GRAND FORKS-Altru Hospital telemedicine coordinator Jessica Piseno heard the live heartbeat of nurse Nataile Halley. Ninety miles away.

All she had to do was connect via video and put on a pair of headphones.

On an average week, Altru Hospital makes 170 appointments from across the region-they may see patients from as far west as Rugby, N.D., or from Baudette, Minn., to the east.

But those patients don't make the 100-plus-mile drive to the Grand Forks hospital. They sit in their local clinic, as Halley did this week at Altru Clinic Devils Lake. A stethoscope in hand, she placed the instrument over her heart, which Piseno picked up in Grand Forks.

Devils Lake's clinic is one of 43 Altru facilities that use telemedicine.

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"We do 10 to 15 appointments a week (via telemedicine)," Halley said.

Telehealth technologies like telemedicine, e-emergency and e-pharmacy are being used more frequently in North Dakota and western Minnesota since hospitals there started investing in the services in the 2000s. Altru's telemedicine encounters went from virtually no appointments in 2008 to more than 5,000 last year. Last year alone, the hospital's telemedicine grew by 52 percent, Altru Regional Services Manager Marsha Waind said.

"What they always said is that it would grow exponentially, and it is," she said.

What is it?

Telemedicine, a part of telehealth, is the use of technology, usually via video, to diagnose patients remotely.

Doctors can hook up tools, such as otoscopes, to cameras that send images of the patient's body parts, like the inside of an ear, to a physician who is hundreds of miles away.

North Dakota's telemedicine started to grow after the North Dakota Telepharmacy Project was launched in 2002 through North Dakota State University. The state was the first in the country to pass laws allowing retail pharmacies to operate in remote areas without a pharmacist present the previous year, according to NDSU. The project created grants to help pharmacies join the telepharmacy project, and 81 have signed on so far.

"They really were the lead in the state and, really, across the country in telepharmacy," said Lynette Dickson, associate director of UND's Center for Rural Health.

Avera Health of Sioux Falls, S.D., also launched an e-emergency program that allows rural hospitals to connect with doctors in the emergency room, including in North Dakota.

Telepharmacy is a service Presentation Medical Center in Rolla, N.D., uses daily, CEO Mark Kerr said. The hospital can't staff a pharmacist 24/7, but patients may need medication any time of the day, especially in emergencies.

The hospital also uses e-emergency services "at a high level" and Altru's telemedicine program four to eight times a month, Kerr said. It saves customers time and money-some patients can't afford to drive to a health care facility hundreds of miles away multiple times, Kerr said.

"It's not a really big deal, but for someone who can save a whole day of their life for a 15-minute appointment, or just the peace of mind to just be able to talk to a specialist ... I think it is just a win-win for our rural community," he said.

'Total package'

A shortage in health care workforce also may be a reason rural hospitals and clinics invest in telehealth technologies, Waind and Dickson said. It can help keep patients and business local, keeping rural health care facilities open, Dickson noted.

"It's been harder and harder to get physicians everywhere, so to maintain access in these small hospitals and clinics, and to keep their patients served, it is very important that we do this," Waind said.

Telemedicine can be used for a variety of appointments, though oncology, psychiatry, renal dialysis and infectious disease appointments appear to be Altru's most frequent uses, according to its numbers.

North Dakota isn't behind the rest of the country, though there is plenty of room to grow, Dickson said.

Altru also has remote home monitoring-doctors can use technology to monitor patients who can't leave their homes, Waind said. Some schools and businesses have used telemedicine to connect with doctors as well, she added.

Waind said telemedicine is a growing industry with much more likely to come. She said she felt the advancements are beneficial, especially for rural areas like North Dakota and western Minnesota.

"This is really a total package of connective care," she said.