Bridging the gap


USDA spotlights DLT
technolog to mark
50th anniversary of
telecommunications program


By Pamela J. Karg,
Field Editor
hile most Americans have enjoy d a period of unrivaled economic expansion during the past decade, some rural communities are still struggling with doubledigit unemployment and per-capita incomes that lag far below the national average. That's the case in many of the Appalachian Mountain communities of southwest Virginia, which is also home to some of the most medically underserved towns in the nation. Until the advent of distance learning and telemedicine (DLT) technology, rural communities such as Vansant, Va., were not good places to live for those needing the regular care of a medical specialist. That was the situation facing Alexandra Bartley, who, at age 18 months, underwent surgery at the University of Virginia Medical Center in Charlottesville to repair a cleft palate and tumor on her face. Following the surgery, she needed regular postoperative checkups and treatment at the medical center, more than 200 miles away from her home. Fortunately, Alexandra and her parents were spared the travel ordeal thanks to the universitysponsored Southwest Alliance for Telemedicine, which established a fiber optic cable link between a health clinic in Vansant and the Medical Center in Charlottesville. The link enabled a pediatric plastic surgeon in Charlottesville to examine Alexandra with video equipment and to direct treatments as she recovered from surgery. Alexandra's mother, Lisa Hubbard said each trip to Charlottesville not only would have required her to miss a day of work, but also cost her dearly for gas, food and lodging - not to mention how traumatic the long journey would have been for a little girl trying to recuperate from extensive surgery. The result? Alexandra's beautiful little face beamed out at the crowd that gathered at U.S. Department of Agriculture headquarters in Washington, D.C. in October to celebrate die 50th anniversary of USDNs rural telecommunications program. Agriculture Secretary Dan Glickman said there could be no better anniversary present than this real-life testimony to the value of telecommunications technology in rural areas. On behalf of the university, Alexandra and her mother accepted a $230,000 USDA grant which will be used to expand telemedicine service to two additional rural communities in southwest Virginia, part of $13 million in USDA grants awarded that day to projects in 34 states and Puerto Rico.

Saving lives on the High Plains
Further demonstrating the value of telemedicine, a live video-link was established between USDA headquarters and a rural health clinic in Haxtun, Colo., a small farming community about 120 miles northeast of Denver. There, Bryan Nation of the High Plains Rural Health Network (HPRIIN) spoke about the tremendous impact telemedicine has had on public health service in rural communities of the High Plains. The High Plains network began 10 years ago, and now provides vital services and economies of scale to 19 rural healthcare facilities in western Kansas, eastern Colorado, western Nebraska and southern Wyoming. These healthcare facilities -in towns ranging in population from a few hundred people to as many as 10,000 -are connected via telecommunications to two urban hospitals. In addition to providing direct healthcare services for patients, the network helps local clinics with recruitment and retention of physicians and nurses, insurance claims, collections and purchasing. Professional healthcare staff, local paramedics and others in the healthcare field routinely use the network for distance learning in required continuing education seminars. Dr. Greg Holst, family practitioner in Haxtun, credited telemedicine for enabling him to keep abreast of advances in medical technology and for improving direct patient care in his community. He introduced Phyllis Ash, who told how her husband, Dick, had nearly lost his leg to a staph infection. It was saved, thanks to an early diagnosis and treatment made possible through telemedicine. "In another 24 hours, he probably would have lost his leg," she recalled.

DLT increasingly affordable
Telemedicine technology is becoming increasingly affordable. By one industry estimate, a typical telemedicine set-up cost nearly $300,000 five years ago. With improvements in technology, innovations in data compression and reductions in computing costs, the expense of the equipment can be less than $5,000 today. For remote patient monitoring, the cost of some monitors is now less than $300 each. The real costs today are not in purchasing hardware but for telecommunicanons transmission, training health professionals in its use and integrating telemedicine into existing healthcare systems. HPRHN's Nation related how, during the first few years of the organization's operations, irrigated corn in rural areas grew so high and gave off enough vapor that it would knock out local telephone service. When a telephone company finally laid fiber optic cable, a farme accidentally severed the cables when he went out to plow. Gophers ate through other cables. "We're talking about very rural areas where there's one telephone company that doesn't necessarily install a lot of new technology because of the low density," Nation explained. That low density also creates high costs for rural distance learning and telemedicine projects. Another challenge HPRHN has experienced results from users who want "easier technology." Some rural hospitals may only use their system once a month. Even if one person is designated the "technology guru" in the healthcare office, it takes time to remember exactly how to operate the equipment. Distance learning and telemedicine practitioners also warn that programs need to be established with the end-user in mind. "It's one thing to think of a really great service you can finally provide to rural America over the Internet or via satellite," said Nation. "It's quite another thing to actually match your idea to what your target audience is willing to use."

