Telemedicine: Seeing the Future Today

During the past 40 years, experts in technology, telecommunications, and medicine have collaborated on numerous demonstration projects that have documented the efficacy and efficiency of telemedicine. Today, this research is paying dividends in the form of a variety of telemedicine projects and applications that are enabling physicians to provide healthcare services to patients located anywhere from 100 feet to 10,000 miles away. Telemedicine has moved beyond the demonstration stage, with many applications starting to be integrated into daily practice in a variety of settings from large hospitals to private physician offices to direct use by consumers.

It’s easy to describe the benefi ts of this new technology in broad, sweeping terms. However, examples of specifi c applications and their results can best demonstrate how telemedicine is beginning to transform the delivery of healthcare.

Medical Imaging

Teleradiology is a means of electronically transmitting radiographic patient images and consultative text from one location to another. Teleradiology represents, by far, the most widespread use of telemedicine today, and for good reason; due to an ongoing shortage of radiologists and increased use of medical imaging, a critical need exists to use such effi cient applications as teleradiology to meet demand. Once considered merely an interesting demonstration of the technology, today several hundred US hospitals use teleradiology services, allowing radiologists to work from home or the hospital to outsource certain imaging services.

One growing element of remote radiology services is the use of internationally based companies to provide after-hours (sometimes

called “nighthawk”) services. Th e companies employ radiologists in such locations as India, Switzerland, Australia, France, and Israel to provide US hospitals with needed services.

Children’s Services

According to a report published by the Agency for Health Care Research and Quality and the Harvard School of Public Health, in 2000, 37% of hospital stays for children across the US were paid by Medicaid, with respiratory conditions the most frequent

diagnosis for one to nine year-olds. Remote monitoring can significantly reduce this problem, as the following example illustrates.

Researchers from the Army Medical Department demonstrated that home telemonitoring of children afflicted with asthma can

significantly improve outcomes over traditional offi ce-based care. A group of “virtual patients” recorded vital sign data online (such as pulmonary functions) and submitted it online to their case managers weekly. These were compared to a control group receiving traditional care.

The one-year trial showed that children who accessed care through the Web-based case management system had better MDI/S scores, were more likely to keep a journal of daily asthma symptoms, and demonstrated a greater increase in asthma knowledge. The “virtual patients” achieved excellent asthma care, revealing that store-andforward technology combined with case management can provide an important tool to assist in disease management. The benefits of pediatric telemedicine were also explored by the University of Iowa College of Medicine, which conducted a study of specialized interdisciplinary team consultations for children with health and developmental disorders.

The study included four groups of children: those with severe behavior disorders, with swallowing disorders, needing assistive technology, and with unmet health needs—primarily traumatic brain injury (TBI). The results indicated a high degree of satisfaction between parents, children, healthcare providers, caregivers, and teachers. The telemedicine network provided access to high-quality healthcare and was a timesaver for both the providers and the family. The cost savings to the local school district equaled $971 per session. Th e travel and time costs to parents for out-of-pocket expenses equaled $125. As a result of the study, the telemedicine clinic for children with special needs was adopted as part of the regular clinical venue at University of Iowa Hospitals and Clinics and participating schools (Harper D, Journal of Telemedicine and e-Health, June 2001).

Employer-Sponsored Health Plans

Incorporating workplace telemedicine for employer-sponsored health plans can yield a number of benefits, including:

• Increased patient convenience

• Increased employee productivity

• New employee peace of mind

• Increased efficiencies due to less actual patients in waiting room

Several years ago, the University of Texas Medical Branch at Galveston initiated a project with the American National Insurance Company to determine if telemedicine could lower employer costs and increase employee convenience without lowering the quality of care. After the initial 100 visits, it was discovered that telemedicine consultations averaged 27 minutes, compared with 122 minutes for face-to-face visits (includes travel time, waiting time, and time spent with the provider). This translated into an average time savings of 1.6 hours and a direct salary savings of $47.37 per telemedicine encounter. It is clear from this example, and many others, that telemedicine can not only help provide good healthcare for employees but also reduce costs for employers.

Treating Obesity

Reports on two demonstration projects completed at the University of California, Davis and the University of Colorado using remote consultations, monitoring of vital signs, and online discussions show how telemedicine can eff ectively help people lose weight and keep the pounds off. The California demonstration focused on children and adolescent patients and concluded that children struggling with weight problems embraced the telemedicine weight management services and that telemedicine could help facilitate the delivery of care to individuals in rural areas lacking access to healthcare services.

The Colorado demonstration provides a remote option to the University’s traditional weight loss program by providing individuals with home access to self-monitoring software programs, Web-based reporting, and health professionals.

