How can we employ technology to help bridge health access gaps in rural and isolated areas?

Texas—which still functions as a frontier state, if not in the historical sense, then in attitude—sits poised on the leading edge of another frontier, that of teletechnology. Loosely defined, teletechnology is the science of doing things across distances. While increasing use of microwave, optic fiber and satellite technologies to support our abilities to communicate “instantaneously” has led us to perceive that the world is “shrinking,” it isn’t. Our physical existence is still tethered to a terra firma sphere, and we remain distanced by sheer global geography. Attempting to overcome the time/space bounds of geography, and easing operational conflicts as the industrial age is transformed by the informational age is what teletechnology is all about.

Teletechnology as applied to the practice of medicine in Texas usually takes two forms. One is distance education. This can mean anything from elementary science enrichment courses shared among networked schools, high school health technology classes delivered by satellite downlink and courses for college credit accessed via Internet connections, to a university lab session simultaneously linked by interactive televideo to multiple community campuses, area hospitals receiving continuing education seminars via a regional network and a rural doctor receiving updates for disease treatment protocols on his or her desktop computer.

Distance education in Texas is a growing business, in part because of the interest in exploring distance education modalities demonstrated by the state’s academic institutions. It has been particularly successful serving universities as a one campus/one program/different locations model. Recent growth in telecommunications and distance learning infrastructures was spurred by the state’s Telecommunications Infrastructure Fund (TIF). Acting on a mandate from the Texas Legislature, the TIF Board awarded grants for Internet access to more than 1,000 school districts in Texas. TIF monies enabled 2,552 of the state’s 7,673 public school campuses to obtain Internet access or distance-learning equipment. And, of the state’s 789 city and county libraries and branches, 656 received grants.

Though the enabling legislation did not provide funding to cities and counties, they also took advantage of TIF grants by joining community networks to access school or library systems. Towns and local government entities also now have access to low-cost packages of communications services, such as 800 numbers, cellular and pager services, video conferencing and high-speed DSL connections through the General Services Commission’s (GSC) Tex-An 2000 networks.

Enter telemedicine. As the second basic form of teletechnology used to address health disparities, Texas telemedicine currently exists primarily on a limited or experimental basis. Next steps include developing models to fit consumer needs without duplicating efforts and teaching users how to employ the technology effectively.

One telemedicine model is an interdisciplinary health science center “team” comprised of caregivers from different locations consulting on complicated cases. Another model provides telehealth services to the Texas prison system inmates. Other forms of teleconsulations use a combination of static images, image annotation and interactive voice over networks, as well as live digital video conferencing to provide support for rural providers or health systems in radiology or emergency services, for example.

Telemedicine holds special promise for rural areas that have long distances between towns or medical centers, shortages of medical providers, lack of public transportation or other access issues and harsh weather conditions. Tele-connectivity looms as an option of interest for the 62 Texas counties with no hospital and the 23 counties with no doctor.

Central to the success of telemedicine is patient acceptance of “electronic office isits,” though initial research indicates that patients are generally positive about these, some even reporting feeling increased involvement with their own care.

Practitioner concerns about the use of telemedicine center around the possibility of loss of sole provider status or loss of “personal touch” with patients, as well as uncertainty over the lack of uniform insurance reimbursement policies. Also, physicians are faced with anticipating which patient needs can be best served by care coordinated with distant providers and learning how to use the technologies involved.

General concerns with telemedicine include legal and regulatory worries, such as whether the local physician or the specialist across the state is actually responsible for the patient, whether a practitioner is credentialed to provide services in a rural facility that crosses state lines, and managing electronically transmitted information to protect patient privacy. Infrastructure issues, especially in rural areas, that include limited Internet Service Providers (ISPs), limited available bandwidth in transmission systems and high inter-LATA (Local Access and Transport Area) telephone rate charges present obstacles. And, the impact of telemedicine linkages on the overall cost of health remains unclear.