DiversityNursing Blog

By PAM BELLUCK

Published: October 8, 2012

“I thought I was going to see a regular doctor,” she said, but instead she saw “this giant screen.”

Suddenly, two doctors appeared on the video screen: dermatologists in Boston. A nurse in the room with Ms. Cohen held a magnifying camera to her face, and suggested she close her eyes.

Why? she wondered — then understood. The camera transmitted images of her face on screen, so the doctors could eyeball every bump and crater. “Oh my God, I thought I was going to cry,” Ms. Cohen recalled. “Even if you’ve never seen that pimple before, it’s there.”

That, she realized, was the point. Technology, like these cameras and screens, is making it affordable and effective for doctors to examine patients without actually being there.

More hospitals and medical practices are adopting these techniques, finding they save money and for some patients work as well as flesh-and-blood visits.

“There has been a shift in the belief that telemedicine can only be used for rural areas to a belief that it can be used anywhere,” said Dr. Peter Yellowlees, director of the health informatics program at the University of California, Davis, and a board member of the American Telemedicine Association. “Before, you had to make do with poor quality, or buy a very expensive system. Now, you can buy a $100 webcam and do high-quality videoconferencing.”

The technology is especially being embraced in professions like ophthalmology, psychiatry and dermatology, which face shortages of physicians. At Kaiser Permanente, dermatologists “sit in a suite in San Francisco” and tele-treat patients throughout Northern California, Dr. Yellowlees said. “It’s much more efficient than having 20 hospitals, each with a dermatologist.”

On Nantucket, an island 30 miles from the nearest spit of mainland, “telemedicine just makes a lot of sense,” said Dr. Margot Hartmann, chief executive officer of Nantucket Cottage Hospital. “It allows us to meet the mission of the hospital better because we’re offering more locally,” and saves patients the cost and time of flying or ferrying off-island, then driving to Cape Cod or Boston hospitals.

The island may be small, but it has strikingly diverse medical needs. Its year-round population of about 10,000 balloons to 50,000 in the summer. And while it is famous for wealthy visitors, its year-rounders are much less affluent. They include immigrants from many countries, and range from businesspeople to scallopers.

Nantucket has all the ailments one would find anywhere, plus some exacerbated by island life: skin cancer, tick diseases, water accidents.

“Most people are within an hour of some major hospital,” said Joanne Bushong, the hospital’s outpatient clinical coordinator. Not Nantucket. “We’re not practicing rural medicine; we’re practicing island medicine.”

Nantucket’s hospital has a handful of year-round doctors. While mainland specialists do visit, fog or storms can keep them from getting there. And specialists cost money. The hospital, millions in the red in recent years and now needing $60 million to replace its outmoded 1957 building, must pay for the specialists’ travel and lodging.

Telemedicine, done by doctors at Massachusetts General Hospital, saves some of those costs, and generates revenue because it means more tests are done on Nantucket. “If someone was going off-island to see a dermatologist, they would probably have their labs and X-rays done where that dermatologist was,” Dr. Hartmann said.

Instead, tele-dermatology saves nearly $29,000 a year because two dermatologists now visit only four times a year, but appear on screen six times a month and see 1,100 patients a year. Previously, dermatologists visited monthly, and always had “100 people on the waiting list,” Ms. Bushong said.

Nantucket also uses tele-radiology, having Boston radiologists, some specializing in certain body areas, read X-rays and scans. It has used tele-pediatrics twice, for a child in a car accident and one in diabetic crisis. Tele-stroke uses video neurologists to quickly determine if a patient’s stroke type warrants a clot-busting drug, tPA, or if tPA could harm the patient.

Tele-endocrinology, for thyroid problems and diabetes, is starting. And Nantucket hopes to have video sessions for autistic children “so parents would not have to take kids with autism off-island, since it’s hard to travel with them and it upsets them,” Ms. Bushong said.

Dr. Hartmann envisions tele-rheumatology and tele-psychiatry, among other teles. Instead of screens in one exam room and the emergency room, “I would love to see every room telemedicine-capable,” she said.

