Slowly but surely, rural medical facilities are turning to teleradiology for timely and accurate image analysis. Now that technology allows for the transmission of diagnostic-quality images, cost and politics are the only obstacles to the proliferation of teleradiology.
Cost, nonetheless, can be a formidable obstacle in rural areas, particularly in light of the need to cost-justify every expenditure in the contemporary health care environment. But where there is the will, radiologists and underserved rural medical facilities are availing themselves of government and private grants as well as existing transmission technology to improve health care for patients in remote and rural locations.
Some facilities are already well ahead of the rural curve in teleradiology. With funding from the University of Iowa, Van Buren County Hospital in Keosauqua, Iowa, started using teleradiology in 1992. Today, radiologic technologists at Van Buren use a sophisticated digitizer to scan films and transmit diagnostic-quality images via a T1 line to radiologists at the University Hospital School in Iowa City, almost 100 miles away. Van Buren’s digitizer came courtesy of a private grant from the University of Iowa, while a government program dating back a decade provided the dedicated T1 line.
A roving radiologist still pays a daily visit to Van Buren and teleradiology fills in the gaps. “The radiologist comes at 10:30 AM and sometimes stays until noon,” says radiologic technologist Gena Oberman, RTR, Van Buren County Hospital. “If a car accident victim comes in at 2 PM, then, chances are, we’re going to send those films to Iowa City.”
In some areas, the road to a working teleradiology system can be a little more circuitous. In an effort to improve radiology services to its small rural outreach clinics, the Centura Medical Group in Colorado recently contracted reading services with Richard Strand, MD, of Desert Valley Radiology, Phoenix.
“A test site that we are developing right now is the Custer County Clinic in Westcliffe, Colo,” Strand says. “We are trying to develop a seamless approach to allow us to give real-time, on-site help to rural-based physicians.”
Until the necessary equipment is in place, the clinic in rural Westcliffe will continue to send films via courier-as well as some patients-to St Thomas More Hospital in Ca?on City, Colo. “If we need a read on an acute basis, we normally do not do the x-ray,” says Toloa Pearl, administrator, Custer County Clinic. “We send the patient by ambulance to the hospital in Ca?on City about an hour away.” Patients (mostly vacationers) in acute situations such as car or horse accidents are stabilized and transported. Westcliffe does not have MRI, CT, or nuclear medicine technologies on site, so patients who require them must also be transported to Ca?on City.
Strand is confident that outreach efforts will eventually bring better service to the people of rural Colorado. “This is not just teleradiology on call,” Strand says. “We are actually going to be able to interpret these films and extend high-quality care to rural communities.”
When Westcliffe begins transporting its images via phone lines instead of courier, two Ca?on City radiologists affiliated with Strand’s Phoenix group will read the films. Images from Westcliffe will arrive via plain old telephone service (POTS) rather than T1 or ISDN (Integrated Services Digital Network) lines. “Although we do have T1 lines at the Westcliffe clinic for telemedicine uses, we are going to use POTS lines for teleradiology because we do not expect a critical mass of transmissions,” says Vera Rose-Kloepfer, director of the Colorado telehealth network. “It is significantly less expensive than the T1 line, and even less expensive than ISDN.”
Rose-Kloepfer expects the clinic in Westcliffe (population 450) to transmit up to 10 films a week-mostly for skiing and ranch-related accidents. She acknowledges that the data-intensive files will be slow without high-speed lines, but says Westcliffe should fare well for about 2 years. “We have determined this is the best way to start. We are planning for our sustainability,” Rose-Kloepfer says. “In 2 years, we’ll have options. T1 lines will probably be less expensive and ISDN lines will be available if we need them.”
PRIVATE, PUBLIC GRANTS
With Rose-Kloepfer’s help, Strand secured a private grant that began Centura’s latest outreach efforts. A Catholic group (Sisters of Charity) funded the $75,000 grant to improve the quality and timeliness of rural Colorado health care, without regard to volume or potential return on investment.
Grants such as these help fill in the gaps between the cost of the technology and the volume of business most rural facilities generate. “If they had the volume, they would have a full-time radiologist,” Strand notes.
To get a public or private grant, Rose-Kloepfer says a thorough needs assessment is essential. “It does not have to be a long, intensive process, but you really must address the hard facts of why you want the system, what your situation is without it, and how many people will be served,” Rose-Kloepfer says. “I work with grants a lot and I also review grants on a federal level. We look at the needs assessment and the level of sustainability.
“Granters do not want to give money to projects that are going to be funded and successful only during the time of the grant. They want to know the project will go on,” Rose-Kloepfer explains.
Public money is more elusive for radiology groups seeking funding for rural tele-radiology projects. Departments such as Health and Human Services (HHS) will not fund single-purpose applications such as teleradiology. “The people who get our grants may do teleradiology, but they are also providing a range of services,” says Dena Puskin, director of the Office of the Advancement of Telehealth, HHS. “One of our concerns about putting in a high-priced radiology unit in a small facility is the question of how it is to be sustained financially after the grant is over. Teleradiology is reimbursed, but who is going to pay for the maintenance and upkeep?”
