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Healthcare sweeps across the plains: university telemedicine program allows Native Americans on North Dakota reservations to consult with specialists hundreds of miles away.

Capable of providing personalized healthcare to people living great distances from medical specialists, telemedicine programs are quickly becoming popular for government initiatives and academic health centers interested in obtaining grants.

Such is the case with the University of North Dakota School of Medicine & Health Sciences (SMHS) in Grand Forks, N.D., which formed its Health Information Technology (HIT) Center in 2002 as part of a more than $1 million grant from the U.S. General Services Administration to establish a telemedicine program. The program's goals included improving the flow of medical information to and from remote rural communities and digitizing clinical information and medical records.

To launch the program, key SMHS staff particularly CIO Robert Rubeck, Ph.D., and HIT Center Director of Technology Nasser Hammami--had to identify the program's participants, the kind of healthcare to provide to participants and the telemedicine software that would deliver it.

Advanced Healthcare for the Neediest

Rubeck and Hammami began the first phase of the program in late 2002 by determining the State's rural healthcare needs. After visiting a number of North Dakota physicians and asking what they thought should be done with the telemedicine program, Rubeck determined that indigenous Native Americans living on reservations lacked access to specialty healthcare and could benefit greatly from the program.

Next, the SMHS team learned that what the residents needed most for good healthcare was better eye care. Native Americans are more than twice as likely to be diagnosed with diabetes as non-Hispanic whites of similar age, according to the American Diabetes Association. One of the most serious complications of diabetes is diabetic retinopathy, or abnormalities of the retina's small blood vessels, which can lead to blindness.

For the program's first participants, Rubeck chose 1,200 diabetics of more than 16,000 Chippewa living on the small, isolated Turtle Mountain Reservation. Since there was just one optometrist at the Quentin N. Burdick Memorial Hospital in Belcourt--the reservation's only city with a hospital--tribal members had been routinely referred to ophthalmology or retina specialists in Minor or Fargo, a round trip of more than 200 miles.

To get even more advice and participate in numerous product demonstrations, Rubeck attended telemedicine conferences and held many meetings with healthcare professionals, consultants and vendors. Among these sources was a friend of Rubeck's who headed the Arizona Telemedicine Program at the University of Arizona College of Medicine, which also was providing healthcare for rural communities.

Putting the Pieces in Place

Rubeck and Hammami began purchasing telemedicine hardware and software in January 2003 and tested them in-house before making their final recommendations to the program's full committee and having them approved in October 2003.

One of the program's key components is Session from San Diego-based Wave Three Software, a communication software that utilizes Voice over IP, Video over IP, application sharing and media sharing in a single application for standard desktop and laptop PCs. This allowed SMHS to use the Internet, which is easier and cheaper than dedicated voice transmission lines, for consultation among physicians and their patients. "It had all the functions that we needed, including a compressed frame rate to control bandwidth," Hammami says.

The software is located on three Dell servers at SMHS; each has a different function, either as a registrar server, a multipoint conference server or a firewall server. Participating physicians use Dell Inspiron 5100 laptops loaded with Session to communicate with each other. By using broadband communications, the laptops can determine each other's IP address via the registrar server, which connects the conferencing physicians, allowing them to communicate from any location rather than being tied to a specific address.

"We received everything at the telemedicine center, configured all of it, drove the laptops to the sites and installed them, trained the doctors and troubleshot problems. We would do the training in-person or by using Session," Hammami says.

Telemedicine Delivers

The SMHS telemedicine program went live in November 2003 for Turtle Mountain when the Belcourt optometrist began using Session for consultation. Rubeck and Hammami had chosen a Medweb All-In-One Server to store and forward digital images captured by a Kowa retinal camera. "Nondigital retinal images took too much time to send back and forth, so the specialist will examine the patient's digital retinal images, which are taken by the optometrist with a digital retinal image camera and stored on the hospital's dedicated images server, and within minutes can reply back to the patient or the optometrist with a diagnosis," Hammami says.

One month later, Belcourt physicians started using the telemedicine program for cases of suspected child abuse and neglect on the reservation, providing images of kids' bruised and broken bodies to trained specialists who could validate such claims. Beginning in 2004, dentists working out of the Belcourt hospital used the new system for second opinions of patients with dental trauma, storing bitewings and other X-ray images on the server.

The telemedicine program was such a success that SMHS rolled it out in June 2004 to Spirit Lake Reservation, where more than 3,000 Sioux reside. As with the Turtle Mountain Reservation, SMHS started Spirit Lake with the eye care phase, followed by the suspected child abuse/ neglect and dental care phases.

SMHS has scheduled a fourth phase of the program, for mental health, to be deployed at Spirit Lake. Traditional videoconferencing will allow physicians caring for the Spirit Lake Sioux to consult with psychologists in other cities. Eventually, all four phases will be rolled out not only to residents at Turtle Mountain, but also to more than 3,000 Sioux at Standing Rock Reservation and more than 4,000 members of the Three Affiliated Tribes (Arikara, Hidatsa and Mandan) at Fort Berthold Reservation.

The telemedicine program has proceeded according to plan and met the SMHS team's expectations, Hammami says. "We still provide technical support for the doctors, which takes a lot of our time. ... If there were any surprises, they were good surprises. In one case, a Minor doctor performed a spinal tap and prescribed an antibiotic for a patient. The Belcourt optometrist was taking retinal images of the same patient and told the doctor that another spinal tap was unnecessary. Not only did this save money for the hospital and the patient, but it also saved the patient from additional discomfort."

For more information about Session from Wave Three Software,
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Title Annotation:Telehealth/Telemedicine
Author:Reynolds, Phil
Publication:Health Management Technology
Geographic Code:1USA
Date:Apr 1, 2005
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