Staff Publications and Presentations
Going the Distance: Expanded Options in Telemedicine Technologies
By Marshall G. Hoff, BA
Marshall Hoff coordinates videoconferencing for the Academic Health Center at the University of Minnesota and telemedicine for the Fairview University Telemedicine Network.
Telemedicine is a new and dynamic area of medicine that is continually evolving as new technologies broaden its scope. The American Telemedicine Association defines telemedicine as the use of medical information exchanged from one site to another via electronic communications for the health and education of the patient or healthcare provider and for the purpose of improving patient care. Technologies that drive telemedicine affect both the way telemedicine is delivered and the tools used during a telemedicine encounter. For the purposes of this article I will be addressing the use of videoconferencing as the means of electronic communication of patient information.
Methods of Delivery
Videoconferencing can be transferred from one site to another using plain old telephone service (POTS) lines, high- speed digital telephone lines (ISDN lines), and local area networks (LANs) using the internet protocol (IP). The big difference between these networks is bandwidth, how much data can flow through each of these systems. The size of the pipe is a frequent analogy used to describe bandwidth. A regular phone line has a bandwidth of 64 kilobits per second (kbs). Bandwidth for ISDN lines can range from 128-1500kbps. Using IP for videoconferencing is becoming more efficient and preferred because it offers the advantage of greater bandwidth without leased lines and the long distance charges of POTS and ISDN lines.
Telehomecare
Our recently completed telehomecare demonstration project was funded with a grant from the Telecommunication Information and Infrastructure Assistance Program and lead by Stan Finkelstein, PhD. Patients in Wadena, Staples, Crosby, Wyoming and Minneapolis were instructed in the use of POTS videoconferencing and home physiological monitoring. Low cost hardware was used by patients in their homes and compared to a control group of patients receiving traditional home care visits from nurses. The experimental group used a product called ViaTV that connected to the patient's home telephone service and their own television. A separate camera connected to the ViaTV enabled the patient to manually focus and manipulate the aiming of the camera. Costs for both ViaTV and camera were under $500. 47% of the control group was readmitted to the hospital or nursing home compared to 17% of the experimental group. While the quality of videoconferencing was not near broadcast quality, the study did show that low cost equipment using current technology readily available in any home was adequate to improve quality of care and reduce health care related costs.
Clinical Consults
A federal grant from the Office for the Advancement of Telehealth (OAT) lead by Stuart Speedie, PhD, enabled us to form the Fairview University of Minnesota Telemedicine Network. The network provides more than 40 hours of telemedicine consults per month. ISDN telephone lines allow videoconferencing for patients in Wadena, Hibbing, Onamia, Crosby, Aitkin and Red Wing to see doctors at Fairview University Medical Center in Minneapolis. Polycom Viewstations running at 384 kbps are used to conduct real time video consults between doctor and patient. These Viewstation codecs (coder/decoder) translate regular video signals to a digital format for ISDN or IP transmission. A Viewstation at the distant site then decodes the signal for viewing on a television monitor. Besides the built in camera on the Polycom, peripheral video equipment enhances the consult. A document camera with a built in light box allows for viewing of x-rays with the ability to zoom into small areas. An exam cam made by AMD Telemedicine, Inc. is an ergonomically designed hand held peripheral camera with up to 50x magnification and freeze frame. Its polarization feature allows teledermatologists to see beyond the first layer of skin. Telecardiologists use a digital stethoscope also made by AMD.
Telepharmacy
The city of Sebeka, MN, recently lost access to a local, on site pharmacist. Sebeka is now looking to telepharmacy as an alternative method to filling prescriptions. Telepharmacy provides a better option than driving to the nearest pharmacist located in Wadena, Park Rapids or Menagha. Once the program is in place a pharmacy technician in Sebeka will be able to videoconference with a pharmacist at Tri County Hospital in Wadena. The program is funded from a rural health, RUS grant and lead by Maureen Ideker, RN. A Polycom Viewstation at Sebeka will provide a close up of the prescription for the pharmacist to see. The pharmacy technician will fill the prescription, and then show the pharmacist in Wadena the written prescription as well as the medication itself. The pharmacist also will have the ability to talk with the patient using the videoconferencing technology. The pharmacist in Wadena will then instruct the patient regarding the medication, side effects, and any special considerations. The pharmacist at Wadena will use a Polycom ViaVideo, which is an inexpensive, IP videoconferencing codec that attaches to and runs on a Windows based computer. The transmission will be on a local area network that is already in operation between these two sites.
Other sites have taken the concept one step further. A vending machine with prepackaged quantities of the most commonly prescribed drugs is activated remotely by the pharmacist when the patient holds a prescription up to a video camera. The pharmacist then remotely releases the correct package from the machine and the patient holds it in front of the camera as a final quality check by the pharmacist.
Telesurgery
Surgeons are using videoconferencing in the operating room for exchanging live, real time information with other hospitals and institutions. Surgeons at Moose Lake and Crosby are teleconsulting during surgery using video endoscopes in high tech endosuites created by Stryker Communications. Small video cameras built into endoscopes provide a high quality video signal that can be fed into a codec for transmission to colleagues at the distant site. The endosuite helps the surgeon become more efficient by combining technology and room design in the operating room. Surgical images can then be stored, printed or transmitted to distant sites. Two operating rooms at each site have been installed with this technology. A third site in Aitkin will also have two endosuite operating rooms. These three facilities will be connected over a private LAN and videoconference over IP. Fairview-University Medical Center will soon have similar endosuites.
Security
The use of technology in facilitating health care cannot compromise patient privacy or individually identifiable health information. Telemedicine technologies will have to comply with confidentiality standards required by the Health Insurance Portability and Accountability Act (HIPAA). As of this writing, HIPAA has not finalized what privacy standards will be necessary to provide proper security during an ISDN or IP videoconferenced telemedicine session. Videoconference hardware manufacturers such as Polycom and Tandberg are working closely with HIPAA in order to integrate software and hardware security compatibility. Tandberg uses proprietary encryption that will ensure some degree of privacy between videoconferences using the same brand of hardware. Stand-alone hardware such as the Babylon encryption devices can be connected between the ISDN or IP line and any brand of equipment to provide a high degree of security.
Store and Forward
Store and forward technology can be used for telemedicine when a live encounter is not needed. Much like an email with a file attachment, store and forward telemedicine might use a software program that sends a photo, movie and/or audio file with text to consulting physicians using the Internet. The receiving physician can then act on the information when convenient and return an evaluation in the same manner. One of the most common applications of telemedicine, teleradiology, makes almost exclusive use of store and forward. It also makes perfect sense for other diagnostic modalities. High-risk fetal ultrasounds examinations performed at Fairview Lakes Medical Center in Wyoming, Minnesota are transmitted to perinatologists at Fairview-University of Minnesota Medical Center for interpretation.
Ongoing Issues
Reimbursement issues were an early impediment to the acceptance of telemedicine. While reimbursement has become more common, the high costs of doing telemedicine still remain an obstacle to more widespread acceptance. Telemedicine hardware expenses have dropped dramatically but the costs of ISDN delivery remain high. Eight years ago the cost for a videoconferencing codec was around $50,000. Today a much more powerful codec with more features can be purchased for approximately $5000. It is exciting to think what new telemedicine technologies will develop in the next five or ten years. Evolving technologies like third generation (3G) wireless networks will certainly provide opportunities to provide health care to more people at more distant sites at reduced costs. Stay tuned.
Published in MINNESOTA PHYSICIAN; Volume XVI; No. 9; December, 2002
