Business of Medicine
Telemedicine in Georgia – 2017 Update
October 12, 2017
By any measure telemedicine services across the country are in a growth mode. From an estimated 350,000 patient users in 2013, telemedicine services are expected to reach 7 million patient users in 2018, a 2000% increase. The global telemedicine market value is set to hit $36.2 billion by 2020, up from $14.3 billion in 2014.
The market forces driving this growth are numerous. Less costly interactions with physicians, more frequent and efficient monitoring of chronic health problems, and increased access to specialty care that would otherwise be unavailable or logistically difficult all play a part.
The telemedicine trends seen on a national level are also evident in Georgia. Telemedicine continues to grow and its use has been addressed by both the Georgia State Legislature and the Georgia Composite Medical Board. It is expected that telemedicine use will continue to grow in Georgia both in the number of interactions between healthcare providers, the number of patients utilizing the technology and in the breadth of conditions evaluated and treated with telemedicine. The impetus behind the growth of telemedicine in Georgia is similar to the growth on the national level, but, from a patient safety perspective, the increased ability of rural Georgians to access specialty care is one of its greatest benefits.
Georgia is predominately a rural state. Of Georgia’s 159 counties, 109 are classified as rural according to the Georgia State Office of Rural Health. Residents of these counties tend to be older, have less health insurance, and have higher rates of chronic health conditions such as diabetes, heart failure and obesity. According to a report by the Georgia Board for Physician Workforce, these rural counties lack access to medical care that residents of urban areas in Georgia enjoy.
Telemedicine is a tool that has helped bring needed healthcare services to rural Georgians. While there are many important telemedicine initiatives in our state, what follows is a brief discussion of three telemedicine projects in Georgia and how they have impacted rural Georgians.
Child Abuse and Neglect Resources
Each year, thousands of children in Georgia require specialized evaluation and care in cases of sexual or physical abuse and neglect. While these children may reside anywhere in the state, resources needed to evaluate these children are concentrated in urban areas, making access to these resources logistically difficult for patients and their families.
To address this disparity in access between urban and rural children, the Children’s Healthcare of Atlanta Center for Safe and Healthy Children (CSHC) turned to telemedicine. In 2009 the CSHC partnered with the Georgia Partnership for Telehealth and several child advocacy centers around Georgia to provide children in rural areas access to practitioners who specialize in child abuse and neglect. Child advocacy centers provide education, intervention and treatment to victims of child abuse or neglect.
In the case of suspected abuse, legal authorities will contact a local child advocacy center associated with the telemedicine network and schedule a telemedicine consultation. At the appointed time the child and parent come to the child advocacy center where they are met by a social worker and a medical professional, typically a nurse. The nurse explains the procedure to the family and introduces the family to the specialist. The specialist in Atlanta greets the family using a high-resolution video and audio interface that allows for two-way conversation. Together the nurse and doctor elicit the history and the nurse performs a physician examination on the child with the guidance of the specialist.
Beyond reaching children with medical resources that might otherwise be unavailable, the benefits of using telemedicine in suspected abuse cases include decreased parental anxiety along with the prompt evaluation of children. There is also the benefit of families and law enforcement officials not having to travel for evaluation, saving time and travel expenses.
According to Dr. Jordan Greenbaum, a staff physician for the CSHC, there is another benefit of the telemedicine interaction. The interactions are a way to act as mentors to sexual assault nurse examiners, or “SANE” nurses, in remote areas. Physicians at the center in Atlanta can provide pointers and coaching during evaluations to build the confidence and expertise of the SANE nurses who can then provide more care independently.
Decreasing Preterm Birthrates
In its 2016 Premature Birth Report Card, the March of Dimes gave the state of Georgia a grade of “D” based upon the state’s preterm birth rate of 10.8%. Georgia ranked 32nd out of the 50 states according to the March of Dimes. While preterm births are a problem in both urban and rural settings, the difficulty of accessing appropriate medical care, particularly for high-risk pregnancies, is more acute in rural areas of the state.
To address this lack of access, the Southwest Health District’s Centering Pregnancy® program teamed with Women’s Telehealth in Atlanta to deliver access to advanced pre-natal care through telemedicine to minority populations in two counties in Georgia. The program initially focused on low-income African-American women in Dougherty County and then expanded to (often undocumented) low-income Hispanic women in Colquitt County.
