Where ER Doctors Work Entirely Via Webcam

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In South Dakota, long-distance doctoring is bringing health care to rural communities.

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Doctors in Sioux Falls, South Dakota assist the staff at a rural hospital through two-way video conferencing. [Avera]

Every day -- and through the night -- in Sioux Falls, South Dakota, doctors report to work in a hospital where there are no patients.

And in over 70 rural communities in four states, patients stricken by heart attacks, or injured in car accidents, or facing other urgent health issues are rushed to an E.R. where there are no doctors. Or, more precisely, there's one doctor. More often than not, he or she is trained in family practice, not emergency care. And if the call's coming in the middle of the night, he legally has a half-hour to get out of bed and report in.

They report an 18 percent decrease in transfers to major hospitals, equating to $6.6 million saved.

In these small-town hospitals, which often have 25 or fewer beds, South Dakota's largest city is the closest available source of comprehensive healthcare. The people who choose to live in small, geographically isolated communities throughout the Midwest are used to making the trek -- long car rides come standard with country life. But during emergencies, the up-to 200 miles to Sioux Falls becomes very, very far away.

But when the call comes in the middle of the night, with the push of a button -- mounted right on the ER's wall -- the nurses on-duty are able to connect with ER doctors in Sioux Falls, who have been waiting, in their patient-less hospital, for their call. 

Avera Health Network is believed to have the only long-distance critical care center in the U.S., and possibly the world. Based at Avera Mckennan Hospital, the nonprofit provides a range of "telemedical" services that take advantage of technology -- including high-definition two-way video consulting -- to make it possible for experts to be available 24/7 in locations throughout South Dakota, North Dakota, Minnesota, Iowa, Wyoming, and Nebraska.

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Their four main services -- eConsult, eICU Care, eEmergency, and ePharm -- are set up to provide resources and support to the 10 percent of America's doctors currently serving the 25 percent of the country's population that resides in rural areas. As the rural population ages -- the proportion of people over the age of 65 is about 72 percent higher in South Dakota than the rest of the U.S. and is expected to double by 2020 -- the need for easy access to high-quality care will only increase.

"If you think about, there's an awful lot of medicine that is just done through visualization of X-rays, looking at the chart, talking to the patient, making assessments, writing prescriptions," said Fred Slunecka, COO of Avera Health. "There's an amazing amount of care that can be done that way." The Avera team calls this "hands in pocket doctoring." Of course, physical hands are needed to carry out virtual orders, and real doctors and nurses are always on hand to provide that. But even IRL (in real life), crisis situations require someone at the head of the room, keeping tabs on everyone and calling the shots. In emergency situations, where every second counts, the long-distance physician is able to be in the room an average of 14 minutes sooner than the local doctor.

The doctors back at the hub spend their time monitoring ICU patients -- they have virtual access to 60 percent of the beds in South Dakota. Pharmacists are on-hand to review prescriptions, make sure doctors aren't missing any allergies or medical history, and keep them abreast of the newest recommendations and standards of care.

"The magic is being able to see into room," said Jay Weems, the executive director of eCare. "But the bigger magic, we think, is the people are on both ends -- in the rural community and in the hub -- that support each other and work together as team, as medicine is meant to be practiced."

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When the concept for eICU was invented in 2004 at Johns Hopkins, its innovators saw it as a way for the hospital to extend its vast resources to slightly smaller, but still very sophisticated, medical centers. Avera, with the help of grant money from the Helmsley Trust, has been able to expand the technology's potential. And it's still far from being maximized: at the same time that they're adding more hospitals to their network, they're also developing new programs. Recently introduced were "eLongTermCare," for nursing homes, and a service for prison infirmaries which has reduced transfers by 60 percent. According to Senior Vice President of Quality and eCare Deanna Larson, the latter has garnered praise from the Secretary of Health, if not the inmates.

As of October, they report an 18 percent decrease in ambulance and helicopter transfers to major hospitals, equating to $6.6 million saved. What's more, every time they're able to maximize a small community's ability to care for its patients on-site, they're keeping health care dollars in the local economy. In the long run, they hope for the programs to be self-sustaining. 

This might be the most important metric to watch, because at the heart of Avera's innovations is not just a mission to save lives and reduce spending, but to preserve a dying way of life. "I think technology like this is actually the best opportunity that rural communities have for ongoing success," said Slunecka. "I think we can reverse, or at least limit, the decline of these small communities."

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Lindsay Abrams is an assistant editor at Salon and a former writer and producer for The Atlantic's Health Channel.

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