A New Take on Health Screenings
Telemedicine helps deliver specialized healthcare to remote regions of rural Kentucky

Screening for health problems has taken on a whole new meaning. Kentucky has long served as a statistical example of underserved rural areas when it comes to healthcare: over 30 counties without hospital beds, the reluctance of qualified physicians to move into remote communities, a host of medical problems that prompted former UK heart specialist Dr. James Muller to launch the "Coronary Valley" Project, based in Manchester. But the technology and convenience of a collection of practices broadly termed "telemedicine" is helping patients and physicians to connect more effectively than ever before.

Defining terms In undefined territory

In the Commonwealth and across the country, projects exploiting the distance-defeating technologies of television, telephone, computer and Internet are unfolding in dozens of disciplines and applications.

A company called Home Access Health has long marketed an AIDS self-test using confidential telephone consultation, and is now seeking FDA approval for an at-home hepatitis-C test as well.

The Department of Defense is engaged in a wide range of telemedicine projects: teledentistry, forward combat units, psychology, pathology and neurology, even teledialysis. Such projects are especially promising for remote island bases, as well as care on board aircraft and ships. And as resources are trimmed, such programs maximize available expertise.

The term "telehealth" is a broad term that can refer to educating health professionals and consumers, disseminating information on public health, performing research and administrating health services. But telehealth isn't a one-way street with the public. Patients today educate themselves better than ever before, doing research on the Internet if they have the tools, or just paying close attention to the booming selection of health information available through traditional media.

"The increasing awareness and intelligence of the consuming public is the biggest change in today's healthcare," says Frank Beirne, CEO of Samaritan Hospital in Lexington. "They have options, and they exercise those options."

Reaching the underserved

Most physicians would love to see that educated public just exercise period, no matter the setting.

Kentucky ranks 40th in the nation in the overall health of the state's population. In 1994, 29 percent of the population was overweight. Over 67 percent reported living a sedentary lifestyle. The state ranked near last in alcohol consumption, but made up for it in the vice department by coming in third in tobacco consumption, with over 28 percent of its adult population smoking like chimneys.

Whereas telehealth activity is helping to dent those figures, telemedicine -- the use of electronic communication and information technology to provide or support clinical care at a distance -- is helping to reach those isolated human figures beyond the reach of normal health institutions. Nearly one-third of rural hospitals use some form of telemedicine in diagnosis and medical data transmissions. The range of uses includes advanced imagery and audio capabilities, high-resolution still images and sophisticated interactive teleconferencing systems.

While it's long been considered restricted to non-invasive procedures, telemedicine could be considered a part of the growing medical field of laparoscopy too, wherein a small video camera is inserted through a port incision, and surgeons operate through other incisions while watching their progress on a monitor. UK has just accepted a $2.4 million gift from United States Surgical Corporation to train surgeons in these techniques. And it gets even more high-tech, as many of these surgeons will train in these procedures using an "ImmersaDesk" virtual reality system similar to that used by airline pilots.

Home healthcare

Home healthcare may be the ultimate use of telemedicine's capabilities. UK HomeCare now covers a 16-county area.

"Appalachian Regional Healthcare (ARH) has recently partnered with the University of Kentucky Medical Center to bring home infusion therapy to the Bluegrass area," says Dr. Forrest Calico, CEOand president of ARH. "We are also one of nine developing partners to use technology in home care, providing specialty services such as psychiatric nursing, wound-care and cardiac rehabilitation."

The growing elderly population may be one of the prime users of telemedicine's capabilities, enabling physicians and other health professionals to facilitate motor skills observation, patient follow-up and even pill counting.

"We want to use it for home care and homebound patients," says ARH's telemed coordinator Stephanie Fendley. "It's extremely inexpensive -- they can put it on top of the TV monitor and have the patient do mobility exercises, walk across the room, look at incisions, wounds, etc. It cuts down on the expense of providing home care. Because of the terrain and distance, some of the nurses in our home health program only make six visits a day. So we're looking for funding and ways to initiate this service."

Peering into the future

Perhaps no one in Kentucky is more fluent in the application and exploration of telemedicine than Dr. Robert Schosser, clinical director of telemedicine, chief of dermatology and associate professor of medicine at the University of Kentucky. A native of Harlan (where he practiced as a primary care doctor for five years) and son of two health practitioners, he has a pretty good idea of what will and will not fly.

"Telemedicine is like so many other things -- one technology is not a panacea," Schosser says. "Having the right technology out there is the real critical part of this. We need to make it efficient and ergonomic.

