Long-Distance Expertise

Virtual appointments and consultations help remove barriers to delivering specialty care

on-demand consultations with patients and physicians at smaller community or critical care hospitals in the region. Scheduled outpatient virtual visits peaked at more than 2,500 per day at the height of the pandemic and are currently leveling off at about 700 per day.

“The Department of Medicine was an early leader in telehealth,” says Katelyn Darling, director of Telespecialty Services and Outpatient Virtual Visits. “They were doing telemedicine even before the pandemic. They got their providers trained and patients set up before the shutdowns, so they had fewer technology failures.”

SSince the onset of the pandemic, virtual appointments have become widely used and greatly appreciated by patients and physicians alike. Dartmouth Health has long been ahead of the curve in the move toward telemedicine.

“This is a rural area and access to specialty care is challenging,” says Kevin Curtis, MD, MS, the medical director of Dartmouth Health (DH) Connected Care, which partners with healthcare providers and medical facilities throughout northern New England. “A patient might be hours away and have to take a day off of work. Travel might be difficult, or they might not have childcare. So how do we bring specialty care to this area with a strong focus on rural care?”

The answer was the Center for TeleHealth, established at DH more than a decade ago, and its services have broadened in that time to include

The department continues to lend its expertise to people who need specialty care and medical advice— even if they’re 100 miles away.

Rheumatology

Long before the pandemic, Daniel Albert, MD, and other DH rheumatologists had an arrangement with outlying hospitals to treat patients virtually from those facilities. Rather than driving several hours round-trip to Dartmouth Hitchcock Medical Center (DHMC), patients went to their regional hospital and had a virtual consultation with a DH rheumatologist. A nurse at the local hospital assisted the patient in-person. While the volume was low at the time, patients found the virtual visits much more convenient.

When COVID-19 struck the country, however, patients did not want to go to their local hospitals for fear of contracting the virus, so DH switched to virtual visits in patients’ homes. Albert estimates that 80% of his appointments were virtual during the worst surges, and he now serves about 30% of his patients through telemedicine. He sees patients in-person if that’s their preference or when they need a physical exam or have other medical conditions that make telemedicine difficult.

“I like to do telemedicine because patients like it,” Albert says. “I also like that patients often feel more open about their medical situation when they’re at home. I can see their home environment, and that gives me perspective of people’s living situation—a significant other who might not attend an in-person appointment, or kids and pets. I get a more rounded view of the whole person.”

Gastroenterology and Hepatology

Patients who need subspecialty care for complex conditions might have to drive two or more hours one way to see physicians at DH, says Corey Siegel, MD, RES ’02, FEL ’05, MS ’09, section chief of Gastroenterology and Hepatology. He says telemedicine has been a valuable way to deliver care for subspecialty chronic disease management for patients with no alternatives closer to home.

The Inflammatory Bowel Disease (IBD) Center in the GI section started a new program funded by the Helmsley Charitable Trust called RADIUS—rural APPs (advanced practice providers) delivering IBD care in the United States. Through this program, DH providers partner with small regional practices to deliver specialty care for people living with Crohn’s disease and ulcerative colitis in northern New England. In a two-hour virtual visit, these patients see a team of DH providers—an IBD specialist, a psychologist, a dietician, a pharmacist, and a nurse coordinator.

“We’ve had wonderful feedback from patients about how comprehensive the visit is,” Siegel says. “Having IBD is not only about the bowels but also about how the disease affects their entire life. It takes a team to give the best care to this group of patients, and now patients can see the entire subspecialty team from home.

The DH specialists mentor rural APPs who continue the patient’s care at a regional practice. “It’s a way to provide high-level care without patients having to drive here,” Siegel says. “The APPs in these rural practices are able to care for their patients in their own communities with the virtual support of our team of providers.

Infectious Disease

Infectious disease is a small specialty with few physicians in the New England area, but their expertise is invaluable to patients living with HIV/AIDS, hepatitis C, and other diseases. Distance, however, can be a barrier to delivering this expert care.

The outpatient parenteral (IV) antimicrobial therapy (OPAT) program helps mitigate that problem, serving patients who are discharged from DHMC but still need close monitoring for their long-term antibiotics, says Bryan Marsh, MD, D ’80, RES ’93, FEL ’96, section chief of Infectious Disease and International Health. OPAT allows high-risk patients in rural areas to see a dedicated nurse practitioner at their local hospital for interim follow-up care. The patient returns to DHMC only for an end-of-treatment visit.

