In-depth: Telemedicine
By Lorna Collier
Published by Newmedia.com
An 83-year-old woman living in rural Missouri needs to see her
physician, but lives two hours from the clinic and suffers from severe
arthritis, making travel difficult. So, the doctor's office comes to
her--via a videoconferencing device in the woman's home that lets her
speak with, and be seen by, her physician. Her home-care device
includes an electronic stethoscope that she uses on herself; she
transmits its readings over the phone to her doctor, allowing him to
listen to her heart and lungs as if she were standing right in front of
him.
A six-year-old girl in Istanbul has a congenital heart defect that has
her doctors stumped. They upload the child's test results to a
cardiologist in Boston, then discuss her case with the cardiologist in
a videoconference. The cardiologist recommends surgery; the girl flies
to Boston for the operation and later resumes a normal, healthy life in
Turkey.
These are just two examples of how modern telemedicine is working to
help patients and physicians today. And as equipment prices drop and
broadband Internet access spreads across the world, the potential for
telemedicine technology to further revolutionize health care is
enormous.
"We used to, and still do, dream of the day you'll be sitting in your
chair at home with your remote pointed at this thing you might call a
TV, and be able to press one button for shopping, another for
education, and another to get into a health care network," says Dr. Max
Stachura, director of the Telemedicine Center at the Medical College of
Georgia and eminent scholar in telemedicine at the Georgia Research
Alliance.
That dream of a digital health care system--with doctors available for
virtual house calls--is quickly becoming reality, he says: "It's a
matter of integrating it into what we're comfortable with."
Serving the underserved
Telemedicine is being used today in a variety of ways in the United
States and other developed nations. For example, patients in rural or
remote areas who don't have easy access to doctors can receive medical
care via videoconsultations, either from their homes using home-health
units, or by visiting nearby satellite clinics. These clinics are
equipped with more sophisticated "room-based" telemedicine services,
such as X-ray machines that send results to radiologists in distant
cities.
Urban residents with chronic, disabling conditions also are taking
advantage of these newer home-care devices. Prisons are another large
consumer of telemedicine services, since it is often more economical to
bring the doctors to the prisoners--albeit virtually--than it is to
transport prisoners to medical facilities.
In addition to provider-to-patient care, telemedicine commonly is used
for educational purposes among medical providers, who can schedule
ongoing classes, seminars, and even "grand rounds" on a videoconference
network. Also, physicians can conduct multiple, simultaneous
consultations with other doctors from around the world via
videoconference.
What isn't happening on a large scale yet is remote diagnosis. "The
ability to do real telemedicine--that is, clinical diagnostic
procedures--is currently hampered by the lack of bandwidth in rural
America, and security issues," says Dr. David Balch, director of East
Carolina University's Telemedicine Center. "Those things will be
resolved, but I still see it being three years out."
Once higher bandwidth is readily available, more sophisticated tests
will be able to be performed routinely. For example, doctors can use a
dermascope to take highly magnified pictures of skin surfaces, and with
higher bandwidth could then send these images electronically to
dermatologic specialists for appraisal. Similarly, electrocardiograms
and fetal ultrasounds could be done remotely, as could high-resolution
3D renderings of images, such as models of a patient's brain or other
organs.
3D and VR
NASA's Ames Center for Bioinformatics has developed an experimental
Virtual Collaborative Clinic that uses a high-performance wide-area
network to transmit 3D renderings simultaneously to consulting
physicians at several participating medical centers around the country.
Virtual reality applications also may become more feasible. Such
applications would include "haptic," or tactile, devices that allow a
doctor to "touch" a patient through virtual gloves equipped with
sensors, even though the doctor is thousands of miles away. With such
gloves, doctors can do such things as probe skin surfaces for lesions
or palpate organs.
Robot-assisted surgery
Virtual telesurgery is another application being developed. NASA, for
instance, is investigating the possibility of remote surgery being
performed on astronauts in outer space by robots directed by physicians
on the ground using virtual reality equipment. This is not so
far-fetched as it sounds, given that virtual operations already are
taking place.
