Telemedicine In Utah: The Rural Utah Telemedicine Pilot Project Marta J. Petersen, Donald A. Baune, I. Greig Huggins, Deborah J. LaMarche Telemedicine Outreach Program University of Utah Salt Lake City, UT 84132 Abstract Telemedicine is broadly defined as the use of telecommunications technology in the delivery of health care at a site removed from the provider. Telemedicine can improve access to specialty care in rural areas and reduce the sense of isolation experienced by many rural health care providers. The University of Utah, in partnership with the State Department of Health, is establishing a rural telemedicine network to rural hospitals throughout the state and in western Nevada. In this paper, we describe the development and implementation of this network and some of the barriers encountered in its implementation. Introduction Telemedicine, the use of telecommunications technology to deliver health care at a site distant from the provider, has been suggested as one solution to reduce disparity in access in rural areas. It has been suggested in a report by the American College of Physicians that telemedicine can also improve the quality of rural health care [1]. Goals of telemedicine include: 1) increasing access to specialty services, thereby allowing patients to be treated locally and retaining their health care dollars within the rural community, and 2) decreasing professional isolation of rural health care providers, thereby improving recruitment and retention of such providers. Telemedicine includes clinical consultation using interactive compressed video, transmission of digital representations of x-rays and other imaging studies, continuing medical education using the videoconferencing equipment, and electronic access to library and other information services available in tertiary care centers and medical schools. It also involves distance education of students in the health professions by transmission of courses to rural communities as well as supervision of health trainees in rural health care settings. Much of the rural population of Utah has limited access to essential health care services as defined in a state-sponsored report, Utah s Vision for Rural Health Care: A Framework for Action [2]. Utah is comprised of 29 counties, 25 of which are rural. These 25 rural counties contain 96% of the State s land mass and 22.5% of its population. Fifteen of the 25 counties have six or fewer people per square mile and are designated as frontier counties. Residents in rural Utah are generally poorer and less likely to have health insurance than the urban population. Rural Utahns are both more elderly and younger than the population of the State as a whole. This has important implications for rural health care delivery since these groups tend to require more health services than middle-aged adults and adolescents. Despite access to the Internet and destinations on the electronic highway, the majority of practitioners in rural Utah are not actively using these services. A survey of the physicians in the participating rural hospitals revealed only two of ten practitioners were connected to the Internet prior to this project. Although specific reasons for its limited use are not known, unfamiliarity with and lack of time to learn the technology, as well as cost, undoubtedly contribute to limited utilization of the electronic highway in rural areas. Administrators of the ten publicly-owned rural hospitals in the state recently identified information support systems and telemedicine services as two of the eight most immediate needs for their hospitals and staff. Rural Utah Telemedicine Pilot Project Planning for the Rural Utah Telemedicine Pilot Project began in 1995. Two types of telemedicine sites were envisioned: full telemedicine and data-only sites. Full telemedicine sites would be outfitted with videoconference equipment allowing real-time telemedicine consultations, an x-ray digitizer to convert plain films into digital information which can be transmitted and read at a distant facility, and a personal computer providing access to network information services including literature searches, article retrieval, drug information, and e-mail. Data-only sites be outfitted with a personal computer for access to the information services described above, but would not include videoconference capabilities. Description of Full Telemedicine Sites West Wendover, Nevada, is located immediately over the Utah/Nevada border from the smaller town of Wendover, Utah. Together, the population of the two
towns approaches 5000 and is expected to double in the next two years as the casino industry expands. The nearest hospitals are located in Tooele (100 miles) and Salt Lake City (120 miles). The clinic in West Wendover has had difficulty retaining its health care providers and has closed on several occasions for this reason. The University of Utah Health Sciences Center (UUHSC) acquired the clinic in 1994 and it reopened on August 1, 1994. The clinic is staffed by family nurse practitioners and one physician from the University one day per week. There is a portable x-ray machine and, prior to this project, x-rays had to be transported via ground transportation to the UUHSC for interpretation. This site was chosen because it represents a health care facility staffed by mid-level providers, with minimal on-site physician backup, the need for teleradiology, and its affiliation with the UUHSC. Milford Valley Memorial Hospital is located in Beaver County, a frontier county with a total population of 5,000. Milford recently acquired a major industry (pig farming) and is projected to double its current population of 1,200 within the next five years. The hospital is a 24 bed facility, with an outpatient clinic contiguous with the hospital, and an Emergency Department (1539 visits in 1992). The hospital and clinic are staffed by a general practitioner, a internist and a physician s assistant. X- rays are read by a radiologist in Cedar City, one hour away. Films are transported via UPS, the average turnaround time for interpretation of x-rays is 24-72 hours. Many patients, including trauma cases, are referred to the UUHSC for specialty care and hospitalization. Milford was chosen because