The eHospital: Avera Sets Out to Build the Ultimate Telemedicine Hub

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After entering the telemedicine arena in 1993 with a service called eConsult, Avera has grown to be one of the nation’s most robust telemedicine hubs, servicing 31 hospitals through eight distinct service lines – including eEmergency. Telemedicine caught up with Dr. Brian Skow, executive medical director of the eCare hub in Sioux Falls, South Dakota, to learn about Avera’s operations.
Interview by Logan Plaster

Telemedicine Magazine: Describe your eCare “hub”. This is a somewhat novel concept, even in the telemedicine space.

Brian Skow: Here at our eCARE hub, our service lines consist of eEmergency, eICU, ePharmacy, eLongTermCare, which is our nursing homes; eCorrections, which is prisons; our eSchoolNurse, our eConsultative service and AveraNow, which is our direct to consumer play, partnered with American Well.

TM: Tell us a bit more specifically about eEmergency

Skow: eEmergency is our largest service line. We use high definition audio and visual equipment and it links emergency departments across our nation to board certified emergency physicians and in addition, emergency certified nurses at a centralized hub called eCARE. By pushing a red emergency button, the rural hospitals have immediate access to our eCARE staff for collaborative and peer-to-peer support for their local rural providers. And this occurs 24/7. Once our eEmergency video feed is live, our local rural emergency department determines what level of involvement they would like. They request the type of support they need for each patient. Our eEmergency physicians then can render decisions regarding what type of treatment when the local provider is not yet present. We can work with the nurses. And this occurs because we are licensed in their state and also credentialed and privileged in their hospitals. In all instances we are able to respond to emergent conditions as they arise.

TM: What makes Avera’s eCare unique in the telemedicine market?

Skow: It’s our suite of services. We have a team of 20 telemedicine board certified emergency physicians. And we’re providing support and guidance on patient care and we’re using our high definition cameras that have 20 times zoom capacity. Over the camera we can read an EKG from across the room; we can zoom into a GlideScope screen. We have the capacity even to read your iPhone if we needed from across the room. In addition we have a remote control where we can preset monitors. So for example if we’re on live with the facility, we can lock into a Lifepak, a vital signs monitor, their airway and just a broad view of the room through our camera with the push of a button. We’re also logged directly to their EMR. So in real time we can review labs, patient information. In many cases we’re alerted to a critical lab just by logging into their EMR. We can alert the providers and nurses that we need to treat something. In addition we’re logged in directly to their X-ray machines. So we review images in real time shortly after the X-ray or CT is completed.

TM: That’s eEmergency. What are some of the other services that you offer?

Skow: One thing we offer which is quite popular in the rural setting is our nursing documentation. This allows the local nurses to stay at the bedside and treat the patient while we perform all the documentation for them directly. We can directly enter it into their EMR or we can fax or scan it to them. At the end of the call they have all the documentation. What will happen is during a code, they’ll yell out where the IV’s going, what the bolus is, what meds are given in our nurse’s to document for them on our end.

TM: How do you handle privacy concerns when you talk about basically live-streaming every patient encounter?

Skow: None of the video calls are recorded. So we’re documenting just by listening to the audio, in addition to seeing what they’re doing. For example if they’re placing an IV in the right antecubital, we can see that over the camera. In fact we can zoom into the IV, see what color it is and document what gauge it is on their documentation.

TM: What long does it take for a spoke site to get up and running?

Skow: Before we go live, we perform a full site assessment. We send a team to the rural hospital and collect all their contact information, their typical transfer patterns, what flight services do they use. We go through their entire emergency department and determine what equipment they have already and what they may need in the future. We also look what medications they have so that we’ll have it all on file during a video consultation. We also look at lab capabilities, because not all labs can get a lactic acid. In those situations where we have a septic patient, we don’t even ask if they can get it because we know they can’t. And then we look at their ancillary services, including CAT Scan, ultrasound, anesthesia; to see what do they have available to call in if we need it.

