Technology Today, June 1997

Telemedicine: a better connection to health care


The country doctor ­ it can be a rather quaint notion. In reality, though, being on-call 24 hours a day, every day is an impossibility and certainly crimps one's quality of life. Buffalo Hospital and Allina Health System are helping to alleviate the rural doctor's burden through telemedicine.

Telemedicine is a real-time interactive video communications system that links urban and rural physicians and patients across geographical distances. The technology is not new, but doctors treating patients miles away is.

Almost two years ago, Allina Health System and the Rural Health Alliance inaugurated a telemedicine network with eight hospitals in central Minnesota. The network has since expanded to 28 hospitals.

"From the beginning, the network had a three-fold purpose ­ consultation, education and administration," said Dr. William Goodall, regional vice president for medical affairs at Allina Health System. "Up to a year and half ago, consultation was strictly between physicians," he added.

As it was becoming increasingly difficult for small rural towns to maintain a 24-hour emergency room, Allina decided to use its telemedicine network to aid these hospitals. Initially they considered networking a Twin Cities emergency room with the rural hospitals. Buffalo Hospital, also had a 24-hour emergency room and was not utilized to the extent as those in the metro area. Therefore Buffalo Hospital was a logical choice.

A three-month pilot program was launched in January 1996, linking Buffalo Hospital via interactive television to Long Prairie Memorial Hospital, Elbow Lake Health Center and Arlington Hospital. Buffalo Hospital then provided emergency physician services nights and weekends to patients using those rural emergency rooms.

Prior to telemedicine, rural area patients were faced with a long drive to another hospital or arousing the local physician during the wee hours.

For more critical cases, such as heart attacks or trauma victims, the remote physician can start immediate care until the local physician arrives. Telemedicine eliminates arousing the doctor during the night for those sore throats or ear infections.

"Doctors in a small town can burn out quickly," said Dr. John Robinson, emergency room physician at Buffalo Hospital.

Since January 1996 more than 600 patients have been treated via telemedicine. Patient satisfaction is very high said Robinson. They are usually pleased to have immediate access to a physician.

It was skepticism however, that loomed among doctors. Doctors liked the idea but were not sure it could work.

"Patients' overall acceptance was excellent but physicians are trained to be skeptical," said Goodall.

Telemedicine's success depends on how the doctors feels about it. Hands-on patient care is optimal but not always possible.

"I try to ignore the fact that I'm making a diagnosis over telemedicine. A diagnosis comes from patient history. History is still the most important part," said Robinson in an interview with CBS in March 1996.

Another condition for the program to be successful was training for nurses. They had to learn how to suture, splint, and debride wounds. A special waiver was needed for nurses to dispense prescriptions. Actually, what the board of pharmacy approved was for the physician to fax the prescription and the nurse to dispense the medication in front of the camera.

"There was a lot of protocol to be worked out," said Mary Ellen Wells, president of Buffalo Hospital. "We went to the nurses' board to see if this was in the realm of nursing."

"Due to telemedicine, these hospitals can now stay open. They can keep their jobs," added Wells. It wasn't long ago, we were a small hospital and in a similar setting. There's a kinship."

Telemedicine can also make rural areas more appealing to young physicians, since rural doctors now have a connectivity with their urban counterparts

"It's more attractive to recruit physicians if you have an up-to-date facility. There's an increased connection with the rest of the medical community versus having to travel far to conferences or meetings," commented Robinson.

Presently telemedicine usage is about 41 percent for emergency room services, 38 percent for meetings, six percent for consultation and the remaining 15 percent for demonstrations, education or training.

"This is one of the busiest networks in the country," Wells said. "Hospitals from all over are wondering what we are doing. We had to limit the number of requests for tours."

Telemedicine is being utilized elsewhere in the nation but not to the extent of Buffalo Hospital. According to Wells, there's a program in New York that has seen a small number of patients, and in Dallas, telemedicine is used to treat prison inmates.

Robinson and Goodall recently attended the American Telemedicine Association (ATA) second annual conference. Robinson said ATA members gathered to examine what works and doesn't work, with the idea to provide a more cost effective and timely care.

Regardless of its success, funding for treatment is a hurdle telemedicine faces. Presently telemedicine bills are not all reimbursed. Though some insurance may cover such costs, Medicare does not.

"Medicare believes telemedicine will increase access. The issue is that of access and immediate costs for both consultations and emergency room services," said Wells.

Since telemedicine was implemented at the three emergency rooms, Wells said they have not really seen an increase for its usage.

"We are trying to prove its (telemedicine) worthiness," added Wells.

For now, continuing government funding, is a challenge Allina faces.

With such a vast array of opportunities for telemedicine, it will most likely be here to stay.

"Telemedicine gives people the same access, whether rural or urban," said Goodall. "It is the broad use of electronics to eliminate time and distance from the equation."

How telemedicine works

Telemedicine actually dates back to about the 1920s, when radio was used to link physicians on shore to ships at sea to assist in handling medical emergencies. In the 1970s, telemedicine via interactive television was possible. However, images were poor and costs were high.

With the emergence of digital technology and image compression, interactive video became more feasible.

"As it (the computer) processes the information, only the elements that are moving are sent. There's less information being sent, so less phone lines are needed. It's down to 12 lines rather than the 2,000 initially needed," said Dr. William Goodall, regional vice president for medical affairs, Allina Health System.

The Allina Health System/Rural Health Alliance Telemedicine Network is operated through video camera, telephone lines and television monitors. The network has point-to-point connections via dedicated T-1 telephone lines.

A T-1 has 24 lines. Buffalo Hospital utilizes half a T-1. Information travels at 768 kbps in half a T-1. To give you an idea of how fast that is, most modems on home PCs are 28.8 or 33 kbps. ISDN lines send at 128 kbps.

Besides speed, image resolution is also high. Transmitted pictures are about as clear as one can see said Dr. John Robinson, emergency room physician at Buffalo Hospital.

Nurses use electronic scopes to transmit pictures of ears, eyes or throat. There's also a document camera by which x-rays or various medical forms can be sent. Using the control panel and a pen-shaped computer mouse, the physician, for example, can point out certain areas of an x-ray to the nurse for diagnostic purposes. There is also the ability to store fixed images for later recall.

Each Allina network station has two television monitors. Buffalo Hospital has a Vtel 227, which is a system with two 27-inch monitors. Each party can view themselves on one of the monitors as they speak. This insures that you are within camera view and not leaving the screen.

"The network is intelligent enough to know who's talking, ," said Robinson.

During conferences, the speaker appears on one monitor, while the other monitor rotates from site to site.

Buffalo Hospital will be testing a desktop unit which will have one screen with an inset. Robinson said image quality is what will be compared with the present 27 inch monitors. A smaller unit will be user-friendly, especially when used one-on-one.

For more information on telemedicine, check out the following Web sites:

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