Thanks to telemedicine, respiratory therapy students now have the world at their fingertips.

In the spring of 1998, a handful of students in Hope, Ark, working toward certification as respiratory therapists, enrolled in a 2-hour course on leadership and supervision offered by the University of Arkansas for Medical Sciences (UAMS) in Little Rock. Rather than drive more than 100 miles into Little Rock to attend classes, these students gathered in a classroom at their local hospital and dialed up their instructor via two-way videoconferencing.

Without leaving their hometowns or taking time off from their jobs at the hospital, the students were able to study the same curriculum with the same instructor as students in Little Rock, through the use of telemedicine technology.

An Educational Tool
Many people are familiar with telemedicine as a diagnostic tool. Using ordinary telephone lines or high-speed transmission lines, telemedicine equipment broadcasts both video and audio signals. This technology has been employed for almost 2 decades to relay x-ray images and for medical consults in prisons and remote rural areas.

The same features that make telemedicine equipment useful for remote consults–the ability to communicate in real time, to see the person with whom you are speaking, to ask questions and to observe demonstrations–make it ideal for distance education. The same course can be delivered to multiple sites with one instructor. One student or 100 students at each site may participate. “The educational services have really taken off,” says Ann Bailey Bynum, EdD, director of UAMS Rural Hospital Program. “We do about 2,000 presentations a year to our rural hospitals.”

The UAMS Interactive Video Network reaches 18 rural hospitals, three community health centers, a rural health clinic, and several sites on the UAMS campus, where it is used for both clinical and educational services.

Although the technical knowledge and equipment for this kind of videoconferencing date back to the 1960s and the beginnings of the modern space program, only recently has the infrastructure existed to support widespread telecommunication networks. As equipment prices drop and transmission lines become more readily available, a growing number of hospitals and medical centers are setting up their own telemedicine networks.

Lack of funding has always been the biggest barrier to establishing telemedicine networks. A 1997 report1 on Rural Applications of Telemedicine found that the average cost of establishing a main, or hub site, was $287,503, while the cost of establishing an outlying, or spoke site, averaged $134,378.

Most networks have many lines, arranged in a hub-and-spoke system. One example of this arrangement is East Carolina University School of Medicine’s Rural Eastern Carolina Health Network (REACH-TV), in Greenville, NC. The School of Medicine serves as the hub of the system with 11 sites in five rural hospitals, a rural health center, a prison, and three rural physician practices, as well as home health services, programs in rural schools, and rural mental health services as spoke sites. Outlying areas connect to the hub but not necessarily to one another.

In the early 1990s, the federal government, particularly the Office of Rural Health Policy in the Health Resources and Services Administration (HRSA), began offering grants to hospitals, medical schools, and groups to develop telemedicine programs to serve rural areas where the lack of specialists and advanced medical education was most keenly felt. These grants fostered a mini-boom in the growth of telemedicine programs throughout the United States. HRSA grants typically extend over 3 years and provide funds to purchase equipment and lay telephone lines to get started in a telemedicine program.

In 1993, Avera McKennan Hospital in Sioux Falls, SD, received a HRSA grant to deliver telemedicine services to rural hospitals in that state. “South Dakota and this region in general are very rural,” says Mary DeVany, Video Conferencing Group Manager for Avera McKennan Hospital. “The majority of health care specialties are concentrated in the higher-population areas. We needed to figure out a way to get access out to those more rural sites.”

The answer was telemedicine. Established in 1994, the McKennan Health Services network uses interactive video-conferencing at six hospitals throughout the state. UAMS has also received more than $3 million in HRSA grants to fund its telemedicine program. REACH-TV has benefited from the grant program as well.

At roughly the same time the federal government began promoting telemedicine as a way to reach rural hospitals, many states began laying fiber-optic cable and T1 computer lines to link state facilities such as schools, prisons, hospitals, and medical schools. In Ohio, this statewide network is known as SOMACS–State of Ohio Multi-Agency Communications System. University Hospital/Health Alliance in Cincinnati took advantage of state funding to tie into SOMACS. In addition to broadcasting medical and educational services to rural hospitals, SOMACS has allowed University Hospital to transmit educational programs to rural schools, so that undergraduates can work toward receiving their degree.

