In the coalfields, telemedicine provides antidote to doctor shortages, poor health

David Cattell-Gordon is explaining the marvels of the University of Virginia’s telemedicine programs when he decides to show what he means.

He turns on a computer screen at the UVa Center for Telemedicine in Charlottesville where he is the director, and with a couple of clicks, a stroke cart with a video monitor jumps to life in the emergency department at Norton Community Hospital, broadcasting Cattell-Gordon’s image. He has tele-transported himself into a hallway 300 miles away. The staff in Norton notices immediately and peers at him curiously until he explains he’s doing a demo.

During a real emergency, someone in Norton pages the center to say they have a possible stroke patient. Immediately, a stroke neurologist is notified, and engineers in Charlottesville talk with the person in Norton doing the CT scan to make sure the images are pushed through.

“Within six minutes roughly, that cart is in the room with the patient, we get the CT images, the neurologist looks at the images, and the camera is on,” Cattell-Gordon said. The neurologist can see and question the patient, the same as if she is physically in the room, and determine if it’s an ischemic stroke, the type arising from a clot rather than a bleed, and then decide whether to push an antithrombotic drug with the potential to save the person’s life and limb.

“It’s an amazing thing. A stroke neurologist will tell you every minute you lose a million brain cells. Time is brain, and we are able to rapidly do that,” he said. “With Norton Community Hospital we do it fairly frequently and allow the patient to get care quickly and walk out of the hospital.”

Norton is one of six hospitals in UVa’s telestroke program and the only one in Virginia’s coalfields. Last year, UVa marked its 1,000th telestroke consultation in its first three years. Thirty-five to 40 patients a month in rural hospitals benefit from specialty care that they wouldn’t otherwise have had. In most cases, they can remain in their local hospital rather than be transferred to a larger hospital an hour or more away.

Southwest Virginia has the highest stroke rate in the state, Cattell-Gordon said, but there is no neurologist, let alone a stroke neurologist, at Norton or any of the nearby hospitals.

Physician recruitment is tough in the coalfields. Family doctors are scarce and specialists scarcer. Many people rely on nurse practitioners for primary care and either travel far for specialty care or do without.

Telemedicine is changing that. Twenty years ago, UVa began to connect with health centers in the coalfields. It is affiliated with about 43 hospitals, clinics, schools and other facilities in rural Virginia and has served more than 5,000 patients.

Cattell-Gordon recalled how it began.

“During the early days of telehealth, we did a transplant on a Saudi princess. We connected to Riyadh, and the [UVa] president was enamored that we could be a global leader in these things. So in the president’s annual report, he wrote about this,” Cattell-Gordon said. A legislator from far Southwest Virginia read the report. “The guy gets on the horn, and he calls the president of the university and says, ‘What the hell, John? I think if you can go to Riyadh, Saudi Arabia, you can surely come to Pound.’ And so the word went out at UVa to say these are our brothers and sisters. This is our community, so you department chairs, you will do telemedicine.”

Catell-Gordon understands the coalfields. He grew up in Bluefield, West Virginia, when the mines were prosperous.

“I had a family doctor that came to the house with a black bag and lived in a community that was prosperous in its time and had a hospital,” he said. “Bluefield is a struggling community. It’s hard to recruit. You think about the cost of medical school and residency and fellowship and the demands to the man or woman to go out and make a good living. The incentives to practice in rural communities are not there.”

He’s watched as local diets switched from beans and cornbread to highly processed food and saturated fats, and as the mines contracted, jobs dried up and a health crisis blossomed.

“One of the powerful things for me has always been those maps on the CDC [Centers for Disease Control and Prevention]. You can look at diabetes, obesity, heart disease — the whole range of disorders — and they are flash maps. You can see over time your increments going forward,” he said. “It always starts in Appalachia and it spreads out to the rest of the country.”

For Cattell-Gordon, it brings back the old mining expression. “Appalachia really, if you think about southwestern Virginia and the central Appalachian region, is the bellwether. It’s the canary in the coal mine for the entire nation. So go those families in rural Virginia, so goes the rest of us.”

