Telehealth touted as a rural health innovation

Telehealth touted as a rural health innovation, so why do rural ... unknown

ROCHESTER — On an average day at the Olmsted Medical Center's Pine Island Branch Clinic, family medicine physician Dr. Matt Florek sees between 15 and 20 patients who are visiting him for a concern or check-up. But he doesn’t see everyone in person.

“On a typical day, I’ll have one or two telehealth visits, either a phone or a video visit,” Florek said.

Telehealth, or telemedicine, had its moment during the height of the COVID-19 pandemic when many health care providers who could see patients online did so.

“Shortly after the COVID pandemic started in 2020, a lot of us providers at OMC were seeing between 25% and 50% of our patients through telehealth because patients preferred to be home and stay away from large groups,” Florek said.

This quick switch from in-person to virtual visits was especially important for therapists and other mental and behavioral health providers.

“They had no choice during COVID,” said Teri Fritsma, lead health care workforce analyst at the Minnesota Department of Health. “They either had to shut down or they had to figure out how to make it work for them. I think necessity was the mother of invention there.”

Between 2019 and 2022, MDH found that telehealth use among most categories of health care providers grew. Among Minnesota’s physicians, for example, 64% report using telehealth at least some of the time in 2022, compared to 32% in 2019. Mental health providers saw the biggest jump in telehealth use, with 80% of those providers using telehealth some of the time versus 21% in 2019.

But that uptick isn’t evenly distributed between rural and urban patients. Per MDH’s 2021 Minnesota Health Access Survey, rural Minnesotans were less likely to use video or telephone visits than urban residents.

“It’s really hard to characterize the penetration of telehealth, but by almost every measure … people in urban areas used more telehealth during the pandemic and continue to this day to use more telehealth than folks who live in rural areas,” said Jonathan Neufeld, director of the Great Plains Telehealth Resource and Assistance Center, based at the University of Minnesota.

Telehealth is often touted as a tool for expanding access to health care in rural areas. So, why is telehealth less popular among rural Minnesotans?

The answer, according to Neufeld, is nuanced. A mix of post-pandemic preferences, internet access and provider availability all come into play when a patient decides whether or not to see their doctor from their living room — or if that option is available at all.

“It has to be offered to you before you can accept it,” said Neufeld. “So what happens, even though, broadly, a lot of people think telehealth is the patient choosing to use it, you can’t choose to use it until the doctor gives you the choice to use it.”

While telehealth came into the spotlight during the pandemic, the practice of meeting with patients on a video call or over the phone isn’t entirely new.

“Site-to-site telehealth, which is from one institution to a more rural institution, where folks come in and they get a video appointment from a mental health provider at a rural site,” said Dr. Tyler Oesterle, a Rochester-based Mayo Clinic psychiatrist who specializes in addiction treatment, “that’s been around for a very long time, pre-pandemic, and I had started doing some of those services out in Albert Lea and Austin.”

Before the pandemic, the type of insurance patients had often determined how or if they used telehealth services, said Pamela Mink, director of Health Services Research at MDH.

Rural patients and those on Medicaid or Medicare were more likely to use telehealth appointments for mental and behavioral health, Mink said. For urban patients and those with commercial health insurance coverage, virtual visits tended toward acute conditions “like a sore throat or a sinus infection or a urinary tract infection.”

But the pandemic hit, and telehealth appointments, especially site-to-home visits, became more common, at least temporarily. With that change in the status quo, pre-existing gaps in health care coverage were further exposed.

“Telehealth is built on two rails. One is the internet infrastructure, and the other is the health care system,” Neufeld said. “And both of those rails are fundamentally inequitably distributed in our society.”

MDH’s Minnesota Health Access Survey found that almost 20% of rural Minnesotans don’t have access to internet reliable enough for a video visit. This lack of internet access is an acute issue for rural medical providers. At Gundersen St. Elizabeth’s Hospital in Wabasha, clinical social worker Mindy Wise sees it firsthand.

“It’d be great if everybody had internet access at fair and reasonable costs, especially for the senior group,” Wise said. “The budget can be a difficult thing for some people.”

Providers ran into similar problems at Zumbro Valley Health Center. Heather Geerts, ZVHC director of clinical services, said even if patients have a cell phone, limited data can make a telehealth visit less desirable.

“Our clients who have limited data, it’s extremely hard for them to use 50 minutes of that, or so many gigabytes, to do a session,” Geerts said.

ZVHC provides mental health and substance use services at its physical locations in Rochester and Harmony. Geerts said that as COVID receded, ZVHC’s rural patients were more eager to return to in-person care.

“Those clients wanted to get back in the office faster than even, sometimes, our urban area because they didn’t have internet,” Geerts said. “It was a lot harder for them to do telehealth. It was a lot easier to come in in-person.”

Other factors that can make telehealth visits difficult, Geerts said, include kids’ attention spans and the inability to use the technology required for the visit.

“Individuals that had symptoms of paranoia, delusions that were uncontrolled, it was sometimes hard for them to utilize technology in the mental health field,” Geerts said. “There were some mental health diagnoses and symptoms that made telehealth hard to use.”

