The Rural Drive-By...Not as Loud but Equally Deadly

Drive-By’s are happening every day in Rural America.  In this case, it's the resident driving by their local hospital in favor of the city.   Viewed as good enough for the sniffles, but not for more serious issues, rural medicine has an image problem.  Unfortunately, it's hard to make a living treating the sniffles.  Mixed with the sprains and cough, there needs to be cancer patients, heart disease and kidney failure.  And ultimately, as goes the hospital, so goes the economic health of the community.  The rural hospital is often the primary direct and indirect employer of the town.

Keeping the patients they can, sending those they can't

A rural hospital can not compete with their urban counterpart.  Size matters for sub-specialization. Academic center of excellence with cities.  These factors determine "brand" for the consumer.

Ideally, rural centers would work in close collaboration with urban centers .  I am not suggesting a moniker on a building ( "X" Community Hospital in partnership with University of Whatever).  There should be a close relationship where the patient sees equalivant care delivery.  

Ideally, patients would see and talk to their specialty nurses and doctors at their local facility.  Travel would be reserved for serious issues- surgery, advanced radiation.  Infusion, follow-up imaging and other recurrent services would be performed locally but overseen remotely.  This provides shared revenue model for the urban and rural center while the patient gets convenience and reassurance. 

Nerds don't live rural....healthcare as a managed service

Telemedicine (tmed) is an enabler of this vision.    With tmed, the patients can meet and review their results with an oncologist hundreds of miles away.  The nurse from the city can be there during chemotherapy.  When it's time for a bone marrow, it's time to drive.  

To date, tmed has been an expensive proposition.  First, there is all that equipment to buy, and then you have to find a nerd (to feed and water the technology). Nerds are hard to find in small towns.  But, things are changing.  The cloud, aka...servers in the sky, can delivery tmed to a PC or handheld, over a browser.  This frees providers to manage patients, not technology.

And , the timing is good.  The telcos are starting to see an opportunity.  Providers can purchase healthcare infrastructure as a subscription.  Get your movies, your EMR, your system for referral and collaboration, etc..all as a monthly subscription, everything kept up to date, HIPPA and HITECH compliant.  No local nerd is required.

Rural hospitals are integrally to the economic health of their communities.  Unless we want a country of urbanites, care delivery models must evolve. Rural centers should keep the patients they can and send only those they can't.   Collaboration enables better care, patient reassurance and revenue sharing.  Technology has evolved to execute on these business imperatives.  We just have to think about care differently. 

Topol's Healthcare in American - At a Crossroads of Innovation and Ossification

I recently read Eric Topol’s Creative Destruction of Medicine: How the Digital Revolution Will Create Better Health Care.  I highly recommend it.  Dr. Topol’s main premise is that innovative deconstruction of people (patients) into their more base components- (their DNA, RNA and proteins), will help us design better, more personalized treatments for a host of diseases.  

This relates to the science of pharmacogenetics, how our genetics individualize our respond to drugs.  This is in contradistinction to the current pharma model- treat as many people as possible even if the benefits are modest for most.  

Unfortunately, as Topol points out, medicine as an institution, and physicians in particular, have not kept pace.  The system is relatively ossified.  Through a combination of bureaucracy and tradition, medical education has not changed substantially since the last great paradigm shift, Flexner Report, in 1910.  In the face of an information explosion, the subjects I studied in medical school 25 years ago were similar to those my father learned 50 years ago.  Unless something drastic happens my daughter, currently a pre-med, is likely to have a similar curriculum.  This results is a type of healthcare delivery focused on the hospital, not the clinic, emphasizing the heroic not the chronic.  In part, this mismatch has lead to the US spending almost twice what other nations spend for healthcare with no perceptible benefit.  This is not sustainable.  Of course today’s medical students and residents are more likely to Google for answers than open a book.  Physicians no longer have to be walking encyclopedias.  However , the system continues to value test taking over personality.  I personally believe the best test takers do not make the best providers- just the opposite.   

The book regrettably gives short rife to telemedicine and opportunities for collaboration.  With the information explosion, no single provider can have all the answers.  More granular data will only exacerbate this problem.  Healthcare is moving from a one on one sport to more of a team game.  In order to have a sustainable delivery system, each provider will have a role to play to fully realize the value of new, personalized therapies.  Telemedicine can be leveraged to bring the healthcare pyramid, stratified expertise, to the bedside.  Most people think of this as expensive, limited technology.  However, browser based solutions allow telemedicine to be done over devices in your pocket.  Teams can be brought together to enable the right care at the right time.

Overall, I agree with Topol’s primary assessments- granular data will allow more effective, personalized treatments, and that the current educational and care delivery models are ill prepared for these disruptive innovations.  However, ultimately personalized medicine will be a combination of technology and choice.  No therapy, no matter how elegant, is without risk.  The past few decades have taught us that just because we can do something, even extend life, doesn’t mean we should.  The role of the provider and the team will be to understand the patient, their desires and act as a translator in this brave new world of personalized medicine.