Understanding the Value of a Hub-and-Spoke Telemedicine Program

Hub-and-spoke telemedicine networks can extend specialty services and education into rural areas and improve clinical outcomes and provider efficiencies. But providers have to do their homework before jumping online.

Telemedicine is designed not only to improve patients' access to care, but to extend the reach of healthcare providers beyond the hospital, clinic, or doctor's office. That's especially true for specialty care providers, who are fewer in number but in high demand throughout the country.

The Cardiovascular Institute of the South (CIS), based in Houma, Louisiana, specializes in cardiovascular care in a part of the country where those resources are limited and a higher percentage of people are living with at least one chronic condition. With that in mind, the institute has leveraged a hub-and-spoke telemedicine platform, with CIS at the center, to help rural patients in Louisiana and surrounding states access care.

"It gives us many more opportunities to treat patients," says Craig Walker, MD, who founded CIS as a solo practice in 1983 and now serves as president of an operation encompassing almost 90 cardiologists and more than 60 nurse practitioners. "We can be in places where we couldn't be before, providing better care for our patients and helping physicians in rural areas."

The hub and spoke telemedicine model exists in many forms around the country, and is perhaps most popular in rural areas. It places a large, often academic hospital or health system (or in this case a specialty clinic) at the center, on a telemedicine platform that connects to smaller hospitals, clinics, and other healthcare sites. Specialists at the hub connect virtually with these spoke sites to treat patients, assist remote care providers, or even provide mentoring or clinical education services.

Forming a Bond With Patients

CIS launched its telehealth program in 2017, in a partnership with InTouch Health, and has continued that relationship through Teladoc's acquisition of InTouch in 2020. Alongside teleneurology and stroke care, cardiovascular disease is seen as an ideal form factor for hub-and-spoke telemedicine, as it affects roughly one in four people, drives some $320 billion in annual healthcare spending, and accounts for about one-third of Medicare costs.

Craig Walker, MD, founder and president of the Cardiovascular Institute of the South. Photo courtesy CIS.

"Telemedicine has the ability to transform the way cardiology care is delivered, through expanding access across rural areas, managing bed capacity, easing travel burden on sub-specialties, improving collaboration between sub-specialties, and expanding our own coverage internationally," Walker said in a 2017 press release announcing the CIS collaboration with InTouch.

Today, Walker says CIS is conducting more than 200,000 virtual visits a year. The clinic reports a response time of less than 30 minutes and a 99% patient satisfaction rate, with some 86% of patients able to stay in their community to access care rather than travelling to a distant location.

"We're forming a bond with [our patients]," Walker says. "It tells a patient that we're interested in them, so we're reaching out to them."

With this model of care, CIS specialists can help treat patients in rural and remote locations who either can't get to CIS or another hospital or who would have difficulty making that trip. The specialists use the virtual platform (typically a telemedicine robot or audio-visual link through a computer) to meet with patients and help care providers in those spoke sites, whether it be a hospital, clinic, or managed care site. With that platform, rural providers know they have a specialist helping them—not only guiding them, but giving them the skills and confidence to improve their own care management.

As health systems struggle to fill vacant positions, and in the case of rural hospitals, stay open, telemedicine models like the hub and spoke offer important opportunities to improve care and keep more patients in-house. A small hospital in a remote location can, for instance, create virtual channels with larger, distant health systems to provide everything from backup ICU care to behavioral health services.

"Any time a hospital has to refer a patient out, they lose," Walker points out, noting that he's been surprised at how well this platform can eliminate hospitalizations and transfers. "They need those patients to stay [in the hospital and get the care they need, which is closer to home."

The Project ECHO Model of Care

These platforms can also be used to educate and train care providers in rural areas on chronic care management, public health, and other issues, enabling them to provide better care for their patients rather than sending them to specialists. The model is known as Project ECHO (Extension for Community Health Outcomes), and was developed in 2003 by Sanjeev Arora, MD, at the University of Mexico, as a means of teaching rural provider how to care for patients living with hepatitis C. Similar to a clinical care model, it places an academic hospital at the center and enables specialists to use telemedicine to conduct virtual education sessions for rural providers.

[Related: Telemedicine Project to Help Rural Docs Identify Autism in Young Children.]

"Community providers, particularly community-based health centers, provide coordinated, patient-centered care in facilities proximate to their patients," Arora and his colleagues wrote in a 2011 article in the New England Journal of Medicine outlining the Project ECHO model. "Patients are likely to have greater trust in local providers, who tend to be culturally competent with respect to their specific communities. This may enhance patients' adherence to treatment and allow for greater direct contact with the clinician, including more frequent visits."

"As a result, local providers may be better able to comply with best-practice protocols, ensure close assessment of the results of laboratory tests, offer education tailored to the patient, and provide better and more timely management of side effects," the study concluded. "In addition, the fact that the primary care of the patient and the management of Hepatitis are provided by the same clinician ensures better coordination of care and fewer communication challenges."

There are now hundreds of Project ECHO programs across the country in almost every state, offering education on topics such as pediatric care, substance abuse treatment, behavioral health, diabetes care management, cancer care, senior care, HIV/AIDS care, and more recently, COVID-19 and infectious disease treatments.

Balancing Patient and Provider Workflows

At CIS the focus is on clinical care and improving outcomes not only for the patient but the care provider.

Walker points out that the telemedicine platform gives his staff the ability to care for more patients, but not at the expense of their own health and wellness. Specialists are able to factor virtual care into their workloads, creating schedules that are comfortable. While those video visits comprised about half of their work week during the height of the pandemic, when in-person care was reduced to emergencies, they now factor out to around 10% of the workload.

"This reduces a lot of stress that leads to burnout," he says.

With telemedicine part of the model of care now, even integrated into the electronic medical record platform, CIS is hiring staff specifically for virtual care, and has created a 6,000-foot facility for those visits.

"[It has] all the technology we need and a lot of TVs," Walker says. "It looks like a sports bar. And yes, we probably will need more space."

But there's value in expanding. While the program initially cost CIS more than the hospital could bring in, they're now seeing a 180% return on value (according to the Teladoc case study). Walker says they're "getting a lot of referrals" as healthcare providers in surrounding areas and states see the value of connecting with specialists, and payers—especially Medicare and Medicaid—are starting to reimburse for those services.

Walker says more services can be handled on a telemedicine platform, including check-ins and check-ups, remote patient monitoring services, and education sessions for patients on how to manage their own care.

But they can't—and shouldn't—replace in-person care.

"There's a lot you can do with technology now, and it's getting better," he says, "but the physical exam" is still an integral part of the care pathway that can't be completely done via video. Any program that incorporates telemedicine has to factor in-person care into the routine, at a frequency that meets the needs of both patient and provider.

That's part of the checklist that Walker says any healthcare organization should fill out before launching a telemedicine program, either as a hub or as a spoke.

"Do your homework first," he says. "Visit programs that are established. Understand what telemedicine can do, but also what it can't. … And make sure you have everything in place before starting."

That includes not only the technology, but staff and patient buy-in, and a full understanding of workflows.

"It's often the programs that are least ready that need this the most," he says. "So, it's important that you know what you’re getting into. And then you'll see what it can do."