Telecommunications technology in rural health care

Reports/Viewpoint

the group, and ask them to demonstrate skills, concepts, and creative ideas. A set of individuals that may not ever meet are brought together as members of a telecommunications group, seeing and being seen, to share experiences and to gain expertise. To isolate and measure the value of return video, the day-care centres in the cable area were randomly divided into two groups. Caregivers at the first group of centres received and used cameras and could only watch. Tests at the end of the programme revealed that those without cameras learned just as much as those who actively participated and could be seen over the cable. Thus return video did not seem to be having a return video capacity and did not add to each individual student’s learning. The data did show, however, that the viewers enjoyed the live interaction, and it strengthened their involvement in the programme. The lesson seems to be that the greatest value of two-way video is a of developing low-cost means programmes that can be generated in the local community.

we had starting the difficulties Spartanburg project. First, technology is nor the major issue. Cable is only one of several technologies available to provide telecommunications services, and the best and cheapest system is likely to use a mix of technologies. Too often we have chosen a technology, and raced out to find uses for it. A more logical way of proceeding is to make decisions about what we want to accomplish, and then choose the appropriate technology mix to accomplish that task. The difficulty, and my second point, is that we do not know what telecommunications services rural areas really want. In Spartanburg, we began by assuming that the greatest need - and therefore the greatest market - for educational services was for adults without a high school diploma. The same assumption was made about rural areas in a staff paper prepared for OTA’s rural telecommunications conference. That need may be the greatest, but there is some doubt that students will enroll in high school programmes in vast numbers. On the other hand, parents have turned out in remarkable numbers for our parent programmes on child education development, a response we had not anticipated. Thus, before a major demonstration is launched, careful needs analysis must be coupled with a thorough assessment of what rural

Conclusions There are a variety of policy implications that can be derived from our own findings, but let me emphasize 3 points that bear directly on the future of rural telecommunications systems. In general, they are derived from the

citizens and local agencies want and will participate in, as opposed to what federal officials or technologists feel that they should have. Third, even if we were sure what services we wanted to offer and local services agencies in a rural area were eager to deliver those services, there would still be many barriers to telecommunications services. Each service area has an array of rules and regulations that seek to safeguard the rights of the clients and to ensure funds are not shifted to serve some other client group. Bound by these rules, it is very difficult to combine services and funding; without such combination, one cannot achieve the economies of scale essential to a costeffective telecommunications system of service delivery. Without enabling waivers of legislation permitting categorical programme requirements and strong federal agency support in revising eligibility requirements, reimbursement procedures, and professional standards, any rural demonstration will be crippled before it William A. Lucas. Senior Social Scientist; The Rand Corporation, Washington,

DC, USA

The views presented in this statement are those of the author, and do not necessarily reflect those of the Rand Corporation or the sponsors of its research.

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Telecommunications technology has been frequently cited for its potential to improve rural health care delivery. A substantial amount of research has been carried out in this field. The telecommunications options to be considered start with the telephone,

TELECOMMUNICATIONS

radio, or satellite for voice-only communication. There are low-cost telephone adjuncts such as speakers that permit both ‘hands-free’ operation and involvement of a patient in a communication between a health care provider who is physically with the

POLICY December 1977

patient and a remote health care provider; call-forwarding to permit offhours coverage; and conferencing, in which three or more people remote from one another (eg patient, nurse practitioner, and physician) can participate in a call. There are technologies such as facsimile for document transmission, telemetry for such things as remote EKG interpretation, and slow-scan television for image transmission on a one-frameat-a-time basis, such as that used to transmit images back from the moon. Finally, there is full frame rate two-way television, in monochrome or in colour.

