COLUMN ONE : High-Tech House Calls Catching On : From the South Pacific to rural Kansas, doctors find long-distance telemedicine can save lives and money.
Dr. Jim Troxell unwinds the bandage from his patient’s foot to reveal gangrene, which has eaten away much of the heel. A consulting orthopedist takes a close look, and after a few questions endorses Troxell’s treatment.
It’s the kind of consultation that takes place in medicine all the time. But in this case, Troxell and his patient are in Kwajalein, an atoll in the South Pacific. The orthopedist is 2,200 miles away at Honolulu’s Tripler Army Medical Center. The doctors communicate on television screens linked by satellite.
The technique is called telemedicine. Amid all the bluster about the potential of the information superhighway, physicians around the country already are using high-speed communications networks to provide crucial care.
Long-distance medicine is already saving lives as well as money. Residents of remote areas who never had easy access to advanced medical know-how find it increasingly available thanks to satellite and other links.
Skeptics fear the technology could dehumanize medicine and boost costs if there is sudden access to expensive care for those previously content with local solutions. But advocates are convinced that more and earlier medical care will prevent costlier illnesses later, and that medical resources can be used more efficiently when high-priced specialists can make diagnoses for patients around the country without leaving their big city hospitals.
Conceivably, the United States could even cut its trade deficit by selling medical services abroad. Experts at Massachusetts General Hospital and the Mayo Clinic in Minnesota are using video teleconferencing systems to advise patients in Jordan and Saudi Arabia.
Telemedicine has been around since the mid-1960s, when doctors used microwave transmission to exchange medical opinions and observe groundbreaking operations over two-way TV systems. But high costs kept the technology from catching on.
Now, falling prices and advances in data compression, which allow images to be more easily transmitted, have combined with a new federal and state eagerness to experiment with the information superhighway. The result: Telemedicine projects are breaking out everywhere.
Last year, Hawaii, West Virginia and eastern Montana built networks to connect remote hospitals and clinics to large medical centers. In the next year, 20 more projects will go on-line in various parts of the country. Telemedicine could soon be used to extend medical services to underserved inner- city clinics and nursing homes.
In North Carolina and Georgia, prison inmates who once were transported in chains long distances for medical treatment can now be examined by specialists from leading medical centers many miles away. They use electronic stethoscopes and other remote instruments to make diagnoses and advise prison doctors.
The Medical College of Georgia will break ground this fall when it begins using special cable TV lines to offer care to 25 households in Augusta where patients have chronic illnesses.
“We’re bringing back the house call,” said Jay Sanders, director of the school’s Telemedicine Center. “We will create an electronic umbilical cord to the home.”
The potential savings are huge. Regular monitoring of asthma and high-blood pressure patients at home could catch problems before they reach the critical stage that requires emergency hospitalization. “You can save an average $15,000 to $20,000 for every hospitalization you avoid,” Sanders said.
Federal and state agencies have strongly endorsed the trend. The National Telecommunications and Information Agency will spend $100 million next year to sponsor use of communication networks for health education. The National Institute of Standards and Technology recently budgeted $185 million over five years to help set standards for such things as patient medical records.
Such efforts could provide big savings. The National Health Foundation, a nonprofit group in Los Angeles, is working on an ambitious project to electronically connect hospitals with laboratories, suppliers and health agencies, a move that could save as much as $3 billion annually in California by reducing paperwork and avoiding duplicate tests, says Rita Moya, president of the foundation.
Proponents envision a day when all this information would be automatically fed into a giant database that would help doctors make diagnoses, recommend treatment and spot new diseases. If a doctor prescribes a drug that is incompatible with a drug already prescribed by another doctor, the computer would flash a warning.
“Telemedicine is necessary to have the kind of health reform that (the Clinton Administration) has planned,” said Dr. C. Everett Koop, former U.S. surgeon general. He is building a consortium of private health care companies, at Vice President Al Gore’s request, to promote the technology.
Since managed-care operators are paid a fixed fee per patient, they have a strong incentive to keep patients out of high-technology medical centers.
“Big hospitals used to rate their success based on high occupancy,” said George Conklin, vice president of information systems at Oklahoma Healthcare Corp. With managed care, he said, “we will be rated successful the lower our occupancy is.”
The corporation has begun to build a network that will enable specialists at its prestigious Baptist Medical Center to offer consultations to patients in 50 rural hospitals in Oklahoma so they can be treated locally for most ailments.
Because the bulk of problems of patients who enter the medical system do not require a doctor’s care, new ways of answering patient questions could sharply reduce the burden on hospitals.
The California Department of Transportation is backing a San Francisco Public Library project that could one day help keep cars off the road and people out of hospitals by providing health care information over phones and computer lines.
Skeptics say there is still little documented evidence to prove telemedicine saves money. The technology could result in even higher medical costs, for example, if rural patients learned of new options for care and demanded expensive treatment available only in cities.
But rural America, where about 64 million people live scattered in small towns, is already embracing technology as a matter of survival.
Rural hospitals are closing down and also cutting services as they lose patients to larger medical centers. Since the hospitals are typically the largest employers in town, their losses can be devastating to local economies.
“We found that in most cases we had to transfer patients (to city medical centers) because we couldn’t make a diagnosis,” said Robert Cox, a physician in Hays, Kan., population 18,000.
Cox was an early telemedicine enthusiast. In 1990, he persuaded his hospital, the Hays Medical Center, to install a system equipped with a video camera, a large TV monitor and a codec, a machine that compresses images from the camera so they can be transferred more cheaply over high-speed phone lines. The system is connected to similar systems at the University of Kansas Medical Center and in other rural hospitals.