The women meet in groups for educational programs periodically during their pregnancies. They are joined, via television monitor and audio connection, to a remote maternal fetal specialist who participates in the educational session. If the women experience no problems during their pregnancies, they have no additional interaction with the specialist. If, however, they were to develop a complication, they are already familiar with both the specialist and the telemedicine format. This familiarity can ease any apprehension the woman may have about an obstetric evaluation using telemedicine.
Initial results of this program show promise in reducing rates of preterm deliveries. The rate of preterm births among African-American women in the Southwest Health District from 2004 to 2008 was 18.2%. The Dougherty location, where the telemedicine intervention was implemented, had a preterm birthrate of 8.6%. Similarly positive results were seen among the Hispanic women in Colquitt County. Compared to the rate of preterm births of 12.1% for all Hispanic women in the District, those in the Centering program had a preterm birth rate of 6.7%.
Bringing Specialized Stroke Care to Rural Hospitals
Nearly 800,000 people suffer a stroke every year in the United States. It is the leading cause of long-term disability and one of the top causes of death in the US. The numbers are similar in Georgia where stroke was the fifth leading cause of death in 2014 according to the CDC. In 1996 the Food and Drug Administration (FDA) approved tissue plasminogen activator (tPA) for the treatment of acute stroke.
While tPA could be found in most hospitals’ pharmacies, it use was rare for many years after its approval by the FDA. The reason for this was that the medication was most efficacious if used quickly after symptom onset. Most small hospitals, however, did not have neurology specialists who were comfortable administering the mediation. The end result was that stroke victims were transferred to tertiary care facilities where they could see a specialist in stroke care, but they were outside of the temporal window for treatment of the stroke.
The situation at Augusta University, a leading stroke treatment center, was similar. They were admitting half of their stroke patients from outside hospitals and they were using tPA approximately once per month to treat acute strokes. In the early 2000s a group of doctors at Augusta University decided that telemedicine could help get quick specialist evaluation of distant patients with stroke symptoms.
Their initial tools involved one-way video capacity coupled with audio provided by phone line. The service was provided to eight small, rural Georgia hospitals. While the service and reach of the project was limited, the doctors began to see clinical improvements in their stroke patients. The neurologists, centrally located in Augusta, had enough clinical information to make educated decisions about the best course of treatment. Physicians in the distant emergency departments and hospitals could feel reassured that their clinical decision making was being aided and supported by an expert in stroke evaluation and management.
The program has flourished and now serves 30 healthcare facilities in Georgia and South Carolina. The technology now allows for two-way video and audio which is integrated with clinical workflow and patient data. A PACS viewer is included and clinical documentation can be completed contemporaneously. The technology is designed for rapid, easy deployment by appropriately trained personnel. Administration rates for tPA have increased at all facilities served and clinical outcomes have also seen improvement. Augusta’s telestroke system continues to grow and has been implemented in other healthcare networks around the country.
The three examples above show how telemedicine has begun to take root in Georgia. The ability to reach areas of our state with sophisticated medical care through an economical medium will benefit not only the residents of rural counties, but will also improve the overall health of Georgians.
What does the future hold? As telemedicine technology improves and becomes more affordable, the possibilities are immense. The diabetic who can transmit his blood sugars daily to his home health nurse, the patient with CHF who sends his weight each day to his internist or the patient in the emergency department at a small, critical access hospital who can have a minor fracture evaluated by an orthopedic surgeon in Atlanta; all of these patients can benefit from telehealth.
 IHS Technology report, January 17th, 2014.
 Nathaniel Lacktman, “Five Telemedicine Trends Transforming Healthcare in 2016”, November 16, 2015, Foley & Lardner LLP, published on website.
 Georgia’s State Office of Public Health Presentation to Georgia Southern University College of Public Health, February 11, 2009.
 “Doctor shortage Remains Acute in Rural Areas” Georgia Health News, January 2, 2014.
 CenteringPregnancy® is an evidence-based model of scheduled health assessments and educational opportunities for pregnant women. The women are placed in gestational age matched groups that are going through similar physical, mental and social changes secondary to their pregnancies.
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