Western Washington Rural Health Care Collaborative

Western Washington Rural Health Care Collaborative recently received a health information technology network development grant from HHS. WWRHCC is one of 40 rural recipients across the US. HHS has awarded a total of $11.9 million and WWRHCC will receive almost $300,000 in the first year to assist five members: Forks Community, Whidbey General, Morton General, Willapa Harbor and Ocean Beach. The hospitals will use the funds to adopt electronic health records and other health IT tools and to qualify for Medicare and Medicaid incentive payments for the meaningful use of EHRs. The grant funds will also be used to purchase equipment, software and provide training for staff members.

Under the 2009 federal economic stimulus package, health care providers who demonstrate meaningful use of certified EHRs can qualify for Medicare and Medicaid incentive payments.

HHS’ Health Resources and Services Administration will distribute the funds, which come from existing appropriations authorized for the Rural Health Care Services Outreach and Rural Health Network Development Program.

HRSA Administrator Mary Wakefield said, “Collaboration is key to this effort,” adding, “Working together, these rural health networks will be in a better position to achieve economies of scale and enhance their services and organizational capacity” (Monegain, Healthcare IT News, 9/6).

Congratulations to Tom Tomasino, recently appointed as CEO of Whidbey General Hospital, one of our nine member facilities. Tom had served as interim CEO while their Board of Directors sought to fill the vacant position, and they have determined they need look no further. Following is a piece appearing in the hospital’s newsletter, “Pulse,” which offers more in-depth information on Tom’s background as well as his excellent fit for the hospital’s needs. Thanks to Trish Rose, who authored the piece.

Tom Tomasino of Coupeville, Washington, has been named Chief Executive
Officer (CEO) of Whidbey General Hospital (WGH) after a national search that
included more than 30 candidate resumes. Tom will also serve as
administrator of Whidbey Island Public Hospital District, which operates
WGH, its clinics and other offsite services. Tom first came to our community
in 1975 where he met his wife, Katie.   He worked in Electronic
Countermeasures at Naval Air  Station Whidbey Island.  He was based in Oak
Harbor, both as a military member and civilian contractor for the United
States Navy until 1996.  Tom's love for this community and desire to do
meaningful work here led to his first appointment at Whidbey  General
Hospital in 2000.  He was recruited by McKesson Information Systems (IS),
the hospital IS contractor, where he was instrumental in establishing an IS
strategic plan by working with administration and assessing hospital data
needs.

In 2002, administration recognized Tom's skills and leadership ability.  He
was recruited away from McKesson to be the hospital's Chief Information
Officer. This assistant administrator position had oversight
responsibilities for both clinical and support departments such as
Diagnostic Imaging, Laboratory, Rehabilitation Services, Pharmacy, Plant
Operations, Environmental Services, Purchasing, Printing and Duplicating and
Management Information Systems.

In 2007, he was again promoted, this time to Chief Operating Officer (COO).
As the CEO's right hand person, Tom was responsible for the day-to-day
operations of the hospital.  He also assumed additional departmental
oversight responsibilities adding; Human Resources, Medical Ambulatory Care,
Central Services, and Emergency Medical Services.  Early in 2008, Tom's
oversight role was expanded to include the final remaining departments of
the hospital, Nursing and Financial Operations.  In September of that same
year, upon the resignation of Hospital Administrator Scott Rhine, Tom
stepped up to assume the role of interim CEO, while maintaining his
responsibilities as the COO.

Upon completion of a national CEO search by our Hospital Board of
Commissioners, it was unanimously decided that Tom had the courage,
leadership, and support, both internally and externally, to successfully
fill the position and take our Public Hospital District forward.  As CEO,
Tom has the overall responsibility for patient care, employee safety and
hospital operations, to include physician relations and physician
recruitment.  He has already made great strides in this area by recruiting a
new General Surgeon to the Whidbey General Hospital medical staff.

The current climate of financial recession and healthcare reform will be
difficult waters to navigate. WGH looks forward to his decisive and
forthright leadership style as he continues to tackle the tough issues
facing all hospitals today; safety, quality, physician recruitment, and
strengthening the bottom line so that Whidbey General Hospital can continue
to provide "Healthcare Excellence, Close to Home".