UAMS is part of the State of Arkansas Network (STAR-Net), which has more than 100 sites at schools, hospitals, universities, and libraries. “We had an opportunity to apply for a state grant to deliver services to two rural hospitals and we thought that this was an excellent opportunity to deliver services–educational and clinical services– in a more cost-effective manner,” Bynum says of UAMS’ expansion into telemedicine.

Corporate sponsorship has provided another option for funding telemedicine programs. UAMS partnered with Southwestern Bell, which installed T1 lines for them. Other local businesses also contributed to funding. The Rural Electrification Administration (REA) and corporate sponsors also helped University Hospital/Health Alliance build its telemedicine network.

Grants often cover the initial construction of the telemedicine network, but once the network is in place there are other costs to consider. Monthly line charges can run from $300 to $1,000 per site. “For a small hospital, that can be a burden,” Bynum says.

Different networks handle these ongoing charges in different ways. Some choose to make them part of the facility’s operating budget, or part of the budget for telemedicine. “We wanted to make our network as sustainable as possible, so all of our rural hospitals paid their own line charges after the grant funding ended,” Bynum says. Other costs to consider include salaries and benefits for personnel to manage and operate a telemedicine program.

The Growth of Telemedicine
With funding from the federal government in the form of HRSA grants and an infrastructure supplied by the state or through corporate funding, many hospitals and medical schools have begun to participate in telemedicine for the first time. Although many anticipated using the network primarily for clinical consults with education as a secondary function, many systems have discovered educational use of telemedicine equipment growing at a faster rate than clinical applications.

“Right now, REACH-TV is about 60 percent educational use, 30 percent clinical, and 10 percent administrative,” says Ted Kummer, telemedicine project manager. He expects these ratios to change, with growth in clinical use as more physicians become accustomed to telemedicine.

A similar situation exists at University Hospital/Health Alliance. “Continuing education was a much easier fit for us,” says Geri Hinkle, project director for telemedicine. “Telemedicine is not the easiest [program] to initiate. You’re giving physicians a tool to use, but you’re also asking them to alter their plan of care.”

The majority of the education use of telemedicine is concentrated in delivering continuing-education classes. It is an economical way to offer courses at rural hospitals, where only one or two people may need a particular course, without the expense of travel by students or instructors. Smaller hospitals can also offer a greater variety of continuing-education courses through telemedicine. For example, UAMS has offered continuing-education courses in neonatal resuscitation and stabilization, ventilator management, new trends in management of chronic obstructive pulmonary disease, and airway management. “This increases the quality of care in small rural areas,” Bynum says.

Hospitals are also discovering that telemedicine encourages more students to take advantage of continuing-education offerings. “We have been able to educate more people,” DeVany says. “Instead of one person going out and taking a course and bringing the information back, three or four people can be educated on the same topic.”

In addition to continuing education, some hospitals and medical schools have expanded their telemedicine offerings to include undergraduate courses. University Hospital offers six classes a week for bachelor’s and master’s degree students through the College of Nursing and Health. UAMS offers certification courses for CRTs to work toward their undergraduate degree, and more advanced courses for RCPs to work toward a master’s degree. “We have evolved in the respiratory therapy program,” Bynum says. “Now we’re using a combination of video tapes, interactive compressed video, and email for courses in research methods and community health and education.” Students watch video, then have meetings by interactive television, then email questions and answers. “These people would probably not be able to advance their degree if this was not available,” Bynum says. “Not very many people could leave their jobs and family for a semester or two–or for however long it would take.”

East Carolina University School of Medicine has found its telemedicine network to be a valuable tool for mentoring allied health workers and undergraduate students. “In rural areas, health care practitioners suffer from feelings of isolation,” Kummer says. “The network allows them to see and talk with one another just as they would with colleagues in the same building.”