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Viewpoint The National Center for Health Services Research has supported a number of experiments~u%ng two-way television. A major problem in the use of this technology in rural areas is the high cost of transmitting television signals; it is often necessary to install a microwave system. Another problem is that the terminals tend to be centrally located in the back-up community because of the point-to-point nature of television transmission; this means that the radiologist or the dermatologist must leave his or her office to go to the television terminal to provide a consultation for a general practitioner physician providing and that a consultative support to a non-physician provider must also go to the terminal. Scheduled consultation periods and scheduled teleclinics go some way towards solving this problem. Because of these difficulties, the use of telephone-based technology in which several devices permit the transmission of images and physiological signals over existing telephone lines is now being systematically explored. An important characteristic of these devices is that they use the existing telephone network for transmission, so that any terminal can communicate with any compatible terminal, anywhere.

Problems in rural telephony telecommuniadvantages of The cations technology are: patient travel and inconvenience can be reduced: decentralized sites can handle more complex cases: remote sites are more professionally attractive because the providers feel less isolated and part of a complete system, and because they feel more comfortable with difficult decisions when they have the ability to consult readily; and patient services can be facilitated and coordinated. The disadvantages are : it is expensive, and although telephonebased systems are less expensive than television systems, even they can incur significant long-distance charges; it may be inconvenient and time-consuming to out a teleestablish and carry consultation; and in many rural areas the telephone services are inadequate. With reference to the last remark, concerning the inadequacy of rural

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telephony, I was surprised to learn that the USA has 1600 telephone companies. Obviously, most of the small, undercapitalized ones are in rural areas. This produces major adverse conditions for the delivery of health care specifically and for rural economic development generally. First and second, there are the problems of quality and availability of adequate lines and services. It is perverse that the rural practitioner who is isolated in so many other ways may also lack access to the simple telephone services that are taken for granted in urban areas. The physician’s assistant seeing patients on the mobile unit in New Mexico has a mobile telephone over which he must ‘push to talk’ in consulting a doctor about a patient. A computer project in South Carolina, described below, was held up for two months while the telephone company’s field engineer made it possible for the local computer terminals to dial up the local computer. A young pediatrician in Ohio was told that he would have to wait three years for a private line to his home so the mothers of his patients can (a) find the line not busy and (b) discuss their problems without fifteen neighbours being able to listen in. There is no doubt that availability and quality are serious problems, indeed. Third, there is the cost problem. A doctor in rural Mississippi sees a Medicaid patient for which he receives $6.50. He spends more than that on long-distance charges if he thinks the patient needs to be referred to an urban specialist. There is no recognized method of acknowledging these costs and recovering them. Surely a telephone call can be as much a part of the care process as a medical procedure! Yet, one can imagine an even worse scenario in which ‘telephone call’ becomes a billable procedure subject to audit and review that will define stringent conditions under which a call is ‘necessary and appropriate’. It is expensive to upgrade rural telephone service and revenueproducing traffic is low, so the situation looks bleak from an investment perspective. I have no solutions to offer, but rather raise the issue because it is a serious problem in the field of technology and rural health care that must be faced.

Computers Computer technology also holds great promise for rural health care delivery. Applications in computer-aided instruction and diagnostic and therapeutic decision making support have been developed; however, here I review only applications of computerized records. A particularly interesting Rural Health Initiative project is underway in Hampton County, South Carolina, which illustrates many of the possibilities. A computerized medical record system that was developed at the Medical University of South Carolina is being installed throughout the County’s health care system. There are seven private physicians practising in five offices, four pharmacies, a hospital, an old age home, a mental health centre, and the health department. All will have on-line terminals. The computer system will contain a patient’s problem list and his medications. It will do billing for the doctors and pharmacies - the first major benefit anticipated by the participants. A second benefit is that the computer system will help create a mechanism through which and with which the providers will be able to communicate with one another for professional and patient care needs. They anticipate being able to take call for one another more easily. They will be analysing and comparing their practice patterns. The doctors hope that the computer system will help them to attract young physicians to the county. The integration of pharmacy services is an important aspect of the system. The Medical University of South Carolina trains pharmacists and family practitioners to work in teams and the pharmacist assumes much of the responsibility for educating patients about their medications and for intervening at drug-dispensing time when there is a potential for a drug-drug interaction. Finally, a unique aspect of the project is that a household census has been performed with the help of 260 volunteers in the county to register every county resident in the system. Questions were asked about the individual’s perception of his own health

