Healthcare In Rural Areas

A) Telemedicine-cloud: Perinatal Care in Rural Areas:



America has the highest maternal mortality rate among the industrialized countries. A gradual increase in the maternal mortality rate was observed from 12/100,000 births in 1990 to 28/100,000 births.1 This alarming statistical data has been mentioned in both the print and electronic media (The Washington Post, New York Times, USA Today, Wall Street Journal, NBC, CBS, and National Public Radio). A new paradigm for the postpartum care in America was proposed by the American College of Obstetricians and Gynecologists.2 Several publications mentioned that the quality and quantity of maternal care declined in rural America.3-8 In 2015 pregnancy-related complications caused 64% more deaths among rural area pregnant people than people in urban area.9 Recently attempts were made to improve the rural health care10 especially the rural hospitals and the reimbursement system.11

We have solved the problem of providing perinatal care in rural areas of America. The quality of care is comparable to an urban hospital and the obstetrician does not need to travel to the pregnant people.

1) Wetzel LM. Maternal Mortality Statistics; Data collecting Methods improving but still a challenge. Contemporary OBGYN 2018; 63(1): 24-27.

2) American College of Obstetricians and Gynecologists. Committee opinion no. 736: optimizing postpartum care. Obstet Gynecol 2018; 131(5): e140-e150

3) Another Thing Disappearing from Rural America: Maternal Care. PROPUBLICA

4) Maron DF. Maternal Health Care is Disappearing in Rural America-Scientific American. 2017

5) Joszi Laura. Loss of Obstetric Services in Rural Counties Associated with Childbirth risks. In Focus Blog, March 12, 2018. counties-associated-with-childbirth-risks

6) Health Disparities in Rural Women. The American College of Obstetricians and Gynecologists. Committee Opinion No. 586. February 2014 (Reaffirmed 2018).

7) Shah NT. Eroding Access and Quality of Childbirth Care in Rural US Counties. JAMA 2018; 319(12): 1203-2014

8) Kozhimannil KB, et al. Association Between Loss of Hospital-Based Obstetric Services and Birth Outcomes in Rural Counties in the United States. JAMA 2018; 319(12): 1239-1247.

9) Brabaw K. Too Many Pregnant Women are dying in Rural America.

10) Iglehart, JK. The Challenging Quest to Improve Rural Health Care-Health Policy Report. N Engl J Med 2018; 378: 473-479

11) Murphy KM, Hughes LS, Conway P. A path to sustain rural hospitals. JAMA 2018; 319(12): 1193-1194

The Solution:

Fortutec developed a solution that integrates portable devices and Telemedicine platform. The caregiver carries the portable devices and record the readings in the system which are in turn sent to Electronic Medical Record.

How it works:

The pregnant patient launches the online portal and request for an at-home peri-natal screenings. A schedule and a care plan are then created for the patient and a Mid-Wife or Registered Nurse in the same or near by zip code is assigned to the patient. Following the care plan, He/She visits the patient and get all the vitals and readings using the portable devices and record them in the system from where they are sent to EMR. If the Mid-wife/Nurse has a question, they can have a conversation via telemedicine platform with Physician and get the questions/concerns/issues addressed. If needed, the patient is asked to visit hospital.

Value proposition of the solution:

1) Very helpful to pregnant women living in rural areas.

2) At home service and can avoid stressful journey to clinics.

3) Physicians time is effectively used.

4) Cost savings to Health care system.


No competition in the market at this time.

B) Telemedicine-cloud: Tomosynthesis-Breast Cancer Screening in Rural Areas:



America’s land mass in rural areas is 97% and only 19.3% of the population lives there (approximately 60 million people). In rural areas 11.3% of the residents have no medical insurance.

In America breast cancer is the most common cancer in women and is the second leading cause of cancer deaths. The National Cancer Institute (NCI) in 2016 projected that 12.4 % of women will develop breast cancer in their lifetime. NCI estimated that 246,660 women will be diagnosed in 2016 with breast cancer and 40,450 women shall die of the disease.1 Recent study by the Center for Disease Control and Prevention, Atlanta, GA indicated that deaths from cancer are higher in rural America.2,3

A significant number of rural women fail to undergo breast cancer screening for several reasons beyond their control, e.g., lack of medical facilities in their area of residency, inadequate and infrequent outreach programs by the clinicians, long travel distances to a clinic, proper training to implement the self-examination of their breasts, lack of knowledge about mammogram, etc.4

Breast cancer is typically detected in women by clinical breast examination by a clinician, mammogram, additional tests, e.g. ultrasound, Magnetic Resonance Imaging, and biopsy. Elizabeth Krupinski was the first radiologist in America to provide access to 2-dimensional mammography in rural areas, but it was limited to few areas in the State of Arizona.5

We have provided the state of the art technology and service to all the women in the rural areas by employing telemedicine-cloud based Digital Breast Tomosynthesis (DBT) for the screening of breast cancer. The physical examination is done in a van equipped with “General Electric Senographe Pristina” mammography system.