Remote Mental Health Visits

We are seeing a widespread and rapidly growing use of telemedicine in mental health. In fact, telemental health services are one of the three most frequently provided health services using telemedicine technologies. Telemedicine is used to provide many types of mental health services, including pre-admission and discharge planning, pyschotherapy, support groups, case assessments and evaluations, medication management, court commitment hearings, and continuing medical education (CME) for providers.

A project at Fletcher Allen Health Care in Vermont found that telemental health is actually superior to face-to-face consultations in certain cases. Treatment for cases of paranoia or schizoid states, extreme shyness, comorbid nonpsychiatric illness, terminal illness, and some phobias were found to be more eff ective using a “distance” approach with remote videoconferencing. Additionally, videoconferencing allowed nurse facilitators, family members, or social workers to be present and improved scheduling coordination with diff erent parties. The use of videoconferencing allows providers to tilt or zoom in to observe specific body parts (eyes, mouth, hands, face) or to watch a family member’s or caregiver’s responses to a consultant’s questions or remarks without disturbing the patient, other parties, or both (see our Day in the Life piece in the Pulse section of this issue for more on these findings, provided directly from the lead investigator).

Ocular Telehealth

The goals of using telemedicine in eye care include preserving vision, reducing vision loss, and providing better access to medicine. There is no better use of such applications than identifying early onset of diabetic retinopathy (DR), a leading cause of new-onset blindness in the United States and many other industrialized countries.

DR develops in nearly all persons with diabetes, aff ecting more than 5.3 million Americans older than age 18 years (2.5% of the US population). The medical, social, and economic ramifi cations of the disease are substantial, making early detection and treatment of the disease absolutely essential.

A University of Pittsburgh study found that using telemedicine for diabetic retinopathy screening enabled the healthcare team to reduce the time for patient screening to approximately 15 minutes. Another study of more than 250 patients in Minnesota found virtually no significant diff erence between in-person DR screenings and those performed remotely. Today, a telemedicine service for diabetic retinopathy screenings has been used to assess more than 25,000 patients. In addition, the Indian Health Service has chosen remote DR screenings as one of its priorities in the use of telemedicine for Native Americans and Alaskan Natives.

A study in Montreal found that 18% of the diabetics who participated in the telescreening of DR went undiagnosed in traditional screening. In comparison, as part of an external endocrinology clinic, 6.2% of diabetic persons were identifi ed in the same way. In addition, researchers consider that with a mass screening program, six out of 10 persons followed by an ophthalmologist could avoid regular screening tests, enhancing the margin of time available to ophthalmologists for follow-up and eventual treatment of those screened at the right time.

Telemedicine in Oncology

Telemedicine has applications in oncology from diagnosis to treatment planning to follow-up care and consultation. A review of telemedicine research at the National Cancer Institute (NCI) notes that telemedicine “has the potential to facilitate better communication between patients and their providers, help patients take better care of themselves, help their caregivers keep better track of their health condition and their self-care, alert doctors to medical emergencies, and provide reminders when patients are due for cancer screening tests and other appropriate medical services.”

The NCI notes that telemedicine systems will enable oncologists to remotely view biopsy specimens, MRIs, digital mammography and other imagery, and discuss cases with experts at geographically isolated locations. Other possible applications include remote monitoring of patients who are undergoing chemotherapy or coping with end-of-life issues, online assistance for parents of children with cancer, and applications that promote and encourage cancer screening.

One successful telemedicine program, organized through the NCI’s Cancer Disparities Research Partnership program, enabled patients and radiation oncologists at New Hanover Regional Medical Center (NHRMC) in North Carolina to connect with University of North Carolina, Chapel Hill (UNC) oncologists using TELESYNERGY^® medical consultation workstations. NHRMC physicians examined patients with locally advanced head and neck cancer and initiated intensity modulated radiation therapy planning, “contour[ing] tumor target volumes (TTVs) and adjacent normal organs at risk (OARs).” Using the TELESYNERGY set-up, they shared images (including “contours and dose volume histograms for TTVs and OARs”), isodose distributions, pathology slides, and other data with UNC oncologists for review and consultation.

The examples in this article provide merely a glimpse of the potential uses of telemedicine technologies. Telemedicine can also be usefully applied in obstructive sleep apnea assessment, robotic surgery, dermatology consultations, and dozens of other specialties and settings. Even greater capabilities are in store for the future, as the technology continues to advance with faster

data transfer, improved voice and video transmission, and increased interest among both patients and practitioners.

Jonathan D. Linkous is the executive director of the American Telemedicine Association (ATA), the largest membership-based organization in the world focusing exclusively on providing health and medical care through telecommunications technology. Mr. Linkous has spoken and written extensively in the US and in other countries on policy issues, emerging applications, and market trends that impact telemedicine. Mr. Linkous has more than 20 years experience in the nation’s capital working in corporate and public sectors.