By Bryan M. Gold | Contributing Editor
New legislation and renewed federal interest in telemedicine may help put an end to the outdated laws and regulations that have kept it from going prime-time.
Telemedicine is still a fairly new phenomenon. But this method of delivering health care and exchanging health care information using telecommunications technology is so popular that Congress may pass a telemedicine package before passing any of the other popular technology bills that lay before them.
In May, legislation was introduced that would simplify federal regulations and enhance the delivery of telemedicine services targeted to senior citizens living in rural areas.
"In remote rural areas, where a patient and the closest health professional can be hundreds of miles apart, telemedicine can mean access to health care where little had been available before," said Sen. Jim Jeffords, R-Vt., who authored S. 2505, known as the Telehealth Improvement and Modernization Act of 2000. "This legislation streamlines federal regulations to help hospitals and patients better utilize telemedicine programs. By better utilizing technology, we should not only be able to increase the quality of health care, but also increase efficiency and see cost savings. My legislation will ensure that the federal government is a leader, not a follower, when it comes to telemedicine."
The bill is picking up steam. Last summer, a number of U.S. senators added their names as cosponsors of the bill, joining the original 15. The issue has become one of significance, as there are several bills in the House that are companions to the Senate bill.
"Jeffords legislation is extremely important to eliminate the barriers that are there with the federal government," said Jonathan D. Linkous, executive director of the American Telemedicine Association, which is based in Washington, D.C. "The federal government has lagged behind the private sector and the rest of the world. Medicare reimbursement is not there, so we need to have legislation that encourages [this]."
The Office for the Advancement of Telehealth, based in Rockville, Md., said various technologies are used in telehealth, such as videoconferencing, the Internet, store-and-forward imaging, streaming media, satellite and wireless communications. "[They] already exist, but are not yet part of the regular landscape for our nations rural and urban underserved peoples," said officials of the Rockville office, echoing the sentiments of Jeffords and Linkous.
The federal government is a key player in the growth of telemedicine. The 1990 Farm Bill authorized the Distance Learning and Telemedicine (DLT) Grant Program to provide grants to rural schools and health care providers. The 1996 Farm Bill reauthorized the DLT, which helps rural schools and health care providers invest in telecommunications facilities and equipment to bring educational and medical resources to rural areas.
From its inception in 1993 through fiscal year 1999, the DLT funded 306 projects in 44 states and two U.S. territories totaling $83 million. For fiscal year 2000, the DLT is capitalized with $20 million in grant funds with $130 million available through the loan program.
Not to be outdone, the Department of Veterans Affairs Veterans Health Administration has national telemedicine initiatives that include the management of a satellite television network with two-way audio that provides the capability for all 173 VA medical centers and outpatient clinics to receive education and information via satellite.
The equipment is also used by individual VA medical centers to receive programming from organizations, including the American Hospital Association, the Joint Commission on Accreditation of Healthcare Organizations and the Healthcare Informatics Telecom Network.
In October 1996, Health and Human Services Secretary Donna E. Shalala announced that the National Library of Medicine, a part of the National Institutes of Health, was funding 19 telemedicine projects affecting rural, inner-city and suburban areas with a total budget of $42 million.
"The projects we are supporting will evaluate the use of telemedicine in a wide variety of settings, all the way from the care of newborns and children with disabilities to the elderly and chronically ill, and those needing a range of specialist care," Shalala said in her announcement. "These are imaginative and well-targeted projects that will help us determine how we can best use information via telemedicine for clinical decision-making."
The projects include supporting rural primary care physicians consulting with remote specialists in West Virginia; improving care to high-risk newborns and their families in Massachusetts; testing the real-time transmission of vital sign data from patients in ambulances to a hospital trauma center in Maryland; improving disease prevention and managing chronic illnesses in home settings in New York; preventing adverse drug interactions among the elderly in Missouri; providing vital health information to health professionals in rural and urban settings across the Northwest; and providing patients with access to their own medical records while preserving confidentiality of that information in California.
With the incorporation of "e-health," which has been around for three or four years, and its merging into the telemedicine arena, the capabilities increase. There is some flirting with the idea of online patient consultation, and patient follow-up care is already online. The concept of telemedicine has grown to the point that its integrated in the delivery of care in medical facilities. A growing number of hospitals are contracting out for services, especially with specialty care such as radiology. With the help of telemedicine, radiologists no longer have to be at the hospital. They can be at a separate site servicing multiple hospitals and clinics at one time.
Telemedicine at Issue
While telemedicine is making the move toward mainstream society, the number of problems being reported is increasing at a similar pace.
In July 1999, the Center for Telemedicine Law (CTL), based in Washington, D.C., reported that doctors in a number of states were fined or had their licenses suspended for using technology to prescribe Viagra, baldness treatments and weight-loss drugs without performing physical examinations. In some cases, doctors prescribed medication without having ever seen the patient. Congress also stepped in at this point and held hearings on the matter.
"This increased scrutiny of the online prescription drug business seems to be primarily focused on those sites that sell and prescribe medications without requiring a physician to physically examine a patient," the CTL wrote. "Although reasonable arguments can be made that a physicians face-to-face meeting with a patient may not be necessary with respect to certain drugs," prominent organizations, including the American Medical Association, didnt agree.