Currently, a doctor must accompany a patient during a teleconsultation with another doctor. In some rural areas, though, physician's assistants, registered nurses or other certified health professionals staff clinics. On-site doctors are not always available, and some insurance companies do not want to pay any reimbursements for the telemedicine consultation without doctors at both ends of the fiber optic cable.

Saving rural schools
Delbert Wilson, manager of the Central Texas Telephone Cooperative Inc., in Goldthwaite said his co-op received one of USDA~ first telephone loans back in 195 1, when an average of 12 to 16 customers had to share every party line. In those days, farmers had to do double duty as linemen, maintaining the telephone lines that crossed their land. just two years earlier, in 1949, President Harry Truman had signed the amendment to the Rural Electrification Act that enabled USDA to begin loaning money to rural telephone cooperatives and companies. At that time, only 3 9 percent of farms had any phone service. Twenty years later, that figure had risen to 83 percent, and today it is more than 95 percent. Wilson's co-op is a perfect example of that progress. From humble beginnings, the co-op has leapt into the future, and now offers state-of-the-art digital telecommunications service to 6,500 customers scattered across 3,300 square miles in 14 central Texas counties. The co-op offers modem telecommunications service to rival that found in any urban area, from caller I.D. to being a local Internet service provider. Wilson said distance learning technology may be the biggest boon yet that the co-op has offered its customers. This technology has helped many rural towns in the co-op's service area improve and save their schools - a life or death issue in many small towns. "Rural schools are the heart and soul -as well as the largest employer - in most small rural towns," he noted. "When a community loses its school, we often lose the community as well." Many rural communities in central Texas have been trying everything to save their schools. While some consolidations have been inevitable, many districts now offer courses taught in distant locations, vastly expanding educational opportunities and future career options. By boosting the quality of the curriculum, more families are willing to remain in - or move to - rural towns, without the fear that they are sacrificing the future of their children because of inferior education. Better schools also help attract new businesses. This point was also underscored during a video link between USDA headquarters and the Towanda School district in a rural area of northeastern Pennsylvania. Dr. Dan Paul, project director for Partners in Distance Learning and the former Towanda school superintendent, said this distance learning project started with just six schools in 1993. "We saw the grant from USDA not only as a means to improve education in our rural schools in northeast Pennsylvania, but as a chance to demonstrate a better way for all rural schools to use technology to open opportunities for their students," he said. This distance learning program has been so successful that is has now been expanded to 3 00 schools in seven states. Last year, 30,000 students and 5,000 teachers participated in distance learning classes. "We are not aware of any other approach to distance learning in our country that involves more students and more teachers on a daily basis," Dr. Paul added. Students also participated in the event, relating what distance learning meant to them. One high school girl said the technology made it possible for her to take college preparatory math classes and German - classes her rural school doesn't offer. Other students told of taking virtual field trips via distance learning to places such as a NASA training center and the Philadelphia Museum of Art, all without leaving their desks.



"Indians finally victorious!"
Velasquez Sneezy, vice chairman of the San Carlos Apache Telecommunications Utility Inc., in San Carlos, Ariz., said telephone lines are truly the tribe's lifelines to the outside world. Before the tribal-owned telephone cooperative received a $14.1 million USDA loan in 1997 to expand its system, only about a quarter of the homes had telephones across the 2,854square-mile reservation. By comparison, 93.7 percent of all American households had telephone service; the rate was just 50 percent among rural Native Americans. In San Carlos, population just under 3,000, there was only one pay telephone. "People would start lining up at 6 a.m. to use the phone, and the line didn't go away until after midnight," Sneezy said. Thanks to financial and technical assistance from USDA Rural Development, "we now have the best telecommunication equipment to be found in the country," he said. Law enforcement has benefited greatly from improved telecommunications. Sneezy told of an incident when a tribe member, living in an isolated part of the reservation without phone service, was threatened by a gun-wielding assailant. The victim had no way to summon police. That type of terror is less likely now that most tribe members have telephones. Healthcare has also improved on the reservation. Parents can now call a doctor when a child is sick to discuss symptoms and determine if a long trip into town for a checkup is really necessary, Sneezy said. "Now, unlike in the movies, we can say that the Indians are finally victorious! I'll probably be talking to you again sometime in the future over a TV screen to ask for another loan to improve the system," he added.