But one of the biggest barriers is access to health care in general. A telehealth visit with a health care provider can’t happen if a patient can’t access that provider in the first place.

“Telehealth is not going to solve the problem of moving health care to rural areas,” Neufeld said. “Those are going to be policy issues — the rails have run out there, and telehealth can’t help with those issues.”

An important piece of the telehealth puzzle is recognizing that telehealth can’t — and shouldn’t — be used for every medical need.

“If you can’t see a rash, for example, that would require an in-person visit,” Florek said. “Most dermatology concerns, orthopedic problems, joint pain, severe injuries or severe illnesses, they definitely require in-person visits, and a lot of those will need X-rays or lab tests, things like that.”

Dr. Adam Fletcher has also noticed where telehealth is easier or harder to apply. As a physician at Winona Health, he splits his time between family medicine and sports and orthopedics.

“As you can likely imagine, sports and ortho isn’t exactly conducive to telehealth,” Fletcher said. “I need to examine joints, and it’s rather difficult to do that virtually. We can do quite a bit more in family medicine.”

Because hands-on care will always be necessary at some level in medicine, there’s a natural ceiling on how often telehealth can be used. Figuring out what the “right” level of telehealth access is appropriate for patients, rural or urban, is difficult.

“We don’t really know what the right level is,” said Zora Radosevich, director of the Office of Rural Health and Primary Care at MDH. “Is there a goal that we should be moving toward, because we want to make sure that use of telehealth is appropriate from the provider side, the patient side, the service side … and those are still kind of playing out.”

And just because a tool is available doesn’t necessarily mean it will be used. For Florek, the patients he sees remotely are, by and large, using telehealth because it’s their preference.

“It’s typically patient-directed at this stage,” added Fletcher. “More often, it’s folks asking — maybe we tell them a telehealth or telemedicine visit would be something to consider for a follow-up, and I’m always happy to oblige.”

This mix of access, feasibility and preference muddles where the “right” level of care is given via telehealth in any particular community. Perhaps a “correct” level of telehealth use doesn’t exist.

For Oesterle, telehealth is ultimately a tool that can be used in conjunction with in-person care in order to reach as many patients as effectively as possible.

“What we’re learning through this process is that we’ve expanded a tool, but the old tools are still helpful,” Oesterle said. “It’s just integrating this new tool into the practice that we already have, and that integration and flexibility allows us to connect with the largest groups of folks. … If you can offer both to folks, that’s what we found from our research that’s most helpful.”

The doctor will Zoom you now

The general public’s medical vocabulary grew a bit as COVID-19 became part of people's lives in early 2020. People used the words "quarantine" and "pandemic" and "asymptomatic" on a daily basis. Social distancing and personal protective equipment — PPE — became common terms.

We also quickly learned about telehealth and telemedicine, otherwise known as visits with a health care professional via audio or video conferencing.

While the use of telehealth expanded rapidly amid the pandemic, it wasn’t new circa 2020, and Minnesota’s medical experts say it’s a tool that will continue to transform medicine.

“We’re trying to utilize our workforce to attend to more human needs,” said Dr. Gokhan Anil, a Mankato-based Mayo Clinic OB-GYN, medical director for Mayo Clinic Health System Digital Practice Enablement and regional chair of clinical practice for southwest Minnesota. “We don’t want to use technology for technology’s sake. We want to make life easy for our people who work in health care, also for our patients because our lives are complex.”

Prior to the pandemic, site-to-site video appointments were in use by Mayo Clinic and many other health care systems. For example, through a site-to-site appointment, a patient could visit their local primary care clinic and connect with a specialist, located elsewhere, via a video call. But just as video conferencing use exploded as COVID set in, site-to-home telehealth visits became more common.

“Since the pandemic, we’ve been doing site-to-home telehealth, and that’s new — new for us, anyway,” said Oesterle, the Mayo Clinic psychiatrist and addiction specialist. “That just blew up in the midst of the pandemic, and we’ve continued a lot of that.”

At Olmsted Medical Center, across all specialties, providers conducted nearly 10,000 telehealth visits in 2022.

“About 5,000 of those were telephone visits, and just over 4,000 were video visits,” said OMC's Florek, a family medicine physician at Olmsted Medical Center’s Pine Island Branch Clinic.

Among medical providers in the Rochester area, 46.1% said they have provided medical care through telehealth services at least some of the time, according to an MDH survey. That represents the highest level of telehealth usage in the state with about a quarter of Southeast Minnesota’s providers using telehealth up to 10% of the time, while another 12.1% of area providers say up to 25% of their patient care happens via telehealth.

“There was definitely a before and after with telehealth,” said MDH workforce analyst Fritsma, lead health care workforce analyst at MDH. “Those levels (of telehealth use) are higher than ever. They’re not going back down, I don’t think.”

Telehealth appointments have remained especially popular for therapy sessions and other mental health services. ZVHC moved some of its services to telehealth during the pandemic, Geerts said. In 2023, Geerts said 85% to 90% of ZVHC’s services are delivered in person, but some therapists are still doing up to 20% of their therapy sessions with clients via telehealth.

