In-depth: Telemedicine

By Lorna Collier
Published by

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

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