If you ask an attorney, says David Kapaska, D.O.’86, the standard of health care is the same at the renowned Mayo Clinic as it is in Bowdle, SD, population 499 (U.S. Census Bureau).
“That’s a high bar,” says Kapaska, regional president and chief executive officer of Avera McKennan Hospital and University Health Center in Sioux Falls, SD. “Patients should be able to expect that same standard, but it’s hard to do in a small town.”
Hard to do because of several factors, such as a paucity of primary care providers and specialists in rural America, the geographic distances rural patients typically have to travel to get care and the chance that bad weather can make that travel difficult or impossible. Those are among Avera’s constant challenges, with a service area spanning 71,550 square miles over five states.
Yet Avera Health Network has succeeded in delivering high-quality care with what is likely the nation’s most comprehensive approach in telemedicine. An article in the Atlantic Monthly in December noted that the network provides a broad range of services that “take advantage of technology – including high-definition two-way video consulting – to make it possible for experts to be available 24/7 in locations throughout South Dakota, North Dakota, Minnesota, Iowa, Wyoming and Nebraska.”
Kapaska played a lead role in Avera’s innovative achievement. A graduate of the U.S. Air Force Academy who flew Air Force cargo planes for seven years, he earned his master’s of business administration degree from Southern Illinois University, worked for Mobil Chemical in sales and then “got this crazy idea to go to medical school.”
Those diverse experiences shaped his career, including his family practice training at Des Moines’ Lutheran Hospital and in family practice in Ankeny and Sac City, IA, his hometown.
“Having an M.B.A. before medical school was rare. Any time anything remotely related to business came up, they’d say, ‘Give it to Kapaska – he’s got an M.B.A.,’” he says. “I got into these projects and found I enjoyed them.”
In 2004, he began guiding development of Avera’s “eICU Care,” which connects critical care experts to rural locations and allows patients to get care in their communities instead of being transferred to larger hospitals. A study by Leapfrog Group, a consortium of large employers that work together to purchase health care services in ways that enhance quality and affordability, had shown that patients in intensive care units have better outcomes when their hospitals have intensivists on staff, the physicians who specialize in the care of the critically ill.
“My boss said, ‘How are you going to do that at all our locations and meet that standard?’” Kapaska recalls. “It was an opportunity to answer that question, of how you take care of really sick patients especially when you don’t have all the specialists at your elbow. Basically, the eICU is air traffic control for all intensive care patients.”
Avera’s eICU Care lets critical care doctors in Sioux Falls see and treat those patients remotely. They have access to each patient’s health records; all electronic data feeds, such as heart rate and blood pressure; lab test results; and input from staff on-site with the patient.
“With the high-resolution camera in the room, the physician [in Sioux Falls] can easily look at the patient’s pupils and count their nose hairs,” Kapaska says. “It’s like being in the room with your hands in your pockets.”
Computers enhance patient care by monitoring health status variables within certain parameters. “If, for example, a patient’s heart rate goes outside a set of parameters, a warning light goes on to say, ‘Hey, look at me!’” he explains. “There are 60 to 240 variables going on at any one time with an ICU patient. Our brains are capable of watching seven, plus or minus two. With the computer watching, that allows one doctor and one nurse to watch after 75 critical care patients. The eICU is monitored all the time.”
The benefits are many, Kapaska says. He and his colleagues have found that patient outcomes are improved dramatically. The average number of days patients were on ventilators declined by a day. And in many cases, telemedicine allows patients to get the care they need in their own communities.
“I’m amazed at the variety of things providers are asked to take care of in rural areas. The ability to connect with specialists can fill a lot of gaps,” he says. “Weather is a major challenge for us here. Sometimes the sickest patients need to be transferred during the worst weather. Moving them can be dangerous and is a tremendous burden for their families.”
“With the high-resolution camera in the room, the physician [in Sioux Falls] can easily look at the patient’s pupils and count their nose hairs. It’s like being in the room with your hands in your pockets.”
Avera has expanded its use of two-way communications and video equipment into a suite of technology applications – eEmergency, ePharmacy, eHospitalists and eLong-term Care, which serves nursing homes – that link rural medical staff to experts at a central hub, 24 hours a day, seven days a week. Obstacles exist, including the fact that medical regulatory and payment systems are based on the in-person provider-to-patient approach, and the orientation of physicians to “see patients in a room and push on tummies,” Kapaska says.
He believes the need for greater access and efficiency in health care will help push change.
“By proving we could significantly improve outcomes through e-medicine for our critical patients, that proved telemedicine is a viable option of care for all patients,” he notes. “With health care reform and accountable care organizations, we see more centralization of health care and can start to think about these systemic solutions. We’re being asked: Are there other ways we can be as effective as possible with less cost? I think telemedicine is one way.”