(2:00 pm, Thursday)
Edwin A. Holtum, BA, MS
The University of Iowa
Susan Zollo, BA, MA
The University of Iowa
A National Laboratory of the Study of Rural Telemedicine: Mosaic in the Maize
The development of a National Laboratory for the Study of Rural
Telemedicine is described. Special emphasis is devoted to a
description of the Laboratory's Resource Center and to the
information support sub-projects including the Virtual Hospital, a
digital medical multimedia database, and the expansion and
enhancement of the Hardin Library's Health databases. The paper
also emphasizes the important role which librarians are playing in
In response to an RFP issued by the National Library of Medicine entitled Biomedical Applications of High Performance Computing and Communications, The University of Iowa developed a proposal to establish a “National Laboratory for the Study of Rural Telemedicine.” In April of 1994, the UI was awarded a $7 million 3-year contract to develop a testbed network for the delivery of clinical and educational applications over the state supported high-speed fiberoptic network.
Background and Present Status
In the broadest sense, telemedicine refers to the electronic transmission of medical information and services (voice, data, video) from one site to another using telecommunication technologies. Applications can be as simple as a phone call or as complex as interactive video consultations and robotic surgery. In rural states such as Iowa, telemedicine applications have potential significance for improving access to health care for elderly populations, rural (geographically dispersed) patients and their families, victims of farm accidents, and populations with special health care needs (for example, children with disabilities for whom travel is difficult for both patient and family). For our purposes, telemedicine will be defined as being patient- rather than technology-driven.
The Iowa Communications Network (ICN)
In 1989, the Iowa General assembly passed legislation recommended by the Governor to create the nation’s first state-owned, fiberoptic communications system. Construction began in 1991 and resulted in the connection of Iowa’s fifteen community colleges, three regents’ institutions, and Iowa Public Television to the statewide fiberoptic hub at Camp Dodge Armory in the Des Moines metro area.
During a second construction phase in 1992, an additional 84 links were established. Today, all 99 counties have endpoints in the in the 3,000 mile statewide fiberoptic system, the Iowa Communications Network (ICN). In June of 1994, Governor Branstad signed legislation providing access on the ICN to medical facilities and health care institutions
Rural Health Care Challenges
Unique population. Iowa ranks third in the nation in percentage of redicents over 65 and also in longevity of its residents (average age at time of death + 75.8 years). As might be expected, rural hospitals treat a greater percentage of elderly patients than of their urban counterparts. Rural Iowans tend to be geographically dispersed and often have to travel great distances to receive health care beyond the primary level. (Iowa ranks in the top 10 states for the number of actual road miles within its borders.)
The leading cause of death in Iowans under the age of 40 is trauma, and there is a strong correlation between traumatic injuries and the use of heavy farm machinery and equipment. In 1993 alone, there were over 2,300 farm related injures and 287 people died in farm-related accidents. In agricultural states such as Iowa, widespread use of chemical pesticides and fertilizers can contribute to complex trauma care in the areas of poisoning and toxicity.
Access to health care. Access to advanced technology, allied health services, emergency trauma centers, and public health is limited in Iowa’s rural communities. Despite the large elderly population, only around 10% of Iowa hospitals provide geriatric health programs, Alzheimer’s diagnosis units, or respite and hospice care. Allied health services tend to be underrepresented in most many community hospitals as are public health programs such as psychiatric care, hospital-based social services, and substance abuse counseling. And, despite the large number of trauma cases, only 12.5% of Iowa hospitals have certified trauma centers.
Financial Concerns. Rural areas face serious economic barriers to adequate care, with many families living in poverty, requiring federal or state assistance or having no insurance at all. Unlike their urban counterparts, many of the rural poor do not seek out public assistance such as Medicaid to assist them with medical bills.
Many rural hospitals are endangered by current reimbursement and regulatory constraints. Iowa’s hospitals receive lower than average Medicare payments per inpatient stay than most of the other states in the midwest region. Changing economic circumstances have resulted in the closure of many small rural hospitals. Risk of closure has been associated with small size, low occupancy rate, low patient case complexity, type of ownership, local economy, and competition among neighboring hospitals The closure or a rural hospital often commences the final chapter in the viability of a rural community.
Recruitment/Retention. The health provider workforce in rural communities reflects difficulties in recruitment and retention. Rural physicians are professionally, and often physically, isolated. This isolation results in inadequate access to information and services available in secondary and tertiary level institutions. Such conditions create a barrier to optimal patient care and to the professional satisfaction that could potentially keep physicians practicing in the rural primary care setting.
Telemedicine in Iowa
The challenges to rural health care delivery outlined here have combined with other variables to make the study of telemedicine a promising focus for research in the state of Iowa. Health care reform measures currently under discussion, such as managed competition, will put additional responsibility on the rural health care provider to become the requisite ‘gate-keeper’ for such systems. The rural primary care provider will be required to make increasingly complex decisions about the care and referral of patients. The availability of telecommunications technologies and the statewide fiberoptic infrastructure have the potential to play an important role in optimizing health care delivery to rural patients and to preserve and strengthen the rural hospital system.