"UK's program has been a pioneer in dealing with a lot of things," he points out, "including equipment. We ask the right questions, make hybrid systems by taking one company's stuff and making it work with another company's stuff. I've been disappointed in industry's approach to this. I think their dollar-focused approach didn't work. Getting bandwidth in rural America is a huge problem -- phone line availability, types of switching, phone company hardware and software issues.

"That hasn't been true in Kentucky: the state's initiative has gotten us low uniform pricing for T1 lines (lines that transmit data, voice and image over the equivalent of 24 phone lines). But telemedicine was not appreciated as a big enough market for the industry to support extensive research and development. They smelled an ability to sell stuff, but that was the end of it. There's just not significant industry-generated research and development in telemedicine."

Looking at the big picture

There is presently work underway at USC to establish a teleopthalmology project in order to evaluate retinal images of diabetics. Given the large population of diabetics in Kentucky, it might seem a natural direction to take for any telemedicine program. Schosser agrees, but offers caution once again.

"We have lots of opthalmologists scattered across the state," he says. "If they can do these things, we don't need to. We have pretty sophisticated opthalmology in Harlan, Hazard and other places, and it's relatively easy for people to get from one place to another. Different areas of the Commonwealth have different needs -- but one of the things we don't want to do is run off the doctors that are there serving those populations."

Ask the telemed team at ARH and they'll say that's the last thing they want to do too. In fact, they believe telemedicine is serving to strengthen the rural physician base, by assuring a sense of connection and support that wasn't previously possible.

"Part of the problem with attracting physicians to the country is the isolationism effect," says Jeff Brady, chief information officer for ARH. "They fear they have no resources. What this does is make those available to them without being right down the street."

Sterile telemed units called FREDs (Friendly Rollabouts Engineered for Doctors) are set up at hospitals in Hazard and Harlan, with expansion to Williamson and Middlesboro expected later this year. Pediatric cardiology and dermatology consults occur on a weekly basis, but perhaps the best use so far for ARH has been in the field of mental health, especially child psychiatry.

"We got the mental health network started with the Department of Mental Health," reports Brady. "They made us a pilot, along with Bluegrass Mental Health and Retardation network. It's connected to the UK Telecare network.

"Telemedicine has also tied us to other providers, so there are relationships developing there, between ARH and non-ARH facilities. The effort is to keep medical care within the community," says Brady.

But first that community has to obtain the right equipment, which isn't exactly cheap despite drops in cost over the past several years.

"We're further along than a lot of states. They're building a loop of fiberoptics through the whole state of Kentucky," says Brady. "Our problem is there's nothing similar in West Virginia right now. Five hundred dollars a month for a phone line here is $3,500 a month over there."

ARH has only been implementing telemed for two years, but they're on the verge of installing it in the rest of their hospitals, thanks to a matching fund USDA Rural Utility Service Grant. Other payment mechanisms, especially Medicare reimbursement, are still being worked out in the telemed realm. Yet according to Brady, it doesn't take long for such systems to justify themselves.

"In Morehead, the number of times they used telemed on a trauma and were able to keep the patient in area was about 15 cases in the space of a month or two -- which in effect paid for their system," he says.

"We're positioning ourselves to be in touch with other communities in the country," adds Brady. "There's a psychiatrist in McDowell who's the only one in Kentucky with his specialty. He will probably be a consultant to everybody in Eastern Kentucky, if we can just get him onto telemedicine. I could see somebody from Louisville or Lexington calling ARH to talk to him, which would be the reverse of everything that's ever happened."

"I'd like to see us continue to identify niches where we can offer significant improvement in the quality of existence for people in the Commonwealth," Schosser concludes. "Home health monitoring is a big one. Sub-specialty clinics geared toward specific questions. We're looking for ways of smoothing the transition from hospital to home, of making it safer to get people home earlier."

"At places like the Purple Cow in Beattyville or the Courthouse Cafe in Whitesburg, it would not be unlikely for someone to come up and start talking about healthcare, because they associate you with their own personal health," notes Donna Slone. "That is one of the great opportunities in rural healthcare. People don't affiliate with an institution, but with the people in that institution."

Likewise, healthcare practitioners in Kentucky aren't hiding behind the computers and cameras and monitors. They're finding ways to deliver care through them, to finally reach the people that need that reaching the most.

Adam Bruns is a staff writer for The Lane Report.

Back to February Issue

Back to Healthcare Index

Copyright 1996-98, by Kentucky Business Online, LLC.  All rights reserved.

Editorial content is copyright 1998, Lane Communications Group
All editorial materials is fully protected and must not be reproduced in any manner without prior permission. 

Buzzword and the Buzzword balloon are registered trademarks of Buzzword, Inc.  The Lane Report is a trademark of Lane Communications Group.  All other trademarks are the property of their respective owners.