of its limited access to specialty services, its need for teleradiology to decrease the time for radiologic interpretation, and the interest expressed by the physicians for access to library and information services. Allen Memorial Hospital in Moab is located in Grand County in southeastern Utah. Grand County is a frontier county with a population of 6,620. Moab is the county seat and the largest town by far (population 3,971). Tourism is a major industry with over 700,000 visitors each year to nearby Arches and Canyonlands National Parks. Allen Memorial is the only hospital in the county and the nearest larger hospital is in Grand Junction, Colorado, 100 miles away. The hospital is a 34 bed facility, staffed by 3 family practitioners, 1 general surgeon, a nurse midwife and a family nurse practitioner. Radiologic services include routine x-rays, ultrasounds and computed tomography. Radiologic interpretations are provided by a radiology group in Durango, Colorado. Moab was selected due to its location in a heavy tourist area and the interest of the administrator to retain more of their referrals within Utah, instead of nearby Colorado. Network Design Phase I, providing full telemedicine services to University of Utah Wendover Clinic, was implemented in February 1996. Telemedicine services at this site include interactive televideo (IATV, see Appendix 1) with document stand and an ophthalmoscope/otoscope peripheral device, and an x-ray digitizer. The T-1 line was configured with ten channels devoted to transmission of the compressed video signal, six channels devoted to voice transmission, six channels devoted to data transmission and two channels devoted to the digital stethoscope. The central University-based hub was designed such that 14 additional T-1 connections could be added to the network with the existing hardware. The hub at the University can also dial-up other telemedicine video sites around the country, using a T-1 ISDN link. In Phase II, full telemedicine services to Milford Valley Memorial were implemented in March 1996. A dedicated T-1 line from the University to Milford Valley Memorial Hospital was leased from US West. A refurbished VTel videoconference unit (purchased from the Utah EDNET system) was installed, enabling interactive video between personnel at Milford and the University or other video sites on the network. A plain film digitizer was installed at Milford and digitized data from plain films are sent to Dr. Phillips in Cedar City via the T-1 line to the University and a 56K frame relay connection to Cedar City. Additional equipment installed at Milford included an ECG machine linking with Cardiology at the University, and two personal computers with access to the University network (library, drug information, e-mail). In addition to the video site installed at Milford and the 56K link to Cedar City, Phase II also implemented network connectivity to four additional rural hospitals. Frame relay connections (56K), leased from the State s Information Technology Services (ITS) network, were established to hospitals in Gunnison, Nephi, Beaver, and Price. A personal computer and equipment necessary for the telecommunications link (a router, a CSU/DSU, and a 10BaseT hub) were installed at each site. These data-only links provide access to the University network, linking the hospitals to library services drug information. The Telemedicine Outreach Office also has a server, providing e-mail services to the sites on the network. Digital radiology images (CT s, digitized plain films) may also be transmitted over the frame relay connections. In Phase III, full telemedicine services will be installed at Allen Memorial Hospital in Moab. A T-1 connection will be leased from ITS and used to transmit the compressed video images from the IATV. This link is scheduled to be implemented in the fall of 1996. Network connectivity to an additional four rural hospitals, using
56K frame relay connections leased from the ITS network, is also planned for Phase III. The design of the network is open, in the sense that different sites are able to speak electronically to each other as well as to the University Hospital. In such cases, the hub at the University routes the signal, without participating in the electronic interaction.
Training and Evaluation In collaboration with the Eccles Health Sciences Library, training sessions are conducted at each site to familiarize the users with the equipment and its capabilities upon installation of the equipment and network. Follow-up training sessions will be held within 1-2 months of installation and more frequently as needed. The project will be evaluated at six and twelve months with the assistance of personnel from the Utah Area Health Education Centers. Interviews with end-users, conducted in-person or by telephone, will be performed. End-users will be asked to comment on the system (easeof-use, service provided), ways in which their practice was altered using the system, efficacy of training, as well as other satisfaction measures. Usage logs will be kept at all sites, allowing us to track frequency of use. Services and Utilization Clinical services offered include dermatology, cardiology, pediatrics, family medicine, psychiatry and radiology. Continuing education for rural health care providers can be provided using the videoconference equipment. Students from the University working in these rural health care facilities will interact weekly with their preceptor at the University over this network. As it is early in the project, utilization has been limited to primarily dermatology consultations and meetings with personnel at the rural sites. Information from other programs around the country has suggested that utilization cannot be adequately assessed during the first year following implementation. Funding The UUHSC provided funds to establish the hub at the University Hospital and the link and equipment at Wendover (Phase I). The 1995 and 1996 Utah legislatures each appropriated one-time funding for telemedicine efforts in rural Utah. The Department of Health contracted with the Telemedicine Outreach Program to extend the network to sites in rural Utah (Phases II and III). Additional funding has been obtained from