Many people see telemedicine as a solution to the nation’s health disparities and in Mississippi as a solution to our last place in health. More than 13 years ago, the University of Mississippi Medical Center developed a successful TelEmergency program that saved rural Critical Access Hospitals and now provides telehealth services throughout the state. This occurred without acrimony because of partnerships that the University of Mississippi Medical Center developed with telecommunications companies, state government, health professions’ licensure boards, and private donors. Today, the telemedicine market is exploding across the country with the entry of for-profit corporations into the medical market. These corporations often are more inclined to work with legislators rather than physicians, and some physician groups have attempted to limit their expansion. With the future of telemedicine now determined in part by the courts, rather than the providers, new pitfalls have arisen. The Mississippi experience may be helpful in navigating this new territory.
A neighbor stopped by to report that he had a seizure on a business trip. I asked about his medical follow-up. He said the pharmacy at our local dollar store had opened a telemedicine kiosk, you could see a nurse practitioner for a “doctor visit,” and he planned to go there. More about this later.
How Did Mississippi Become a Leader in Telehealth?
In Mississippi, the social determinants of health are stacked against us, and a libertarian approach to correcting them explains our perineal “last place in health” designation.1 Medicaid expansion has yet to occur, leaving 165,000 residents without health insurance.2 The lowest physician to patient ratio, rural geography, and a large African American population approaching a racial majority of whom 37% live in abject poverty also help explain our health disparities.3 Twenty-one Federally Qualified Health Centers with clinics at 187 sites, pro bono care, teaching, state health department, Rural Health Clinics, and emergency departments staffed by nurse practitioners at Critical Access Hospitals have unsuccessfully attempted to fill the access gap.
Critical Access Hospitals, created in 1997 after an epidemic of rural hospital closures, have 25 or fewer inpatient beds and are required to provide around the clock emergency services to receive cost-based reimbursement.4 By 2003, too few doctors were available to provide collaboration with nurse practitioners to staff Mississippi’s Critical Access Hospitals. Robert L. Galli, MD, Chair of the University of Mississippi Medical Center Department of Emergency Medicine, conferred with faculty and piloted a 3-hospital “TelEmergency” system using off-the-shelf electronic components and specialized training for nurse practitioners. Clinical faculty and medical center leadership helped obtain scope of practice approval and new Mississippi code rulings on the practice of telemedicine, and a highly successful pilot program, the first of its type in the United States, began operations in 20035 (Table 1). Now, 15 Critical Access Hospitals form a statewide TelEmergency network (Figures 1 and 2). Installation of fiber optic cable across the state, clarification of billing status, and approval of these services for all Medicaid recipients have made telehealth widely available6 (Table 2). The approximately 200,000 members of the State Employee Health Plan will be eligible for direct to consumer telemedicine starting in March 2017 (C. McIntosh, personal communication to K. Rodenmeyer, July 2016). This marketplace has resulted in a number of private initiatives (Table 3).
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-Richard D. deShazo, MD, MACP, Sara Bolen Parker, BA
This article originally appeared in the April 2017 issue of The American Journal of Medicine.