His role is to connect specialists and programs to the region so that the doctors are, in a way, making house calls. With Medicaid expansion and the creation of Ballad Health, he sees a great opportunity for change. Ballad was formed last year after Virginia and Tennessee allowed two competing hospital systems to merge. In exchange for gaining a monopoly, Ballad is required to improve population health.

Nearly everyone involved in improving the health of the people living in Virginia’s coalfields, including Ballad executives, points to the benefits that telemedicine is producing already.

Telemedicine is being used to manage chronic diseases, diagnose cervical and bladder cancers, check the ears and throats of children in school nurses’ offices, care for wounds, discharge fragile newborns from neonatal intensive care units to their nurseries at home, check the lungs of smokers.

Virginia requires commercial insurers to cover telemedicine as if they were office visits. It’s best known for its use in mental health and substance-use disorder treatment. One of the payment hurdles, though, is that Medicare covers telehealth only for rural hospitals. Because of quirks in the way the government counts statistical areas, hospitals in Abingdon and Marion, for example, are not considered rural.

‘I can live my life’

Betty Lowe believes telehealth is saving her life. She’s what doctors call a compliant patient. She follows orders, but after a decade of watching her sugar rise no matter how many carbs she counted, diabetes classes she attended or medications she swallowed, Lowe knew she was heading for trouble.

“My blood was so full of sugar, it was thick like syrup running through my heart,” she said. “I knew it, but I just didn’t know what to do.”

Lowe is 59 and insulin dependent.

She’s not alone. According to health statistics compiled for the Appalachian Regional Commission, adult-onset, or Type 2, diabetes is more common where she lives than most other places in the U.S., and mortality rates are 41% higher in central Appalachia, which includes Virginia’s coalfields, than the national rate.

Lowe thinks she has been fortunate, so far.

Her vision was still fine, her feet were not yet tingly, but her energy registered in the dragging-like-you-have-the-flu range. Her A1c, the lab test that measures blood sugar, routinely was over 10. A normal test is below 5.7; prediabetes is 5.7 to 6.4, and diabetes is 6.5 or above.

Betty Lowe of Hillsville shows how she uses a kit to control her diabetes that she received through the University of Virginia’s telehealth program. Lowe said no matter what she did before enrolling in the program that links her electronically with a diabetes specialist, she could not get the disease under control. Now her readings are routinely in line and she no longer feels as though she has the flu. (LUANNE RIFE | The Roanoke Times)

Betty Lowe of Hillsville shows how she uses a kit to control her diabetes that she received through the University of Virginia’s telehealth program. Lowe said no matter what she did before enrolling in the program that links her electronically with a diabetes specialist, she could not get the disease under control. Now her readings are routinely in line and she no longer feels as though she has the flu. (LUANNE RIFE | The Roanoke Times)

Doctors told her she had to get it under control. But how?

“We live in Hillsville, which is a rural community, and you don’t have a lot of options as far as specialists,” she said.

Lowe, who had been living in Alaska, moved with Michael, her husband of 40 years, to Virginia in 2016 to be closer to her aging mother. They are raising three of their seven grandchildren.

For the first time in her life, Lowe was without health insurance, so she started going to Tri-area Community Health Center in Laurel Fork where she could pay on a sliding scale. She is newly enrolled in Virginia’s expanded Medicaid program this year, but she said she would continue to go to the center as she likes Dr. William Bess Jr.

“He’s a really good doctor, but he’s not a specialist in diabetes,” she said. “He was doing all he could. We just weren’t getting it under control.”

Then in December, Bess told her the center had a virtual connection with UVa endocrinologist Dr. Richard Santen. Lowe had just researched telemedicine while working on an online health administration degree through Colorado Christian University, and she was intrigued.

“My husband and I were in a conference room with the computer screen in front of us and having a conversation with this very distinguished doctor, and he was very intelligent. He knew diabetes, and I could sense his competence,” she said. “Then he started explaining things to me that no one ever explained before.”

He told her the job that each medication performed in her body, so she could better understand how and why to take them.