But there are limitations, nationally and on Nantucket. Dr. Yellowlees said interstate telemedicine was hindered by rules requiring that doctors be licensed in the state where patients are treated.

Insurance coverage varies, with Medicare and some policies covering telemedicine services only in rural areas. “If you’re in a city, Medicare will only reimburse if you’re in the same room as the doctor,” Dr. Yellowlees said.

And some telemedicine is not cost-saving or accepted by doctors on the receiving end. Memorial Hermann Hospital-Texas Medical Center in Houston ended a tele-I.C.U. program in which intensive care specialists monitored and assisted intensive care units at five other hospitals. It was expensive and not demonstrably better, and some doctors and nurses disliked being watched from afar, said Dr. Eric J. Thomas, associate dean for health care quality at University of Texas Medical School at Houston.

On Nantucket, Dr. Timothy J. Lepore, 67, a surgeon and the hospital’s medical director, sees value in some long-distance doctoring, but has some concerns. He especially prefers having a radiologist on-site because he believes that conferring in person helps prevent mistaken readings and gets quicker results.

Dr. Lepore said that one tele-radiologist misread a chest X-ray, missing that the patient had pulmonary edema, fluid in the lungs. And when Dr. Lepore injured a hamstring while running, a tele-radiologist said an M.R.I. showed Dr. Lepore had pulmonary edema of the hip, which was bizarre and impossible. His actual diagnosis: a torn hamstring.

Occasionally, Dr. Lepore said, “it just goes completely off the trolley.”

Dr. Efren Flores, a radiologist who divides time between Boston and Nantucket, said he has learned to heed Dr. Lepore’s insistence on fast, accurate tele-radiology readings because on Nantucket it is important to determine if patients can be treated there or must be flown to Boston.

Many patients appreciate that telemedicine saves them trips off-island, but not everyone likes it.

“There are some people who just flatly refuse, and I see them in person,” said Dr. Peter Schalock, one of the two Mass General dermatologists who treat Nantucketers remotely. He said he has had to get used to diagnosing without feeling a patient’s skin, relying on the nurse, Ms. Bushong, for that. “Somebody with 100 strange-looking moles, I can probably do in 10 or 15 minutes myself, when it might take half an hour with the camera. Definitely people with more interesting moles, I like to see myself.”

Still, “we’re pretty good at picking up what looks funky, to use a technical term,” Dr. Schalock said. “I really feel like we’re providing essentially the same quality care.”

So, in August Dr. Schalock remotely diagnosed eczema in Aaron Balazs, 35, but saw him in person in September and increased his medication dosage and switched him from a cream to pills.

Mr. Balazs, stationed on Nantucket with the Coast Guard, was not expecting video doctoring, and said initially “it was sort of awkward.” But he concluded “it’s definitely beneficial for both parties.”

By the time Ms. Cohen had her second session in August, this time with Dr. Schalock, she said, “I feel like it’s the same thing” as an in-person visit. She had accepted the mega-magnifying camera by then.

“It kind of freaks out some people,” Dr. Schalock said. “They say, ‘Oh my God, I should have shaved my legs!’ I’m not looking at the hair. I’m looking at the mole.”

By DAN FROSCH

The debate pits nurse anesthetists, who specialize in administering anesthesia and maintain that they are well equipped to treat patients on their own, against anesthesiologists, who are physicians and say nurses lack the necessary training.

The dispute dates to a 2001 change in Medicare and Medicaid regulations, allowing states to opt out of a requirement that nurse anesthetists be supervised. And it is part of a broader turf war over how much power nurses should have in treating patients.

“With the removal of the requirement, it actually increases access to health care for citizens in rural Colorado,” said Scott K. Shaffer, president of the nurse anesthetists association in Colorado, one of 17 states that have chosen to allow nurses to deliver anesthesia without supervision.

