Smith Island Offers a Case Study in the Challenges of Rural Telemedicine Development

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A unique partnership seeks to bring telemedicine to one of America’s most remote island communities. The biggest challenge so far has been supplying fast, reliable internet connectivity at a price a small town can afford. 

An 84-year-old woman was experiencing dizziness and, according to her daughter, literally bouncing off the walls. So the daughter called Kerry Palakanis, DNP, NP-C, head of the Crisfield Clinic, who was aware of the mother’s history. Palakanis immediately became concerned that the 84-year-old woman had had a stroke.

Under ordinary circumstances, providers in Palakanis’s situation would have asked the daughter to bring her mother to the clinic as soon as possible. But these were hardly ordinary circumstances. The mother and daughter lived on Smith Island (population 276), 10 miles offshore in the Chesapeake Bay in Maryland, which is reachable, even in the best of circumstances, only by boat or helicopter. Once in Crisfield, patients still need to find a taxi or other vehicle to get them to the clinic, which then could lead to a possible consult with a physician in Baltimore.

But because of gale-force winds and ice, the circumstances were less than ideal. If Palakanis had the requisite telemedicine equipment available at the clinic, she would have been able to adequately evaluate the patient and, if the weather had cleared, determine whether to request a helicopter to transport her. As it turned out, it took three days for the weather to improve enough for the mother to be able to get on a boat to cross the bay.  The woman, in fact, had had a stroke, and Palakanis was forced to deal with its tragic aftermath.

Palakanis was determined to do everything in her power to make sure that this kind of situation didn’t occur again. She began a partnership with Ellumen, an Arlington, Virginia-based IT company specializing in developing medical imaging for health care systems, and University of Maryland Medical Center’s Telehealth Office, to secure telehealth equipment for the clinic and establish an Internet link to the island.

With the proper telehealth equipment and optimal broadband capacity, Palakanis would have been able to better manage the case of the stroke victim, and deal with more routine care situations, says Ellumen project manager Dan Bray. Smith Island residents could be trained to take blood pressure readings and engage in video consultations, he says, in a variety of settings. “For example,” he explains, “cameras allow dermatologists to examine spots on the skin to determine if they are cancerous.”  In addition, telehealth carts provide the ability to conduct more complicated procedures, such as sonograms. “All of this can be done without anybody having to leave the island and that’s really significant when weather prevents patients from getting off the island in the first place,” he adds.

A Work in Progress
The project to bring telehealth to Smith Island is still a work in progress. When completed, the project is expected not only to reduce costs but provide better service to all residents while serving as a model for telemedicine in other remote areas, according to Bray.
The project is far from completion principally because of a pesky bandwidth issue. “It’s not so much a question of needing more bandwidth,” Bray explains, but “its reliability.” The Smith Island bandwidth experience provided Ellumen with an understanding of what many resident in rural areas experience every day—having to deal with cable and telephone companies that can be as much as part of the problem as the solution. “We were able to go in and help straighten out Dr. Palakanis’s network in-house at the clinic, but that led to us identifying problems with the actual cable and landline providers,” he notes.
“You’d think running cables or putting up a wireless link at Smith Island would be relatively easy,” says Bray. However, he says, it’s not that simple. The locals — including the mayor, city manager, and zoning authorities — have been “extremely helpful,” he explains, but the regulatory issues have remained problematic.

Built-In Inefficiencies
There are built-in inefficiencies in our current telecommunications regulatory rubric, asserts Bray. Although the bandwidth is available, it’s too costly to implement and the project managers are continuing to work with regulators to find an acceptable financial solution.

“In rural areas, where you don’t need extensive service, it’s very expensive to buy at a high volume,” Bray explains. “So we’re looking at how to stitch together different locations, thinking beyond just solving this link out to Smith Island—trying to afford to buy the bandwidth that makes it all work for everybody—“Bray says. The project’s long and winding journey has had less todo with technical issues, and more to do with the regulatory situations in rural areas, emphasizes Bray. The bottom line: “It’s been a learning experience. If it were easy to do, it would have already been done.”

To accentuate the point about technology, Bray refers to the fiber optic backbone in Crisfield that goes right through the center of town. The fiber backbone literally runs adjacent to the clinic. This backbone was built primarily with federal grant funds under the policy of extending broadband capacity.

Unfortunately, Bray says, the cost to get her hooked up to Internet is prohibitive. “If you’re only buying a small slice of bandwidth, it’s expensive.  But if you’re buying a lot of bandwidth, it’s a much less costly proposition.”

Building Your Own Towers?
The partnership is trying to solve this problem by thinking outside the box. “We’re examining building our own towers to link to Smith Island because no one has put any money into the current infrastructure for half a century. But we really can’t afford to do that, unless we’re buying enough bandwidth to make it cost effective,” says Bray. That’s why this issue is bigger than just an Internet link. “If there were jobs for technical professionals who were using the bandwidth, you could get the price down, but you can’t get those people to come to Smith Island until you have the bandwidth,” he explains. “That’s the chicken-and-egg problem.”

Ellumen views this as a kind of a pilot program, Bray says. “We’re not aware of anyone who has cracked the code. There are wireless ISP providers delivering service in rural areas — but not at a price point and a reliability standpoint that meets the modern needs.”

The Role of the Feds    
The Federal Government can be a major player in this space. The Federal Trade Commission and the Department of Agriculture are investing millions of dollars to encourage businesses to service rural areas, says Mary Vogel, Vice President. Client Solutions, at Ellumen.
In Maryland last year, for example, the Feds used only $30,000 of the millions available in grants for that purpose. “And if that doesn’t point to something that’s just totally screwed up, I don’t know what else would.”

The grants are administered through the Universal Service Administrative Company (USAC), explains John Kornak, Telehealth Director at the University of Maryland Medical Center. USAC provides about $400 million worth of funding annually to develop cheaper broadband, Internet, telecommunication services in rural healthcare locations, schools, and libraries.

“If there’s grant money available, and yet you can’t get people that can put together the right combination of solution to the economic, technical and regulatory environment, there’s something that needs to be changed in the way it’s structured,” says Bray. Finances are clearly an issue, the partners in the project all agree.

It’s been a while since the incident with the stroke victim, but the telehealth solution is still a top priority for Palakanis. She provides a current example: “A Smith Island resident with a cardiac history was visiting friends near Annapolis and experienced a cardiac event. He went to the hospital when he was seen by a cardiologist or pulmonologist, is back down in my community, which is about two hours away on the island.  He had his testing done, while he was up there and he needs to go back up this week for a follow-up.  And I explained to him that he really shouldn’t have to get in the car and drive two hours for follow-up, which could be performed by telemedicine.

The telemedicine equipment has the ability for that cardiologist and pulmonologist to evaluate him on the island, if we can create that link. Follow-ups are a classic point of access for patients when the higher-level testing like CAT Scans or nuclear stress tests have been performed in a hospital facility.  And this is a patient that’s coming in after the fact for either routine follow-up or follow-up for recording and testing.  They don’t necessarily have to be physically present with that provider. My peripherals allow for EKGs and spirometry and a stethoscope that enables cardiac and pulmonary assessment.”

Palakanis concludes: “All of that can be done by telemedicine and could be instrumental in keeping people out of readmission situations, as well as preventive healthcare.”


Michael Levin-Epstein, JD, M.Ed is a Maryland-based freelance writer who contributes to EPM, Telemedicine and other health care and business-related publications.

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