Holley Carlson had good news from her physician following a checkup in February 2009 : a clean bill of health.

It’s nothing earth-shattering for most women her age. But Carlson is in a league of her own. Six months earlier, the otherwise healthy 44-year-old dodged a cerebrovascular bullet when Jefferson Healthcare Emergency Room physicians teamed up telephonically with neurologists from the Swedish Neuroscience Institute, a part of Swedish Medical Center in Seattle to diagnose a severe blockage in her carotid artery.

It’s true that the Port Townsend woman was seen at both facilities following her August 2008 incident. But the critical evaluations came early on, within minutes of her arrival at Jefferson Healthcare. Thanks to a telemedicine program between Jefferson and Swedish, Carlson’s evaluation, diagnosis and treatment unfolded in a timely manner which may well have saved her life.

“I know I was really lucky. I know that,” the Port Townsend Realtor said in an April phone interview.

Her luck started long before she developed tell-tale symptoms, which in her case resembled the migraine headaches she’s suffered for years. Patients arriving at Jefferson Healthcare receive evidence-based care from the start, due to process improvement work in January 2008 __and a formal contractual agreement last December for a Tele-Stroke program which features state-of-the-art technology allowing for video and data transmissions that place Swedish specialists working together with Jefferson Healthcare Emergency Department physicians in early, critical stages.

Jefferson’s Chief Nursing Officer Terri Camp was an early advocate. With backing from the public hospital district’s Board of Directors, and CEO Vic Dirksen, Camp and others at the facility liked what they saw in early interactions with Swedish. Forming a permanent partnership made sense, she said.

“We’re aligned with the Swedish stroke team. They know us,” Camp said. “That’s part of our strategy: Where it’s appropriate to streamline the care for patients who start here, we can connect them with tertiary care as needed.”

Geography plays a role

Telemedicine itself is hardly in its infancy. Health care providers have networked through telecommunications avenues for decades. But with developing technologies, the possibilities become mind-boggling.

Georgia’s Center for Telehealth has identified a “rural penalty” in stroke care for their state – a pattern which logically follows throughout the nation. Their commissioned study showed that nearly 25 percent of patients receiving tPA were treated within 90 minutes of onset of symptoms, and half were treated within two hours. An analogous urban system of stroke intervention showed a rate only slightly better.

Such urban-rural partnerships are especially useful for rural patients who may be hours away from an urban hospital. In Jefferson and Clallam counties the matter becomes critical this month, when the Hood Canal Bridge – a thoroughfare connecting the Olympic Peninsula with access to Seattle – closes for a six-week retrofit.

Yet deeper into Clallam County, Camille Scott faces ongoing obstacles with her patient base at Forks Community Hospital, where she serves as Chief Executive Officer. Nestled in a sparsely-populated, forested haven, Forks depends on a single U.S. highway for traveling to and from metropolitan Western Washington. Consistently low clearance in the treed region makes airlift services impossible.

Even a transport to nearby Olympic Medical Center in Port Angeles may be complicated by weather and other conditions. Scott was resolute about providing first-rate cardiac care for the financially struggling, elderly and indigent population. “Like most rural communities with a high level of chronic illness, we could not get people to see specialists, so we were having to look toward Seattle,” Scott said. “But even if we could find someone, how can we get them there? We’re very far from anywhere.”

Her answer? Expand on their existing network connecting with Jefferson Healthcare and other providers by formally engaging with Kitsap Cardiology on an impressive Tele-Cardiology program.

Like Dirksen and Camp at Jefferson, Scott sought and secured grant funding for a suitable program. Unlike Camp, her telemedicine cases aren’t billed as ER visits; Forks receives a nominal $15 reimbursement per patient session.But without this service, those without any insurance would have to travel to either Seattle or Bremerton to receive care. As a public hospital district that is mission-driven, this is the right thing to do, Scott said. Also unlike Jefferson Healthcare, Scott’s facility qualified for federal funding through the USDA, allowing her to purchase high-end equipment using $300,000 in matched funds – an investment she doesn’t regret.

“To get specialty services to roll in a remote facility like ours, you’re really going to have to look for out-of-the-box, creative ideas,” Scott said.

