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Issue 1, March 2001
The Use of Telecommunications in Clinical Medicine - Telemedicine
Likang Chin
Bioengineering, University of Pennsylvania
Rebuilding
the Face of a Kosovo War Victim
In December
1999, telemedicine successfully aided the facial reconstruction
of a Kosovo war victim. Eight months earlier, in the village of
Zaza, Besim Kadriu was shot in the head as he was running through
the area in search of his missing wife. The damage done was massive;
Kadriu's entire right cheek was completely blown off by the bullet,
as well as his right eye and entire nose. Photographs were taken
of the victim by British army doctor Lieutenant Colonel David Vassallo
with a couple of Olympus digital cameras, and the images were transmitted
via email to several philanthropic surgeons using a Toshiba laptop,
a satellite phone bought by the British, and an America Online account.
A team of about five specialists in reconstructive surgery received
the images and began planning the difficult repair of Kadriu's face.
Eventually, Kadriu was sent to England, where he underwent the fifteen-hour
operation at North Manchester General Hospital. Thanks to the compassion
of the medical personnel involved and the power of telemedicine,
the surgery successfully restored the handsome Kosovar's face.3
Telemedicine Defined
The story of Besim
Kadriu is an example of modern technology and telecommunications
in clinical medicine that can be encompassed in the term telemedicine.
Telemedicine is the art of transmitting medical data electronically
from one location to the other. The data can take one of many forms
- video, images, patient records, or sounds. Transmission is facilitated
through telephone lines, integrated services digital network (ISDN),
fractional to full T-1, Asynchronous Transfer Mode (ATM), the Internet,
intranets, satellite, microwave, and wireless equipment. Telemedicine
is most popular in the fields of radiology, pathology, dermatology,
oncology, surgery, cardiology, psychiatry, and home health care.6
History
of Telemedicine
In some form or another, telemedicine has had a role in clinical
medicine for approximately 30 years, but it has only been highly
recognized in the past five years. In its early stages during the
1960's, the National Aeronautics and Space Administration (NASA)
played a major role in telemedicine's development when physiological
parameters were received from astronauts and spacecraft during missions.
NASA also was a key contributor to one of the first endeavors of
telemedicine, a program located in Arizona. From 1972 to 1975, the
Space Technology Applied to Rural Papago Advanced Health Care (STARPAHC)
program provided a Papago Indian reservation with medical care.
A van supplied with medical equipment, such as x-ray and electrocardiography,
was connected to the Public Health Service. The program, involving
Lockheed, the Indian Health Service, and the Departments of Health,
Education and Welfare,6 ended due to high expenses and
technological limitations.
Value of Telemedicine
The ability to transmit
information over a distance can be utilized for clinical diagnosis,
direct care delivery, patient education, and also medical information.
Telemedicine is generally carried out through two-way interactive
TV or store-and-forward technology. The first offers examinations
and discussions that occur simultaneously in real-time between the
patient and provider, and the latter offers delivery of images and
bioinformation, which can be saved and interpreted at a later time.
Telemedicine, as seen in STARPAHC, is driven by the need of communities
for convenient, affordable, and accessible health care services. More
specifically, telemedicine assists underserved populations, generally
in rural or remote areas, which often suffer from expensive and impoverished
specialized healthcare. Even for areas that are not rural or remote,
telemedicine efficiently applies healthcare resources while offering
convenience for both the patient and care provider. This encourages
patient compliance and promotes follow-up exams. Furthermore, telemedicine
enables hospital networks to share their resources,9 such
as in a hub and spoke system, where an academic hospital is central
in providing information to various branch primary care facilities.10
Telemedicine attempts to lower the rising cost of healthcare while
increasing service and expanding to new markets and populations. 9
Quality of Telemedicine
A study conducted
in 1998 evaluated the utilization of telemedicine between two hospital
systems - the University Hospital of Basel (Switzerland) and the
University Hospital of Zurich. The quality of transmitted images
versus the quality of live images was determined. Located 120 miles
apart, the two hospitals were connected via ISDN with a transmission
rate of 128-kilobit/s. For two months (May and June), 112 digestive
or endocrine surgery patients were evaluated by radiologists and
surgeons using both transmitted and live magnetic resonance imaging
(MRI) and tomographic scans. Of the transmitted images, 92.9 percent
achieved ratings of "good" or "excellent" as
compared to 95.5 percent of the live images - a difference of only
2.6 percent. In all scans, whether live or transmitted, 100 percent
of target organs were distinguishable. However, fine organ structure
was visible in only 89.3 percent of the transmitted scans versus
95.5 percent of the live scans. The structures of the organs as
well as pathological findings could be examined in 98.2 percent
of the transmitted images and 99.1 percent of the live images. Diagnosis
could be made from 84.8 percent of the transmitted documents as
compared to 93.8 percent of the live documents. The disparity between
the percentage in loss of quality (2.6) and the percentage in loss
of diagnosis (9.0) indicates that other factors exist when making
clinical diagnosis, such as "choice of radiological studies,
additional clinical information required, etc."2
The study did confirm the hypothesis that real-time consultation
is not necessary to provide patients with accurate diagnoses.2
Obstacles Telemedicine Must Overcome
Several hurdles
must be overcome before telemedicine can become a large part of
mainstream medicine. The biggest obstacle currently is a lack of
reimbursement. Medicare only supplies full reimbursement for radiology
and images such as ECG, EKG, and EEG. Otherwise, Medicare has strict
guidelines for funding based on providers, services covered, and
geographic regions as stated in the Balanced Budget Act of 1997.