Since Colorado’s rural hospitals were exempted from the supervision regulation in 2010, Mr. Shaffer said, some medical facilities that may not have employed anesthesiologists have been able to attract specialists because there is no longer a concern about who would administer anesthesia or supervise.

“Now patients don’t have to turn around and go to Colorado Springs or Denver when they can be taken care of in their hometown,” he said.

In Colorado, however, the issue has prompted a legal battle. In 2010, anesthesiologist and medical societies filed a lawsuit in state court asserting that allowing nurse anesthetists to deliver anesthesia without supervision was not consistent with state law, a requirement for opting out of the federal rule.

But a judge dismissed the case, ruling that the legislature had indeed intended for the practice to be permitted. The medical groups appealed last May.

“There is a very different background between nurses and physicians in both education and training,” said Dr. Randall Clark, a spokesman for the Colorado Society of Anesthesiologists. “Anesthesia is a very complex and technically demanding area of medicine that, at its core, needs to be either performed by a physician or supervised by one.”

Dr. Clark said that despite concerns about health care access, his group believed that there were more anesthesiologists than nurse anesthetists currently working in the nearly 50 rural Colorado hospitals affected by the opt-out decision. And in those instances when a hospital does not have a staff anesthesiologist, he said, it is still safer to have a physician on hand to supervise lest complications arise.

At a state appeals court hearing in Denver on Tuesday, Assistant Attorney General LeeAnn Morrill argued that Colorado law clearly permitted doctors to delegate medical functions to advanced practice nurses. Joseph J. Bronesky, a lawyer for the anesthesiologist society, said the law was murkier.

The case is being watched closely by national nursing and anesthesiologist groups, for whom the debate has become increasingly contentious. Each side has promoted studies backing its perspective.

The American Society of Anesthesiologists cited a 2000 study financed by the federal Agency for Healthcare Research and Quality, which found that the presence of an anesthesiologist helped prevent deaths in cases where an anesthesia or surgical complication had occurred.

Conversely, the American Association of Nurse Anesthetists referred to a study it financed that was published in Health Affairs in 2010. It examined Medicare data from 1999 to 2005 and found no evidence that opting out of the supervision requirement resulted in increased inpatient deaths or complications.

“When it comes to giving anesthesia, certified registered nurse anesthetists and anesthesiologists are identical,” said Christopher Bettin, a spokesman for the nurse anesthetists group. “There are no differences in what they learn, the drugs and equipment they use and the standards of care they follow.”

Colorado is not the only state where the dispute over nurse anesthetists has ended up in the courts. Last month, the California Society of Anesthesiologists petitioned the State Supreme Court to review its lawsuit over California’s 2009 decision to opt out of the supervision requirement. The group’s suit, initially filed in 2010, has so far been unsuccessful.

“Our concern is patient safety,” said Dr. Kenneth Y. Pauker, president of the California group. “Is an independent nurse able to tender the same quality of care as an anesthesiologist or an anesthesia care team? What happens when things get really complex and you have to call upon all your years of medicine?”

Jana Du Bois, chief counsel for the California Hospital Association — which has sided with the nurses, as has its Colorado counterpart — said that rural areas in California continued to struggle to recruit and retain specialists.

“If there aren’t enough physicians and a woman in labor comes in, you can’t say, ‘We have to wait until next week to get an anesthesiologist,’ ” she said.

The Family Health Clinic of Carroll County, in Delphi, Ind., and its smaller sibling about 40 minutes away in Monon provide full-service health care for about 10,000 people a year, most of them farmers or employees of the local pork production plant. About half the patients are Hispanic but there are also many German Baptist Brethren. Most of the patients are uninsured, and pay according to their income — the vast majority paying the $20 minimum charge for an appointment. About 30 percent are on Medicaid. The clinics, which are part of Purdue University’s School of Nursing, offer family care, pediatrics, mental health and pregnancy care. Many patients come in for chronic problems: obesity, diabetes, hypertension, depression, alcoholism.