Glickman issues call to action
Agriculture Secretary Glickman said the purpose of the celebration for the 50th anniversary on USDXs telecommunications program was not only to recognize the accomplishments of USDA partnerships with rural telecommunications providers, "but to issue a call to action for the next 50 years!" Glickman noted that up to 60 percent of all new jobs created in the next century will be high-tech jobs. "The Internet already accounts for 6.5 percent of America's gross national product," he noted, "and 10 years ago nobody had even heard of it!" Development of the Information Superhighway means even more to rural America than to urban areas, Glickman said. An urban location is no longer necessary to start a new business with a regional, national or even international scope. "The talent and brainpower needed to fuel the nation's high-tech industry in the 21st century can now be found, and remain, in rural communities," Glickman said. "And telemedicine projects are bringing better healthcare service to remote communities, saving time, money and even lives." John Podesta, President Clinton's chief of staff, echoed those sentiments, saying USDA will continue to play a role to ensure that the rising tide of high technology does not leave rural America stranded. "We cannot allow information technology to drive a greater wedge between the haves and have-nots, between urban and rural, or between young and old," he said. "Technology must be a force for both prosperity and social progress."



USDA offers record amount for DLT
To help spread DLT technology to even more rural communities, USDA will make a record $220 million in loans and grants available to rural communities in fiscal year 2000. Applications for DLT loans and combination loan/grant applications will be accepted until Sept. 30, 2000. Applications are processed on a first-come, first-serve basis. Applications for grants must be postmarked no later than March 17, 2000. Jill Long Thompson, USDA under secretary for rural development, said the DLT program's success has helped garner support from President Clinton and Congress. "The DLT program is giving us a clear view to a better future for rural education and healthcare service," she said. "With $81 million in USDA funds already invested in more than 304 projects since 1993, this program has improved the educational opportunities for thousands of students and provided better quality healthcare to rural citizens served by more than 800 hospitals and rural healthcare clinics."

Eyeing future DLT growth
Jon Linkous, executive director of the American Telemedicine Association, says the rapid growth of telemedicine is a worldwide phenomenon, but measuring it is tricky for several reasons. Telemedicine products and services are often part of a larger investment by healthcare institutions. Telemedicine is not a separate specialty and is often integrated with the overall delivery of health. Second, telemedicine is a very new investment for many institutions and there is little history from which to draw projections. "Finally, there is no commonly recognized definition or set of services and devices that constitute telemedicine. Different healthcare institutions and consulting firms define telemedicine in quite different ways," Linkous adds. Business Communications Co. (BCC), a Connecticut consulting firm, estimates that the current U.S. market for telemedicine is $65 million and will reach $3 billion by the year 2002. BCC also predicts a 42 -percent increase in public sector investments and an 89percent growth in telemedicine sites by 2002. The report predicts a 28-percent increase in prison telemedicine sites over five years and a doubling of military investment over seven years. In its ninth annual survey of senior healthcare executives, the Healthcare Information and Systems Society reports 34 percent of its 1,754 respondents currently use telemedicine. Another 10 percent plan on using it in 2 000 and 2 8 percent are investigating its use in the future. And the Telemedicine and Telchealth Networks magazine recently completed a survey of selected telemedicine program managers. Ninety-three percent reported that they expect to expand their operations in the next five years.






According to the 1998 Report on U.S. Telemedicine Activity produced by the Association of Telemedicine Service Providers, certain specialty areas continue to dominate use of telemedicine, such as mental health, cardiology, orthopedics, radiology and dermatology. Yet the types of facilities, programs, organizations, technologies and applications used to deliver these services have expanded and diversified in the last two years. The ATSP survey found that California, New York, Texas and North Carolina are leading the way in the number of their programs and teleconsultations. That rural America is sharing in the digital revolution is in large part the result of the partnerships USDA Rural Development has forged with rural telecommunications cooperatives and companies during the past half century, said Wally Beyer, who retired in October after six years as administrator for USDNs Rural Utilities Service. "USDA has been building the foundation for the Information Superhighway in rural America for 50 years. It is the foundation that will keep our nation's rural communities thriving during the next century."

Editor's note: For more information on
USDA telecommunications and DLT
programs, visit the USDA Rural Development
website: www.rurdev.usda.gov.