Beyond House Calls
Jun 1, 2005 12:00 PM, By Rosanne Soifer
A look at the basics of telemedicine.
Lights, camera, scalpel! Telemedicine is making its mark on the medical world. This article provides an overview of telemedicine and includes a discussion with several medical professionals about their initial interest in telemedicine, its advantages and disadvantages, and their current involvement in the field.
Telemedicine means medicine at a distance. The American Telemedicine Association defines telehealth much more broadly than telemedicine, describing telehealth as “a comprehensive infrastructure for the remote delivery of health care … involving disciplines other than medicine.”
No matter how the field is labeled, it encompasses (among other things) patient diagnosis and treatment, videoconferencing, and medical distance learning.
The American Telemedicine Association is one of many associations worldwide that holds conventions, hosts websites, and is dedicated to following the advances in this rapidly evolving field.
Of all the forces driving changes in health care, the three main ones are increased health consumerism, economic need (rising health-care costs), and technology, according to Peter Yellowlees, telemedicine expert and director of academic information systems at the University of California-Davis.
So how did this rapidly growing field begin? According to the “History of Telemedicine” chapter in the textbook Handbook of Telemedicine, the roots of telemedicine can be traced back to the inventions of the telephone and radio around 1900. At the end of the 19th century, radio communication became possible, initially by Morse code and later by voice. The potential of radio to allow doctors to provide medical advice to seafarers was quickly recognized, and by the 1920s, most maritime nations had established such services.
Telemedicine using videoconferencing began in the late 1950s, with Dr. Cecil Wittson's microwave-based rural telepsychiatry program at the University of Nebraska Medical Center in Omaha. With the rise of the personal computer, the movement continued to grow in the 1970s and 1980s. However, the most growth and development occurred in the 1990s, with the rapid expansion of telecommunications networks and the Internet.
BASIC TELEMEDICINE TERMINOLOGY
According to “Telehealth Technology,” in information put out by the U.S. government's Health Resources and Services Administration (HRSA), the four basic aspects of a telehealth technology information plan include networks, network equipment, telehealth equipment, and room evaluation.
Constantly evolving telemedicine technology requires the following:
- Compatibility: Newer and older versions of the same technology must be compatible with each other. Therefore, vendors must provide some commitment to their clients regarding backward compatibility.
- Interoperability: Multiple technologies and networks need to be able to interface with one another.
- Scalability: Technology purchased for telehealth should be capable of expansion without total replacement.
- Accessibility: Health-care providers should judge the vendor's accessibility in terms of sales, timely delivery, and equipment maintenance.
This is obviously familiar terrain that professional sound and video vendors investigate at the beginning of any large-scale project involving multiple networks and media.
According to the California Telemedicine and eHealth Center (CTEC) in Sacramento, Calif., telemedicine applications can be classified as realtime or store-and-forward. With realtime telemedicine, the patient is actually seen by the provider in an interactive environment, and two-way communication (both video and audio) can take place. Store-and-forward applications use captured video clips, audio clips, still images, or data that are transmitted and received at a later time. These applications enable asynchronous communication, with the advantage of not requiring concurrent participant involvement.
Two primary sites in telemedicine include the patient, or originator, site and the consult, or distant, site. The patient site is where the patient is physically located when audio/video information is gathered, and the consult site is the physical location of the provider delivering patient care.
WHERE TO START
Many of the same issues that apply to a large multifaceted project such as distance learning or animated signage apply to telemedicine as well and may need to be explored.
First, what are the characteristics of the patients (age range, demographics, etc.)? Will someone other than the patient (such as a home health aide or a family member) be using the technology to transmit information? What is the patient's financial situation? If the patient is from a lower socioeconomic class, the need to purchase and install high-tech apparatus may defeat the purpose.
The basic computer setup and Internet speed (dial-up vs. broadband) have to be determined at the beginning. Another consideration is that many homebound patients may resent the intrusion of yet more medical technology in their home.