Nuts and bolts

Forks’ program indeed is unique. While urban facilities such as Swedish have well-developed telemedicine programs, very few private practitioners have jumped into the fray. For Forks and Kitsap Cardiology it was an ideal marriage, as cardiologists from Kitsap had long been making the trek westward. Adding Forks as site was not much of a stretch. A streamlined process, aided by technology, made the partnership more enticing.

But don’t look for private-practice clinicians to jump on board en masse. Their reimbursement structure usually makes telemedicine services break-even ventures – if not worse.

“Most cardiology groups look at us and say, ‘Why are you doing this? You’re losing money,’” said Mary Berglind, Clinic Administrator for Kitsap Cardiology. “But we have an exceptional group of physicians who see the overall value in providing these services. Critical-access hospitals are truly unique – people living there are down-to-earth, loyal, good people.”

The Forks-Kitsap program “virtual clinic” features state-of-the-art technology, including electric stethoscopes, EKG streaming, and even hand-held cameras transmitting images of vessels from the side of a patient’s neck. The patient is hooked up to a cart which functions as a computer with a small server. A number of modalities are available, such as EKG and a blood-gas monitor. Attached to exam room walls, hi-resolution screens offer patients and attending physicians face-to-face contact with cardiologists on the remote end, and vice-versa. Better yet, data from prior exams may also be transmitted on the spot, aiding the diagnosis and evaluation process.

Berglind and Scott say patients feel completely comfortable with the process because they can make virtual eye contact with a member of their treatment team.

Jefferson Healthcare’s Tele-Stroke equipment inventory is evolving. The Swedish program offers the opportunity for Jefferson to have access to a specialist virtually. Swedish Medical Center’s Neuroscience stroke team provides expert analysis from their location at work or from their laptops at home. A telephone consultation determines whether there is a need to activate the tele-video connection.

“It’s a really pragmatic decision-- we can give the clot-busting drug here and then transport the patient as needed,” Camp said.

Jefferson also works with Kitsap Cardiology for Tele-Cardiology, employing a secure-Internet transmission system routed from a telemedicine cart. Eventually they will convert to broadband. The hospital has current plans to purchase a second cart -- estimated to cost about $6,000 -- to prepare for the extra caseload anticipated during the Hood Canal Bridge closure.

Berglind said Kitsap Cardiology’s incentive is to provide critical-access hospitals with both convenience and an opportunity for revenues through ancillary services.

“We have a core value. We’re here to do this for the community.

“My goal with all of these smaller hospitals is this: We can help them,” Camp said. “I don’t see a downside to any of it. Telemedicine, echoes …. If they can get trained, they can put in pacemakers. That’s a lot of value for the community.”

Requirements and funding

There are some hurdles to clear before taking on a wide variety of telemedicine programs that can increase the bottom line. Medicare and Medicaid limit reimbursement to facilities working with certified labs. A board-certified cardiologist must examine the program’s quality indicators on a monthly basis. As a cost-defraying measure, Kitsap Cardiology permits its partner facilities to obtain accreditation under their licensure.

Providers must also be trained and certified to use equipment. In many cases, grant funding is available for that purpose.

Ironically, government health care providers have embraced telemedicine earlier and more frequently than those in private-sector services. One reason is fiscal: The United States Armed Forces aren’t compelled to seek grant funding for projects. But dire need also plays a part. Soldiers and other military personnel wounded in conflicts abroad benefit from specialized assessments delivered remotely. In Alaska, where topography makes physician travel extremely difficult, tribal clinics rely on telemedicine for their safety net.

Paying for these programs proves to be an issue for smaller hospitals facing dire revenue cuts in the ever-troubled economy. But a silver lining may be found in the Obama administration’s economic stimulus plan.

The president has addressed his campaign goals for health care reform through a $19 billion slush fund for Health Information Technology, including almost $5 billion for a Broadband Technology Opportunities Program, and an additional $4 billion targeted for distance-learning, telemedicine, equipment purchases, research and telehealth technologies. The funding appears in Obama’s 2010 federal budget.

While eligibility is variable, the movement toward bringing health care into the 21st century is evident. Telemedicine, and its rural facility beneficiaries, will be on the winning end.

That’s good news for Terri Camp and others working diligently to maximize services deliverable to their patient populations. Camp feels telemedicine is a front-runner in those efforts, but is clear about the overall reward it brings.

