Ahead of Its Time?

— Most San Diegans have medical help available, even the uninsured. Many residents are minutes away from an emergency room; even rural San Diegans can be life-flighted to a trauma center. But what do you do when there is no hospital in proximity when you are injured or gravely ill? The answer is telemedicine.

Dr. Daniel R. Masys is a cancer-and-blood specialist and the director of bioethical information for UCSD Medical School in La Jolla. He is also one of a few San Diego experts in this field of medicine. "It's the use of information technology to serve health-care purposes when distance separates the participants. They are not face-to-face but in separate places. That includes not only high-end applications like two-way audio and video, but things as ordinary as the use of a telephone or e-mail."

The need to deal with medical emergencies in distant locales brings the military to mind. "They've put the largest amount of resources and operational testing in telemedicine because they are exactly in that situation. They have corpsman trying to take care of people on submerged submarines where they can't break radio silence or they'll risk their mission. They've put a lot of attention and resources into it. The action in Bosnia was the first war where there was a major commitment to telemedicine, where they used satellite-based communications. CTMR scans [a combination of CAT scans with MRIs] from the front were interpreted from Walter Reed and other places. They didn't save any money doing that, but they didn't intend to. They did find out, however, that it was effective, especially for specialty services. They can't be having neuroradiologists flying into harm's way."

UCSD has explored the possibility of an on-campus telemedicine institute. "We did have a research contract, for which I'm the principal investigator, which started in 1996. That gave patients for the first time access to their medical data in the UCSD system through a highly secure specialized Internet connection through their Web browser. So anything your doctor could see in the hospital computer, you could also see. If you went in for a lab test or you had an x-ray, you could get the results yourself. It required a lot more than a password and a code. You needed a user ID and password to even begin the session to download what's called a 'cryptographically signed job applet' that then challenged you for additional evidence for a string of characters that you sent back with a password that was never used a second time. It was a high-assurance system, much higher than using your credit card on the Internet. It was a successful test. We completed the first phase in 2000, and we had about 210 physicians and 56 patients signed up. The patients were uniformly positive about the idea that they could get their medical information as easily as their doctors could. They thought it was wonderful, though there were complaints that they needed help understanding the information because it was technical. We expected that and had a support desk. But doctors, who are used to having easy-to-use systems with less security, didn't like it at all. It took about a minute and a half to go through the high-security log-in, and for most doctors, that was unacceptable.

"There have been a number of federally funded research programs and demonstration projects in telemedicine. The closest one with the University of California is based in Davis, where they have a telemedicine center and have had for almost a decade. They have built upon other demonstration projects, like the one in the state of Georgia that created a statewide telemedicine network. In North Carolina, East Carolina University has had a very vigorous telemedicine program, and there are some in Texas too. The ones that seem to be sustainable -- that is, not just doing it as a grant or research project, then dropping when the money goes away -- have been prison telemedicine."

Prison telemedicine has grown rapidly because of two incentives: cost and the undesirability of practicing medicine on convicts. "From the point of view of the prison, it's very high-risk to have their inmates going outside the institution to visit doctors in the community. It's also very costly to have two guards going along. The most successful telemedicine programs to date have tended to be prison telemedicine, where the money that was being spent on guards and vans could be put into technology instead. The consultant can be on the other end of the wire in a television interview with a nurse-practitioner presenting the case or a doctor inside the walls getting a consult on something not commonly seen. This way you can bring a specialty to people who could otherwise not get it cost-effectively...or at all."

Dr. Masys's favorite example of telemedicine involves a female physician in Antarctica. "She was flown to Antarctica and was providing care there. For six months out of the year, it's completely inaccessible, and shortly after she arrived she discovered a lump on her breast. Very quickly, lumps were developing under her arm. Communicating over the Internet with cancer specialists in Indiana and other doctors who were providing advice, she was able to train the people around her, none of whom had medical training, to do biopsies, interpret slides, and send pictures of what the slides looked like. They airdropped from the C130 Hercules the chemotherapy drugs that she administered to herself until they got a brief period where they could land. It was only minus 30 degrees instead of minus 60 degrees, and they had 90 seconds to get the airplane off when they got her back to the States. That was clearly a life-threatening situation where she had a very rapidly developing form of cancer. If they had waited for the sun to come back to Antarctica, she would have been dead. That's got a lot of play in the press."