Before implementing a telemedicine system, also consider who will teach both the providers and the patients how to use the technology and who will be ultimately responsible if something goes wrong technically. Finally, the worst-case scenario has to be considered: Could this result in the death of a patient who couldn't use the system properly?
Service contracts need to be explored as well. Which parties are the sound and video contractors ultimately doing business with, the patients, the health-care providers, or the actual sites? All technology comes with a disclaimer regarding secondary damages.
Speak with your business insurance carrier about secondary damages and liability. If the health-care provider (clinic, private doctor, hospital) provides the technology and outsources the installation/setup to you as the independent contractor, your liability may be different than if you are directly providing (and reselling) the technology.
According to Russ Dubrow, president of Electronic Technology in Harbor City, Calif., “There should be backup technology — the simplest and most obvious are the phone, fax, and computer. Warranties from the manufacturer are [the] responsibility of your client. Also, an outside extended warranty (for when the manufacturer's expires) from companies such as Philips and Warrantec, or a service contract, can be sold by the vendor to the client — usually for a good profit.”
Do the doctors themselves have any input regarding the hardware and software chosen for telemedicine applications?
“Not directly,” says Dr. Stephen E. Hyler, a clinic professor of psychiatry at Columbia University and a member of the psychiatry department of St. Luke's Roosevelt Hospital in New York. “Here at St. Luke's, until the 1980s all we basically had was closed-circuit TV. Now we have a chief tech director.”
Dr. Paul Conlin, chief of endocrinology at VA Boston Healthcare System and associate professor of medicine at Harvard Medical School, explains his role in the selection of telemedicine technology. “Here at the VA Hospital in Boston, our major focus in which I had input was to have direct access to medical records.”
CTEC outlines five major factors that have led to the growth of telemedicine:
- Lower costs and more widely available communications
- Lower-cost, high-performance computers
- Greater public confidence in the technology
- Greater acceptance of the technology by medical professionals
- Emerging global standards in communications, videoconferencing, and medical disciplines.
Hyler says he was immediately interested in telemedicine because he is an enthusiastic AV consumer and hobbyist. As a psychiatrist, he uses film depictions on a regular basis for teaching courses on mental health at conferences and seminars.
Dr. Barry Hirsch, professor of otolaryngology at the University of Pittsburgh School of Medicine, says, “Many hospitals are eager because of potential revenue generation and to broaden publicity for the institution.”
Conlin adds, “Many hospitals love the concept but are generally resistant when it comes to time issues — such as exactly how much and what they have to do to get it underway — plus the issues of reimbursement.”
Conlin's interest in telemedicine from the perspective of a diabetes specialist began when he observed what he termed a “disconnect” between when his patients collected blood sugar information at home and when the information was actually brought in to the clinic and analyzed. “Web technology can provide a secure portal for feedback almost immediately,” Conlin says. “Any form of information exchange works, whether it's from patient to provider or provider to patient.”
One of the few obstacles to the common use of telemedicine is legal issues. The specific and very involved clinical and medical/legal issues are outside the reach of this article. However, common areas of legal concern for sound and video professionals, as well as health-care providers, may include:
- Aspects of harm, results, duty of care, and breach of duty
- Specific areas of responsibility and liability
- The frequent informality of telehealth policies of practice
- Issues of privacy and control of information with patient medical records, which are now often stored and transmitted electronically to many different parties.
Other problems can be seen in telemedicine's use of email and the Internet. A patient may have problems accessing a website to renew critically needed prescriptions. A worst-case scenario in the area of telepsychiatry might be a potentially suicidal patient trying to send an email that doesn't reach a doctor or is not read in time because of a broken server or computer malfunction.
One disadvantage Hyler sees is that treatment can be more problematic. Treating an unknown patient remotely raises legal, moral, and ethical issues.
Also, telemedicine obviously doesn't work perfectly in every situation. Hyler says, “Directing surgery at a distance is still in the experimental stages.”
Conlin agrees that remote surgery is still in its infancy. “The surgical operator's ‘fine’ movements may be hard to translate — such as the exact length of an incision — unless there is a running commentary provided, plus the inherent time lag [can cause problems]. For example, a United States-to-Europe transmittal may have a one-second delay in sending a signal to routers, which may not sound like much but could definitely contribute to the risk.”