About a year ago, an 8-year-old boy came to the Hays hospital with headaches and his left side paralyzed. He was given a CAT scan and taken to the video room. A pediatric neurologist at the University of Kansas looked at the CAT scan over the video screen, talked to the boy and his doctor about the symptoms and quickly concluded that the only treatments required were painkillers and time. Insurers saved the several thousand dollars it would have cost to airlift the boy and care for him at an expensive medical center.
With telemedicine, rural hospitals find they can keep 50% to 80% of the patients they once sent away to large hospitals that charge twice as much. The systems also help keep rural doctors up to date on modern medical advances and enable them to obtain credits for license renewal.
But though telemedicine networks are being installed at a rapid pace, many are not used fully. Last year, the top 10 telemedicine projects in America conducted 750 consultations of more than a few minutes, said Ace Allen, an oncologist at the University of Kansas Medical Center and editor of Telemedicine Today, a newsletter. In Norway, by contrast, one clinic conducted 603 consultations last year, Allen said.
There are several reasons for the slower pace. Some doctors are uncomfortable making diagnoses without being able to touch patients. Patients also express some discomfort. “It was kind of awkward because you are on the television,” said Vicky Nesmith, an employee at Dodge County Hospital in Georgia who recently had her ear examined remotely by a specialist in Augusta.
Many hospitals say telephone companies will have to lower rates, which can cost tens of thousands of dollars a month for a network of dedicated high-speed lines, before telemedicine is broadly practiced.
But the main obstacle to broader use remains reimbursement. Most doctors and specialists using telemedicine today are not reimbursed for their time. Private cardiologists in Oklahoma still fly around in their own private planes visiting patients because they are not paid for examinations they give over two-way television.
Douglas Perednia, director of the Advanced Telemedicine Research Group at Oregon Health Science University, says insurers are right to be skeptical. Hospitals could use grant money to rush into expensive purchases of new equipment only to find it inappropriate.
Perednia believes, for example, that dermatology can be practiced most cheaply and conveniently using a system he designed that consists of a cheap personal computer, a store-bought video camera to take pictures of the skin and a regular phone line to transfer the pictures to a specialist. His plan’s equipment and communication costs are a fraction of an interactive video system’s and it offers a dermatologist the flexibility to study the pictures on an office computer rather than at a scheduled time in a special room.
Farrokh Alemi, an associate professor in Cleveland State University’s health administration program, is also seeking low-cost approaches to telemedicine. He has developed a range of programs for the underserved, including one computer registry of drug-abusing mothers and their doctors.
A computer checks to see if the mother has had her baby immunized. If not, the computer telephones the mother and then the doctor. If the mother still has not seen the doctor after three weeks, the computer calls an outreach worker who goes to the mother’s home and brings her to the clinic. Of the 150 mothers participating in the pilot program, 85% had their babies immunized. The rate is 45% among clinic patients not in the special program.
Still, with lower semiconductor prices and better techniques for squeezing images through phone lines, the cost of interactive television systems has plunged. A system that cost more than $500,000 per site a decade ago, costs as little as $14,000. Vtel Corp., a leading manufacturer, says its entry-level system will cost just $5,000 by year’s end. At those prices, the system pays for itself quickly.
One of the most promising applications for telemedicine is in the area of mental health. When a 6-year-old boy in eastern Oregon grew disruptive at school, he was taken to a video studio established at a nearby high school with his teacher, his parents, his doctor and the mental health caseworker. A psychiatrist in Portland used an interactive video system to interview the boy and the others and prescribed medication that resolved the problem.
Without the network, said Cathy Britain, director of the Rodeonet project, the boy’s mother would have had to drive him 600 miles to Portland and put him in a private hospital, where he would have had to stay a week. Adult mental health patients can often have their medication adjusted over the network, avoiding police custody in rural communities with little mental health care.
Telemedicine could eventually turn America’s sophisticated but expensive medical system into a successful export.
“There is no reason the U.S. shouldn’t become the medical center for the world,” said Betsy Blakeslee, director of the recently established Telemedicine Institute at the Center for the New West in Denver.
Jordan’s King Hussein, who underwent heart surgery at the Mayo Clinic, backed a soon-to-be-completed $18-million hospital in Amman that will use a satellite to consult with specialists at the Mayo Clinic and elsewhere. Renowned heart surgeon Michael DeBakey says he has received requests from Turkey and other nations to buy a commercial telemedicine package for which he has acted as medical adviser.
If research funded by the Department of Defense is successful, America may export more than just consulting services. Advanced Research Projects Agency is financing research that may one day permit surgery from remote locations, enabling surgeons to conduct battlefield operations at a safe distance. And doctors at the University of Washington are working on pressure-sensitive gloves that give the wearer a sense of touch linked to what a robot hand at a remote location is touching.
In Kwajalein, which has the size and population of a small aircraft carrier, the Army spends $800,000 a year sending dependents and their families to Honolulu for treatment. Now, dependents are increasingly taking a short walk to the video room.
One recent stormy afternoon in Honolulu, a small group gathered in a room at Tripler packed with video equipment and three large display monitors. An orthopedist sat behind a conference table. The television was turned on and Troxell appeared.
Although his image was bounced off a satellite, picked up at a receiving station in Washington, D.C., and sent across land lines and submarine cable to Honolulu, the doctor and his patient came across loud and clear.
After the cross-Pacific consultation, Troxell was grateful. “We’re operating by the seat of our pants here,” he said later. Without the ability to refer the patient to experts, he said, “the option might have been to cut off his foot.”