“We think it provides better care,” Camp said. We are aiming for the most appropriate care for all patients, not just telemedicine patients.”

Residents of Western Washington will recall the first week of January as an unpleasantly wet and cold start to 2009.

Heidi Keyes will remember it as a critical test of her employer’s emergency-readiness preparations.

Swollen rivers spilled flood waters over their banks, washing out bridges and forcing thousands from their homes after vital access roads were cut off – including the road that would bring Keyes to her job as assistant administrator at Morton General Hospital in Lewis County.

“I was stuck that first day – January 7 – but I had my cell phone and computer and did whatever I could from home,” Keyes said. “You have to think outside of the box.”
Administrators and staff at hospitals, which are well known as Ground Zero in disaster events, focus year-round on developing strategies for a variety of natural and man-made emergencies. Flooding isn’t unheard of in eastern Lewis County, but this year’s rapid onset caught many by surprise.

Morton General, a 25-bed Critical Access Hospital (CAH), escaped the direct path of flood waters. But with a service base of 10,000, and modest tax funding flowing through Lewis County’s Public Hospital District, Keyes and her co-administrators didn’t have the luxury of enacting elaborate planning. They knew a challenge lay ahead.

First, the hospital would operate without some staffers who were unable to show up for work. Those who were stranded at the facility were put up in a nearby hotel between shifts.

Food service was a priority, and kitchen staff worked grueling shifts to make that happen.

“We fed everyone – fed the staff, and prepared extra meals,” Keyes said. “We wanted to make sure they were taken care of.”
Food service also proved critical for Ocean Beach Hospital in Ilwaco when flood waters ravaged much of Pacific County in November 2007. Dietary supervisor Debbie Brisbin led efforts to set up a “soup line” for residents who were evacuated from their homes or had no power with which to cook.

“People were really grateful to have a cup of hot coffee. It’s just one of those things,” Brisbin said. “In an emergency, people look to a hospital for comfort and food. It’s the last thing you think of when everything is going well, but the first thing in a crisis. Hopefully the hospital is able to provide it.”

Brisbin said the soup line provided not just nourishment, but a community gathering place for distraught and impatient residents left stranded for days on end.
Though Morton’s event was shorter-lived, it presented dire challenges. City water supplies were cut off, forcing the hospital to tap into reserves stored in an outdoor shed that had several feet of piled snow blocking its entrance.

Meanwhile, county officials worked with the Washington National Guard to assess road conditions and open thoroughfares for essential traffic and, especially, emergency transport.

“There is the day-to-day stuff – babies are born, diabetics go into shock, and there are traffic accidents. You have to take care of that,” said Jill Kangas, Emergency Management Planner for Lewis County.

Kangas said severe weather events that block access to the larger Providence Hospital in Centralia pose a significant problem.

“We have quite a crisis when Interstate 5 goes under water,” Kangas said. “For us in Lewis County, it can be a two-hour drive to the next-closest facility anyway. Having the rural hospitals open and able to treat patients is absolutely critical.”

Patients in emergency events include not only evacuees and victims of traffic accidents, but first responders in public safety who may suffer cut feet and other injuries received while trying to access citizens in trouble.

Keyes said organized efforts from an excellent staff allowed Morton General to function at the top of its game during the crisis. No one in Imaging made it in, so an Emergency Room physician coordinated the transport of an X-ray technician from Mossy Rock to Morton on a National Guard helicopter. The Guard also opened roads for transport of critical patients by ambulance to airlift pads. And the hospital’s chief financial officer, Tim Cournyer, picked up workers and brought them to the facility.

But not every critical situation can be anticipated. The hospital picked up the hotel tab for out-of-state relatives of a dying patient, and an organ-harvest on a recently deceased patient which would normally be performed onsite was rerouted to the Medical Examiner’s office.

After five days of active disaster mode, conditions improved and the facility began to run as usual. Keyes said de-briefing by administrators and lead staff led to a unanimous conclusion: The staff at Morton General responded effectively, and with professionalism.

That sentiment is shared by many in the surrounding community, including Ellie Worsham of the Morton Chamber of Commerce.

“Morton General is so important to our region, as most health care is a long way away without it,” Worsham said. “It’s an up-to-date facility that we are most proud of.”

Article by Jan Rodak