Teleradiology a boon for Arizona’s rural communities

Dr. Kai Haber opened a drawer in his desk at the University Medical Center Radiology Department to reveal a rare piece of medical history.

After carefully removing its wrapping, Haber held up a 60-year-old glass plate, a remnant of a bygone era in radiography.

A silver-chloride film emulsion covering the plate depicts the elbow of a small child – proof of just how far medical imaging has come since the X-rays of the 1940s.

“Not many people have seen this,” Haber said. “There are not many left. Most are in museums.”

Carefully returning the plate to its packaging, he added, “Things have changed dramatically in our field.”

Haber, director of teleradiology at the University of Arizona, knows what he’s talking about. Thanks to advancements in digital technology, he and his team spend their days interpreting radiological images sent over the Arizona Telemedicine Network.

The program gives remote hospitals, such as those on the Hopi, Navajo and Apache reservations, access to specialists who diagnose cases in a matter of minutes.

A bit of history

Today, computer tomography (CT), positron emission tomography (PET) and magnetic resonance imaging (MRI) depict internal organs, bones, soft tissue and blood vessels with greater clarity than ever before.

And a computer screen is all it takes to view the images.

The technology can be traced back to the University of Arizona Radiology Department and the work of Dr. Terry Ovitt, Dr. Sol Nudelman and Dr. Paul Capp in the early 1970s.

“That group of physicians developed digital radiography – the whole process behind it,” said Dr. Elizabeth A. Krupinski, a professor in the University of Arizona departments of radiology and psychology and the Arizona Telemedicine Program’s associate director for evaluation.

“Unfortunately we didn’t patent it, but we developed it all here and were one of the main groups in promoting digital radiography and in developing the computer work stations that go along with viewing the images.”

Due to its digital nature, radiology simply lends itself to the field of telemedicine – a rapidly developing trend in which the transfer of digital images allows doctors to work from afar.

Through an association with the Arizona Telemedicine Network, the university’s teleradiology program provides services to more than 20 sites across the state.

Described by Haber’s colleagues as “the 500-pound gorilla” on the Arizona Telemedicine Program’s network, the program sees more than 100,000 cases a year, roughly 90 percent of all telemedicine cases.

Results in no time

A man walked into the emergency room at Whiteriver Hospital on the White Mountain Apache Reservation recently, expressing concern because he had been progressively losing his voice.

Years ago, doctors would have taken X-rays, asked him to come back in a week and sent the images to Phoenix by truck.

This time, a CAT scan was performed and doctors sent the images digitally to the UMC Radiology Department. Thirty minutes later, they had their answer.

“Unfortunately, this man had a large cancer growing in the back of his mouth at a dangerous level,” said Dr. David Yost, clinical director of Whiteriver Hospital. “We were able to get him on an airplane and send him to Phoenix where specialists were able to attend to him within 24 hours.”

The man, a single example of how teleradiology has changed clinical medicine in Arizona’s rural communities, is now undergoing multiple procedures in Phoenix.

“The availability of the telemedicine allowed us to get him to a place where he was stabilized and had the ability to think rationally about what he was going to do next,” Yost said.

From emergency CT scans to ultrasounds, the wait time for results has gone from days or weeks to minutes.

“Teleradiology allows for accurate and efficient interpretation of the images so the information gets back to the primary-care physician and he or she can treat the patient in a more timely manner,” Krupinski said.

In Arizona, the practice of teleradiology began with a pilot program in Globe in 1997.

Soon after, the UMC Radiology Department signed a contract with the Navajo Nation in 2003.

“We went from doing three or four cases a week to doing 100,000 cases a year almost overnight,” Haber said.

As the program grew, other hospitals, including those on the Hopi, Zuni and Apache reservations, followed suite. Haber said that at one point, the university was the largest teleradiology provider in the United States.

Today, private providers have a hold on the market, but the university’s program still stands out due to its academic nature.

“It really is one of the leading (teleradiology programs) in the country,” Krupinski said. “It was one of the first ones, and for an academic medical center, we are doing a high volume of cases.”

A speedy diagnosis

What difference does a few days honestly make? Just ask Yost at Whiteriver Hospital, who has worked on the White Mountain Reservation since 1990.

“To tell (a patient) it will be four or five days until we get their results back, that is a hard thing to say to someone who scrounged up some money or hitchhiked just to get here,” he said. “Now we are able to say, ‘If you walk down the hall and get a drink, in about 15 minutes we will have the results.'”

The importance of a speedy diagnosis is compounded by the fact that many cases seen in rural areas are far advanced.

“We see things that you ordinarily don’t see because people in urban areas come in to the doctor way before they get to this stage of the disease,” Haber said.

Yost added that when a patient has allowed his or her condition to worsen over a long period of time, “your window of time to act drops because they are already behind in the process.”

Extreme cases include stage-five or metastatic cancers, tuberculosis and even the occasional case of rickets – a softening of the bones in children.

Enter the iPad

Today, it is the workstation that continues to evolve.

Radiologists probably won’t find themselves using mobile robots – which are now used by primary-care physicians practicing telemedicine – but they could soon find themselves with more mobility.

“Instead of viewing images on big computer work stations, people are talking about reading certain types of images on iPads,” Krupinski said.

Mobile devices such as the iPad and Kindle have made waves in the publishing world and are already making their way into hospitals across the globe.

Haber added that there is even the potential for viewing certain images over mobile phones.

Though radiologists can do the bulk of their work over telemedicine networks, there are still certain procedures, such as biopsies, that require doctors like Haber to “drive the circuit,” visiting sites across Arizona and parts of western New Mexico. Haber returned from his most recent trip in mid-September, during which he drove more than 1,300 miles.

There probably will be further advances in the future that could replace these lengthy trips, Krupinski said.

“Way in the future is certainly the possibility of trying to do more complicated things such as interventional radiology,” she added.

For example, pediatric cardiologists from UMC can now guide sonographers in Yuma to perform echocardiology examinations on newborns. By watching the exam in real time, cardiologists can diagnose certain birth defects and determine whether a child needs to be airlifted into Tucson.

In the meantime, Haber said the teleradiology team will continue offering residents of some of the most remote areas of Arizona the same radiology emergency service provided at urban hospitals.

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