TELECOMMUNICATIONS

POLICY December

1977

Viewpoint

quality of care can be more easily audited; groups of patients ‘at risk’ can be identified; and the continuing education needs of the providers can be more systematically determined. The disadvantages of automated records are: there are potential privacy problems, although many who have considered these point out that traditional record-keeping systems are not immune to unauthorized access; many rural telephone systems are discussed above; inadequate, as automated systems require structured input that may be annoying to practising professionals, as would any system that required major changes in established behaviour patterns; and the costs are high, as most of the recordkeeping systems are developmental and heavily susbidized (although billing

status and about what health services he used. One of the project’s goals is to identify underserved residents over time and to focus resources and attention on them. The advantages of automated billing, then, are: clerical personnel costs can be reduced; lost charges and rejected claims can be reduced; cash flow can be increased; and practice management can be improved. The advantages of medical records are: automated professional communications can be improved; one provider can take call for another more readily; continuity of care can be increased while, conversely, episodic care can be decreased; quality of care can be increased by improving the availability of medical information in terms of accessibility, timeliness of retrieval, legibility and organization;

systems alone are widely marketed now). Nevertheless, developments in this field are taking place rapidly as computer costs drop and I think we can look forward to having reasonably priced systems widely available in the USA that will support rural physicians, as well as urban ones, in the delivery of high-quality health care. Maxine National

L. Rockoff.

Center for Health Services

US Department Education H yattsville,

Research, of Health,

and Welfare,

Maryland.

USA

This article is a summary of a presentation before the 30th National Conference on Rural Health of the American Medical Association, Seattle. Washington, 1 April 1977.

‘Compunications’: a policy agenda There are four points which are especially world

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The science and technology of computers and of communications are now indistinguishable. Because we grow tired of having to say ‘computer and communications’, we have coined the term ‘compunications’. The commonality appears in basic components like integrated circuits. It is present in basic principles like the digital encoding that has been the hallmark of computer technology since the second world war and that is increasingly used in telephone networks to transmit both voice and data. Computers and communications have merged not only in terms of hardware components or techniques, but also in terms of services or, more broadly, in terms of functions. Whether we talk about transmission or storage or manipulation of information, we can no longer tell communications functions apart from computer functions.

TELECOMMUNICATIONS

To add to the confusion, compunications also extends into other industries which perform these functions. These are being actively drawn into the competition. Banks, for example, are in the money business, but their production line is information processing. Electronic funds transfer (EFI’) systems expedite this processing. As soon as more than one bank is involved, several familiar questions arise. Is EFf a service or a facility? Must it become a common carrier and take on all comers? Who shall own the lines? Who controls the service offerings? Who gets the profits from operation? Who sets the standards? Department stores have traditionally offered credit. How does this differ from bank credit? Who can be kept out of where by what jurisdiction? EFI is a major threat to the chief non-electronic funds transfer system. In

POLICY

December

1977

the USA, over half of the first-class mail - the most profitable kind - is financial: bills and payments. What will happen to the US Postal Service if these vanish into wires? Who will subsidize the remaining money-losing services? Should the Post Office fight back with reduced rates for utilities? Should it fight back by forbidding EFT as a violation of the Private Express Statutes? Should it levy a surcharge on these transactions, just as it does on courier services? A more general question: should the US Post Office offer a competitive service over wires? If so, should it compete as well with electronic transfer of other traditional postal business such as messages? How do we distinguish between such an effort and an operation already in existence, known to the world as the telephone system? The existence of computer data banks draws in another set of industries. banks Data information. supply Newspapers, books and broadcast stations supply information. These industries are competing with each other. They are using all the traditional weapons, including lawsuits, lobbying and pushing special-interest legislation. The media, including newspapers and

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