To date, there are three federally funded telemedicine programs in the state of Iowa: two (Iowa Methodist and Mercy Hospital Medical Centers - both in Des Moines) are funded by the Health Care Financing Administration (HCFA) and one (The University of Iowa) is funded by the National Library of Medicine (NLM).
Challenges to Implementing Telemedicine
Barriers to telemedicine include technology, standardization, and cost. At the present time the technology is still quite complex and there is relatively little standardization in equipment, hardware, and software. This could lead to the rapid development of many small, proprietary, and mutually exclusive systems and networks.
Further, the current technology is costly. Cost and effectiveness studies must be developed in order to justify the use of advanced telecommunications technology in rural hospitals, many of which are currently in marginal financial condition. Grant funding allows smaller hospitals the option of connectivity and networking, but may not provide ongoing support beyond the life of the contract period. We still have a lot to learn about what specific services are needed, will be utilized, and will be effective in the rural care setting. A tremendous diversity exists among rural health care sites in terms of patient demographics, physicians characteristics, and hospital capabilities. It would be inappropriate to assume that requirements (technological and patient services) for all rural hospitals and communities are similar.
Rural Telemedicine Laboratory
The University of Iowa’s Telemedicine Laboratory includes five developmental projects, (three clinical and two educational); a Telemedicine Resource Center; and a telecommunications testbed network connecting three community hospitals to the University of Iowa. The smallest hospital, Van Buren County Hospital in Keosauqua serves a poor rural county; the Ottumwa Regional Medical Centers services a more prosperous rural county and is staffed by both primary care providers and specialists; the largest of our testbed hospitals, Genesis West in Davenport, provides considerable secondary- and limited tertiary-level services to their community. Each hospital will be supplied with several computer workstations, teleradiology sending and receiving units, a Sun workstation, an on-line document delivery station, and other hardware, software, and equipment as needed to support the delivery of the services delineated in our contract with the NLM.
The purpose of the Resource center is twofold. First , as a core administrative facility for the Rural Telemedicine Project, the Center will provide information and support for contract management, program development, technical assistance, telecommunications options, evaluative services, interactions with the testbed hospitals, and the organization and dissemination of information relating to telemedicine and distance learning initiatives.
The organizational structure includes the Laboratory’s Director and Principal Investigator of our Project, Michael Kienzle, M.D., Assistant Professor of Cardiology and Associate Vice-President of Clinical Affairs for the College of Medicine. A number of faculty affiliates have been written into our project in the areas of telecommunications, information technologies, and health services research. Staffing for the Center includes a program director and two support staff, an instructional designer to assist faculty with educational program development; a computer consultant to provide technical support to health practitioners in the community hospitals; and a research assistant to develop data collection mechanisms and interpret results.
The second role of the Resource Center is to serve the broad needs of the Iowa Health Services and Education Telecommunications Network (IHSETN). The goal of the IHSETN is to develop and provide state of the art services to Iowa’s Healthcare providers and educators using the fiberoptic ICN. The Resource Center role is complementary to the activities of the Rural Telemedicine Laboratory in that the Network provides the basis for widespread application of educational and clinical support services and technical advances that have been studied and validated at the Laboratory’s test sites. The long term goals of the IHSETN are to: link Iowa’s major health care educators and providers in an innovative, collaborative partnership designed to serve the health education needs of the entire state; increase the accessibility and availability of rural and urban health providers to high quality, timely and cost effective educational programming; and support and enhance the timeliness an cost effectiveness of patient and community health education initiatives undertaken by local health care providers and organizations.
External Advisory Committees for the IHSETN will play a key role in identifying user requirements. The composition of the external advisory committees include representatives from such constituencies as the Iowa Hospital Association, the Iowa Medical Society; other telemedicine projects; and staff of the Iowa Communications Network.
Clinical support projects
Teleradiology. Only about half of Iowa’s hospitals have a radiologist on staff (66 of 120). Although teleradiology is not an uncommon application in telemedicine networks, many questions remain regarding these services. Specific issues which we will be investigating include: standardization of sending and receiving units for networked hospitals; resolution and quality of images using teleradiology vs. plain films; value-added teleradiology reports utilizing interpretation by tertiary care subspecialists; and the time and accuracy of report delivery using teleradiology as opposed to traditional ‘circuit-riding” approaches.
Three-dimensional image analysis. Using conventional (low-end) CT scanners available to all three hospitals (one via a mobile unit), physicians and technicians from the community hospitals will have access to enhanced, 3-dimensional images of heart and lung via a sophisticated, computer-based image analysis system. Data will be collected to assess levels of technical, educational, and clinical training necessary for health providers and to determine the extent to which patient diagnosis and care are enhanced by this capability.
