Ashley Dehart, 8, is getting her regular six-month examination and it's going well. The little girl from Morehead was born with a hole in her heart, and had corrective surgery as an infant. Dr. Carol Cottrill, a pediatric cardiologist, examines her frequently to ensure things inside her chest are normal.
Today, Cottrill examines Ashley's surgical scar; listens to her heart; studies EKGs and X-rays. ``There is very little heart murmur left and the EKG looks normal,'' Cottrill tells Ashley's mother, Karen Dehart. ``She sounds just the way she ought to sound.''
There is one twist to this routine visit: The doctor and patient are in different cities. Cottrill is at the University of Kentucky Chandler Medical Center in Lexington. Ashley is more than 60 miles away at Morehead's St. Claire Medical Center. The exam is being conducted through a telemedicine hook-up that links UK, St. Claire and almost 50 other hospitals, rural clinics and schools in Eastern and Central Kentucky.
Some medical leaders think such networks could be the best hope for addressing two principal rural health care problems. First, many residents must travel long distances to see physicians, particularly specialists. Second, rural doctors have few opportunities to attend distant training programs that could help them keep up with the latest medical advances.
There are about 150 telemedicine systems nationwide. Dr. Jay Sanders, who helped design a statewide system for Georgia, thinks their potential is almost unlimited. Reaching the isolated ``We now have the capability to offer the geographically isolated patient access to the same type of health-care resources he would have if he lived in an urban community,'' said Sanders, who plans health-care systems for NASA.
``All we're doing is what other service industries figured out quite a while ago: bringing the service to where the consumer-patient is.'' Such systems aren't cheap. Rob Sprang, director of UK's Kentucky Telecare, says it costs $345,000 a year to run the university's network. Adding a new telemedicine site can cost up to $60,000 for equipment, plus more than $11,000 a year in phone line charges and related expenses.
The UK system is used for 40 or more doctor-patient ``encounters'' every month, Sprang said. Medical students doing rotations at hospitals out in the state, ``meet'' on the system weekly to discuss their work. Last year, the system conducted almost 12,400 ``student hours'' of continuing medical education for doctors and others.
No one expects telemedicine to replace traditional face-to-face medical care. But Sprang and other enthusiasts say that often it really is the next-best thing.
``The fact is that many smaller communities in our rural areas just will never be able to financially support medical specialists or sub-specialists on site,'' Sprang said. ``But telemedicine does offer a way for those communities to have access to these specialists despite the distances involved.''
Still, Sprang admits that newcomers usually are skeptical. ``The first time that you ask a physician to see a patient by television, the first response almost invariably is, `Oh, I can't do that.' But most adjust to it very quickly,'' he said.
Skeptic converted One initial skeptic was St. Claire Medical Center nurse Catherine ``Cookie'' Crawford. ``Frankly, I didn't think telemedicine would work,'' said Crawford, who joined the program in 1976. ``I had spent 15 years working in a coronary intensive-care unit; I thought you had to be in the room with the patient.
``Now, I've probably done 500 patients across the system. And I truly, truly believe that telemedicine is the answer for us in rural areas,'' said Crawford, the St. Claire program's clinical coordinator.
Crawford recalled the night a girl was brought into the emergency room after accidentally stabbing herself in the back of the throat with a toy sword. ``It's 10 o'clock at night and the child is bleeding badly,'' she said. ``She's scared, the parents are scared.''
Emergency room workers hooked a tiny endoscopy camera into the telemedicine system. The girl held it in her mouth as pictures were beamed to an ear, nose and throat doctor in Lexington. He took one look and said, ``That's fine. She doesn't need anything.''
``Three days later she was back in day care,'' Crawford said. ``Otherwise, we probably would have sent the child to UK. The parents would have to make a late-night trip to Lexington, probably missed work the next day and gone through a lot of unnecessary stress. It was almost like magic.''
In neighboring Carter County, a local medical clinic is connected by TV not just to UK but also to Olive Hill Elementary School.``Now a student with, say, a skin rash can go to the nurse's station and be seen by someone at our clinic,'' said Mary Horsley, a nurse at the Carter County Medical Clinic in Olive Hill. ``If the rash looks suspicious, someone at St. Claire can check it. And if there's still concern, the child can be seen by a pediatric dermatologist at UK. And the child never leaves school.''
Last year, a similar hookup made it possible for diabetic students at Lewis County High School in Vanceburg to get 10 weeks of diabetes education training, telecast from St. Claire. Three more schools will join the system this year.
Lunch-hour seminars Doctors benefit too, said Dr. Tony Weaver, medical director of St. Claire's telemedicine system. ``I can literally go to a conference on my lunch hour,'' he said, instead of driving for hours, as he used to have to do. ``That's huge from a physician standpoint.''
Televised training means rural doctors don't have to shut down their practices to attend seminars. Since the system is interactive, doctors watching a televised seminar can ask questions and hear answers in real time. ``It's like having a seat next to the department chairman at UK,'' Weaver said.
Now, officials are gearing up to use telemedicine in a new way: putting small units into the homes of terminally ill patients so they can be ``visited'' by hospice nurses.
One of the first such cases involved a patient who lived on a farm so remote ``you could hardly reach it in rainy weather,'' said Robin Franklin, director of the St. Claire Hospice program. ``It worked so well, we want to make it a regular part of our operation.''
To use the new system, a patient would need only a telephone and a television set, Franklin said. ``It will never replace a staff member physically visiting the patient, but it is an added comfort level in many situations,'' she said.
Meanwhile, Sprang says officials are still trying to decide how many telemedicine sites are needed to fully cover Eastern Kentucky, and where they should be. Similar plans must be made for Western Kentucky.
For now, the technology already makes life easier for people like Karen Dehart. Without telemedicine, Dehart would have had to bring her daughter Ashley to Lexington for her checkup. But Dehart doesn't have a car.``I would have had to hire somebody to take us down there and back,'' she said. ``Having this system helps us very very much.''
