenocturnists must be licensed in the state or states where their patients are located, and they must be credentialed in each hospital where they treat patients. A doctor covering two or three hospitals in different states must therefore be licensed and credentialed in each.

“At the end of the day, it isn’t about the technology as much as it’s about putting a quality physician in front of a patient,” says Vadia. “They really don’t care who saves their lives.

Eduardo Vadia, MD, in action during a telenocturnist consult
Eduardo Vadia, MD, in action during a telenocturnist consult

Source: Xtelligent Media

A Daytime Job with Nighttime Duties

Sometimes a physician can forge a pretty good career in telenocturnist services. Such is the case with Dr. Jayne Lee, an Eagle Telemedicine physician who has provided coverage for several American hospitals from her home in Paris for more than five years. Eagle also has telenocturnists living in Israel and Romania.

Jayne Lee, MD

Jayne Lee, MD

Source: Xtelligent Media

I moved to Paris first before working telemedicine full time,” says Lee. “I wanted to try something new after finishing med school [and my] residency, and it has been my dream to live in Paris. I decided to move there on a whim.  At that time, I was working locum tenens and travelling back and forth every month. I met our current CEO randomly at one of our hospitals and discussed my move to Paris with him. He supported me and asked if I wanted to get involved in telemedicine. The rest is history.”

Lee, whose European location enables her to provide night-time coverage in the US during her days, sees her job as the same as an on-site hospitalist. She’s responsible for all admissions, consults, rapid responses and code blues.

“I started in 2010 with InTouch Robots, and they have advanced their technology where the newer robots don’t require excess equipment on the operator side,” Lee recalls. “Even the stethoscope quality has improved. We are also using smartphone applications in which the nurses are able to easily communicate with us without having to call our cell phone each time. It’s kind of like using the WhatsApp app. This, of course, is all HIPAA compliant. The technology just keeps getting better, and my job is much easier using these tools. “

“I still enjoy listening to patients’ histories and talking to them about what brought them in,” she says. “I am still amazed that I continue to see interesting cases even though I am taking care of patients located thousands and thousands of miles away. Also, because we cover several hospitals across the country, the most interesting part for me is to discover different patient populations and how they differ epidemiologically.”

Lee says France hasn’t caught on to the values of telemedicine yet, but she suspects they will. And she sees the trend continuing to grow across the Atlantic.

“There are still a lot of skeptics that think telemedicine cannot work and is not feasible,” she says. “But after working in this industry for more than five years and having thousands of patient encounters, including running codes and rapid responses, I can say that it’s a system that works very well and allows patients to receive continued physician-based care.”

“There are so many hospitals throughout the country that are struggling with staffing issues,” Lee adds. “They want a physician on board, but help is difficult to find and maintain. Telemedicine fills in these gaps. We have already seen it in the hospitals where we work: Patients demand physician care for their treatment, and this is an excellent way to provide them with the care they deserve."

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