What these clinics don’t offer are doctors. They are two of around 250 health clinics across America run completely by nurse practitioners: nurses with a master’s degree that includes two or three years of advanced training in diagnosing and treating disease. By 2015, nurse practitioners will be required to have a doctorate of nursing practice, which means two or three more years of study. Nurse practitioners do everything primary care doctors do, including prescribing, although some states require that a physician provide review. Like doctors, of course, nurse practitioners refer patients to specialists or a hospital when needed.

America has a serious shortage of primary care physicians, and the deficit is growing. The population is aging — and getting sicker, with chronic disease ever more prevalent. Obamacare will bring 32 million uninsured people into the health system — and these newbies will need a lot of medical care. According to the American Association of Medical Colleges, the United States will be short some 45,000 primary care physicians by 2020.

The primary care physicians who do exist are badly distributed — 90 percent of internal medicine physicians, for example, work in urban areas. Some doctors go to work in rural areas or the poor parts of major cities, treating people who have Medicaid or no insurance. But they are few.

In part it’s the money. Primary care doctors make less than specialists anywhere, but they take an even larger financial hit to treat the poor. Particularly in the countryside — even with programs that offer partial loan forgiveness, it’s very hard to pay off medical school debt treating Medicaid patients, much less those with no insurance at all.

And the job of a primary care doctor today is largely managing chronic disease — coordinating the patient’s care with specialists, convincing him to exercise or eat better. Poor patients can be a frustrating struggle. Compared with wealthier patients, they tend to have more serious diseases and fewer resources for getting better. They are less educated, take worse care of themselves and have lower levels of compliance with doctors’ orders. Very few people start medical school hoping to do this kind of work. Those who do it may burn out quickly.

It might seem that offering the rural poor a clinic staffed only by nurses is to give them second-class primary care. It is not. The alternative for residents of Carroll County was not first-class primary care, but none. Before the clinic opened in 1996, the area had some family physicians, but very few accepted Medicaid or uninsured patients. When people got sick, they went to the emergency room. Or they waited it out — and then often landed in the emergency room anyway, now much sicker.

Just as important, while nurses take a different approach to patient care than doctors, it has proven just as effective. It might be particularly useful for treating chronic diseases, where so much depends on the patients’ behavioral choices.

Doctors are trained to focus on a disease — what is it? How do we make it go away?

Nurses are trained to think more holistically. The medical profession is trying to get doctors to ask about their patients’ lives, listen more, coach more and lecture less — being “patient-centered” is the term — in order to better understand what ails them.

“I’ve been out of nursing school since 1972 and I still remember that when faculty members finished talking about the scientific parts of the disease they would talk about the psycho-social part,” said Donna Torrisi, the executive director of the Family Practice and Counseling Network, which has three clinics in Philadelphia. “It’s not about the disease, it’s about the person who has the disease. While in the hospital you’ll often hear doctors refer to a patient as ‘the cardiac down the hall.’”

Younger doctors are no doubt better at this than their older peers. But the system conspires against them. The 15-minute appointment standard in fee-for-service medicine — which pays doctors according to how many patients they see and treatments they provide — makes it unlikely that doctors will spend time discussing a patient’s life in any detail. Physician reimbursement places a zero value on talking to the patient. But nurse practitioners are salaried, giving them the luxury of time. At the Family Health clinics, appointments last half an hour — an hour for a new diabetic or pregnant patient.

Jennifer Coddington, a pediatric nurse practitioner who is a co-clinical director of Family Health Clinics, said that she spends a lot of time teaching patients and their families about their diseases and how to manage it. “We want to know socially and economically what’s going on in their life — their educational level, how are they making it financially,” she said. “You can’t teach patients if you’re not at their educational level. And if a patient can’t afford something, what’s the point of trying to prescribe it? He’s going to be non-compliant.”

A physician might suggest that a patient lose weight and hand him a diet plan — or refer him to a nutritionist. At the Family Health clinics, nutrition counselors — graduate students at Purdue — will sit down with patients to talk about the specific consequence of their diet, and suggest good foods and how to cook them, Coddington said. “When you don’t have enough money to buy fruits and vegetables, so you go to the dollar menu at McDonald’s — we help those people put planners together for the week.”

