Current staffing models cannot deliver the benefits of hospital medicine to the 1300 critical access hospitals (CAHs) located throughout the rural United States.   Staffing each CAH with local hospitalists would require at least 5500 hospitalists (more than 10% of the workforce), to cover less than 2% of the hospitalized population.   A “virtual hospitalist” program utilizing telemedicine can deliver hospitalist expertise using existing resources.


To decrease the percentage of patients requiring transfer to a higher level of care at a CAH through implementation of a virtual hospitalist program.


This program was a partnership between an academic medical center and a CAH located in the Midwest United States.  A combination of physicians and advanced practice providers (APPs) delivered local care.  When APPs were providing local care, a physician was available to respond on-site within 30 minutes. Virtual hospitalists were all MD physicians who staffed the general internal medicine services at the University of Iowa.   

The program had set contact times at (8:45am and 4:30pm) when an interprofessional conference was held with the CAH provider, critical access nursing staff and the virtual hospitalist.  After the morning conference, the virtual hospitalist performed video “rounds” with all admitted adult patients.  CAH providers also contacted virtual hospitalists with any new admissions or acute patient issues. 

In the first two weeks of implementation, the virtual hospitalist saw 29 unique patients.  Average census at the CAH was 2.63 (prior 12-month baseline 2.22).  During this time, 14.9% of CAH emergency department patients transferred to an outside hospital (baseline 19.8%, p = 0.323).   Virtual hospitalists spent a daily average of 105 minutes within a 24-hour period:  34 minutes for video conferences, 65 minutes for review and charting within the electronic medical record, and 6 minutes on non-video phone calls with VBCH providers.  The intervention was well-received by CAH providers, who praised the expertise and teaching of the virtual hospitalists.

Limitations to the current implementation include the requirement for broadband wireless internet coverage at both locations, as well as the inability to perform a complete physical exam remotely.  This program utilizes less than a full FTE for a single CAH, and may require additional responsibilities assigned to the virtual hospitalist to be sustainable.  The observed sample too small to determine if the primary outcome will improve.  


Installation of a virtual hospitalist program is feasible and can deliver the benefits of hospital medicine to CAHs with available hospitalist staffing.  Other benefits include continuous training of CAH personnel, to improve the local care of higher acuity patients. Further integration of information technology and inclusion of other specialties would extend the ability to deliver care in patients’ home communities.