Hirsch adds that telemedicine is lacking in fields where three-dimensional viewing may be critical. “Optic resolution may be compromised in certain situations,” he says.
Smaller clinics and solo practitioners may need to proceed with caution. Conlin advises them to consider their needs: “A retinal camera costs about $25,000. But a regular digital camera setup — which may be fine depending on what the needs are — is only a few [hundred] dollars.”
Hyler says it depends what the small clinics want to do. “Do they want to see the patients in person and only monitor the medication long distance?”
Hirsch cites access to media as a potential problem smaller outfits may face. “To receive the transmission they will need dish or cable line or Cat-5. Telephone lines are possible but slow.”
Other disadvantages include the financial aspects, professional liability (which can also affect the independent sound and video professional), and payment for services. Although there are certainly savings down the line, says Hyler, initial expenditures are high and may be hard to justify for hospitals that consider themselves financially strapped. He adds, “Many telemed/telepsych services are not reimbursable. However, a hospital may generally be eager to embrace telemedicine in terms of good will — such as being able to service [the] homebound patient.”
Ted Rothstein, president of TRTechnologies in New York City, remarks, “I don't trust insurance. Yes, there could be liability if technology fails. One must be careful what one promises, always passing through the manufacturer's claims as their responsibility. But general professional liability insurance is supposed to cover you when selling anything, even if the manufacturer can't back up his own product.”
Dubrow says, “As always, don't try to sell a product or service the client can't buy.” Or can't get reimbursed for, which brings us to our next topic.
FOLLOW THE MONEY
Solo practioners and small clinics may be put off (as are many large health-care systems) by what they perceive as the initial start-up costs of telemedicine. Michael Vendetti of Video Corporation of America in New York City says, “Although we do quite a bit of work with hospitals and health groups, most of our projects seem to be the more corporate side of business. • It seems that as much as hospitals give lip service to these technological breakthroughs, they are slow to accept and deploy them.”
Hirsch says so far most telemedicine monies are received and set up through federal grants. He adds that telemedicine payments do not represent those of a well-covered service and there are violations of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
Hyler adds that in the area of telepsychiatry there is often a question as to who is actually the primary caregiver.
Suzi Birz, principal of HiQ Analytics, states in a recent issue of Nursezone.com that the “digital divide,” as applied to economics and age, must be crossed. In addition, the very real business issues of practicing across state lines and reimbursement must be addressed.
The HRSA's Office for the Advancement of Telehealth outlines issues of which health-care practitioners should be aware. Sound and video professionals should take notice of these issues as well. They include the geographic limits for reimbursement and what teleconsultative services, technologies, practitioners, and sites will be covered.
A hospital may outsource (for tax- and employment-related issues) all of its technology needs to a company such as slp3D or Cap Gemini Ernst & Young.
CapGemini America has taken up residence at Beth Israel Hospital in New York. The staff includes Robert Cabrera and Matthew Simonetti. Says Cabrera, “We take care of all the information systems by running the desktops, the server, and acting as the webmaster. We also oversee surgery streamed over videoconferencing.”
Independent contractors may be able to gain entry to this field by getting to know health-care professionals who are also techies. Keep an eye out for hospitals or clinics that are undergoing reconstruction, renovation, or expansion and contact the project manager or perhaps the venue's business manager. And many hospitals, large and small, now have some type of AV or IT department.
Many thanks to: Dr. Eric Goldman; Dr. Donald Simonson; Dr. Barry Hirsch; Dr. Paul Conlin; Dr. Steven E. Hyler; Dr. Richard Rosenthal; Miriam Nagler, RN; Robert Cabrera; Matthew Simonetti; Russ Dubrow; Ted Rothstein; VISICU; and Jason Koehler of Vantage
Rosanne Soifer is a New York City-based musician and writer. She can be contacted at SRJRSD@aol.com.
For a look at speech intelligibility in teleconferencing, check out the article by Mei Wu and James Black here.
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