When people are injured or sick and need immediate medical attention, they usually find their way to the nearest physician or emergency hospital. In rural Arizona, that is easier said than done. Many people must travel 20 or more miles to reach the nearest doctor. This harsh reality has left those with low income and no transportation to struggle on their own.
Jill Bullock, the rural health services coordinator at The University of Arizona’s Mel and Enid Zuckerman College of Public Health in Tucson, said that rural communities are suffering the most because there is no access to healthcare for patients, coupled with a lack of funding that has led to workforce issues when recruiting professionals.
“There is always a shortage of medical providers in the rural areas,” Bullock said. “We help set up rural health clinics so that the patients have a place to go for treatment. We have 15 critical access hospitals that are all over the state.”
A critical access hospital is an acute care hospital that a patient would go to for immediate assistance or emergency healthcare needs. The difference between a critical and regular hospital, is that the patient may not exceed a 96 hour stay before being transported or released. However, there is still an issue of transportation for those who cannot make it to a critical access hospital since they are spread out over the state. Bullock said that the hospitals must be at least 35 miles away from another hospital, have less than 25 beds, or be located in communities that are surrounded by mountains or other obstacles that make traveling more difficult.
“If they are on Medicaid, Medicaid will have transportation as part of the plan. If they’re not on Medicaid, then it is up to them and they are on their own,” Bullock said. “If it is a trauma patient, they are going to be transported by ambulance or air.”
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At Rightway Healthcare in Casa Grande, transportation, physician recruitment for the clinic and funding are the three major needs that managing partner David Maki faces.
“The clinic needs to meet the size of the providers and the patients,” Maki said. “However, we are all scattered and servicing a large number of patients. We live in an under-served population, and the biggest barrier is transportation. There is no funding to get physicians out into the public.”
When it comes to patient services, Bullock said that the main difference between rural and urban healthcare is that the urban areas have specialists in many different fields, which the rural areas don’t provide.
Michelle Ziemba, the director of trauma and emergency services at The University of Arizona Medical Center, said that if patients in these rural areas have chronic diseases, it can become a very dangerous situation when there is no access to the sub-specialists. In order to combat the lack of specialized physicians in rural healthcare, many urban medical centers have begun utilizing telemedicine.
Using a secure streaming video program, physicians in rural and urban areas can send photographs and videos of patient injuries and trauma back and forth, in an effort to provide assistance and diagnostics over a large distance. The goals of this program are to assist with assessment, provide advice, guide remote care providers when performing surgeries and procedures, assist in evaluating the need for transfer and suggest the appropriate mode for patient transport.
Ziemba said that her department received a grant from Blue Cross Blue Shield of Arizona to purchase telemedicine equipment and place it in rural sites. However, she said that there is a “revolving-door syndrome,” in that every time they purchase equipment and get the staff proficient with the technology, the technology upgrades or advances. In an effort to avoid this cycle, researchers are looking into using Skype and iPhone technology to better serve the telemedicine program.
“We are embracing wireless technology and attempting to use camera phone pictures to treat patients. This is truly a moment in time when a picture is worth a thousand words,” Ziemba said.
There are also attempts to have a physical presence in the rural areas as well, and many individuals completing their residencies and training will be sent to outreach and education clinics in low-populated areas, Ziemba said.
“A consumer in an urban market has choices,” Ziemba said. “There is readily access and availability of care. There aren’t even physicians in some of the rural areas and there is a feeling of helplessness.”
One of the challenges that Ziemba said she has faced since beginning work in telemedicine, is patient protection initiated by The Health Insurance Portability and Accountability Act of 1996. This act, “…protects the privacy of individually identifiable health information,” according to the U.S. Department of Health and Human Services website. The act sets national standards for security, and physicians must have informed consent from patients before photos or video are passed along. This becomes a challenge when the patients are non-responsive or unable to choose whether to be identified.
Ziemba also said that patients are still hesitant about using telemedicine since it is new and hasn’t had adequate time to get engrained into the rural culture, although she would like to see that change.
“We value it (telemedicine) because it helps us keep the patients’ best interest in mind. We don’t want them to have to drive an hour and a half to see a specialist when they can go to a local physician and use telemedicine,” Ziemba said. “It saves the driving time and the energy.”
Karen Vite, a patient at Rightway Healthcare, said that finding the right doctor has been her biggest challenge.
“The clinic that I used to go to is no longer open, and when I had to find a new doctor, I ended up waiting for over three hours to see someone,” Vite said. “Since they are under-staffed, there was an excessively long wait time and the provider was incompetent. There are better options in urban areas, and the good doctors seem to leave us because of urban incentives.”
Ziemba said that patients take a risk by living in these beautiful, rural environments.
“The mortality rates are higher and people are living longer with worse diseases because they don’t have access. Telemedicine is our bridge to helping patients,” Ziemba said.