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Telemedicine Leverages Power of Clinical Information.

Patients benefit from care providers' use of the Internet.

Telemedicine is the transmission of healthcare information over distance and time. Two primary models have emerged over the years: interactive video and "store-and-forward." Many healthcare providers have used these technology tools to connect with and extend care to patients that might not otherwise have access to it. The introduction of database technology and workflow has further extended the capabilities of telemedicine.

Today, the explosive growth of the Internet changes everything! The Web browser is ubiquitous, and the exchange of information has never been easier.

Leveraging the Power

The scenarios below represent opportunities to leverage the power of the Internet to deliver clinical medical information over a distance for increased communication efficiency. These patients will benefit from efficient, high-content communications between care providers, and the ability to aggregate patient transaction data including diagnoses, procedures, lab results, specialist referrals, and even prescriptions. Instead of relying on multiple phone calls and faxes, exchange of paper medical records, and unnecessary patient transports, care providers can access information on the Web and create electronic healthcare transactions.

Transforming Healthcare

Today, healthcare is the largest sector of the US economy, and 620,000 physicians indirectly control more than 80 percent of all healthcare dollars spent, say authors Steven Fitzgibbons and Richard Lee in a report on the convergence of healthcare and the Internet. Meanwhile, the explosive growth of the Internet is enabling communications efficiencies that will transform healthcare. Already, 43 percent of all Web users in the US use the Web to locate healthcare information, and the impact of the Internet on healthcare delivery has only just begun, according to M. Brown in a report on profiles of consumers using online medical information.

Telemedicine technology has existed for more than 40 years. One of the earliest telemedicine projects dates back to 1959 in Montreal's Hospital Jean-Talon, where radiologists used video monitors to view patients and x-rays remotely. Over the years, several other projects were initiated, involving the Veterans Administration Hospital in Oklahoma City for remote cardiac monitoring in 1969, NASA for monitoring vital functions of the Mercury astronauts, and the first commercial venture by the Mayo Clinic in 1986 to link its facilities in Rochester, MN, and Jacksonville, FL.

Over the last several years, strong economic, political, and social pressure for healthcare cost management, and the shift from fee-for-service to capitated and managed care has fundamentally changed the healthcare industry. In an effort to spread the risk of patient care over larger populations to maintain economic viability, healthcare institutions in the US have undergone extensive expansion and consolidation via mergers and acquisitions.

Disparate Legacy Systems

This has created an environment in which centralized tertiary care facilities with extensive specialist expertise must treat geographically dispersed patient populations, and do so with increasing efficiencies while not compromising quality of care. Additionally, the expanded integrated delivery network made up of formerly independent institutions is plagued with an amalgamation of disparate legacy information systems that cannot easily be integrated to effectively support the care delivery process.

These market factors, combined with technology breakthroughs in compression, multimedia, and communications technologies, have resulted in lower cost and higher performance, thus decreasing the economic barriers for telemedicine deployments.

As a result of both market and technology trends, awareness of telemedicine has continued to grow, with increasing frequency of telemedicine professional conferences and trade shows. Today most healthcare institutions have at least one staff member assigned the responsibility of telemedicine, and many have active programs and full departments. Dozens of successful early pilot projects are entering the process of full-scale ramp-up, while hundreds of new pilot projects are starting to launch.

Limitations of a Paradigm

Two fundamental models of telemedicine emerged over time: interactive video and "store-and-forward," which is essentially multimedia e-mail. Although these approaches have proved effective for evaluating the potential of distance healthcare in pilot project initiatives, inherent limitations have curtailed wide scale deployment.

In the case of interactive video, hardware costs are still relatively high (although they have dropped substantially over the last several years), and required telecommunications connectivity are not universally available in a cost efficient, reliable, and easy-to-deploy fashion. Additionally, real time video requires the simultaneous presence of caregivers on both sides of the call, creating unrealistic scheduling demands on care providers for routine usage.

Regarding "store and forward," the lack of an underlying distributed database infrastructure makes it impossible to ensure security and management of consultation data, putting the confidentiality of the patient's records at risk. With the commonly used e-mail and file transfer techniques for transmitting data, multiple copies of data are created in numerous locations without the ability to centrally control and administer access to those copies.

Additionally, it is difficult to interface such systems to legacy information systems for pre-populating consultation records with medical histories and updating the archival medical record repository.