He asked what she ate — not what she thought she should eat, but actually what and when.

She said the specialist hundreds of miles away told her, “ ‘Keep eating the way you are, and we are going to adjust your medication to the way you live.’ I never had a doctor say that to me before.”

Before, the advice was always count your carbs.

“Well, that’s really hard to count your carbs and figure out how much insulin to give yourself for your entire life. Now if you’re on a diet and you count your calories or count your carbs, you can do that for six months or a year. But your entire life? Dr. Santon didn’t do that. He said for breakfast give yourself this much. For lunch give yourself this much,” she said. “So I did exactly what he told me to do.”

Her numbers dropped.

“My last A1c, which was three months after I started with Dr. Santen, was 7.5. And this is really good. I never had my sugar come down that fast. That is just unbelievable,” she said. He expects her next reading will be even better.

Lowe said she hasn’t been billed for the service. She carries a device about the size and shape of an iPhone.

“He ordered this for me and when it came in this was the coolest thing I ever had in my life,” she said. It has a cellular connection that automatically ties in with her medical record in Charlottesville. She pricks a finger, puts the test strip into the device, which resembles a drugstore glucometer, and up pops her number. But then it does something different. It asks her to select from a menu of options as to when the reading was taken, such as breakfast, snack, exercise.

“Oops,” she said when seeing the number. “That’s because I’m nervous. It should be in the hundreds. For me to see 228, that freaks me out. A year ago, to see 228, I’d have gone, that’s not bad. But today, I go, oh shoot, that’s a lot.”

On the screen are suggestions for how she could lower the count.

In Charlottesville, Santen can look at Lowe’s daily blood-sugar tests, see the relationship with her meals and activities, and then suggest medication adjustments. Initially, he called her at 4 p.m. every Thursday to tell her what to do next.

“I can truly say my diabetes is under control, and this is the first time in a long time I can truly say that,” she said. “My life is so simple now. I can live my life. I don’t have to sit there and count carbs or figure out how much to give myself. I can follow directions. Tell me what to do and I’ll do it.”

Lowe is grateful that she was able to connect with a specialist through telemedicine, as she faces the possibility of brain surgery to remove a malformation.

She’s not looking forward to the surgery, but had she not met Santen, she wouldn’t have had the option.

“They couldn’t have done surgery if my sugars were out of control. That’s they first thing they ask you,” she said. “He probably saved my life.”

Need for broadband

In June, a Federal Communications Commission commissioner visited the Laurel Fork health center where Lowe is a patient to check out the diabetes program. The visit came as the commission weighed developing a $100 million pilot program. The commission agreed in July to set up the Connected Care Pilot Program to help defray the costs of broadband and technology in selected rural areas. The premise is that if specialists can connect to rural patients and monitor chronic illnesses, hospital admissions and more costly care can be avoided and reduce medical spending overall.

“I would argue that broadband is a health factor now. When you look at high cholesterol, weight, blood pressure, blood sugar, I would add to that list, broadband,” Cattell-Gordon said.“If you have low broadband, you are not going to have access to educational resources, you’re not going to have access to the technology, to the remote monitoring and devices that matter.”

Many places in the coalfields lack coverage. Although cellular maps show there is coverage over much of Virginia, 4G maps have bare spots throughout rural areas, and many homes lack internet providers.

Programs such as the one to help control diabetes can still work, Cattell-Gordon said.

“They’ll take their blood sugar, and then they’ll go to Walmart where they can get Wi-Fi and know they can do the data dump,” he said. “We know how to use this technology — when the broadband is there, it is powerful.”

U.S. Rep. Morgan Griffith, R-Salem, said broadband coverage is a great concern in his district, which covers the coalfields.

“I have heard from health care providers who would like to use telehealth but are limited in some cases because of the lack of broadband,” he said. “While there may be a lack of opportunity, no individual has told me they were denied telehealth services because of the lack of broadband.”

Griffith anticipates that new technologies might solve the problem in the next few years.

Connecting people

UVa’s telehealth program has been providing care for patients at a free clinic in Wise for about 20 years.

