Telemedicine in Mendocino County

Meeting the needs of our residents in a difficult environment

Mark Turner, I.T. Director

Ukiah Valley Medical Center

Frank R. Howard Memorial Hospital

Challenging Times
• We have not produced enough physicians to serve the population we
have in this country. This is only going to get worse because we are not
producing enough physicians to meet the needs of the population we
have today or the baby boomers of tomorrow." Peter Fine, President and
CEO of Banner Health in Phoenix

• Rural areas will logically be the hardest hit. Fewer med school
graduates start off in rural communities due to loan debt and lower
projected earnings.

• Mendocino county, with higher-than-average home prices and high

governmental case mix faces an even tougher challenge. This isn’t our
future, but our reality.

1
Bad Timing

• One out of three practicing physicians in the United States is over

the age of 55, and are expected to retire in the next 10 or 15 years.

• Meanwhile, U.S. medical schools have not provided for the loss of 33
percent of the nation's physician work force.

• A number of studies have estimated that by 2020 the United States

will be short anywhere from 24,000 to 200,000 physicians.

• Evidence suggests that younger physicians are not willing to put their
lives on hold and work 80-hour weeks that include weekends, nights
and emergency department on-call duty like their predecessors, which
means it may take two younger physicians to cover the work of one
retiring physician.

A National Shortage of Physicians

"We are in the trenches on this, seeing it every

day. Six or seven years ago we would call Mayo or
Johns Hopkins and they would say, 'We've got more
CVs than we can shake a stick at.' They call us now
and say, 'We are in desperate need of doctors.' That
is like saying the Yankees can't get anyone to play
with them. When that happens, I know we have a
shortage.” Kurt Mosley, VP of Business Development Merritt
Hawkins & Associates.

2
Overview of Mendocino County Medicine

• Three hospitals serving a population of approximately 89,000 with 300

physicians over an area of 3,878 square miles.

• Growing deficiencies in some medical specialties.

• Diminishing pool of on-call physicians.

• A care system challenged by geography and a relatively weak economy.

• Tough to attract new physicians due to low reimbursement and high

property costs.

• And it’s in California, the most regulated healthcare system in the

country

Mendocino is the best place to live…

..but not the best place to have a stroke.
• Every 53 seconds in America, someone has a stroke, interrupting blood
flow to the brain.

• Chances of recovery are significantly improved if treatment begins within

three hours of stroke onset .

• Only 30% of stroke victims arrive at the hospital in time to be considered

candidates for an effective type of clot-busting therapy called
thrombrolysis.

• Only about 20% receive the therapy, often because physicians are
unsure if the patient is an appropriate candidate for the treatment.

• To deem a patient appropriate requires the intervention physician with a

neurological background.

3
Number of full-time Neurologists in
Mendocino County:

Filling in the gaps

• If we can’t bring the physicians to us, we need to

develop ways of getting the patients to them.
• The residents of Mendocino County should have
access to life-saving medical procedures in the time of
need if at all possible.
• Now is the time to strategically position ourselves to
meet the challenges of further challenges in physician
availability.
• Now is the time to build a strong support model for the
residents of our county.

4
Areas of Deficiency in Our County

• Neurology
• Cardiology
• Pediatric Specialties
• Psychiatry
• Orthopedics

Medical specialties conducive to

Telemedicine:
• neurology • obstetrics

• cardiology • gynecology

• internal medicine • psychiatry

• pediatrics • speech-language pathology

• family practice • pharmacy

• rehabilitation

5
What would such a program look like?

• Units in every facility that can connect to regional

centers containing specialists.
• Solid relationships and expectations with the medical
centers we would connect to in the time of need.
• Proven technology that we can trust to work when
needed.
• The necessary bandwidth to facilitate
teleconferencing, medical device feeds, and
teleradiology.

Connectivity to Life-Saving Resources

Broadband
Broadband
UC Davis

Oakland Children’s

UCSF

Stanford

6
A potential case study-A successful
outcome
• 77 year-old woman notices numbness on her left side while cleaning her
apartment, After finishing cleaning, she calls her daughter, concerned.
• Daughter calls ambulance and leaves for the hospital.
• Ambulance arrives at residence, stabilizes the patient and transports to
hospital.
• Upon arrival, ER physician notices slight facial drooping on left side.
Orders stat CT scan. It has now been 90 minutes since the incident.
• CT Scan is performed, ER physician contacts UCSF to request review
by neurologist.
• Neurologist reviews the scan. Decides that stroke protocol should be
started. Orders ER Physician to begin TPA (clot buster). It has now
been 2 hours, 15 minutes since the first symptom. Patient will return
home in 4 days.

Keys to a successful outcome

• Patient didn’t wait to see if symptoms would pass.

• Accurate diagnosis and referral by ER physician.
• CT done in timely manner
• A referral to qualified specialist made possible by both
infrastructure and established practice: It was
possible, it was planned, therefore it was performed
perfectly.

7
We already have success stories:

• Howard Hospital able to save the life of a pediatric diabetic. ER

physician able to consult with Pediatric surgeon at UC Davis who
walked him through the placement of a line that ultimately saved
the child’s life.

• Stroke protocol has been enacted 3 times at UVMC through the

use of telemedicine robot—used to view the CT by using the
camera of the robot to view the film.

• Patients routinely being treated by intensivist at both HMH and

UVMC, keeping them close to home and family. Family
involvement can be the key to a positive outcome.

What already exists

Units that connect to Intensivist and to UCDavis Medical Center

8
Collateral Benefits of Telemedicine:

• Use telemedicine to reach the remote areas of

Mendocino County
• Electronically crossing the coastal range—
better communication between local hospitals.
• Disaster Communication
• Staff Education
• Patient Education

What would it take to effectively reach

out with telemedicine?

• Participation from area hospitals and clinics

• Aggressive pursuit in areas of funding
• Well-defined expectations of the outcome
• A well-ran, long-term project.
• A successful execution with accountable, measurable
results.

9
Obstacles and Challenges:

• Bandwidth: the greatest need….the smallest pipe.

ƒ Ironically, from the standpoint of telemedicine, rural communities

have the greatest need for larger bandwidth.
ƒ Unfortunately, such connectivity is either unavailable or prohibitively
expensive.

• Telemedicine is an emerging, loosely defined offering with sketchy

reimbursement.

• Currently, telemedicine exists in Mendocino County; but not to the level

where it is of the biggest benefit.

• There will come a time when such connections will be critical to the
continuum of care.

Existing/Emerging Broadband Technologies

• DS3
• Opt EMan
• GigaMAN
• SONET Ring
• Local Ethernet
• ISP-Centric Broadband
• Fiber Technologies
Each technology has advantages and disadvantages.
Some being data rate/reliability, some being price.

10
Conclusions:

• Connecting to specialties is both part of our present,

and our future.

• The time to begin building this infrastructure is now.

This will build our foundation for the future, and help
Mendocino County Residents today.

11