Data has shown that nurse practitioners provide good health care. A review of 118 published studies over 18 years comparing health outcomes and patient satisfaction at doctor-led and nurse practioner-led clinics found the two groups to be equivalent on most outcomes. The nurses did better at controlling blood glucose and lipid levels, and on many aspects of birthing. There were no measures on which the nurses did worse.

Nurse-led clinics can save money — but not always in the obvious way. Many are cheaper than comparable physician-led clinics. Suzan Overholser, the business manager of the Family Health clinics, said that their cost per patient was $453 per year — lower than the Indiana average for similarly federally qualified clinics (all the others physician-led) of $549. But nurse-led clinics aren’t always cheaper. Coddington examined published studies of clinic costs and found that in some cases, nurse-managed clinics had slightly higher per-patient costs than traditional clinics.

Although nurses are paid less than doctors (Medicare reimburses them at 85 percent of what it pays doctors,) nurse-led clinics are often very small, and so don’t have the variety of practitioners necessary to keep a clinic running at full capacity. They also serve the most difficult and expensive patients.

The biggest financial benefit, however, likely comes from offering patients an alternative to the emergency room. Coddington’s review cites studies showing large savings in paramedic, police, emergency room and hospital use. A traditional clinic in an underserved area would do that, too, of course — it’s just that nurses tend to go where doctors won’t.

There are about 150,000 nurse practitioners in America today. The vast majority practice in traditional settings — only about a thousand are in nurse-managed clinics. One reason these clinics are rare is that they may equal traditional clinics in health care, but not in business success.

Nurse-managed clinics have to overcome regulatory and financial obstacles that traditional clinics don’t face. Powerful physicians’ groups such as the American Academy of Family Physicians oppose allowing nurses to practice independently. “Granting independent practice to nurse practitioners would be creating two classes of care: one run by a physician-led team and one run by less-qualified health professionals,” says a paper from the A.A.F.P., citing the fact that doctors get more years of education and training. “Americans should not be forced into this two-tier scenario. Everyone deserves to be under the care of a doctor.”

Only 16 states and Washington, D.C., allow nurses complete independence. In other states, some of the restrictions are bizarre — in Indiana, for example, nurse practitioners may do everything doctors do, with two exceptions: they can’t prescribe physical therapy or do physicals for high school sports.

Jim Layman, the executive director of the Family Health clinics, said he thought that nurse practitioners cared for the majority of Medicaid patients in Indiana. But if you look through Medicaid records, you’ll find only doctors — nurses are not allowed to be the primary caregiver of record. So the Family Health clinics, like others, employ a physician off-site from 4 to 6 hours a week who uses electronic health records to examine a sample of cases and consult when necessary. Medicaid is billed in his name.

It is not easy for nurse-run clinics to win status as a Federally Qualified Community Health clinic, which would allow them to get federal grants. This is largely because most come out of universities, and most universities don’t want to cede control to the community — a requirement for this status. Purdue decided it would, and the Family Health clinics qualified in 2009. Before that, they received some money from the state, and raised the rest from local March of Dimes, United Way and Chamber of Commerce donations, plus fund-raising dinners and auctions. This was enough to support just one full-time provider at each clinic. Getting F.Q.C.H. status allowed them to hire more staff and move the Carroll County clinic into a modern new building — and probably saved them from collapse. “It would have been very difficult for us had we not gotten F.Q.C.H. status,” said Coddington. The Affordable Care Act — Obamacare — did authorize $50 million for five years for nurse-managed clinics. So far 10 clinics have gotten a total of $15 million.

In some ways, the nurse practitioner-managed clinic is a throwback to the small-town family practice, when your doctor asked about the schoolyard bully and your dad’s unemployment. Among the many changes needed in how America values and reimburses health care, it’s important to encourage and support these clinics. They may be old-fashioned, but that doesn’t mean they should be financed with bake sales.