Teresa Tyson, executive director of the Health Wagon, said she was accompanying some patients to the hospital in Clintwood, one of UVa’s first coalfields partners, when she heard about the program and thought it was being underused.

“I was like, ‘If you will give me that equipment because they aren’t using it, I will really use it.’ And they said, ‘We don’t want to take their equipment away, but we will give you your own equipment,’ ” she said.

The free clinic began using it for psychiatry and consultations with pain specialists, cardiologists and dermatologists.

Then Tyson went to a funeral for a 28-year-old woman.

The woman had had an abnormal Pap smear when she was 18.

“She lost her health insurance and didn’t go back into the health care system until she presented with abdominal pain at 27. At that time she was diagnosed with stage 4 cervical cancer,” Tyson said. “Her father told how in her last days, he prayed for his daughter to die. No father should have to do that.”

Pap tests can detect early changes in cervical cells. To determine if the cells are precancerous or cancerous, physicians recommend a colposcopy, in which a vinegar solution is painted on the cervix and a lens helps show which areas react so a biopsy can be taken.

“If we can detect it and get treatment early, rarely does someone have to die of cervical cancer,” Tyson said.

She and Paula Hill, the Health Wagon’s clinical director, asked UVa to train them to do colposcopies through telehealth. Tele-colposcopies are scheduled for one day each month in the Wise clinic.

The exam room looks no different than any other where gynecological procedures are performed, except on the computer monitor is Dr. Yvonne Newberry in Charlottesville looking in. She also tunes in for a similar colposcopy clinic at the Wise health department and has recently trained another nurse practitioner in Tazewell.

“When we do colposcopies in person, we look through a camera just the same, and the images are up on a screen on the wall as opposed to transmitting to us via telemedicine,” Newberry said.

More importantly, the nurse practitioner can take biopsies of suspicious areas. When the technology works, the pictures are no different than if Newberry were in the room, and because the lens can enlarge and sharpen, they are better than what her eye alone can see.

But sometimes the technology doesn’t work.

Angela Holbrook of Coeburn was waiting for her procedure, but the scope camera wasn’t working.

Newberry said it had happened before.

“They are going to fix the scope and reschedule her. We at least got her Pap and HPV [tests] repeated,” she said.

At 41, Holbrook said she hadn’t sought much medical care most of her adult life. She didn’t have insurance. She once got a mammogram at a Remote Area Medical clinic, where providers gather one weekend a year to offer free medical care, and she’s learned to live with near constant pelvic pain that worsens with her period.

Then last year she found the Health Wagon, and is grateful that she no longer has to worry about money or distance in getting tests and biopsies.

Tyson said the telehealth partnership has been a lifesaver for their patients.

“We’re using telehealth unlike anyone else has really done it so far for diagnostics because our people don’t have access to diagnostics,” she said.

They were the first, and possibly still the only, nurse practitioners to do telecystoscopies, which allow a urologist to look inside a patient’s bladder.

“What we know is we have really low rates of bladder cancer and high rates of smoking. That does not correlate. If you have high rates of smoking, you should have high rates of bladder cancer.” Tyson said people would have symptoms such as blood in their urine but were not able to be tested.

“The first clinic, we had six patients. All six had bladder tumors,” she said. They then went to UVa for further treatment.

Cattell-Gordon said cystoscopies are much needed to catch recurrences.

“This is the kind of thing if you trained advance practice nurses to do the endoscopy and you have a world-class urologist up here who can sit at a desk and on a high-resolution screen see the bladder and guide the process, that person down there in Southwest Virginia, in Wise County, who has bladder cancer who wasn’t going to get a ride up to here to Charlottesville, who wasn’t going to get that surveillance done, can get it done so maybe we can prevent the recurrence of that bladder cancer,” he said. “To me that is the most amazing thing.”

Telehealth is about connecting people more than about using technology.

“The technology is the wires, the Wi-Fi, the camera,” Cattell-Gordon said. “What makes it work is relationships and partnerships with people like Teresa.”

[This story was originally published by The Roanoke Times.]