The ratio of population to geography is an often quoted reason for both the pros and cons of living in the Arrowhead. Low density of humans can be very attractive for wilderness lifestyle lovers, but presents a major obstacle for accessing health care. In a region where the disparity of health care providers to consumers is woefully imbalanced in many areas, technology and virtual contact is beginning to bridge the gap.

Health care is one of the Arrowhead region’s major industries, and according to the Department of Employment and Economic Development’s 2018 Local Workforce Regional Profile report, nursing assistants and personal care aides are among the top occupations in demand.

Outside of Duluth, northeastern Minnesota’s labor force is expected to continue to decline over the next decade while simultaneously seeing an aging population, exacerbating the tight labor market for health related workers across the board.

Personal care assistants have a vacancy rate of 20 percent in the Arrowhead, compared to a 9 percent vacancy rate average for the state, a clear lead indicator demand is outstripping the supply of workers.

The disparity of home health workers and personal care attendants is an ever-widening gap with no clear solutions in sight, and that is something Teri Fritsma Mogen, a Minnesota Department of Health senior workforce analyst, noted should be a major concern for the trickle-down effect it will have.

“If you don’t have enough home health workers to allow people to age in place, older folks will have to move to nursing homes or assisted living and that just moves the workforce shortage to another area,” she said.

Rural northeastern Minnesota has the highest need for specific mental health providers in the entire state, specifically alcohol and drug counselors and licensed mental health therapists, according to Fritsma Mogen.

“Including Duluth for alcohol and drug counselors the region has the second highest ratio in the state, and if you take Duluth out of that equation the ration is through the roof with 8,000 people to every one drug and alcohol counselor with the average in the metro roughly 2,000 to one,” Fritsma Mogen said.

Including Duluth and beyond, there is one psychiatrist for every 20,000 residents, far short of the statewide average of 11,000 residents to one psychiatrist.

Cautioning that telehealth, the provision of healthcare remotely by means of telecommunications technology, is not a “magic bullet,” Fritsma Mogen does believe new legislation mandating expanded reimbursement for telehealth has started to help alleviate some of the need.

In 2015 the Minnesota legislature passed the Telemedicine Act, increasing the list of professionals eligible to bill for telemedicine practices, including physicians, nurse midwives, clinical nurse specialists, dentists and psychologists. The Telemedicine Act took effect at the beginning of 2016, with some provisions not fully operational until 2017. 

Louise Anderson, director of the Carlton-Cook-Lake-St. Louis Community Health Board said the use of telemedicine to meet client needs is expanding significantly.

“Meeting remotely with clients is especially important in rural areas of the region where mental health providers are less accessible,” Anderson said.

She noted video conferencing technology is also serving to fill a crucial gap for public health nurses. Providing Direct Observed Therapy (DOT) via video conferencing to monitor patients taking oral medication for treatment of tuberculosis has fulfilled some need efficiently.

“One example of this in our region was public health staff time and travel savings of 2.5 hours per day by using (video) conferencing with a patient who lived in a remote area of the county,” Anderson said.

Carlton County Public Health and Human Services director Dave Lee has been an advocate of using the Health Insurance Portability and Accountability Act (HIPPA) compliant video conferencing technology called “Vidyo” in Northeast Minnesota.

In the Region 3 Adult Mental Health Initiative Area several counties are represented: St. Louis, Lake, Cook, Carlton and Koochiching, which comprises 23 percent of the state’s land and contains only 6 percent of the population. That geographical area also happens to represent an area where health challenges such as depression outstrip any other major health concerns two to one.

“All the data points to mental health being the number one chronic health condition in that part of Minnesota and the benefits of using telehealth tools to redirect resources quickly are huge,” Lee said.

Despite working on expanding video conferencing for mental health treatment over the last six years, Lee is frustrated with how slow the system has been to take hold. The technology exists, but he said attitudes are slow to change and minor legal and technical obstacles can take a long time to overcome.

The trend, he said, is for many different agencies; schools, jails and treatment facilities, to develop their own telehealth systems. To overcome logistics of not being able to communicate smoothly across agencies, an interoperable system, like Vidyo, should be universally adopted, he said.

“There’s a huge opportunity to expand the use of this tool, but people need to see the value of it and be sold on it,” he said.

One area being piloted successfully in Carlton County has included mental health treatment in the jail setting, where accessing a mental health professional by video is much more efficient. Transporting an inmate from jail, where many have serious mental health issues, to a psychiatrist is difficult, requiring at least one deputy to escort them. At the same time, local mental health care providers are motivated to fill canceled appointment slots.

“It didn’t take a rocket scientist to figure out that we could fill no-shows and cancellations for psych appointments easily without leaving the jail via telepsychiatry,” Lee said.

County jails in Carlton, Koochiching and Lake counties, Northeast Regional Corrections Center and Arrowhead Juvenile Detention Center have all been implementing some form of video conferencing for mental health treatment. However, Lee said many IT and legal hurdles need to be cleared to make it happen.

“I think the biggest problem is that we are so regimented in our separate professional silos and this approach doesn’t work in isolation, so we have to be open to working with community partners in new ways to solve this chronic mental health problem,” he said.

Another tech tool being used widely by patients across most area health care systems is a portal to access health records, view lab results and send and receive nonurgent messages from providers.

Dr. Michael Whitcomb, Essentia’s chief medical informatics officer, estimates about 40 percent of clinic patients access their patient portal, a system that has been up and running for about six years.

“Patients love to send messages through the patient portal instead of the old-fashioned phone call that can take days of phone tag,” Whitcomb said.

Getting medical care online is not a new concept, but it has had its share of glitches to work out, and after a launch that did not take off several years ago Essentia is seeing greater success with Evisits using a different platform.

Limited to about 30 relatively straightforward conditions, patients connect online to an Evisit web page where they fill out a short form using a branching logic interview format. Responses from a doctor or nurse practitioner come back in under an hour, and any needed prescriptions are sent directly to the pharmacy of the virtual patient’s choice.

“Not only is the demand by patients for immediate care with online access being met, Evisits also decrease access problems in our ER and urgent care,” Whitcomb said.

He said several thousand patients have accessed the online doctor visits in the past year, and they are hoping to expand services to include more conditions.

“The consumer is changing their expectations for online convenience instead of going to a brick-and-mortar facility,” Whitcomb said. “The exciting thing is that technology exists where we can maintain high quality of care.”

Maureen Ideker, senior advisor for telehealth at Essentia, said they have a telehealth presence in all their hospitals, clinics and nursing homes throughout northeastern Minnesota and northwestern Wisconsin, with 10 different hospital services, 30 outpatient clinic specialty consultants and about 5,000 patient consultations performed through the telehealth system in the last year.

Telestroke is Essentia’s biggest hospital program, with its emergency departments throughout the region all connected to St. Mary’s in Duluth. With neurology specialists primarily located in Duluth, and rapid intervention of the utmost importance with this prevalent condition, Telestroke gets the stroke specialists active on a case from the start.

“Wherever that stroke neurologist is the Telestroke alert comes through to them as soon as the patient comes into any of our ERs and they are immediately linked up and can begin giving orders,” Ideker stated.

Recently expanded telepresence through discharge pharmacy consultations recently at St. Mary’s is also a time saver for the patient and the hospital.

“Discharges from the hospital in Duluth with virtual pharmacy counseling is at about 500 visits per month, saving valuable time by having a pharmacy technician bring an electronic tablet to the patient’s bedside,” Ideker added.