In 1993, leaders at Avera Health created Avera eCARE to offer virtual support to rural organizations within the system. Over time, eCARE expanded their service line offerings and began to sell their virtual services outside the system. Leaders at eCARE were also able to leverage the infrastructure to provide clinical expertise to specific niches in the health care market, such as correctional health and school nursing. See the table on the following page for more detail on each eCARE service line offering.

Through developing eCARE service lines, Avera identified three areas where specialist oversight could most positively impact clinical outcomes:

1. Rural hospitals with little access to specialists
2. Units throughout the system staffed mainly with inexperienced clinicians
3. Outpatient sites with a high number of unnecessary inpatient transfers

The scope of each service line differs slightly, but the goal of eCARE clinicians is providing specialist support so that bedside clinicians can focus more time on direct patient care.

For example, each critical care nurse in the eCARE ICU covers 40 beds. During a typical shift they are responsible for the following tasks:

• Monitoring high-risk patients: Software with real-time clinical data helps eCARE RNs to proactivley identify high-risk patients who may need intervention. RNs triage patients to the eCARE intensivist if necessary.
• Conducting live e-consults: Throughout the day, eCARE RNs perform ondemand expert consults. In these consults, the nurse is the first point of triage and escalates to other clinicians as needed. Bedside care teams request these consults by pressing a button in the patient room or calling on the phone. The eCARE RN talks the team through the clinical situation, which could range from an unusual presentation to cardiac arrest. Following the consult, the eCARE RN will perform any necessary documentation so the bedside team can focus on care delivery.
• Vent rounding: eCARE RNs perform rounds throughout the day to assist with vent-weaning.

The Avera eCARE team is staffed 24/7/365 by clinicians with at least five years of experience who are board certified in their specialty. eCARE RNs work the same shifts as bedside RNs, generally 12-hour shifts.

Avera e-Care leaders cite building trust among bedside clinicians as the biggest implementation barrier for the virtual hub model. To overcome this challenge, leaders spend one to four months with the bedside team while the technology is implemented to encourage its adoption. The eCARE staff spend time getting to know the bedside nurses through a series of virtual meetings to create a sense of camaraderie and understanding. Some eCARE staff also go to each site when the technology launches to help further build trust.

When Avera created the eCARE model, it was staffed by experienced bedside RNs from the Avera system. This helped encourage adoption of the technology because the bedside staff knew these RNs and were comfortable asking for a consult. But as time went on, experienced bedside nurses became increasingly interested in working for eCARE, potentially draining expertise from the bedside team.

Leaders from Avera hospitals and eCARE worked together to create a shared workforce strategy to provide experienced nurses the opportunity to extend their career in eCARE without diverting talent from the bedside. They created a split RN position in which nurses work half of their schedule in eCARE and half at the bedside. This schedule requires a strong partnership between care sites. Managers have found hiring split staff in pairs makes scheduling easier. About 25% of the eCARE staff are in split positions.

Today Avera eCARE and bedside leaders meet frequently to discuss staffing logistics and care quality in both settings.