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Hop on the Bandwidth Wagon

November 1, 1998
by David Essex
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Stories that show the amazing potential of telemedicine are easy to find. A Native Alaskan woman avoids a long, life-threatening trek to an Anchorage hospital because a remote consult determines the trip is unnecessary; a doctor, frustrated by the inability of his elderly mother, a two-time stroke victim, to remember to take her medications invents a home device that holds the pills, beeps reminders and transmits reports back to the hospital; Navy fleets that formerly turned sail to return ill sailors to port now avoid the costly trips thanks to on board remote monitoring and conferencing equipment.

But telemedicine as a whole remains unproven in the eyes of many doctors, healthcare organizations and government officials. Its effects on the quality of care and the bottom line seem unclear. High bandwidth digital telemedicine is a thing of the 1990s, so new that its methods still reside mostly in research papers and in the minds and memoranda of its pioneers.

Those pioneers who are now running self-sustaining telemedicine programs have pretty clear ideas about how to cost-justify the investment, how to ensure buy-in from care providers and patients, where the best opportunities are (in both the medical and market sense) and pitfalls to be avoided. Their collected advice can serve as a rough guide to implementing a successful (that is, sustainable) telemedicine program.

Telemedicine basics

Telemedicine is growing rapidly. According to Bill Grigsby, senior research associate at the Telemedicine Research Center in Portland, Ore., there were 41,740 telemedicine consults in 1997, up from 21,500 the previous year. (Grigsby’s statistics, culled from a study of 139 out of 155 active programs in 45 states, exclude teleradiology because it developed on a different path than newer forms of telemedicine and is more difficult to track.) First-quarter 1998 consults totaled 14,326, indicating a continuing growth rate that exceeds 60 percent. Between 1993 and 1996, the number of programs roughly doubled every year.

Reduced to its most basic definition, telemedicine is the use of electrical signals to transmit medical information between two points. In this sense, telemedicine has been practiced for decades. Phone consults and faxing of medical records were long ago integrated into standard medical practice. Teleradiology--transmitting digitized images of X-rays, CT scans and so on for diagnosis by off-site specialists--is well-established and fully reimbursed by Medicare. But today, the leading edge--and the focus of the most controversy--is the use of communications technology to replace existing methods of examination, diagnosis and consultation.

Faster, cheaper and more widely available high-speed phone lines and networks (such as ISDN, T1 and ATM) together with a boom in low-cost imaging and monitoring devices, have made simulation of face-to-face consultation both workable and affordable.

The hardware choices tend to fall into three neat categories: teleradiology, videoconferencing and remote monitoring systems. All-in-one teleradiology and videoconferencing rollabout units are available (they usually cost between $5,000 and $50,000), as are simpler standalone devices, such as videophones and home-monitoring stations, some of which cost less than $4,000. Analog-based audio stethoscopes, digital blood pressure meters and digital dermascopes provide input for transmission to the diagnostic site; price range: $150 to $10,000, with multi-function imaging devices costing the most; single-function data-gathering devices the least.

It’s also possible to piece together affordable setups using either generic or custom desktop PC peripherals, such as small, sub-$500 video cameras and capture cards. (One Oregon teledermatology pilot employed completely PC-based modems, capture cards and commercial still-picture digital cameras to process high-resolution images of skin lesions.) Continuing advances in image-compression software are making it easier to transmit sufficiently sharp images over widely available analog phone lines using 14.4-56 Kbps modems.

Issues and answers

The infrastructure investment decision boils down to bandwidth needs and capacity. Image-based telemedicine, especially two-way videoconferencing, often requires leasing of existing high-speed data lines--or the extension of new ones into outlying markets--which can cost thousands per month. On the other hand, standard phone lines and PC modems can easily support home monitoring applications, including low-quality full-motion video.

Selling the concept to healthcare providers, and educating them in how to use the technology, are often the first major hurdles. Some doctors (though few patients, according to early reports) may be uncomfortable with using the technology. Existing referral patterns are disrupted. Territorial behavior may arise as rural general practitioners fear losing patients to big city doctors, or urban specialists face more competition from other specialists. Doctors and nurses may doubt the technology’s effectiveness, or they might be apprehensive about its effect on their own hard-won effectiveness.