Telemedicine is practiced most frequently in San Diego through the 911 system. "When an ambulance rolls up to your house, those units use EKG telemetry so that they connect to the emergency department at one of our major hospitals in San Diego and the doctor sees your EKG tracings while the emergency medical team technician is presenting the vital signs and other information. Hands-on care at the scene is supplemented by telecommunications technologies that are bringing another pair of eyes, another mind to bear on the decision-making. Emergency-room doctors are listening to the case being presented along with the emergency technicians, and they make the decisions: Is this an emergency? Do we have to get to the closest place as quickly as possible? Can this person be stabilized? Those kinds of things."

Masys sees telemedicine improving emergency response beyond what is now considered cutting edge. "Currently, there's not a video component, with the doctor interacting with the patient. But imagine if we had high-speed wireless communications capabilities in our environment, where the ambulance would almost become a TV studio -- you would roll in to the back of the ambulance, and there you're seeing the providers as if you were already in the emergency room.

"The experience of telemedicine when well done actually removes from the participants the focus on technology. The patient interacts with the doctor on the television as if they were right there. The doctor, similarly, tends to look through the technology and focus on the patient. You look through the medium to see the problem at hand."

His ongoing investigation of telemedicine has led Masys all over the country to observe more advanced applications. Particularly impressive was East Carolina University. "They have little offices set up with soundproofing. There are six of them in a row, and they schedule their practitioners to be there. The doctors have an electronic stethoscope, and they can listen in real time. The nurse-practitioner puts the stethoscope on the chest, and the doctor listens over the link. It's quite a natural communication. Like most communications technologies, when they work really well they appear not to be there. It's bringing people together with the kind of interaction they would get face-to-face."

Telemedicine's beginnings -- the first time it involved more than a doctor returning a phone call -- can be traced to the mid-'60s. "Those were the first programs that developed things like remote EKG telemetry, which was quite a fancy thing in those days. They'd take a telephone and put it in an acoustic coupler. They had very slow radio speeds. It was all high-tech in those days, although very ordinary by today's standards. So there's a history that goes back at least 25 years. But in spite of the increasing amounts of bandwidth and the ubiquity of the Internet, telemedicine really hasn't taken off.

"Outside of having a grant that pays the cost of the technology, when you mix all the technology in and the fact that Medicare, until recently, and most health-care insurers would not pay for telemedicine, there was no incentive whatsoever to do it. Also, the costs saved tend to be the cost of travel. Families don't have to dislocate themselves and drive 100 miles to see the doctor then drive home, but the doctor never paid those costs anyway. The family may save some money, but the health-care institution doesn't realize a benefit. The Health Care Financing Administration, which creates the rules for Medicare reimbursement, has had a number of demonstration projects for telemedicine over the last ten years. Those were projects that would pay both parties, but under a very adverse set of rules. For instance, in most of the financing administration's demonstration projects, they required that there be a doctor on both ends of the line, and they would reimburse 80 percent of the face-to-face rate for the same service and the doctors had to split it! That's not a very strong incentive for anybody to give these demonstration projects.

"Another problem is the issue in the era of the Internet of medical licensure. State medical boards have held that the doctor is transported to the patient by telemedicine. That's a little backwards, because in most face-to-face health care, the patient transports themselves to the doctor. For purposes of licensure, they've said, 'Well, the doctor is transporting himself to the patient, so the doctor has to have a license for any state where the patient might have the need.' That's a real disincentive. Let's say you were the world's specialist in some rare medical condition and you knew more about it than anybody, so you said, 'Okay, why don't I use the Internet to try to make my services available to whoever needs them, because they're scattered all over the planet.' Well, currently, in the United States that means you would have to get 50 medical licenses for every state in the union and pay all the costs and go through all the difficulties, because every state does it differently. That's an insurmountable problem. Then there's malpractice. If something goes wrong, in whose jurisdiction did this event happen? Was it the state where the practitioner is or the state where the patient is?"

If the potential benefits seem distant, there is some movement to get there. "The state of California has passed a telemedicine act that for the first time reimburses any care provided by a California provider to a California patient. There's no face-to-face requirement for, say, MediCal reimbursement. So that's very progressive. At the end of the 2000 session, Congress passed a bill that expands telemedicine services nationwide, reimbursed by Medicare -- and the president hasn't undone it yet! That will, I think, increase some scenarios where it will be feasible to do it. There will be improvement, but how fast, I don't know."

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