Technology links experts, rural patients

SANDPOINT – The ovarian cyst Dr. Deborah Owen found in her patient was large but appeared benign.

Appeared, however, wasn’t good enough. Owen wanted a lab test. But Bonner General Hospital has no pathologist to examine tissue and offer a diagnosis.

A few months ago, Owen, a Sandpoint obstetrician and gynecologist, would have sent her patient to a Spokane specialist for a lab test and same-day diagnosis. Her patient most likely would stay in Spokane for any necessary surgery.

But times have changed. New technology at 48-bed Bonner General allowed Owen to take a tissue sample from her anesthetized patient and send it to the hospital lab, where the specimen was frozen, sliced, stuck on a slide, stained and inserted under a microscope connected to a computer used by a pathologist at Kootenai Medical Center in Coeur d’Alene.

In about 30 minutes, Owen had her diagnosis. The cyst was benign. Her patient was still anesthetized on the operating table, so Owen removed her ovary and sent her to recovery. Case closed.

“With frozen sections, we can keep more people close to home,” Owen said. “We can do the right thing at that time instead of sending them somewhere else.”

Bonner General is a beneficiary of “telehealth,” technology that’s revolutionizing rural health care. Telehealth computers and servers bring pathology services where no pathologists work and psychiatrists to communities that have none. It offers round-the-clock pharmacy services to hospitals with no pharmacists on staff.

Inland Northwest Health Services in Spokane has enabled more than 35 hospitals and 500 doctors to share patient charts and information on hand-held computers. It links neurologists and mental health specialists with small hospitals in Othello, Davenport and other Eastern Washington towns, said Denny Lordan, INHS senior telehealth analyst. It offers teleconferences and education in five states via technology.

“They’re instrumental nationwide in telehealth,” said Sue Fox, project manager for the North Idaho Rural Health Consortium that launched Bonner General’s telepathology program. “They were instrumental in teaching us.”

Since 2002, the North Idaho consortium has worked with Sen. Larry Craig to win more than $500,000 in congressional funding to link Panhandle residents in remote and rural areas with doctors and medical services hundreds of miles away.

That money bought a powerful server for Kootenai Medical Center that linked all of North Idaho’s public hospitals. Mental health services started almost immediately, Fox said.

Teleconferencing equipment – closed circuit televisions – in private rooms now connects patients at Boundary Community Hospital, Bonner General, Shoshone Medical Center and Benewah Medical Center with psychiatrists at Kootenai Medical Center and North Idaho Behavioral Health.

“All of Idaho is a mental health professional shortage area,” said Michelle Britton, director of the state Department of Health and Welfare’s regional office in Coeur d’Alene. “There are not enough psychiatrists for the people in need, and we’re not going to get a psychiatrist to travel up to Bonners Ferry.”

Patients who can’t afford to travel have gone without counseling, often allowing prescriptions to lapse. Medicaid covers the costs of mental telehealth primarily because it helps patients stay current on their medications, Britton said.

“A family can get psychiatric consultation with medication without driving to Coeur d’Alene for 10 minutes of business,” she said.

Three psychiatrists see about 45 patients. The first consultation is in person. Most who use the services are kids.

“They’re adaptable to technology,” Fox said. “They don’t even notice they’re doing this at a distance.”

Telepharmacy now links Benewah Medical Center, which has no pharmacist on staff, with Kootenai Medical Center pharmacists who are available round the clock. Benewah also is learning telepathology, said Dr. Brent Hjermstad, one of a group of pathologists at Incyte Pathology in Spokane. Hjermstad works out of KMC and has offered several long-distance diagnoses for Bonner General.

“The fact that they can have the service in their own community means patients can be treated there and receive equivalent care to what they would have had if they’d traveled,” Hjermstad said. “They have the convenience and family support. All those things make treatment where you live preferable.”

Until September, surgeons in Sandpoint sent tissue samples by courier to pathologists in Coeur d’Alene or Spokane. Patients waited up to a week for results. If diagnoses led to surgery, patients had to go under anesthesia and the knife a second time.

Plenty of patients simply bypassed Bonner General. Then, Fox arranged training for medical technicians Mark Perlinger and Carla Johnsrud and the installation of new equipment – a cryostat that freezes and slices specimens thinner than a hair, a work station with a Web camera that enables a pathologist to tell a medical technician how to prepare a specimen, a microscope connected to a computer.

When a test is needed now, Perlinger, for example, contacts Hjermstad at KMC, who, via a Web camera, studies the specimen at the work station. Hjermstad directs Perlinger how to prepare and stain the sample, studies up to 200 images from the microscope that appear on Hjermstad’s computer screen and calls the surgeon to consult on a diagnosis.

Depending on the medical problem, the procedure takes from 15 minutes to an hour. Hjermstad already is asking Fox to upgrade the microscope for faster service.

To review an entire slide in person takes about 30 seconds, he said. “With the Coolscope (microscope) it takes 30 minutes.”

Ten Sandpoint patients have opted for the telepathology tests so far. Hjermstad’s only problem was with a lung biopsy. The frozen specimen wasn’t good enough quality to reach a diagnosis, he said.

Telepathology is still rare. Norway, Switzerland and Japan use it and it’s starting to trickle into the United States.

“It’s another tool in the toolbox,” said Owen. “I’ve been pleased so far. There are limitations, but it’s a nice service to have on site, especially when there’s definitely not enough volume to justify bringing a pathologist here.”