Officials at the Missouri Valley Health Network (MVHN) in Yankton, SD, successfully addressed these concerns and won a $350,000 grant from the United States Department of Agriculture (USDA). Unlike HHS, the USDA had no problem earmarking all of the money for teleradiology.
“The USDA has a rural development mission: We try to improve the quality of life in rural areas and smaller communities,” says Claiborn Crain, assistant to the administrator of the Rural Utility Service, USDA, Washington, DC. “While $350,000 is quite a bit of money, it still doesn’t really go very far in putting one of these teleradiology systems together.”
The MVHN received the USDA’s maximum grant of $350,000 by showing it had the resources to sustain the project. Crain says the USDA has received grant requests totaling more than $200 million, which is well over the $12.5 million that the USDA has set aside for rural telemedicine (including teleradiology).
In addition to grants, the USDA also offers loans. “The loan program has not really caught on,” Crain says. “The good thing about the loan program is that it’s not a competitive process. If [a facility] puts in an application for a loan and has a revenue stream that can pay it back-and show the right criteria-then they’ve got it.” According to Crain, the USDA has loaned only a fraction of the $150 million set aside for that purpose.
The USDA also offers a combination loan and grant. “If you borrow $10 from us, we’ll give a dollar for a grant, so that buys the cost of the loan,” Crain says. “We’ve had some applications on that and I think it will grow.” For more information on loans, grants, or loan/grant combinations, call (202) 720-0413, or visit the USDA Web site, www.usda.gov.
The National Technology and Information Administration (NTIA), under the aegis of the United States Department of Commerce, also awards grants for telemedicine purposes (which may include teleradiology).
NEED DETERMINED GRANT
MVHN’s grant money will go toward the purchase of teleradiology equipment for 10 rural counties in southeastern South Dakota. “Technology costs seem to be decreasing with time, so we are optimistic that future upgrades in technology will be less expensive than in the past,” says David Anderson, vice president of network services for Avera Sacred Heart Health Services (part of MVHN). The MVHN is also applying for Federal Communications Commission Universal Service Fund discounts to aid in offsetting monthly charges.
As the person in charge of acquiring the grant, Anderson developed an extensive needs assessment that addressed sustainability, equipment needs, and demographics. Each of the counties in the proposed project area has per capita incomes lower than South Dakota’s state average and substantially lower than United States averages. “The criterion is that you have to show a need, and certainly being medically underserved relates to per capita income and economic conditions of the area,” Anderson says.
Anderson says that four of the 10 hospitals will be served by T1 lines that were already in place for information systems, e-mail, Internet, and voice usage. The remaining six will utilize dial-up ISDN lines. Facilities in Yankton, Mitchell, and Sioux Falls will be fully equipped with viewing stations and able to support diagnostic readings, and all other facilities will have top-notch transmission equipment.
A vendor has been charged with selecting and coordinating equipment and training for all 10 facilities. The facilities will use IBM computer hardware and a teleradiology software package to distribute medical images in a virtual picture archiving and communications system (PACS) environment. The software sits on the Windows NT platform and supports any type of wide area network (WAN) communications, including ISDN, POTS, and T1 lines.
The MVHN mother hospitals in Yankton, Mitchell, and Sioux Falls will have quad-monitor 2Kx2K diagnostic workstations. Each facility was given a choice between two digitizer scanners from two different vendors at two different price points.
“We are in the process of installing some of the equipment,” says Robin Berke, director of radiology, Avera Sacred Heart Hospital, Yankton. “Each one of the small town hospitals will have a digitizer that can dial up and forward the image to our reading station, which will then automatically forward the image to the radiologist who is on call.”
Berke says the equipment at Avera Sacred Heart costs slightly more than $100,000, plus an additional $40,000 for the scanner. The total cost of the project is approximately $700,000. “It was a grant requirement that there be some matching funds,” Anderson says. “The matching funds come from each of the 10 facilities that share in the grant.”
For Julie Degen, RTR, Avera St Benedict Hospital in Parkston, news of the grant was a pleasant surprise. “We have a courier who transports the films by car back and forth to Queen of Peace Hospital in Mitchell,” Degen says. “It [teleradiology] is going to be faster. And if I need a stat reading, I can request one.”
RURAL WRONG NUMBER
In the absence of grants, the numbers can get high when adding up costs for diagnostic-quality image transmission systems. “Cost is still the biggest limitation for rural medical facilities,” says James Borgstede, MD, chair of the American College of Radiology (ACR) Commission on Small and Rural Practice. For rural facilities looking to transmit diagnostic-quality images for official reading/diagnosis, the computer hardware and software range from the low $100,000s to the millions.
Communication lines pose an additional challenge. Ideal transmission lines such as ISDNs, DSLs (digital subscriber lines), and T1s are usually not found in rural areas. Designed to operate via existing copper telephone cable, DSL is typically available only in areas adjacent to a telephone company central office.