“OPAT improves post-discharge care for patients who need institutional medical care,” Marsh says. “Without OPAT, some of these patients wouldn’t come back and be seen by a provider, and they wouldn’t get the standard of care they need.”

Weight and Wellness

At the DH Weight and Wellness Center, both outpatient appointments and group classes are offered virtually for patients who need coaching and lifestyle medicine, such as counseling from psychologists, dieticians, or fitness trainers.

Auden McClure, MD ’99, RES ’02, FEL ’04, RES ’08, MPH ’08, the interim section chief of Obesity Medicine and co-director of the Pediatric Lipid and Weight Management Center, says the weekly and monthly virtual group classes are beneficial because they allow DH providers to reach more people at one time. They also facilitate group interaction and peer support no matter how far apart people may live from one another.

Providers are aware that patients have different needs, particularly if they do not have access to the internet or are not comfortable with the technology.

“We partner with the patient to see what’s best for them, either in-person or virtual,” McClure says. “We don’t want telemedicine to be a barrier; it’s an additional tool.”

Critical Care Support

Small, rural community or critical care hospitals often don’t have a specialist on call in the emergency department. Thankfully, the Department of Medicine’s TeleICU and TeleEmergency experts are only a video conference away.

“Most ICUs in the country are staffed by hospitalists who don’t have critical care training,” says Jeffrey Munson, MD, MSCE, medical director of the medical intensive care unit. “We provide critical care expertise to support hospitalists who are caring for their patients at different facilities.”

A critical care specialist on the TeleICU team rounds on patients virtually at four regional hospitals, and someone is on call 24/7 to monitor patients’ vitals and to answer bedside questions from physicians and nurses. High-definition video-audio calls, Munson says, allow the TeleICU provider to see the patient, almost as if they’re in the same room. “It’s better than a phone call because we get a better sense of the situation and the best advice to give.”

TeleICU has two objectives: ensuring patients get the best possible care and helping patients stay at their regional hospital rather than being transferred to a tertiary care center. “This helps alleviate bed capacity problems,” Munson says, “and makes sure patients are getting safe and effective care.”

Department of Medicine

Scholarship Enhancement in Academic Medicine (SEAM) Awards Program

“We partner with the patient to see what’s best for them, either in-person or virtual. We don’t want telemedicine to be a barrier; it’s an additional tool.”

Looking to the Future

Now that telemedicine has become part of the everyday medical experience for patients and providers, DH intends to determine how well it’s working through research. For example, Albert recently published a paper called “Addressing Competency in Rheumatology Telehealth Care Delivery ” and authored two chapters in a new book titled Telerheumatology He also has published research on his earlier years of providing rheumatology telemedicine, including “Disruptions in Rheumatology Care and the Rise of Telehealth in Response to the COVID-19 Pandemic.”

Additionally, Albert secured a grant to develop several short, animated videos to educate providers and patients on preparing for a telerheumatology visit.

“COVID removed many barriers and made telemedicine possible in this country,” Albert says. “Now we must figure out what it’s good for and what it’s not good for so people are appropriately triaged. It’s an ongoing enterprise that’s important to Dartmouth Health.”

The SEAM Awards Program supports academic “dreams.” Successful proposals may include innovations in teaching, discovery/research, publication/ presentation, practice improvement, and/or digital scholarly communications, with the ultimate goal of enhanced quality of patient care. The SEAM Awards funding exceeds $1,255,127 since 2018.

Academic Year 2023 SEAM Awards

Reprogramming the Immune Microenvironment Using a Copper Depletion Strategy in Metastatic Non-Small Cell Lung Cancer

Project Leader:

Ivy L. Riano-Monsalve, MD, PGY4 Instructor in Medicine, Geisel School of Medicine; PGY4 Hematology and Oncology Fellow, Section of Hematology and Medical Oncology

DNA Methylation as a Marker of Corticosteroid Response in Polymyalgia Rheumatica (PMR)

Project Leader:

Vivekanand Tiwari, MD, FEL ’22 Assistant Professor of Medicine, Geisel School of Medicine; Section of Rheumatology

Pragmatic Randomized Trial for Arterial Catheters in the Critical Care Environment (GRACE Trial/ NCT:05411315)

Project Leader:

Terrence Wong, MD, PGY5 Instructor in Medicine, Geisel School of Medicine; PGY5 Pulmonary and Critical Care Medicine Fellow, Section of Pulmonary and Critical Care Medicine

Project Co-Leader:

David J. Feller-Kopman, MD

Professor of Medicine, Geisel School of Medicine; Section Chief, Pulmonary and Critical Care Medicine