Technology and Workflow

Database technology and workflow overcome many of the limitations of point-to-point telemedicine solutions. In a database environment, multimedia objects such as still images (skin lesions, ICG angiograms, etc.), video clips, audio clips, stethoscope clips, and DICOM studies (ultrasounds, X-rays, etc.) are all stored in a database along with text-based medical information, such as consultations, lab requests, and progress notes.

In this way, all of the information resulting from telemedicine consults are captured and stored, so that a record is maintained. Consulting physicians access the database to perform consults, and the primary care physician maintains control over the patient record.

Hooks into Healthcare

Replication technology ensures integrity of the data (multiple copies are not generated and propagated), and transmission encryption helps to ensure security. The database technology in general enables "hooks" into healthcare information systems enabling, for the first time, integration with the central patient electronic records. Rather than stand-alone, point-to-point communications, a patient-centric information system is enabled, which can be integrated with other hospital systems. A database approach to telemedicine provides scalability, security, patient records confidentiality (roles-based access), and standards compliance (HL7, DICOM).

The introduction of workflow further helps to streamline processes and ultimately save time. As an example, a physician can electronically create a lab request for image capture and also create a specialist referral. Automatic messaging notifies other users of pending work.

The benefits of this approach enable the formation of "virtual medical centers." As caregivers have convenient and timely access to vital information, the benefits are manifold:

* Patients gain access to higher quality care and undergo fewer redundant tests and transports;

* Primary care physicians provide higher quality of care through easier and more timely access to specialists and improved case management;

* Specialists expand the reach of their expertise, provide more timely consults, and practice more efficiently;

* Hospitals and Tertiary Care Facilities expand services beyond bricks and mortar, expand referral networks, and save costs by using electronic communications.

Although the convergence of healthcare with these new technologies has created a tremendous resurgence in telemedicine interest and activities, it is the Internet revolution that makes possible for the first time massively scalable deployments that will ultimate transform the healthcare delivery system.


Consider the following patient scenarios:

* A 26-year-old male is involved in a high-speed motor vehicle accident. He has multiple facial fractures, a hemopneumothorax, and a fracture of his left femur. His care requires several specialists: a general surgeon, an orthopedic surgeon, a plastic surgeon, and an oral surgeon.

* A 45 year old Type I diabetic has multiple complications of the disease, including severely compromised vision secondary to retinopathy, renal failure requiring dialysis, symptomatic coronary artery disease, and peripheral neuropathy. Her primary care physician coordinates her care, but requires intermittent consultation from several specialists, including an ophthalmologist, an endocrinologist, a nephrologist, a cardiologist, and a neurologist.

* A primary care physician examines a patient with a skin lesion and needs a specialist consultation with a dermatologist. After some phone calls, an appointment is made for the patient to see the dermatologist in six weeks.


The outcomes for those three patients had the following results through the Internet:

* The car accident victim undergoes numerous tests that are aggregated in a repository that is Web-accessible to all of the specialists treating the case, eliminating the need for redundant tests, facilitating rapid decision making and treatment planning, and leading to a better outcome for the patient.

* The diabetic is treated by her Primary Care Physician (PCP) supported by a virtual team of experts who are rapidly and efficiently accessible electronically, raising the level of expertise and ultimately the quality of care for the patient in-between required specialist appointments.

* The patient with the skin lesion is "imaged" in the office by the PCP, and within 48 hours receives a diagnosis from the dermatologist, rapidly alleviating his anxiety without the need to go to another appointment after many weeks.

Enabling Technologies to Telemedicine

In the early to mid-1990s, these key enabling technologies emerged to make telemedicine more cost competitive:

* Emergence of strong standards for interoperability: H.320, H.323, WinNT, Active-X, TCP/IP;

* Availability of high-performance, off-the-shelf multimedia personal computers;

* Low-cost, high-performance single-board codecs and codecs on a chip;

* Collaborative software development environments;

* Advanced voice, data, and video switching technologies.

William Kazman is president and CEO, and Ann Westerheim, Ph.D., is vice president of marketing and product development, for Global Telemedix Inc., Westford, MA.
COPYRIGHT 1999 Nelson Publishing
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 1999 Gale, Cengage Learning. All rights reserved.

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Title Annotation:Industry Trend or Event
Author:Kazman, William; Westerheim, Ann
Publication:Health Management Technology
Date:Oct 1, 1999
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