Show Some Patients
But if Jeffords and Linkous are right, telemedicine will continue to play an increasing role in society. "A lot of people are saying, Were way past the time when telemedicine was just a demonstration, an interesting little experiment. Its now beyond that," said Linkous. "There have been many studies done on the cost benefits of telemedicine, and its time now to fully implement it."
"We in Washington have made some good-faith attempts to allow for the development of telehealth technologies, but we have fallen short," said Jeffords. "In an effort to restrain the expansion of these programs, the Health Care Financing Administrations interpretation of the laws and its cumbersome rules for reimbursement have all but guaranteed the demise of current programs."
"We are not where we should be because of outdated laws and regulations," added Linkous. "The technology is where [it] should be, but were not able to use some of the technology thats available today. And certainly the experience that has been gained in the last 10 to 20 years in telemedicine has [led to] documenting clinical procedures and operating mechanisms that many health care providers are comfortable with."
With the seemingly uphill battle facing telemedicine, its significance will continue to be evident as Congress deals with the bottom line. "Telemedicine is here. There are some barriers to it and the barriers are frustrating, but telemedicine is here," said Linkous.
A number of major colleges and universities have come to rely on telemedicine as a way of medical treatment.
Consultations, educational programming and administrative conferences offered through the telemedicine program at the University of Virginia Medical Center, for example, provide vital, cost-effective and confidential medical services to virtually anywhere in the world.
The University of Virginia uses store-and-forward workstations as well as interactive telemedicine workstations. The former allows the user to transfer files (images, video or audio clips, medical records, etc.) from one location to another without the use of live, interactive audio and video. These workstations are generally used when interaction between a patient and a doctor isnt required. Interactive telemedicine workstations allow the user to interact with the patient at the remote location through live audio and/or video.
The telehealth program at the University of California, Davis, relies on videoconferencing and electronic transmission of scope sounds and images. The program is designed to provide accessibility to highly specialized services unavailable in the patients community.
The program is also serving Pelican Bay State Prison, Folsom State Prison and the Valley Mountain Regional Center in Stockton. In 1999, another 14 rural sites became operational as the result of recently awarded grants and contracts.
A federal grant from the Office of Rural Health Policy helped telemedicine at the University of Minnesota get its start. The grant helped equip and establish a live, interactive videoconferencing link between the University of Minnesota Hospital and Tri County Hospital in Wadena, Minn., a community that is medically underserved, according to national standards. In the second funding year of the three-year grant, Staples and Moose Lake were added to the network. In-kind contributions have expanded the private network to include health care centers and Rural Health School sites.
And no telemedicine project would be complete without an initiative from Johns Hopkins University in Maryland. "Telemedicine is the use of telecommunications to facilitate health care," the universitys Web site notes. "This could mean using technologies as simple as phone lines, fax machines and e-mail, or the use of more sophisticated computers, scanners, cameras and various diagnostic tools that can instantly communicate information between two or more distant sites."
In July, the Agency for Health Care Administration received approval from the Health Care Financing Administration to offer telemedicine services in a pilot study to 25 selected recipients. CYBeR-Cares patented Electronic HouseCall System (EHC models 400 and 600) will be used during the study, which seeks to demonstrate the ability to effectively monitor patients remotely in their own home using live two-way video, as well as the transmission of patient vital signs to a central network accessible by any number of authorized care providers.
The Statewide Academic & Medical System (GSAMS) is one of the worlds largest two-way interactive H.320 video networks. It provides citizens statewide access to resources without the restrictions of time or distance. Since GSAMS inception in 1992, more than 400 sites ranging from elementary schools to rural hospitals have held more than 100,400 conferences.
On the frontier of telemedicine is the Alaska Telemedicine Project, a consortium of Alaska health care providers, telecommunications carriers, the state and the University of Alaska, Anchorage. Since its founding in 1994, the Alaska Telemedicine Project has been developing sustainable telemedicine and telehealth applications and technologies designed to work in Alaska, including the development and deployment of the Alaska Telehealth System and the National Library of Medicine funded Alaska Telemedicine Testbed Project. The Alaska Telemedicine Project has been recognized by the Alaska Legislature for its leadership in telemedicine and telehealth.
Last August, a telemedicine pilot project was set up between Ugandas University Teaching Hospital of Mulago and the Mengo Hospital in downtown Kampala. Officials estimated that 50 percent of Ugandas 800 doctors are in Kampala, and 60 percent of nurses are in rural areas.
The move was lauded by Ugandan Health Minister Dr. F. Byaruhanga, who praised the International Telecommunication Union (ITU) for its cooperation in enabling his country to implement the use of information technology that could help save lives.
The timing is critical. Uganda has a very high maternal mortality rate ranging from 500 to 2,000 deaths per 100,000 births and an infant mortality rate of 97 per 1,000, making the need to improve medical delivery while making the most of limited medical resources extremely important.
The Uganda project, the second in Africa involving the Geneva-based ITUs Telecommunication Development Bureau, is part of a strategy to provide specialist care in surgery, pediatrics, obstetrics, gynecology and internal medicine in regional referral hospitals whose medical teams can only afford one or two specialists. The project is expected to expand to cover other hospitals in both Kampala and regional hospitals in rural areas.
Bryan M. Gold is a writer based in Washington, D.C.