No mountain too high
Rural broadband service helping to save lives of isolated patients
By Steve Thompson,
Writer-Editor
USDA Rural Development
heva is a healthy,happy three year-old boy, a joy to his parents
and grandparents. But soon after birth he
was a very sick baby, with a potentially fatal
heart defect.
To make matters worse, he was born in a
rural hospital hours from the nearest
neonatal cardiologist, a specialist who
could treat his illness. He is alive today
because new technology made it possible
for the specialist to diagnose and treat the
child from over 90 miles away.
Telemedicine, made possible by broadband
telecommunications, saved Dheva’s life.
Heart murmur endangers infant
Dheva Muthuramalingam was born Dec. 29, 1999, at
Winchester Medical Center, in the town of the same name in
the northern tip of Virginia. His family lived across the state
line in West Virginia. It was soon apparent to his attending
physician, Dr. Edward Lee, a neonatologist, that all was not
right with the child. Examination revealed a heart murmur,
prompting Dr. Lee to call for an ultrasound scan.
The scan was scrutinized by a specialist in adult cardiology,
who discovered a small hole in the infant’s heart. But it was
not clear that this defect was the cause of the baby’s distress.
And the expertise required to make a proper diagnosis was not
available. The Winchester area doesn’t have the population
necessary to support a cardiologist specializing in newborns
a problem it shares with thousands of rural hospitals.
Says Dr. Teresa Clawson, Dr. Lee’s fellow neonatologist
Winchester, “We’re considered a rural hospital. We do provide
neonatal intensive care to critically ill and pre-term newborns.
But Dr. Lee and I are the only pediatric sub-specialists
at this hospital, and we are geographically isolated by the
mountainous region around us.”
Dr. Lee decided to use the hospital’s telemedicine hookup
to consult with Dr. Karen Rheuban, a neonatal cardiologist
the University of Virginia Hospital in Charlottesville, and
coincidentally a strong advocate of the use
of telemedicine.
Dr. Rheuban suggested that the scan be sent to her electronically,
and within minutes was looking at a high-quality
rendering of the ultrasound picture, made possible by the
high-speed connection between the two hospitals. Dr.
Rheuban was quickly able to spot what the adult cardiologist
was not trained to see. Dheva’s descending aorta the main
artery that carries blood from the heart to the lower part of
the body was completely blocked.
The only reason he was still alive was that newborns have
a blood vessel connecting the aorta and the pulmonary artery,
which takes blood to the lungs. Enough blood was getting
through to keep the baby alive, but the passage would soon
close. When that happened, his kidneys and other lower
organs would cease to function, and the child would die.
Dr. Rheuban quickly prescribed a drug that would keep
the passage open and recommended that the baby be immediately
transported to UVa for open-heart surgery. Getting
the baby to UVa Medical Center, including sending a van to
Winchester, took about seven hours. “If we hadn’t been able
to do the long-range diagnosis, the baby probably would
have been dead or on the verge of death by the time he
arrived,” Dr. Rheuban says.
Dr. Rheuban has been a strong advocate
of telemedicine for more than 12
years. She is medical director of the UVa
telemedicine program and was instrumental
in getting a telemedicine system
up and running in rural Virginia.
Conference sparks interest
in wider use of telemedicine
Rheuban says the idea for the system
was born when she and a number of
other UVa doctors attended a conference
on continuing medical education.
One of the speakers was Dr. Jay H.
Sanders, a professor of medicine at
Johns Hopkins University Medical
School and, at the time, president of
the American Telemedicine Association.
Rheuban and a number of other
UVa physicians were galvanized by
Sanders’ lecture detailing the advantages telemedicine could bring to rural
physicians, clinics and hospitals in serving
the needs of their far-flung
patients. Back home in Charlottesville,
they formed an ad-hoc group to promote
a system that would tie the many
rural hospitals and clinics in Virginia.
Their activities quickly led to a small
study group, which paved the way for
launching the program in 1995. The
system began formally seeing patients
in 1997. “We started slowly,” she says.
“We weren’t looking to compete in
areas that have
comprehensive
health services.
We wanted to
reach patients that
didn’t have those
services.”
That meant
looking for independent
rural hospitals
and clinics
that needed the
advantages they
had to offer. It also
meant finding
financing: UVa
raised the funds to
build their central
telemedicine facilities,
but coming up
with the money to hook up and equip
far-flung clinics and hospitals was the
responsibility of the participating institutions.
The funds have come from a
wide variety of sources, including
USDA Rural Development’s Community
Facilities and Rural Utilities programs.
Through its Distance Learning
and Telemedicine Program, a Rural
Utilities Service program, Rural Development
has made two grants totaling
over $300,000 to expand the UVa system,
as well as a Community Facilities
loan of $324,500 to enlarge an existing
telemedicine facility.
Currently, the UVa telemedicine
system has 35 participating facilities
across the Commonwealth of Virginia.
These sites include community clinics
and hospitals, schools, prisons and other
campuses in the state’s university
system. This spring, UVa plans to add
another eight sites in remote and
mountainous western Virginia, where
the population density is less than 10
persons per square mile.
Quality health care
Patients who take advantage of the
system have access to some of the best
care available. UVa Hospital is ranked
among the top 100 hospitals in the
country by one study, and 42 doctors at
the facility were ranked among America’s
best in a survey of their peers.
They include the current president of
the American College of Cardiology
and a former president of the American
College of Surgeons.
According the Dr. Rheuban, the system
has so far made possible more than
5,200 remote medical consultations.
And telemedicine is not used just for
diagnosis and treatment, but also for
providing continuing education for
both physicians and patients. The UVa
system has broadcast thousands of
hours of education programming,
ensuring that rural physicians can be as
up-to-date about recent medical developments
as their urban counterparts.
Funding the infrastructure is not the
entire problem, however. There is the
issue of how clinical costs are billed and
paid when consulting physicians are
miles away, plus the problem of meeting
ongoing routine operating expenses in
remote rural locations. Some medical
insurance providers do not provide reimbursement
for telemedicine expenses.
Rheuban says that there are solutions,
but that a “change in the culture”
is necessary before billing procedures
become routine. Meanwhile, Blue
Cross/Blue Shield has made a grant of
$250,000 to UVa over five years to pay
for telemedicine services to patients
who don’t have coverage.
Dheva’s experience is anything but
unique. In the past six years, hundreds
of patients in rural Virginia have benefited
from the UVa system. Some, like
Marie Sanders, who lives in the southwestern
part of the state, are saved the
bother and expense of being driven
several hours to a major city for a
consultation, and staying overnight at
a hotel. There is also a man who came
to a rural clinic with fever and anemia.
He was seen by a blood specialist miles
away in Charlottesville, who found
that he had a dangerous infection in
the heart caused by an undiagnosed
heart defect.
Another patient in the southwest
part of the state was initially diagnosed
with shingles, a painful but not usually
life-threatening viral disease. A specialist,
consulted through telemedicine,
found that the man was actually infected
with flesh-eating streptococcus
bacteria. Immediate treatment may
have saved his life.
The Bush administration and Congress
have recognized the usefulness of
rural broadband telecommunications
networks, such as those that made
these stories possible. A new USDA
Rural Development Rural Broadband
program makes $1.4 billion available
this fiscal year alone for their building
and expansion (see sidebar). By the
time Dheva becomes an adult, the
technology that saved his life may be as
common as cable television.