As for Oesterle, he sees about half of his patients via telehealth.

“There are a fair amount of appointments, especially in the mental health space, that don’t require necessarily a physical exam,” Oesterle said. “A lot of that can be really easily done virtually. Psychiatry is a great field to utilize telehealth.”

For mental health, in particular, telehealth can come with some pros and cons. An advantage, Oesterle said, is being able to meet patients where they’re at.

“Having them get up and get going and out the door can be a huge challenge,” Oesterle said. “That can be a huge burden, and then they miss out on medical appointments, they don’t get the adjustments in the meds that they need and that’s a huge problem. So I think being able to go where patients are and meet them where they’re at, that’s a huge advantage to our specialty.”

“We’ve heard from our clients that are employed, they don’t have to leave work,” added Geerts. “So it’s easier for them to schedule an appointment and use a break or something like that for the use of telehealth so that it doesn’t interfere with their employment.”

But Gundersen St. Elizabeth's Wise said she doesn’t think telehealth should be the frontline form of mental health care delivery.

“I feel strongly that part of doing good therapy is that therapeutic relationship given in person, whether it be body reaction or whatever’s going on in that room,” Wise said. “We’ve generally found the best practice for us has been to see patients one-on-one in clinic, if at all possible.”

At the end of the day, telehealth use often boils down to the patient’s preference.

“It tends to be … mostly patients self-selecting who want to be seen in that way, either for convenience or for their own personal reason,” Florek said.

Southeast Minnesota’s health systems are trying out different approaches and additions to remote health care.

In January, Olmsted Medical Center debuted On-Demand Virtual Care , an after-hours telehealth model. From 5-9 p.m. Monday through Friday, patients can connect with an OMC provider via video chat to address concerns such as medication refills, mental health needs, respiratory illnesses and urinary tract infections.

“Patients access the online-appointment through their OMC MyChart patient portal,” said nurse practitioner Amy Nelson. “Appointments are 15 minutes in length, and we can see up to 16 patients each evening. Currently we are typically seeing one to four patients each day as the service is new.”

Nelson said that an on-demand virtual visit through OMC is much like an office visit and is billed to one’s health insurance like an office visit. A notable difference, though, is that the patient might have to do some components of a physical exam themselves.

“The provider may ask for the patient’s assistance,” Nelson said. “For example, asking whether the patient has a home temperature, oxygen saturation or blood pressure monitor. The patient may also be guided in a self-exam such as illuminating the back of their throat, doing range-of-motion with their back, performing an abdominal exam or feeling for swollen lymph nodes in their neck. … It becomes even more of a partnership between the provider and the patient.”

This idea of having a patient self-monitor certain vital signs is the basis for remote patient monitoring, a set of tools that can be used to reduce in-person visits while still making sure a medical provider can keep tabs on their patient. Those tools can be as simple as thermometers, scales and blood pressure cuffs.

“OMC has plans to, within the next several months, formalize a home-patient monitoring system where patients can weigh themselves and we can adjust medications,” Florek said. “We can monitor their oxygen saturation at home, we can get real-time monitoring of their blood pressure, which can come right into their electronic medical record.”

Remote patient monitoring is also used by Mayo Clinic in certain cases. For example, some pregnant Mayo Clinic patients can do roughly half of their prenatal appointments via telehealth with the help of fetal heart rate Dopplers and other self-monitoring devices through the OB Nest program.

These tools could also be used to predict and prevent certain medical problems such as asthma attacks, Anil said.

“One of the examples that our artificial intelligence team, led by some of our health system and Mayo Clinic researchers … have developed an algorithm,” Anil said. “They call this a GPS system. Can we predict the next asthma attack and also monitor them remotely with our Cures at Home research program and create a dashboard for the clinicians who are caring for these kids?”

For Anil, remote patient monitoring is one aspect of digital health, a broad set of tools that includes telehealth, too. And digital health tools aren’t exclusively used in patient settings. Electronic consultations are one of the digital tools used at Mayo Clinic.

“Any primary care provider within the Mayo Clinic Health System can ask a Mayo Clinic specialist a specific question that does not require a patient to take a trip or take off from work,” Anil said. “And they get an answer within 48 hours. We have 75 specialties that offer this service. I think that’s amazing and remarkable because I think that really makes a huge difference.”

As telehealth and digital health innovations continue to advance, the possibilities for delivering care could expand or change in ways that are hard, or even impossible, to conceive of now.

“I’m not talking about, you know, that we’re going to become the Jetsons, but there are lots of models that have yet to be developed,” Neufeld said.

Those future innovations could look like small hospitals distributed through every community, or providing direct medical care in a patient’s home.

“Instead of sending the ambulance to pick you up and take you to the hospital, the ambulance comes and unloads the bed in your home and sets you up there,” Neufeld said. “There’s some conditions that it makes sense for, and there are other conditions that it doesn’t.”

No matter what innovations are yet to come, Anil said the goal is to collaboratively produce better outcomes for patients and providers. That’s something he strives for in his role as leading the Digital Practice Enablement team.

“How do we make those wonderful forces come together,” he said, “and (as) a union of forces, provide the best outcome possible?”