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While it’s difficult to find silver linings when it comes to the novel coronavirus pandemic, the long-term expansion of telehealth – the provision of health care services remotely through telecommunications technology – may prove to be one.

Although Mark Twain Medical Center (MTMC) has had telehealth programs in place for years, it has conducted increasing numbers of primary-care appointments through telehealth over the past several months.

“During the COVID-19 pandemic, MTMC has been providing ‘virtual’ primary-care visits for patients through our rural health clinics,” MTMC spokesperson Nicki Stevens said. “For patients with limited internet access, we offer telephone visits in lieu of an office visit based on the patient’s needs. During the past four months of the coronavirus outbreak, around 20% of our visits were either via video or via telephone.”

When the novel coronavirus hit hard in March, federal and state government actions relaxed restrictions and expanded coverage and reimbursement for telehealth services, leading to a dramatic rise in the use of telehealth across the country.

Although the new policies were largely intended as temporary measures to protect patients and healthcare workers from exposure to COVID-19, many are calling for increased coverage and reimbursement to remain in place after the pandemic has ended.

Since 2005, Randy Smart, MD, has been working to expand telehealth services in Calaveras County. Smart serves as chief executive officer of Mark Twain Health Care District, as well as medical director of the district’s independently operated Valley Springs Health and Wellness Center, where he practices internal medicine.

The Valley Springs clinic is currently conducting about 20% of its appointments through telehealth, and expects to do about 30% of appointments through telehealth next month.

“Health care has been well-positioned to provide telehealth services for about the last 15 years,” Smart said. “About 15 years ago is when we had the technology, and we had the mission, and we had the patient-need. Locally, we set up a number of programs which I had the opportunity to be the lead on.”

In the late-2000s, a tele-intensive care unit (ICU) program was set up out of MTMC, as well as a tele-stroke program, both of which are still operating today, along with other programs.

“Our tele-ICU program is still functioning very well today, and is very importantin terms of the pandemic,” Smart said. “The tele-stroke program works out of the MTMC emergency room, and it gives stroke patients the opportunity to get reperfusion therapy. … It’s saved many lives and prevented much disability.”

Smart said that one of the main barriers to expanding telehealth in the county prior to the pandemic had been lack of reimbursement from insurance companies.

“Part of it was there was little reimbursement,” he said. “But with the COVID pandemic, most of the private insurance companies, as well as the government health care insurance programs such as Medicare and Medicaid, have now embraced telehealth.”

Another barrier has been the limited technological know-how of an older population.

“Our population in Calaveras is about 10 years older than the rest of California, and most of our patients are seniors,” Smart said. “So, part of it was making them comfortable, and finding a way for them to connect during telehealth.”

The pandemic brought many changes that spurred the growth of telehealth, Smart said.

“Patients were in many cases required to isolate because they were vulnerable – they were seniors or they had comorbidities or other medical problems – and in the clinics we were trying to protect them. So, we had this perfect opportunity with patients at home, us in the clinics, technology available, and suddenly the insurance companies willing to pay for it.”

Smart said that most of the telehealth appointments at the Valley Springs clinic have taken place over a voice-only telephone connection, though the use of video has been expanding.

“What we were able to find was that we could do a significant amount of health care on the phone,” he said. “And that’s not even with the video connection – with the video connection it gets even more robust – but with a simple phone call with somebody who has high cholesterol or migraine headaches or diabetes, we could do the majority of their care.”

In the past few months, healthcare providers across the country have found that telehealth is an effective way to carry out almost half of regular appointments, Smart said.

“You can’t do surgery; you can’t do interventional things; you certainly can’t do biopsies, and so it’s not perfect for all of health care,” he said, “but what we’ve learned in the last month – and this is really a number that comes from national experts – is that about 45% of health care can be comfortably and reliably done through a telehealth platform.”

The response from local patients has been “a little bit mixed,” Smart said. As anyone who has visited a healthcare facility knows, it’s not always possible to see a doctor at the exact time of a scheduled appointment. While a patient sitting in a waiting room knows that they will be seen eventually, a patient waiting at home by the phone may worry that their appointment has been forgotten. Receiving care through a novel method can also cause anxiety for some patients, Smart said.

“It’s new for everybody right now,” he said. “The feedback about the actual appointments has been fantastic. People feel like they’re respected, they feel like they’re important and they’re getting good care.”

Two new telehealth programs based out of the Valley Springs clinic are planned to roll out in the coming weeks – the “RoboDoc” program and the “e-consult” program.

“Our RoboDoc program is our effort to provide health care and support for the school nurses in Calaveras County,” Smart said. “We’re providing a telehealth connection directly to the school and to the nurse, where our pediatricians can get on the computer, evaluate the child, interact with the nurse, and provide at a minimum an opinion about what is wrong and what to do about it.”

Three doctors are participating in the program, which is planned to begin at four pilot locations, ideally at the beginning of this coming school year. At each location, rolling carts will be equipped with computers – probably connected to stethoscopes and otoscopes – which will connect doctors, nurses and students.

“The doctor in the clinic will be able to look in ears, look at tonsils, listen to lungs, listen to hearts, and do quite a bit from a remote location,” Smart said. “Pediatricians in the clinic will be available to the school nurses pretty much all business hours for consultation.”

Smart said that he wasn’t sure how staff would react when he presented them with the idea for the program.

“When you bring somebody more work, they usually don’t thank you,” he said. “They were so excited. They said, ‘This is exactly what we want to do – sign me up.’”

The e-consult program is expected to begin next week, and will help connect local residents with specialty care not readily available in the county. Patients will be able to meet virtually with specialists – neurologists, rheumatologists and others – and access remote care from a work room in the Valley Springs clinic with help from a nurse.

“So many people in this county have a need for specialty care,” Smart said. “I really think the e-consult program is going to be a huge benefit to our county.”

Smart and other staff have also been discussing a telehealth program for senior centers to provide care on select days, which will be similar to the RoboDoc program for schools, as well as a tele-pharmacy program based out of the soon-to-come pharmacy located at the Valley Springs clinic.

Access to telehealth is especially important in rural areas like Calaveras County, Smart said.

“Part of it is just the distance of the patient from access to care, but the other thing is there are just not a lot of resources,” Smart said. “We are a health professional shortage area, so we are recognized by the federal government as not having enough docs. And that’s not specialists, that’s primary care. … That is the perfect scenario for telehealth. That’s exactly what it’s designed for.”

Proponents of telehealth argue that it has the ability to lower healthcare costs and improve patient outcomes. By making access more convenient, telehealth can encourage patients to seek health care more frequently and address minor problems before they become serious issues, Smart said.

For patients that don’t have readily available access to care, “by the time they come in, the problem they have is often worse, but not only that, now they might have two or three problems,” he said. “And so the efficiency is not as good, the frustration is a lot higher, and the problems are worse. From that perspective, there could be significant savings not only in costs, but in suffering and quality of life.”

While many of the federal and state measures to expand telehealth were intended to lapse at the end of the COVID-19 crisis, Smart believes that the experience of providers and patients during the pandemic will result in telehealth becoming increasingly available in the coming years.

“There isn’t a lot of good about this pandemic, but one of the good things about it is it has pushed telehealth right out into the forefront of health care, and I don’t think we’re going back,” Smart said. “I think this is here to stay, and I think that it’s great that it’s here to stay.”



Noah Berner has lived in Calaveras County most of his life, and graduated from University of California, Santa Cruz with a degree in history.

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