donations with the assistance of the University Hospital Foundation. Barriers to Implementation Several barriers to implementation and utilization have been encountered. Location of the Wendover Clinic over the state line into Nevada presented several challenges. US West, the telecommunications carrier to Wendover, Utah, does not service Wendover, Nevada. Contracting with the Nevada carrier for a T-1 line into the clinic from Wendover, Utah would have raised the monthly line charges to approximately $9,000 (whereas to the monthly line charges to Wendover, Utah are $2,000). A broad-band T- 1 radio link from Wendover, Utah to the clinic was employed to circumvent these high line charges. The T-1 radio has a range of 20 miles and requires a direct line of sight. Medical licensure issues have been an additional barrier to implementation at the Wendover Clinic. Recent changes in Nevada s medical practice regulations require any physicians providing in Nevada via electronic means (even telephone consultations would appear to be included in the wording) must now be fully licensed in Nevada. Licensing all physicians involved in the program at the University has been time consuming and expensive. We have been working with State government personnel to explore means to reduce some of the legal barriers to the practice of telemedicine over state boundaries. Summary The Rural Utah Telemedicine Pilot Project has established a telemedicine network to sites in rural Utah and Nevada. Three full telemedicine sites, involving interactive video, and at least seven data-only sites have been linked to the UUHSC via point-to-point T-1 connections and 56K frame relay links. Hardware at the UUHSC can route electronic signals between any of the sites on the network. The hub at the University can also dial-up other telemedicine video sites around the country. Utilization and cost-effectiveness of the network cannot be reasonably assessed at this time, but such analyses are planned. References 1. American College of Physicians. Rural Primary Care, Annals of Internal Medicine. Vol. 122, No. 5. pp. 380-390, 1995 2. Task Force on Rural Health Policy Development. Utah s Vision for Rural Health Care: A Framework for Action. Final Report, pp. 20-21 April 1993
Appendix 1: Glossary of Terms Telemedicine: Broadly, this is defined as the use of telecommunications technology for patient care and health education at a site distant from the provider. It includes such services as two-way interactive video for patient consultation and continuing medical education, transmission of digital radiology data (CT scans, digitized x-rays) and information services (e.g., access to library services such as literature searches and access to Drug Information). Compressed video: Video signals are converted into digital information (digitized), compressed and transmitted over T-1 line (see below) to the receiving site where they are converted back into a video signal and displayed on a video monitor or computer screen. High-quality compressed video (InterActive TeleVideo; IATV): This is the gold standard in interactive video and its hardware costs are high. This videoconference equipment costs approximately $60,000 $120,000 per unit, with two units needed (one at each end). A T-1 line is required to transmit the digitized and compressed video images. With this equipment, the image quality is sufficient to evaluate patients. Peripheral devices (such as ophthalmoscopes, otoscopes, GI scopes, stethoscopes) are available and their compressed images/sounds are transmitted to the receiving device. Desk-top video: Images from a video camera, mounted on a personal computer, are digitized, compressed and transmitted over computer networks, standard phone lines or T-1 frame relay connections. The compression algorithms are less sophisticated than those used in videoconference equipment, resulting in poorer image quality and choppier motion. The equipment is much less expensive (~$5,000 $10,000) than the videoconference equipment. These systems can be used for one-to-one teaching and meetings, but image quality is such that it cannot be used for clinical assessment of patients. T-1 line: This is a telecommunications link equivalent to 24 standard phone lines, which transmits 1.54 million bits of information each second (Mbps). Transmission of high-quality compressed video requires at least a quarter of a T-1 line. T-1 lines are leased from telecommunications carriers (e.g. US West) and are point-to-point connections between the sending and receiving sites (a so-called dedicated line). The monthly line charges for a dedicated T-1 line is dependent on the distance between the two sites and is in the range of $2,000 $4,000 per month. Frame relay: This is a telecommunications link in which the information is transmitted in packets, rather than a steady stream of data (as is the case with a T-1 line). Frame relay connections come in different speeds: T-1 (1.54 Mbps) and 56K (56 Kbps). T-1 frame relay can be used to transmit low-quality compressed video (see above) as well as data; 56K frame relay can only transmit data. The costs for frame relay connections are much lower than those for a dedicated T-1 line and are not dependent on distance. A T-1 frame relay link costs ~$350 per month at both the sending and receiving sites (total cost $700/month) and line charges for 56K frame relay links are approximately $100 $200 per month. Appendix 2: Approximate Costs for Telemedicine Equipment and Services Equipment costs for full telemedicine services (IATV) Videoconference equipment (VTel) used, with upgrade $40,000 vs. new $60,000 Telecommunications hardware: router, CSU/DSU, hub $10,000 X-ray digitizer $25,000 TOTAL $75,000 $95,000 Line charges for T-1 link Installation $1,200 Monthly line charges ~$2,000 $4,000 (distance-dependent) Equipment costs for 56K frame relay link (data only, no video) Router, CSU/DSU, hub $6,000 TOTAL $9,000 Line charges for 56K frame relay Installation $400 Monthly line charges $100 Equipment costs for T-1 frame relay link (data, low-quality PC-based video) Router, CSU/DSU, hub $6,000 T-1 cards for router @ Univ. $3,000 TOTAL $12,000 Line charges for T-1 frame relay Installation $750 Monthly line charges $800