Telemedicine: where is technology taking us?

At The Informatics Institute, I have the distinct pleasure to work with Tom Klagholz, Director of Media Services for Inova and a pioneer in applying multimedia technologies for education to the field of telemedicine. Inova is a not-for-profit, regional health care system in northeRN Virginia, near Washington, D.C., where The Informatics Institute is located. He teaches the Institute' s course on Informatics for Telemedicine. He has a long-time relationship with physicians and communications specialists in NASA (National Aeronautics and Space Administration) and is working with them to test emerging technologies for practical application to the field of telemedicine. NASA has long had a keen interest in telemedicine because of its responsibility to monitor and, when necessary, render diagnosis and treatment to its personnel in distant places (the moon, the Spacelab, the Space Shuttle), and leaders of NASA are making certain that they "privatize" technologies their organization develops with civilian organizations, such as Inova Health System.

Why all this background information? To explain a trial that is just beginning, involving NASA and a number of health care centers, including Inova Health System, to test the feasibility of personal computers, inexpensive video cameras the size of matchboxes, and the Internet to serve as the basic technologies for telemedicine consultations in the future. Right now, most telemedicine trials involve expensive (>$50,000 per site) and bulky video-conferencing equipment. These devices give physicians the opportunity to see patients on large screens, and, if they are using analog television technologies, physicians can watch patients' gaits without distortion due to digital compression of the signals. In these situations, the consultant and the primary physician, with the patient, interact via video-conference in a "live" session.

One of the major hindrances to greater use of telemedicine, however, is the difficulty of scheduling two busy clinicians to confer by video-conference. By their nature, the "live" sessions using television technologies require major investments in production equipment and time devoted by both patients and physicians. While a telemedicine session may save a patient valuable time he or she would otherwise have to spend driving hundreds of miles to a distant referral center, it is unlikely that the live television-style video-conferences will be the dominant form of telemedicine.

In most situations where a physician wants counsel from another physician on the best way to manage a patient, the physician can benefit substantially from a consultation without the patient's being present, using just textual (electrolytes) and graphic (ECG) laboratory results and still (x-rays, images from endoscopes) and moving (cardiac catheterization cineangiography) images, all of which can be stored in digital format, be transported electronically over communication lines, and reside in a multimedia consultation "folder"--a a form of multimedia electronic mail--on the workstation of the consultant. When the consultant has time to attend to the data, he can call the physician requesting the consultation to review his interpretation of the data and make a recommendation. This is much faster and less expensive than overnight delivery of physical documents and does not require the primary and consulting physicians to be present at a live television session.

NASA has always been a leading user of the Internet. As the digital bandwidth (throughput of data per second) of the Internet increases, NASA and other government agencies are testing the feasibility of video-conferencing over the Internet, using the MBONE informnation Web that is a subset of the Internet for video-conferencing, just as the World Wide Web is a subset (vastly larger, at this point) of the Internet for hypertext. MBONE stands for Multicast Backbone. Live video-conferences take place on the MBONE, using UNIX workstations to receive the multimedia bit streams and present the audio and video components on high-resolution monitors. But soon, personal computers with Pentium processors and Windows 95, Windows NT, or OS/2 operating systems will have the same capabilities at less cost than the less common UNIX workstations from Silicon Graphics and SUN Microsystems.

Here's the likely scenario for telemedicine to flourish. You are a physician concerned about how to diagnose or treat a particular patient. You have findings from your physical examination of the patient and laboratory studies in digital textual form from a word processor. You have images from one or more diagnostic studies: x-ray, ECG, EEG, and pathology, for example. Those images are also in a computer in digital form, having been scanned, captured by a videocamera, or faxed into digital form You pull these various forms of information--text, graphics, images, and recorded sounds--on your personal computer into a multimedia electronic mail message, using readily available software from a variety of firms, and you send the multimedia document via the Internet to the mailbox of a consultant whose opinion you want for this patient. Your office staff may call the consultant's office to make certain he or she is available to respond to consultation requests today. You set a time, perhaps late in the afternoon, when the consultant can contact you for a conversation to discuss the case, once he or she has had a chance to consider what you have sent. Images and graphics make all the difference. It is difficult to describe the x-ray image of a fractured ankle or a pathology slide from a biopsy of a soft tissue tumor by phone. Far better to send a multimedia electronic mail message with the images attached.

You go on about your business, and the consultant calls just before you see your last patient. You want to talk to the consultant, so you tell the patient that you may be on the telephone for 10 minutes, and you go into your office. But you don't just pick up the telephone. Instead you sit in front of your computer and start a video-conference with the consultant, using the MBONE Information Web. You can see him, and he can see you, in small windows on your monitors, and you can both see the images and text that you sent to him in the multimedia message earlier in the day. He has had time to study the information you sent to him, so your interactive consultation takes less time.

The consultant asks a few questions about your patient concerning information in your transmission that was not clear to him, you make a mental note to include such data in the future, and he uses his mouse to point out on the images you have sent to him, that you both are looking at on your monitors, those pathognomonic findings that would lead him to treat your patient in the way he is recommending. You listen, take notes, or record the session to transcribe what he says to be part of the medical record for your patient. After a few minutes, you both sign off, and you go back to your last patient of the afternoon. You have practiced telemedicine, but you did it with personal computers and multimedia electronic mail, rather than expensive television equipment and production personnel.

Marshall Ruffin, MD, MBA, MPH, FACPE. is President and CEO of The Informatics Institute, Falls Church, Va.