TM: Why aren’t more regions doing this? I’m guessing the barrier to entry is the complexity of stitching together this whole eco-system. How were you able to create the holistic system?

Skow: We have 31 hospitals that are associated with our main hospital and the majority are critical access hospitals. We started off seven years ago just with three sites. We asked: “What can we do to keep patients in their local facilities, to be admitted there?” Typically patients do better in their hometowns. And how can we keep them in their local hospitals by assisting the rural hospitals? This also increases their revenue by keeping their patients local. So it all started as a need that we found in our local rural hospitals.

TM: Talk to us about the reimbursement/fee structure.

Skow: It’s a monthly fee model, per facility. We didn’t want to limit the button pushes. For example, we’re happy to take a look at a rash at 4:00 in the morning. If we charged on a per click model, that rash might not make the cut. But what if the patient also had a fever and it happened to be meningococcemia? Well, that could potentially be a lethal rash. If we’re limiting button pushes by having the local facility pay per button push, we might have missed that case.  It’s a fee per month and there’s no limitation on how many times they can push the button. However, what we’ve found is that throughout our 140 eER sites and 255 cameras that we have out there, the sites are really using us appropriately. We’re typically involved in five percent of their total census volume. So, they’re pushing the button only for the sickest of the sick patients. The monthly cost is based on the facility and typically not off of volume, because for example a facility that sees 12,000 a month might only use us two to three percent of the time while a facility that sees 5,000 a month might use us ten percent of the time. However we do have grants available and the majority of our rural hospitals do receive grant funding initially. We receive a lot of support through the Leona M. and Harry B. Helmsley Charitable Trust.

TM: What kind of numbers do you have showing specific cost savings?

Skow:  They can put it on their Medicare cost report, which reduces the annual expense by 30 percent. In addition we’ve found that the billing for hospitals that utilize eEmergency increased from a range of 100 to 200 per visit and also increases ancillary services. So we look at an annual impact per site of revenue of $15,000. We also reduce the transfers; 25 percent is our average for reduced transfers. Which in these cases an annual net revenue can be calculated around $25,000. We also are seeing workforce retention. When our eEmergency board certified docs are in consultation with nurse practitioners and PAs, there’s less burnout because they have backup. In fact, we’ve had PAs and nurse practitioners that have worked in our facilities and when they’ve left and gone to a facility that doesn’t have eEmergency, one of their first questions is: When are they getting it? It’s similar to vRad. When a radiologist goes out and interviews, they want to make sure they have that nighttime coverage. So through eEmergency we can provide that similar support.

TM: Physicians in other regions might say that they want this support, but they might not have the charitable trust. How critical is that element?

Skow: We’re able to sell it to rural facilities without the grant support. It’s approximately the cost of one full time nurse. And just through our nursing documentation piece alone, that’s almost a full nurse FTE. In addition, we’re providing the physician support also.

TM:  Is this a sustainable business outside of the grants and the charitable trust?

Skow: Yep. When we first started eEmergency, one of the goals is we had the support of the trust but we wanted to get to a point where we were supporting ourselves. And to get to that point, we needed to be established in at least 60 to 80 eEmergency facilities and we’re above that now. So without the support to get there, to that point, that was kind of our breakeven area.

TM: And how long did it take to reach that sustainability marker?

Skow: It took three to four years.

TM: How big would you guys like to get? How far beyond the region do you want to expand?

Skow: Typically what we do is we look at a critical access hospital map and say: Where are the most critical access hospitals? In addition to the Midwest we are also in New Hampshire and Vermont, as our furthest East location. In regards to expansion, we’re open to expanding to wherever the need is at.

TM: Do you also expand by dropping in local eEmergency centers for providers? Or do you just have one main facility for that?

Skow: That’s a good question. How we’ve structured it is we have a centralized eEmergency hub, where all of our physicians and nurses work. So we have the capacity with a number of physicians and nurses here in Sioux Falls to continue growth to multiple states.

