Dr. Robert Galli in the TelEmergency suite at UMC

TelEmergency Program Linking UMC ER Docs, Rural Hospitals Reaches Milestone

Imagine a rural hospital in Mississippi that connects emergency room patients to board-certified emergency medicine specialists at University Medical Center (UMC). (See related stories below.)

After taking the patient’s initial history and conducting a physical exam, a nurse practitioner “dials up” the UMC Emergency Department. A monitor and camera located at the foot of the patient’s bed connects both parties via similar equipment at UMC. A physician, who can manipulate the camera in the remote hospital, appears onscreen. Suddenly, the environment is transformed from a small rural facility to a metropolitan healthcare system featuring resources well beyond local means.

Fortunately, this scenario isn’t planned for the future. It’s happening right now at 13 rural hospitals located across Mississippi in a UMC TelEmergency Program that Robert Galli, MD initiated in 2003. It remains the only program of its kind based in an academic institution in the United States. So far, more than 150,000 patients have benefitted from the program. Kristi Henderson, a nurse practitioner who has earned a PhD in nursing since the advent of TelEmergency, started the program with Galli; Greg Hall handles telecommunications technology.

“It’s working beautifully,” said Galli, professor of emergency medicine at UMC. “With all the technologically interconnected communication devices we now have, it seems like a natural next step, yet no other public academic institution is doing this.”

Early feedback showed that adults were, for the most part, pleasantly surprised by the technology. However, it seemed commonplace to most children, Galli pointed out.

“On the first day I was working, I inadvertently left the camera on this woman who’d brought her two children with her,” he explained. “At that time, some schools were participating in a broadband-type initiative where the principal would address schoolchildren. After I talked to her, the woman turned to her children and said, ‘isn’t this wonderful?’ and the older kid said, ‘oh, ma, we have this in homeroom every day!’”

During the pilot phase of the program, UMC conducted a survey with patients looking at several parameters, including: Are you comfortable with the technology? Would you return to this hospital because of the technology? Could you see and speak with the doctor? Do you have confidence that the care was as good as or better than emergency care previously received?

“I wish my own Emergency Department had the same level of satisfaction we found with the survey results,” said Galli, with a laugh. “All categories were greater than 90 percentile. Most were 95 and above. The patients really took to it early on. As we surmised, people in the country recognize that they’re not so sure they’re going to get state-of-the-art care at a local hospital, but they really don’t want to drive three hours to go to the big city. Now the big city is right there.”

Several years ago, a company based in Houston, Texas, rolled out a similar program, but financial woes and operational wrinkles led to its closure. Yet an interesting trend emerged during their short run, noted Galli.

“They found that some patients, instead of going to an ER closer to home and waiting to be seen, would drive to a hospital located an hour away that was part of this program so they could be seen immediately by the same doctors,” he explained.

Here’s how TelEmergency works: Operating under the protocol of UMC's Emergency Department, nurse practitioners in participating rural hospitals see low-acuity emergency patients without assistance. Using telecommunications technology, higher- to critical-acuity emergency patients are jointly seen by a nurse practitioner and an emergency physician at UMC.

The program alleviates the staffing problem at small critical access hospitals that have had difficulty recruiting physicians to cover emergency room shifts around the clock. UMC involves a dozen faculty members and 30 residents in the program 16 hours daily, from 10 a.m. to 2 a.m.

Buoyed by the program’s success, Galli is often invited to talk about telemedicine initiatives. “I’ve lectured in a dozen states now and we learn from each other,” he said. “For example, in Arkansas, we picked up their clues about working with Medicaid to set up the system to fund telestroke. Even though every state has a different process, we share victories with each other. In that sense, it’s a real sharing community.”

Galli is enthusiastic about the recognition telemedicine programs are garnering from the Centers for Medicare and Medicaid Services (CMS).