Only the 15 states of Arizona, California, Georgia, Illinois, Iowa,
Kansas, Louisiana, Montana, North Dakota, North Carolina, Oklahoma,
South Dakota, Texas, Virginia, and Maryland provide reimbursement
for telemedicine applications under Medicaid.9
State licensure
laws are also an issue since service may cross state lines, and
a medical professional must have a license for the state in which
the patient resides.8 It is especially difficult to regulate
telecommunications, and for these reasons, there is also great fear
of malpractice lawsuits among doctors.7
Inadequate technology
also prevents needy rural areas from receiving services via telemedicine.
Regular telephone lines do not have a suitable bandwidth to receive
high-resolution images. The federal government has made some efforts
to provide more affordable lines, such as the Telecommunications
Reform Act of 1996, which allows rural education and remote health
systems to receive connection rates similar to those of more populated,
urban areas through Universal Service; these rates are approximately
one third what areas such as these would normally pay.10
In addition, as of the year 2000, these underserved populations
are also receiving funding for telemedicine.7
A Solution for Rural America - the Televillage
A solution to the
lack of financial support for underserved populations is the formation
of televillages in small communities that lack the demand for the
advanced technology needed for telemedicine. A 1991 investigation
conducted by the Office of Technology Assessment on rural regions
promoted the idea of "rural area networks" (RANs) that
could share telecommunication lines for various purposes in a community.
This concept would enable the community to build enough demand and
satisfy its own need by sharing telecommunication networks amongst
businesses, government agencies, schools, public libraries, and,
of course, health care providers. RANs would offer more effective
and efficient use of shared lines, equipment, and expertise, while
making the once too expensive telecommunications network a reality.4
Trends Seen in Telemedicine
Thus, telemedicine
is making its way into most areas of clinical medicine-including
the military, correctional facilities, federal populations, home
health, and telesurgery applications. The University of Texas Medical
Branch at Galveston Center for Telehealth and Distance Education
offers medical care to prisons and assists over 400 patients per
month.7 Federal agencies, such as NASA, the U.S. Department
of Defense (DOD), and Veterans Affairs (VA), are responsible for
providing care to large numbers of people and in fact, the DOD has
"made one of the largest investments in the world in telemedicine
research."10
Telemedicine's
popularity could lead it to become an export service, where the
prosperity and wealth of American health systems could provide care
to remote areas of the world that do not have adequate healthcare
available to them.1
Home care would
enable patients to receive evaluations virtually from their homes.
The University of Rochester in New York and the MIT media lab are
in the process of designing and constructing products that allow
patients to monitor their own health. Such devices include a toothbrush
that checks blood sugar and bacteria levels as the person brushes,
as well as "memory glasses" that identify patterns of
recognition in order to aid those with memory loss or derangement.1
The Future of Telemedicine
As for the future
of telemedicine, it is "expected to grow 40% annually over
the next 10 years."1 By 2010, 15 percent of health
care expenditure will be used to fund telemedical ventures. Telemedicine
has been one of the greatest influences on modern medicine and could
possibly eliminate the impoverished healthcare systems located in
rural America, replacing them with affordable, efficient, and accessible
healthcare.
Suggested Reading
1 Albright K.,
Slater S.G. Medical Devices in the Home: Present and Future Applications.
Caring Magazine. 19(7): 36-8, 40, 2000 Jul.
2 Demartines N.,
Otto U., Mutter D., Labler L., Wyemarn A.v., Vix M., Harder F. An
Evaluation of Telemedicine in Surgery. Arch Surg. 135(7): 849-53,
2000 Jul.
3 Margolis, John.
"Cutting Edge Humanity." Time 155 (6 March 2000).
4 Puskin, Dena
S., Carole L. Mintzer, and Cathy L. Wasem. "Telemedicine: Building
Rural Systems for Today and Tomorrow." Information Networks
for Community Health. Ed. Patricia Flatley et al. New York: Springer,
1997. 271-286.
5
http://tie.telemed.org/telemed101/faq/international/03/asp.
6
http://tie/telemed.org/telemed101/topics/telemedicine_history.asp.
7
http://trc.telemed.org/telemedicine/primer.
8 Wolf, R. Virtual
Doctors-Ready for Launching. International Journal of Dermatology.
39(7):487-9, 2000 Jul.
9
http://www.3.com/solutions/convergence/telemedicine/overview.html.
10 http://www.atmeda.org/whatis/whitepaper.html.
11
http://www.hiethics.org/Principles/index.asp.
Journal
of Young Investigators. 2001. Volume Three.
Copyright © 2001 by Likang Chin and JYI. All rights reserved.
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