The major advantage of DBT technology over 2-dimensional mammography is that it allows radiologists to view breast tissue using a 3-dimensional dataset that improves diagnostic accuracy by facilitating differentiation of potentially malignant lesions from overlap of normal tissue. The mammography is done on real time basis under the supervision of a especially trained radiologist on 3-D tomosynthesis and the women is provided the interpretation within few minutes.6

1) Breast Cancer by the Numbers: Survival Rates by Stage, Age, and Country.

2) New CDC Report shows deaths from cancer higher in rural America.

3) Davis TC, Connie LA, Rademaker A, Baily SC, Platt DJ, Reynolds C, Esparaza J, Liu D, Wolf MS. Differences in Barriers to Mammography Between Rural and Urban Women. J Women Health 212; 21(7):748-755.

4) Peppercorn JM, Houck K, Wogu AF, Villagra V, Lyman GH, Wheeler SB. National survey of breast cancer screening in rural America. J Clin Oncology 31, no.26_suppl (September 10 2013), pp13. DOI: 10.1200/jc.2013.31.26_suppl 1

5) Krupinski EA. Improving Access to Mammography in Rural Areas. Susan M.Astley et al. (Eds.):IWSM 2006, LNCS 4046, pp111-117, 2006, Springer-Verlag Berlin Heidelberg 2006.

6) Sujana PS, Mahesh M, Vedantham S, Harvey SC, Mullen LA, Woods RVW. Digital breast tomosynthesis image acquisition principles and artifacts (Review). Clinical Imaging 2019; 55: 188-195.

C) Telemedicine-cloud: Bone Density Testing for Osteoporosis in Rural Areas:



In most instances in small cities, towns, villages and the rural areas, osteoporosis is suspected after a broken bone in both older women and men. Most older women and men in small cities, towns, villages and the rural areas have no access to bone density testing for several reasons beyond their control, e.g., lack of medical facilities in their area of residency, inadequate and infrequent outreach programs by the clinicians, long travel distances to a clinic, etc.

Bone density is defined as the measurement of the calcium and other bone minerals that are packed into a segment of the bone. Bone density is determined into two scores, i.e., T-score and Z-score. Bone density testing, also called dual-energy x-ray absorptiometry (DXA) or bone mineral density (BMD), is an enhanced version of x-ray scan that is used to measure bone loss. BMD tests are usually done on bones in the spine (vertebrae), hip, forearm, wrist, fingers and heel.

Bone density testing is commonly recommended in menopausal women and not taking estrogens, men with clinical conditions associated with bone loss, such as rheumatoid arthritis, chronic kidney or liver disease. Bone density testing is also advised in few other clinical conditions, e.g., use of medications (prednisone), excessive collagen in urine, hyperthyroidism, hyperparathyroidism, type 1 diabetes, etc. All these clinical conditions demand access to radiologist, endocrinologist, rheumatologist, pulmonologist, etc., and these specialists are not easily accessible in rural areas.

We have solved this problem by sending “Mobile Medical Van” to small cities, towns, villages, and the rural areas with an installed General Electric DXA machine and other instruments for the evaluation of the person. The DXA scan is transmitted employing Zoom and Dicom to a radiologist working in an urban area and the interpretation is available in thirty (30) minutes.


1) Jain RK, Vokes T. Dual-energy X-ray Absorptiometry [Review], Journal of Clinical Densitometry 2017; 20(3): 291-303

2) Matsuzaki M, Pant R, Kulkarni B, Kinra S. Comparison of Bone Mineral Density between Urban and Rural Areas: Systemic Review and Meta-Analysis. PLOS One 2015; 10(7): e0132239

3) Patient education: Bone density testing (Beyond the Basics). the basics. Sheu A, Diamond T. Bone mineral density: testing for osteoporosis. Aust Prescr 2016; 39(2): 35-39.

4) Rothman MS, Lewiecki EM, Miller PD. Bone Density Testing is the Best Way to Monitor Osteoporosis Treatment. The American Journal of Medicine 2017. 2017.05.044

5) Recently published articles from Journal of Clinical Densitometry (October-December 2019). articles