For example, East Carolina University surgeon W. Randolph Chitwood Jr.
has begun performing heart-valve surgery across the room from a
patient, using a robot to perform the actual incisions while guiding
the process with virtual-reality glasses and gloves. This method allows
the doctor to increase the viewing scale of the area being operated
upon and reduce tremor, so that the doctor can make far smaller and
fewer incisions than would otherwise be humanly possible.
"Most of the virtual reality applications are very much in the
laboratories and too expensive," Balch says. "Yes, there are ways to do
tactic feedback, to feel textures, and to transmit it through some kind
of communications line, but these things are way too high-end for
consumer deployment. It's still way off in the distance."
Healthy competition
Beyond the vision of virtual applications, telemedicine promises to
alter medicine in another way. As more telemedicine programs shift from
direct point-to-point connections and use the Internet instead,
patients will be able to contact doctors from all over the country, for
the price of a local phone call, freeing them from dependence on local
physicians.
"Over the Net, you may have 80 different dermatologists around the
country available online to provide your service," Balch says. As a
consequence, he predicts that "clinical services will be brokered over
the Internet, and it won't necessarily be the closest geographic
location."
As of now, doctors must be licensed in each state in which they
practice--although there is some pending legislation that would change
this.
Until then, telemedicine providers such as Partners Telemedicine in
Boston are restricted to providing medical consultations only within
Massachusetts and outside the country. The bulk of Partners' 600 annual
physician consults--which take place via real-time
videoconferencing--occur between Boston-based doctors and physicians in
other countries, especially those in the Middle East, Latin America,
and southern Europe, says Dr. Joseph Kvedar, director of Partners.
Partners has been using an ISDN network to connect its physicians, as
well as a variety of methods to connect to clients, but is in the
process of switching to a TCP/IP system, which will enable access via
the Web, Kvedar says.
Small change
Audrey Kinsella, research director and owner of Information for
Tomorrow, believes that the glowing predictions about telehealth's
future often are more hype than substance.
"It's ridiculous to parrot what some have 'guestimated' about the
booming home telehealth market after I've asked them how they got their
numbers," Kinsella says. "I truly believe that the home telehealth
market is still an emerging one, and it's going to be very
significant--eventually. Not yet, and not tomorrow."
As yet, no single company stands out among the many piecemeal vendors
of telemedicine technology. "It's being used just a little by many
companies," says Kinsella. "Manufacturers are relatively tiny--like $1
million in sales. In the health care market, that's small change."
Pioneering peripherals
One of the biggest home-health vendors is American TeleCare. Its home
units offer two-way interactive videoconferencing via an
H.234-compliant video module and hands-free speakerphone. Hooked to
these units are a variety of peripherals, such as an electronic
stethoscope, blood pressure cuff, pulse meter, and glucose meter.
Other, similar devices include Kodak's new LifeView care station, which
features a monitor, camera, speakerphone, blood pressure monitor,
stethoscope, and thermometer. The Cyber-Care Electronic HouseCall
system, which is still under review by the FDA, promises to do much the
same.
A leading manufacturer of peripheral devices is Welch Allyn, which
produces such tools as video ophthalmoscopes, video otoscopes,
episcopes (which can magnify skin lesions up to 22 times their original
size), and vital-signs monitors.
Many telemedicine providers buy videoconferencing equipment from VTEL
Corp.. The company's new HealthStation 2000 system connects to a broad
range of video-based medical peripherals and is based on VTEL's
Enterprise Series Architecture platform, which includes a Pentium
processor, Windows 2000, and StandardPlus Video. The system also
provides interoperability with other videoconferencing systems.
Yet to hit the market is a new product being developed by Florida-based
startup Immediate Care with grant funding from NASA: an interactive
health kiosk, similar to an ATM machine, that can be placed in hotels,
office buildings, and condominiums. The kiosk will provide
videoconferencing, plug-and-play medical peripherals, a health
information database, and connectivity to a physician or nurse call
center. Immediate Care president Carl Taylor expects kiosks to be
available in early 2001.
For more information about telemedicine, an excellent overall source is
the Telemedicine Information Exchange. Other sources include the
Association of Telehealth Service Providers and the American
Telemedicine Association.
© Copyright Lorna Collier