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Following the onset of the COVID-19 pandemic, technology—and telehealth in particular—emerged as an important way to improve the distribution of the health care workforce. Three programmes leveraging digital technology—Project ECHO, telestroke, and tele-ICU—deserve attention as promising, evidence-based models where workforce shortages are significant, particularly in rural areas.
Even before the pandemic, the United States struggled with shortages of health care workers nationwide, and even more so in rural areas. Historically, workforce challenges have been cyclical; but over the last three years the United States has deviated from typical patterns with an alarming number of providers exiting the workforce. This has left researchers concerned that today’s shortages may portend long-term problems.
Especially troubling is the disruption in the supply of nurses and direct care workers. In 2021, the national pool of registered nurses declined by more than 100,000 from the previous year—the largest drop in four decades. Surprisingly, the departure of younger professionals, discouraged by everything from long hours to demanding physical tasks and even violence, helped fuel the exodus.
Rural areas have been particularly hard hit with health systems reporting attrition at every level—from top physicians and surgical technicians to dietary and custodial staff. This is especially alarming given that rural hospitals provide care to approximately one-fifth of the nation's population and serve many vulnerable Americans.
Leveraging technology can help improve the distribution of the health care workforce.
Leveraging technology can help improve the distribution of the health care workforce. During the pandemic, Congress and the Trump and Biden administrations temporarily waived many Medicare telehealth restrictions, which substantially increased patient access to care and allowed providers to build their digital capabilities. While many challenges to digital health remain in rural areas, including spotty broadband access, many providers across the country now have the infrastructure they need to sustain telehealth and telementoring programmes.
Also on the Forum Network: It’s Never Too Late to be a Late Adopter: Tech literacy has become critical to our health, by Lawrence Kosick, Co-Founder, GetSetUp
The Bipartisan Policy Center’s (BPC) Health Program recently evaluated three models of digital technology and provided potential federal policy change that could help accelerate digital technology adoption.
Project ECHO (Extension for Community Healthcare Outcomes) is a distance-learning, telementoring model designed to help primary care clinicians and other community providers deliver expert care to patients where they live, including in rural areas. It connects them to a hub of expert specialty providers via video-conferencing technology.
This model, active and gathering evidence since 2003, shows promising results for hepatitis, behavioural health and chronic care. A systematic review of outcomes associated with Project ECHO shows the model to be effective at treating a variety of health conditions and chronic illnesses while having cost-saving potential.
For example, a study published in the New England Journal of Medicine in 2011 found that during a five-year period, patients receiving care for hepatitis C at ECHO sites had outcomes similar to those treated at specialty clinics. Nearly 60% of patients treated at ECHO sites had a sustained virologic response, a rate that was not statistically different from patients treated at the University of New Mexico’s hepatitis C clinic.
ECHO programmes can enhance the ability of rural providers to address complex conditions and keep patients in their communities even when they do not have a specialist on staff. The programme also helps financially vulnerable clinics and practices retain patients by providing expert level care. Academic medical centres, such as the Texas A&M Rural and Community Health Institute, have used knowledge-sharing through ECHO to assist vulnerable hospitals in retaining patients and staying financially viable.
Telestroke allows physicians at tertiary care centres—typically vascular neurologists—to evaluate and remotely treat stroke patients in the emergency department. Evidence supports the use of the telestroke model, particularly because the therapeutic window to treat stroke is short.
Studies found that stroke patients in telestroke hospitals had higher rates of reperfusion treatment to restore blood flow to blocked arteries and lower 30-day mortality rates compared to patients treated in hospitals without telestroke. Smaller rural hospitals were more likely to reap these benefits. The use of telestroke also helped avoid the transfer of patients to other hospitals, which can waste precious time in administering treatment.
Tele-ICU enables intensivists, who specialise in treating critically ill patients, to remotely monitor ICU patients at rural facilities and guide local clinicians through an acute event. Rural areas often experience shortages of intensivists, so this model allows for the transmission of real-time data to intensivists who are not on site.
Evidence shows that tele-ICU programmes enhanced care plans, improved clinical outcomes, reduced hospital transfers and were associated with increased best-practice adherence. An earlier review from 2013 found that these programmes resulted in up to a 60% reduction in mortality rates, and a 30% reduction in lengths of stay.
Smaller hospitals are most likely to benefit from these programmes, yet are often the least likely to have them, primarily due to financial constraints.
Based on the existing evidence supporting these models, BPC pulled together a set of policy options that Congress and the Biden administration could enact to accelerate their adoption. They are intended for rural communities: smaller hospitals are most likely to benefit from these programmes, yet are often the least likely to have them, primarily due to financial constraints.
Specifically, policymakers could consider:
- Developing and testing new and enhanced financing mechanisms
- Identifying ongoing insurer-based reimbursement opportunities
- Providing technical assistance for providers to adopt new models
- Enhancing current cross-state licensure laws
- Accelerating efforts to achieve interoperability of electronic medical records
Project ECHO, tele-ICU, and telestroke are promising models that can make a meaningful difference in the ability of rural health care providers to respond to the needs of these frequently underserved communities.