Consequently, standard telephone lines that make it difficult to send large data-intensive files are the only option available for many rural facilities. Image compression, a technique that uses a mathematical algorithm to squeeze out inessential data and strip images to their essential features, is one way to overcome the limitations of standard telephone lines, enabling the user to send diagnostic- quality images. However, wavelet compression requires expensive specialized equipment, including a digitizer scanner and compression software. Many of the more sophisticated JPEG (Joint Photographic Experts Group) compressions face the same challenge. The bottom line is that compression is still too expensive for many rural facilities.
THE END OF THE MIDNIGHT RIDE
Despite advancements in compression technology and the availability of diagnostic-quality transmission equipment, rural teleradiology, like urban teleradiology, is predominantly a lifestyle enhancement for rural radiologists, though one with important implications for patient care.
“Teleradiology in rural practices is still primarily used for after-hours interpretation in practices where you cannot have an individual at the hospital 24 hours a day,” Borgstede says. “Teleradiology is improving radiologist availability for consultation 24 hours a day in rural areas. In doing that, it is really improving the quality of patient care.” Borgstede notes that one third of the ACR membership is represented by practices of five or less members.
Patients in Ca?on City (population 16,000) have reaped the benefits of after-hours teleradiology for the past 10 years. Then again, so have Ca?on City radiologists Lance Pysher, MD, and Curtis Harlow, MD.
“With only two radiologists in town, we are on call every other week. If you were to be called in just once a night and have to drive to the hospital, it would pretty much ruin your life,” Pysher says. “The ability to review images at home-or on the laptop if you are at a restaurant-makes life tolerable for a small town radiologist. Otherwise you would be at the hospital all the time.”
Pysher and Harlow circumvented the cost of a sophisticated system by creating a relatively low-tech, yet effective, solution. They use a plain flatbed scanner with a transparency adapter, which costs about $1,300. A more sophisticated digitizer scanner would cost between $25,000 and $50,000. It all runs on a Macintosh 8100.
Using Adobe Photoshop, the scanned image is compressed to a standard JPEG suitable for transmission over telephone lines. “We have not used the other compression technologies, because it requires more specialized teleradiology equipment that is very expensive,” Pysher says. “We have difficulty in accessing high-speed data links. Our community has no ISDN or DSL. We could get T1s, but our volume of teleradiology does not warrant the investment.”
Pysher and Harlow use a software package that allows them to make a direct phone line connection to the hospital. Images can then be sent directly to their homes. Images can also be sent via email attachment.
According to Pysher, the flatbed scanner is a vast improvement over the old-camera-on-a-stick method, which basically froze a video frame, digitized the image through a computer, and sent the image over phone lines. He and Harlow make preliminary interpretations at their respective homes and review the hard copy in the morning.
CREDENTIALING AND LICENSING
While teleradiology technology enables the transmission of images anywhere in the world, regulatory and credentialing issues continue to be debated. “When you get into the official interpretation issue, everyone wants licensing of the individuals who are performing teleradiology,” Borgstede says. “It is the opinion of the ACR that individuals should be licensed on the sending end and the receiving end.” Borgstede says the same standards should apply to images sent across state lines (interstate radiology).
As president of the Colorado Board of Medical Examiners, Borgstede worked with the Colorado legislature to require a full, unrestricted license for any practitioners engaged in telemedicine. “We treated telemedicine the same way we would treat face-to-face medicine,” Borgstede says. (See related story, “State Licensure Issues”.)
To establish technical standards and requirements, the ACR has worked with the National Electrical Manufacturers Association (NEMA) and Digital Imaging and Communications in Medicine (DICOM) to set uniform standards for teleradiology.
A brief overview of the ACR standards covers appropriate personnel qualifications, equipment specifications, and quality control measures. For example, the ACR recommends that official image interpretation be done by a physician who not only understands teleradiology technology, but also knows its strengths, weaknesses, and limitations.
The physician should also have demonstrated qualifications for the particular diagnostic modality being transmitted. Professionals at the transmitting site should include a licensed and/or registered radiologic technologist, nuclear medicine technologist, or sonography technologist/sonographer. Any one of these technologists should be under the supervision of a qualified physician. For a comprehensive written review of all ACR teleradiology standards, call (800) ACR-LINE or visit www.acr.org and click on the link labeled Standards.
Harlow in Ca?on City believes teleradiology could improve health care in areas throughout the world. “I think this could be a huge advance for Third World countries,” Harlow says. “There are plenty of places without radiologists, but if there is a plug and a telephone line and some computer technology, care could be improved in some remote places in the world.
“It’s not so important where the image is taken or where the radiologist sits. The radiologist can physically be just about anywhere in the world.”
Here in the United States, Strand believes teleradiology will expand as more people move to rural communities and telecommunications follow the expansion. “It’s pretty exciting,” he says. “As equipment becomes less expensive and high-speed hookups become common, I think more and more people will be doing this,” Strand says.
Greg Thompson is associate editor for Decisions in Axis Imaging News.