By Bonnie Barber
In early May, 83-year-old Pauline Labrecque had a consult with Dartmouth-Hitchcock Medical Center (DHMC) nephrologist Thomas Kaneko, MD. A diabetic, the Groveton, resident had been experiencing kidney problems. But instead of traveling 100 miles from her home to DHMC in Lebanon, Labrecque's daughter Rose McGlone drove her ten miles to Weeks Medical Center in Lancaster, where she had a telehealth appointment with Dr. Kaneko.
"I really enjoyed talking face-to-face with the doctor on the TV," says Labrecque, who worked for 41 years at the Groveton Paper Mill before retiring. "It was just like he was there sitting in front of me. And it saved quite a trip for us. It is two hours down to Dartmouth and two hours back, so this was nice."
She talked to Dr. Kaneko via the built-in camera and monitor on a telemedicine cart while sitting in an examination room with Weeks registered nurse Maureen Eaton at Weeks' Lancaster Physicians Office. Labrecque is one of more than 20 patients Dr. Kaneko has seen since March, when DHMC's Nephrology and Hypertension section and the D-H Center for Telehealth launched a chronic kidney disease program with Weeks. Care Coordinator Lisa Wheelock, RN, who runs Weeks' telehealth program, says patients have been "thoroughly impressed" with the telehealth consults. "Our list continues to grow, with new patient referrals every month," she says.
Help Managing Patients with Chronic Disease
Weeks had earlier partnered with DHMC on a telehealth kidney dialysis clinic in 2014, in which patients consulted with DHMC nephrologists during dialysis, using an iPad with secure video software to talk to them. With no nephrologist on staff, Weeks needed additional help managing its large volume of chronic kidney disease patients whose conditions had not yet reached the dialysis stage.
According to Brian Remillard, MD, section chief of nephrology and hypertension, Weeks has about 100 primary care patients with glomerular filtration rates of less than 30, who have never been seen by a nephrologist. GFR is a measure of how well your kidneys filter blood and a number below 60 may indicate kidney disease. While several Weeks patients had been receiving care at DHMC, Dr. Remillard says many patients were finding it increasingly difficult to travel to Lebanon.
"We've seen patients not coming to DHMC for appointments because of cost, distance, and economics," says Dr. Remillard, who notes that patients whose kidney conditions are not managed by a nephrologist may ultimately wind up in the intensive care unit. "So we started to pick out patients from the North Country and asked them if they wanted to try the telehealth solution."
"We had a willing partner in Weeks Medical Center," adds DHMC continuing care manager Judy Dixon, RN, CNN. "And we knew we had patients in need because we had more than a handful who said they just couldn't get down here any more."
DHMC's chronic kidney disease team then worked with the D-H Center for Telehealth to set up the new telehealth program. Jamie Carmichael, the Center for Telehealth's ambulatory care service project coordinator, says the project launch was seamless since Weeks already had two telemedicine carts in place. They are being used for Weeks' telehealth programs with DHMC's rheumatology and dermatology sections, and by an ALS patient who consults with his DHMC neurologist via telehealth. The telemedicine carts were distributed to Weeks thanks to a nearly $1 million United States Department of Agriculture grant awarded to the Center for Telehealth in 2014 to help fund the deployment of telemedicine equipment and services across six counties in rural New Hampshire and seven counties in rural Vermont.
During Labrecque's telehealth consult she spoke first via live video with D-H continuing care manager Patricia Borden, RN, CNN, just as she would have done during an in-person consult. After answering questions such as whether she learns best through reading, videos, or one-on-one sessions so that Borden could provide her with the appropriate educational materials, Dr. Kaneko then appeared on Labrecque's monitor. Dr. Kaneko asked questions about her health and was also able to perform a physical examination thanks to two electronic stethoscopes—one at Weeks and the other in Dr. Kaneko's office—that communicate with each other.
"The fact that I can listen to someone's heart from 100 miles away just fascinates me," says Dr. Kaneko, who explains that the nurse places the stethoscope on the patient's chest and the sound is transmitted directly to his stethoscope, enabling him to listen to their heart and lungs. "I can really do a fairly thorough assessment of patients. There are certain very sick, very complex patients that you have to see in person and certain procedures that you have to be physically present for. But so far, with select cases, we've been able to take care of patients. And they seem to really like the telehealth option."
McGlone was certainly impressed by the high-tech care her mother received at Weeks. "I was amazed that the nurse here could put certain instruments on her (a detachable camera) and the doctor could see if she had swelling in her feet," McGlone says. "We don't have many healthcare options here in North Country, so this is very helpful for people up here. It eases the mind, body, and spirit knowing that we can get this kind of care."
Convenience and Effectiveness of Telehealth
"For a patient who is doing very well and managing his or her medical issues okay, this is a fantastic way to see them," Dr. Kaneko says. "We'll be monitoring her blood pressure, because keeping that under control is key to avoiding dialysis, and also monitoring her potassium and vitamin D levels, among other things. But the nurse at Weeks or her primary care physician can do this testing and then provide me with the results. She just needs a nephrologist to oversee everything."
Weeks' director of physician services Rona Glines says that patient feedback has been extremely positive, and that patients appreciate the convenience of telehealth and the access it gives them to specialists.
"Having the telehealth clinics in our Lancaster office allows patients to receive services closer to home, often in the same office where they see their primary care provider," says Glines. "Traveling to DHMC is time-consuming and can be a real hardship for some of our patients. By partnering with specialty practices at Dartmouth-Hitchcock, we have increased our knowledge in those areas, which has been helpful in caring for our patients."