Dr. Vinaya Sermadevi sits in front of six screens at a call center in St. Louis, directing a nurse through a video conferencing system. Her patient is in an intensive care unit at a hospital in Arkansas, and he's crashing.

"Do you have a liter of bicarb [sodium bicarbonate] mixed already? I would rather you bolus that and stop the saline," Sermadevi says, eyes switching between a monitor that shows the patient's vital signs, medical records and a real-time video of the patient in bed.

Sermadevi stays with the nurse until an on-site doctor can get to the patient's room, and orders a set of labs for 10 a.m. For Sermadevi, the work day has just started, and for the next 12 hours or so, she'll keep tabs on intensive care units in hospitals as close as St. Louis and as far away as Oklahoma City.

Mercy, a St. Louis-based healthcare network with hospitals in four states, has built what's considered to be the world's first freestanding center for telemedicine: Mercy Virtual. The price tag came in at a cool $54 million.

The ICU monitoring program, or E-ICU, is just one of the programs housed here. Another keeps brain specialists on call so if someone shows up in an emergency room with symptoms of a stroke, they can see a neurologist—even if the hospital they're physically inside doesn't have one on staff. A new pilot program for home healthcare lets doctors check in with their patients after they've been discharged.

"The clarity is amazing. We can even look at pupils to see if they're reactive," Sermadevi said.

Mercy Virtual is a four-story building that sits near a highway and a suburban shopping mall on the outskirts of St. Louis. The floor where Sermadevi works looks like a call center: About a hundred desks are evenly spaced, each one with a privacy screen behind it. At any one time, there are dozens of doctors, nurses and physician assistants murmuring into headsets as they check on patients in hospitals across five states. (Some hospitals aren't Mercy-affiliated, and pay the network for the service.)

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Michael Koenig, a nurse with Mercy's SafeWatch program, keeps tabs on patients with a series of screens displaying their vital signs and medical records. (Durrie Bouscaren/for WHYY)

Hospitals may be full of doctors, but Mercy is banking on the idea that having a virtual backup is important. Sermadevi gives the example of a heart attack in the ICU:

"Even an onsite physician could be far away from the bedside. If they just ping us, we can come in, and those first few minutes are very crucial," Sermadevi said. "The intensivist can recognize, you know, 'impending doom,' and we can ask for the right person to come and help the bedside even though we're not there."

This helps out at night, when a large hospital might be understaffed. A rural hospital may not have a specialist on staff, instead relying on doctors to be on call from outside hospitals. If they're far away, calling just an hour earlier can make a difference. 

A Mercy Virtual program called SafeWatch plugs in to each patient's medical record and checks their vital signs constantly, signaling nurses when it appears that a patient might decline rapidly. Doctors can order labs and make adjustments remotely, too.

"A lot of times things slow down at night, so if it's not slowed down... people are able to get out of the hospital, out of the ICU earlier, because someone else is watching them," Sermadevi said. "A colleague of mine was able to bring down a ventilator setting by the morning, working diligently over 12 hours, and the next morning the patient was doing much better."

This isn't to say there aren't technical difficulties. Sometimes, Sermadevi said, video cameras or microphones in a patient's room won't work. In an emergency, that can be a problem.

The internet connection itself is hard-wired so the program doesn't have to rely on WiFi—one lesson that was learned after a tornado devastated Joplin, Missouri in 2011, damaging a Mercy-affiliated hospital there.

Sermadevi works at the E-ICU for six to eight weeks in a year. After her shifts, she will go back to her regular job as a critical care physician at a 900-bed brick-and-mortar hospital nearby, and another doctor will take her seat here in the virtual center.

A $54 million gamble

Mercy has had some of these "virtual medicine" programs in place since the mid-2000s. What's new is that they're now housed offsite, in this central location. Though telemedicine visits in most states are covered by health insurance through a parity law, the "virtual medicine" component—plugging into a medical record to catch patients declining—is not.

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Top left: Dr. Vinaya Sermadevi, a critical care doctor, coaches a nurse through an emergency in an intensive care unit in Arkansas.  Bottom left: Roberta Gurley, a Safewatch nurse, considered retiring before joining Mercy in 2011. She decided not to because through the telemedicine program, so can use her knowledge without dealing with physical strain. Right: At night and in the early morning, the call center Mercy Virtual is the only section illuminated. (Durrie Bouscaren/for WHYY)

"This has been an ongoing, 10 year journey," said Dr. Randy Moore, the president of Mercy Virtual. Fittingly, he's based in Minneapolis, not St. Louis.

The federal agency that oversees Medicare and Medicaid has announced a shift to reimbursing healthcare providers on a value system, instead of piecemeal for each procedure. A provision of the Affordable Care Act penalizes hospitals that have high rates of readmissions, or if patients become ill with a hospital-acquired condition during their stay.

"If we can keep a person doing well at home, the financial incentives are better than they've ever been," Moore said.

By analyzing the data in their electronic medical records to catch symptoms early, the care itself becomes more efficient, Moore said. And when it comes to those virtual doctors, they're moving electrons around, instead of people. After a previous career in the telemedicine industry, he's confident that patients will adapt.

"I remember a sweet little old lady who started out saying there's no way you're going to have Big Brother watching me in my house," Moore said. "She ended up knitting a doily underneath her telemedicine device, and had a name for it."

A spokesperson for the American Medical Association declined to comment for this story, because he said virtual medicine is "too new" for the organization to have an established stance on the issue. The AMA does have a list of recommended guidelines for one-on-one telemedicine visits, such as physicians and patients should establish a face-to-face relationship before they conduct appointments remotely.

Telemedicine at home

But if telemedicine sounds like a cold alternative to an in-person interaction with a doctor, that's not always the case.

Travel through the wires of the internet connection at Mercy Virtual, and you might end up in the sleepy river town of Washington, Missouri—home to the largest supplier of corncob pipes. A cluster of vineyards are close by, the "Missouri Rhineland." The last census put its population at 13,982.

87-year-old Naomi Coulter is showing off old family photos in her living room. As a young woman, she traveled the country for bowling competitions. Today, she boasts of her 3 children, 6 grandchildren, 13 great grandchildren and 1 great-great grandson. (Another is on the way.)

For her doctor's appointment this morning, Coulter walks to her kitchen, a thin tube of oxygen trailing behind her. After a few technical difficulties with an iPad, she and her doctor, a physician assistant named Mark Saxon, are connected on a video conferencing session.

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Naomi Coulter takes her vitals while using Mercy's home health program to talk with her doctor. (Ryan Delaney/for WHYY)

"You're having a bad hair day!" she jokes.

Mercy's home health program is just getting off the ground. Five days a week, Coulter checks in with her doctor or his assistant using this system. She takes her vital signs at home—blood pressure, pulse, heart rate—and reads them off of a piece of paper. Saxon reminds her they've adjusted her medication.

Eventually, Mercy plans to send patients home with wearable heart and pulse monitors, so those vital signs can get uploaded to their system automatically.

Until recently, Coulter had been in and out of the hospital every two weeks or so. The drugs she was prescribed made it hard for her to walk, leaving her dizzy and nauseous. A Mercy-affiliated hospital is in Washington, but if Coulter's health declined and she wanted to see her doctor, she would have to wait for an appointment.

Coulter credits Mercy's program with helping her stay at home.

"I hope to live to be 100, and still be able to boss my kids. I have 13 years left to work on it," Coulter laughs. Her daughter, who sits next to her, rolls her eyes in mock disbelief.