TM: As a work environment, the eEmergency hub that you’ve created seems really unique. Emergency physicians and emergency nurses coming to work in a high-tech non-hospital environment, where they’re dealing with physicians over video but they themselves are in a room somewhere else. That’s sort of a new healthcare paradigm. Do the physicians get to collaborate on cases with one another? What would you say are some of the unique aspects of that hub environment?

Skow: There are many unique aspects in regards to collaboration at the eCare hub. We’ve had for example a case where our long-term care facility, staffed by fellowship-trained geriatricians had a case in a nursing home where a patient had fallen and hit her head. She’s on Coumadin and went unresponsive. So we saw that case over the camera. That case was transferred to the local rural emergency department, where we have cameras. So now it went from long-term care to an eEmergency call. So we determined that we needed rapid airway assessment, intubated, got our flight team there. From that point, she went from the rural critical access hospital to our main campus, where we also have a camera in our trauma room. So this is her third camera interaction. So now she’s in eEmergency camera number two, where we assist with the nursing documentation for the trauma code. When she was stabilized in the ER, she is transferred up to our intensive care unit; where our eICU intensivist was on board. So in one building we were able to give direct hand-off from geriatrician to ER physician to the intensivist and we’re all communicating under one roof.

TM: And there’s actually communication offline? Do physicians get up and talk to one another during these cases?

Skow: Absolutely. We’re just a few steps away in the one building here. You can just take a few steps over and give the short story or do it over the phone if you’re busy at that point.

TM:  How many people work in your hub facility?

Skow: We probably have over 200.

TM: How do you find the clinicians feel about that work environment?

Skow: Telemedicine isn’t for everybody. When we interview our partners, what we look for is what we call a telepresence: somebody that interacts well in front of the camera and is aware of their visual cues. We also offer media and camera training for our staff before they go live because not everybody is always a good fit. In addition, there’s really a big customer service piece for our facilities that you may not see as much in the main ER. In addition, we don’t take new graduates. We wait until you’re board certified and typically at least three to four years out of training. We want you to get your feet wet before we put you in front of the cameras.

TM: Any recent memorable cases?

Skow:  Recently we had a button push for a rattlesnake bite and this was in our Badlands of South Dakota, near the Mt. Rushmore area. It was a young mother and her daughter that were on a afternoon hike when they stumbled across a den of rattlesnakes. The mother was bitten multiple times in the lower extremity. The daughter was able to help drag her away from the snakes; called 911. And at that point the red button on the wall was pushed. She arrived. She is unstable. She was in shock. We went ahead and administered the anti-venom, the Crofab. And she went into full-blown anaphylaxis. Over our cameras we are able to see the airway – our Glidescopes are attached directly to our cameras – just as if we were there intubated ourselves. Unfortunately, the patient’s airway completed swelled shut. It was a failed airway. We were unable to intubate. At that point, we had our flight team and two family practice doctors – each of whom have the capacity to do a trich but hadn’t done one in multiple years. Using our handheld camera, we were able to peer right above the neck and identify landmarks and essentially walk them through a complete cricothyroidotomy. We were able to get the airway in the patient. The patient was flown to our facility and she walked out of our hospital just a few days later, completely neurologically intact.

And these are some of the procedures that we’re able to assist with over the camera; that we’re experienced in, that the local providers, nurse practitioners or PAs just don’t get that exposure to like we do from our training.


Logan has created, edited and designed healthcare publications since 2005. After redesigning and managing Emergency Physicians Monthly, he founded Emergency Physicians International in 2010, and then launched Telemedicine Magazine in 2015 where he served as writer/editor until 2018. Logan is the co-founder of The mHealth Toolbox, a project that brings practicing physicians into the conversation about innovative medical technology. Logan also served as the Director of Communications for The IFEM Foundation, the leading non-profit supporting global emergency care development.

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