The University of Iowa's
Introduction
The promise of advanced telecommunications (the "information superhighway") for improving access to information and international competitiveness has been the subject of intense public interest and discussion inspired, in part, by the emphasis of the current federal administration. The application of emerging communications technologies to health care has been of particular interest to the public and the government, concurrent with a broader debate around reformation of the health care system. Among the first to facilitate development of programs applying advanced telecommunications and computing to health care was the National Library of Medicine by issuing a Broad Agency Announcement/Request for Proposals entitled, "Biomedical Applications of High Performance Computing and Communications" on May 20, 1993. One-hundred and thirty-seven applications were received in six categories and 12 contracts were ultimately awarded. The University of Iowa submitted a proposal to establish a "National Laboratory for the Study of Rural Telemedicine," and was awarded a $7.25 million contract of three years duration.
Telemedicine at Iowa
Telemedicine has existed in various forms at the Univeristy of Iowa Hospitals and Clinics. Efforts include a teleradiology network serving 8 hospitals in 3 states, and electrocardiographic (EKG) service to a network of hospitals, offices, and state agencies, and a satellite educational network available for health-related programming.
A major impetus for the current project was the availability of the Iowa Communications Network (ICN), a 2800 mile fiber-optic telecommunications system established by the State of Iowa by legislative action in 1987. This state-of-the-art network has a point of presence in all 99 of Iowa's counties and is currently in use for a variety of educational and state governmental purposes. Recent legislation has been passed granting ICN access to Iowa's hospitals and physicians' clinics. Hospitals and clinics, along with selected federal agencies, are currently engaged in a state-wide planning process to define the details and standards of a statewide telemedicine network using the ICN.
Components of the Laboratory Project
The NLM contract supports four developmental components: I) a Resource Center, II) a test-bed of three rural hospitals, III) two information support projects, and IV) three clinical support projects. Each component will be briefly described below.
I. Resource Center
The Resource Center will be housed within the Hardin Library for Health Sciences on the main Health Sciences Campus, adjacent to UIHC and the Veteran's Administration hospital in Iowa City. The goal of the Resource Center is to provide the administrative and technical support necessary to complete the proposed work and to facilitate interactions with other telemedicine investigators on campus, statewide and eventually on a national basis. Staffing of the Resource Center will be by individuals with requisite skills in medical librarianship, telecommunication, computer systems, instructional design and research methodology. For advising on issues related to technology and evaluative services, we have added 2 Faculty Affiliates to the project.
The Resource Center's approach to evaluative services is rather unique. Traditionally, such services have been obtained "on-line," by in-house staff. This approach requires advanced knowledge of the nature of the work to be done. Additionally, this approach requires the acquisition of appropriate personnel and the necessary space and equipment. The university environment has allowed us to take a "just-in-time" approach by utilizing a Faculty Associate to coordinate and contract for evaluative services on a project-specific and as-needed basis. Advantages of this approace are more flexibility and synergy and fewer fixed costs for staff and other resources.
II. Hospital Test-Bed
A conscious effort was made to select hospitals representative of the spectrum seen on a larger scale. The smallest of the three, Van Buren County Hospital in Keosauqua, Iowa, is classified as a Medicare Rural hospital, serves a poor rural county, and is staffed by a handful of primary care practitioners. Ottumwa Regional Medical Center is classified as a Rural Referral facility, serves a more prosperous rural county and is staffed by a range of primary care providers and specialists. The largest of the test-bed hospitals is the west campus of the Genesis Health System. Genesis West is classified as an urban facility and provides considerable secondary and limited tertiary level services such as open-heart surgery.
III. Information Support Projects
Library services have been shown to be highly utilized and capable of influencing medical decision-making (2). The first of two information support projects, based at the Hardin Library, will provide electronic medical library services, including document delivery, to rural hospitals. Patterns of use and incorporation into practice will be tracked.
The second project, the Virtual Hospital, is a digital multimedia database supporting "just-in-time" access to information for practice and continuing information, as well as patient instructional materials (3,4). Information in the Virtual Hospital is taken from medical textbooks, faculty lectures and presentations, patient case studies, and other health information sources. The multimedia aspect allows the user to view textual, graphical, audio, and even full-motion video information within the same interface. A major strength of this database, which is already in limited use on the Internet, is its adherence to industry standard protocols. This enhances its widespread applicability and ease of upgrading. The emergence of the World Wide Web and TCP/IP protocols has allowed the Virtual Hospital to be accessible from anyone on the Internet. The client software is freely available and exists for Microsoft Windows, Apple Macintosh, and Unix systems with XWindows.
IV. Clinical Support Projects
Teleradiology is an application with substantial promise, but many questions remain regarding its widespread use (5). The first of two radiology-related projects will determine cost-effective protocols for interpretation of routine and subspecialty radiographs within a hierarchical system of hospitals.
Given the technology available in rural practice settings, more advanced imaging capabilities are often not available. However, if these capabilities are supported by tertiary consultants, they may become feasible and effective. A second teleradiology project will support more advanced three-dimensional image analysis (volumetric computed tomography) in the test-bed hospitals, addressing the technical, educational and clinical requirements for such an undertaking.
Traumatic injury is the most common cause of death for Iowans in the age group 1-44 years. Improvement in the treatment of trauma patients in rural emergency rooms may favorably impact outcome (6). The use of rapid computer-based information exchange between rural and referral hospitals will be studied in the final clinical support project. The information exchanged will be linked to medical image transfer methodologies in the triage, treatment, and transfer of rural trauma patients.
Project Evaluation
Evaluative services will be provided by the Resource Center. Some of the questions that will need to be addressed are:
Project Time Line
The first year of the contract will be devoted to the establishment of the Resource Center and its staff, making connections between the University of Iowa and the test-bed hospitals, and developmental work on each of the projects. The project protocols will commence in Year 2 and run through the final year, with specific project evaluations running concurrently. It is hoped and anticipated that broader collaboration (state and nationwide) will be possible by the end of the contract period.
References