“Just recently, the new CMS director, Donald Berwick, in conjunction with Mark McClellan, the former CMS director under President Bush, held a joint summit with the American Telemedicine Association and announced that, for the first time, CMS will take a very serious endeavor into providing healthcare through telemedicine, with increased adoption and reimbursement for telemedicine services. Until then, CMS hadn’t embraced telemedicine. This is the first signal … and I believe it will really expand opportunities in the field.”

Related stories

Bumps and Bruises

In 1998, University Medical Center (UMC) began using telecommunications technology to treat inmates at Mississippi Department of Corrections facilities. In 2002, UMC initiated a joint project with NASA to link two hospitals in Japan via telecommunications and medical imaging. A year later, UMC’s TelEmergency represented the first system of its kind to extend that technology into the emergency room.

However, when Robert Galli, MD, then head of emergency medicine at UMC, brought the idea to the medical board in 2002, there was resistance.

“It took 11 months to finally get it approved,” said Galli, a professor of emergency medicine at UMC. “Dr. Wally Conerly (former CEO of the University of Mississippi Medical Center) was a major force in getting it started. At the time, we’d just had a series of issues and votes to allow nurse practitioners to write for controlled substances. There was rumbling, ‘were NPs trying to take over the world?’ Also, the technology was incredible; nobody was doing this anywhere. As with anything new, it’s easier if something’s proven. Yet, growing concern was obvious. We were getting phone calls in the middle of the night. Hospitals were using NPs with no additional training, and the local attending physicians were often out of pocket. Concerns were raised to the medical board, and the key to alleviating those concerns involved getting in the same room with the NPs, watching what they did, and allowing them to have a hands-on, board-certified ER physician ‘in’ small hospitals in rural areas where they’d typically never go. By increasing the level of supervision and making it a true collaboration, the medical board agreed to start TelEmergency as a pilot program.”

To get started, UMC arranged dedicated T-1 lines to each participating critical care hospital, financed by The Bower Foundation, whose principle goal is to provide access-to-care initiatives for dialysis patients.

“We had our technical difficulties when we first started,” said Galli. “We had a little TV and camera for each one of the stations, so you were sitting in a room with four or five Sonys in front of you. You’d move the camera with the remote control. But unfortunately, when you moved it in Lexington, it also moved it in Meadville and Port Gibson. We’ve subsequently fixed that with more and better technology.”

Expanding TeleMedicine

Telepsychiatry in the Delta Project is a mental health services improvement program aimed at reducing disparities in mental health treatment for Mississippians living in the Delta and improving the quality of services they receive at local community health centers. Grayson Norquist, MD, professor and chair of the Department of Psychiatry and Human Behavior at University Medical Center (UMC), is the principal investigator for the project, which uses two-way telemedicine connections to link communities to mental health service providers to offer live psychiatric services.

Last year, University of Mississippi Health Care (UMHC) launched Intensiview, a Philips VISICU eICU program that will provide remote monitoring services at hospitals statewide. Plans are underway to begin monitoring ICU patients at a hospital in the Delta by combining interactive audio and video links with the expertise of specially trained medical staff to expand bedside care.

“While TelEmergency is a terrific program that’s way ahead of the rest of the country, Mississippi is relatively behind in other telehealth initiatives,” said Robert Galli, MD, professor of emergency medicine at UMC. “Telestroke in Georgia is among the first of its kind, quite a unique and special program. We’d like to develop one with neurologists across the state. If you’re a believer that the clot-busting medicine, tPA, is going to reverse damages of stroke, you need to deliver it to the stroke patient within three hours, hopefully within 90 minutes. Just getting patients from their homes, recognizing they’ve been stricken and need to travel to a hospital, to a neurologist who’s qualified kills all of that time. We want to be able to get them to our telemedicine hospitals, where they can get a CT-scan, then a neurologist to see them, and deliver the drug there. Then they’ve got time to be transferred.”

The Arkansas telemedicine program on maternal health “is really stepping out to the front,” he noted. “We’re looking closely at that one. We’re also developing a teleradiology program. Some telemedicine programs have more than 90 specialties delivering some form of telehealth. We’re getting there one step at a time." 

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