Trauma Care. Traumatic injury is the most common cause of death in Iowans under the age of 40. Our third clinical project supports the use real-time computer based information exchange between community and referral hospitals. Linked to medical image transfer methodologies, this system will develop an algorithm for community hospitals to use in determining the triage, treatment, and transfer of rural trauma patients.
Virtual Hospital. Rural and community health providers do not have access to the resources, continuing educational opportunities, and information services available to health professionals in an academic or tertiary care facility. The Virtual Hospital is a multi-media database offering the most current medical information in a variety of formats that include, text, graphics, and full motion video with sound. This full-text database includes electronic textbooks, patient simulations, current diagnostic algorithms, continuing education materials, physician and hospital directories, links to on-line journals, radiographic teaching files, government documents, material from UI faculty and guest lectures, and a large patient information component. While reading through any piece of text, the user has only to click on an image button to view graphics, radiographic or histologic manifestations, or a video of a patient presenting with the symptoms under discussion. Videos of open heart surgery, fluoroscopy, bronchoscopy, tracheal dilatation, intubation, open lung biopsy, pathology specimen preparations, pulmonary angiography, joint fluoroscopies, and pediatric airway obstructions are only some of the full motion clips to be found on the Virtual Hospital. A librarian has recently been hired to develop a searchable index for this database.
Enhanced access to information services. Access to Library and information services have been shown to influence medical decision making in such areas as diagnosis, treatment, follow-up care, and length of hospital stay. UI’s Hardin Library for the Health Sciences will offer community hospitals full access to a variety of medical and health databases including all the Medline files, CINAHL (a nursing database) , Health (covering the hospital administration literature), CancerLit (a comprehensive index to all oncology literature), and Reference Update (an up-to-date current awareness database which provides access to just published literature in the biosciences). All of these include abstracts and are searchable by means of CD-Plus’ OVID software which provides an interface supporting both novice and advanced users. Additionally, the Information Services Project will allow users to telnet to MicroMedix, a computerized clinical information system which provides quick access to toxicology, poisons, drugs, and emergency medicine. The University of Iowa’s online catalog, OASIS, will be available as well.
Because most community hospitals do not own (or even have access to) many of the journals referenced in these electronic indexes, the project will also provide full text document delivery for all end-users at the three community sites. Aerial workstations with printers will be installed at each location for the quick turnaround of documents requested. Manuals for using both the Virtual Hospital and the Health Information Databases are currently under development by Resource Center staff. UI’s Hardin Library’s for the Health Sciences will ensure that their reference staff will be available to answer questions and provide consultation to the sites. Also under development is a tracking system which will measure satisfaction of use. All of our sites will have full Internet connections and web navigational tools, and participants will be able to access the rich and ever-expanding resources available through the information highway in a user friendly fashion.
Integral to the construct and design of our Laboratory is its emphasis on evaluation and outcomes analysis. Given the current national focus on strengthening primary care, what conclusions can be drawn about the efficacy of offering clinical and educational services to rural health providers over a wide area, high speed network? Or, more specifically: Can telemedicine applications be proven to be safe and effective? Has there been a measurable change (better or worse) in the patient’s health status, functioning, or quality of life because of telemedicine? What specific outcomes can be identified using telemedicine in terms of impact on length of hospital stay, reduced re-admissions, reduced number of consultations or tests, and earlier treatment of disease? Is the specific knowledge of the provider or patient changed or enhanced by telemedicine approaches? What factors facilitate or inhibit rural practitioners’ use of telemedicine? Does telemedicine help recruit and retain health care workers? What is the extent of use and user friendliness of electronic services and applications in the areas of distance learning and patient care? What is a reimbursable event? Who should be reimbursed? What aspects of the costs should be reimbursed? What, if any, value-added issues can be measured (e.g. savings on travel costs for the patient and family, savings in time for both patient and provider; access to ongoing health education for patient and provider)? Is it financially feasible to implement telemedicine on a widespread basis?
Collaboration and the Multi-disciplinary Approach
One of the most exciting features of telemedicine is the opportunity to bring ‘to the table’ individuals from a variety of disciplines - both from within and outside the institution. Clinical and educational telemedicine applications require the expertise of health providers at both the primary and referral levels, technical and systems people, educators, policy makers, representatives from third party payers, hospital administrators and planners, linguists, librarians, researchers and statisticians, instructional designers, and vendors of (for example) telecommunication services and equipment, hardware and software, and all types of video/recording devices.
The importance of collaboration, coordination, and communication among health providers is essential to the development of a telemedicine network. It is crucial that health professionals at all levels work together in a relationship that is collaborative and not ‘top-down.’ Communication needs to flow in a cyclical rather than linear pattern and emphasize partnership over competition. And with the advent of managed care, participants in telemedicine services must remember that emerging relationships among health care facilities will be driven, not by the technology, but rather by the needs of patients and primary health care providers.