Telemedicine networks provide another avenue for community outreach, as hospitals offer programs of interest to patients and their families. “This grew out of requests from citizens in our rural communities,” Bynum says. “They knew this system was available and asked if we could offer things that could benefit them.” UAMS has offered programs such as parenting classes, diabetes and weight management clinics, and navigating the Medicare maze.

“We see telemedicine as beneficial because we’re helping the community and we’re helping to strengthen ties to the community, which refers patients to us,” Hinkle says of University Hospital/Health Alliance’s community education programs.

Once the biggest challenge–funding–is overcome, hospitals may face other obstacles to establishing a telemedicine network. “The downside is that it is technology dependent,” Bynum says. “The system can go down. You do have technical difficulties.”

University Hospital/Health Alliance laid the first T1 line in Adams County, Ohio, which required coordination with three different carriers. During the first year, flooding and other disasters took out the line several times. It had numerous software and equipment problems until its software vendor was purchased by another vendor. That vendor updated the software and worked with the facility to get all the problems solved.

REACH-TV has had very few problems, for which Kummer credits the expert engineering staff that worked to establish the network. “It works very well 99.9 percent of the time,” he says. “Occasionally, we’ll experience some feedback with the audio, but we hardly ever have problems with the video.” Kummer also recommends establishing a help desk for the telemedicine network that people can call with questions about the equipment and its operation.

Another problem telemedicine programs face is resistance on the part of some people to use the equipment. “As with anything new, you’re going to have some people who are all fired up for it and would use it every day of the week, and some that won’t even walk in the door with it,” DeVany says. Kummer concurs, and believes training can overcome much of this resistance. “I spend a lot of my time training people at remote sites,” he says.

For Avera McKennan Hospital, scheduling and coordination have been a challenge. “It takes a little more to get everybody on the same page,” DeVany says. “Everybody has to be at the same place at the same time and ready to go, just like a face-to-face class.” Instructors must be properly prepared for telemedicine classes also. “You may have a brilliant instructor, but that doesn’t always translate well to television, so there’s some training involved here,” Bynum says. “And, of course, you have to have the staff to do it. Even though one instructor could potentially have 100 students in a class, they still have all the paperwork involved in a class that was on-site, so there is a limit on the number of students an instructor can handle.”

Many problems can be overcome by proper planning. “Make sure you know what your needs are and work to meet those needs,” DeVany says. “A lot of times programs like this will be adopted because someone in administration says, ‘We gotta have this,’ and then they try to find some uses for it.”

“Anything you’re offering over telecommunications is best done if it’s overlaid on something you’re already doing,” Bynum advises. “You use this to make what you’re doing anyway more efficient. Our rural hospital program was already funded through the state. We already had our staff in place and they were already doing these kinds of programs. So the extra expense of interactive video had mostly to do with the equipment, which was funded by grants, and the warranties, maintenance, and line charges, which our remote sites pay for. So I think from the beginning you have to have a business plan and know how you’re going to sustain the project.”

The Future
As with most things technological, the cost of telemedicine equipment is dropping while the technology is evolving and improving. “Recognizing that there are significant costs involved in building hub-and-spoke systems and operating T1 transmission lines, we’ve started looking at what the next generation might be,” Kummer says. “We think it will be PC-based distribution networks with Web-based video. We’re doing a lot of work with video over the Internet.”

Whatever telemedicine looks like in the future, proponents agree it is here to stay. “Distance education doesn’t fully eliminate ever having to travel. Nothing replaces actually being there,” DeVany says. “But it certainly does offer the opportunity and access to things people didn’t have before. The ultimate goal, I think, is to be able to have access to education no matter where you are. Just because you live and work in a small community, you don’t have to be deprived of educational opportunities.”

Cynthia S. Myers is a contributing writer for RT.


1. Hassol A, Irvin C, Gaumer G, et al. Rural applications of telemedicine. Telemedicine Journal. 1997;3:215-225.