Telemedicine: Just What the Doctor Ordered

Equipment needed for telemedicine is quickly becoming more affordable and the technology is getting better, leading to increased attention by health care providers.

by / June 30, 1995
July 95

Level of Govt: State, city, county.

Function: Health care.

Problem/situation: Many rural and public hospitals lack financial and specialist resources available in city medical centers.

Solution: Telemedicine enables hospitals to share doctors and resources.

Jurisdiction: Denver Health and Hospitals, Georgia.Statewide Academic and Medical System.

Vendors: AT&T;, Compression Labs Inc., Personal Technology Research, Southern Bell/Bell South, Georgia Telephone Association and CAE Link.

Contact: Kirsten Hinsdale, Denver Health and Hospitals 303/436-5629; Andrew Todaro, AT&T; 303/290-2429

By David Aden

Contributing Writer

Telemedicine is a "hot topic" these days - everyone is talking about it. Many feel they ought to get into it, but some fundamental issues such as reimbursement, liability, national licensing, and standards are yet to be resolved. Nonetheless, market forces favor increased deployment of telemedicine systems. For many, the question is not "if" but "when" to adopt the technology.

In fact, despite the relative newness of the field, there are many projects in the works. Sarah Dickson, program director and senior analyst for Video Teleconferencing at Waltham, Mass.-based Personal Technology Research, estimates there are telemedicine projects, in at least the planning stages, in almost 40 states with as many as 2,000 already in use.

At the most basic level, "telemedicine entails sending compressed video images over phone lines," said Dickson. "You have the basic hardware for videoconferencing. You integrate into that certain other equipment for medical applications."

Kirsten Hinsdale, the director of product and program development for Denver Health and Hospitals, has plunged headlong into developing a telemedicine system because it should benefit Denver Health and Hospitals, hospitals in rural areas, as well as the quality of patient care.

Denver Health and Hospitals has 107,000 patients and one of the most successful trauma centers in the country, Hinsdale said. "But how's a public hospital going to survive? We need to capture more of the insured market so we can use some of that to help fund care for the indigent. We are positioning ourselves as emergency and trauma for the region."


Most rural hospitals cannot afford large emergency or trauma centers, including Denver Health and Hospital, but they still need to have access to the expertise of such a center. Hinsdale views telemedicine as a way to extend the reach of the large urban hospital, to leverage its expertise by making it available to multiple rural hospitals and clinics.

"If we have an expert, we can direct a medical provider in Cripple Creek using a telemedicine system," Hinsdale said. "We can save lives and limbs and we can also contain cost by preventing inappropriate referrals to trauma centers."

While Denver Health and Hospitals was looking into telemedicine for some time, it came into focus in connection with the Service to the Citizen Summit held in Denver last February. Hinsdale worked closely with AT&T; Data Networking Marketing Manager Andrew Todaro to put together a telemedicine demonstration for the summit. The project has sparked a great deal of interest.

The demonstration was based on AT&T;'s Vistium system which uses Integrated Services Digital Network (ISDN) lines. The hospital had already embraced ISDN, so the basic network requirements for a system were already in place.


Despite recent declines in hardware, software and network costs, implementing telemedicine involves a major commitment of time and resources and remains very much a team effort. "You have to bring people in from everywhere," said Hinsdale. "Emergency room physicians, primary care people ... and representatives of many different medical specialties all need to get involved. And you can't solve all the problems up front."


Despite these hurdles, systems are being successfully deployed. Over the past two years, Georgia has built such a network. The first hurdle, as usual, was financing.

An over-earnings settlement against Southern Bell several years ago totaled about $140 million. Approximately $70 million of that was given back to telephone subscribers as credits of about $1 for each household.

"Someone realized that there was something of more value that could be done with the money," said Jim Anderson, the director of Strategic Network Development of the Georgia Department of Administrative Services. "The governor wanted to improve access to education services and medical care throughout Georgia with emphasis on rural parts of the state."

The Legislature passed the Georgia Distance Learning and Telemedicine Act of 1992 which mandated creation of the Georgia Statewide Academic & Medical System (GSAMS) network. The GSAMS network was built by a public-private partnership between Georgia and a variety of partner corporations including Compression Labs Inc. (CLI), Southern Bell/Bell South, Georgia Telephone Association and CAE Link.

The result is a two-way, interactive distance learning and telemedicine network with more than 220 nodes. The telemedicine side of the network currently has 23 systems deployed and is slated to grow to 59 by the end of October.

The results of the initial pilot program with seven hospitals were dramatic. "The statistics from the medical college shows that there were about 400 to 500 consultations," said Anderson. "Among those, the most important statistic is the fact that 86 percent of the patients seen through the telemedicine system were able to remain in the local community. In economic terms this is particularly important in a rural community where the hospital is an important economic center.


Unlike the planned Colorado network, George uses a private, dedicated network of T1 lines. According to Melissa Baten Caswell, manager of Market Development Programs for CLI, the network operates at 768 Kbps which was chosen after Georgia officials looked at the video quality available at those speeds. CLI's Radiance system, which is the primary equipment used on the Georgia network, delivers 30 frames per second, or near television-quality transmissions.

"The system is an investment by the state to benefit the state," said Caswell. "Georgia is using it as a way to draw people and industry in because the network is providing a workforce that is better educated as well as providing greater access to medical care."

Currently, there is no federal reimbursement for telemedicine. But the Health Care Finance Agency, which disburses federal medical funding, is working with various states, including Georgia, to establish standards. In the meantime, Georgia tackled reimbursement itself.

"In Georgia, telemedicine consultations have been approved by Medicare and Medicaid on a case by case basis," said Anderson. "That is, each of the seven pilot sites have been approved for reimbursement. This was achieved by providing assurance of meeting standards of care and the assessment that the telemedicine consultation was just as if the patient was seen by the doctor in the same room."


According to Anderson, a doctor can currently do everything in a telemedicine exam that he can do in person except for palpating, or feeling the person. Exams are conducted by adding other equipment to basic videoconferencing, such as an electronic stethoscope, which transmits a digitized heart beat to the host end and ultrasound doppler which gives the consulting physician live ultrasound images.

While use of this technology may mean the difference between saving or losing a limb - or worse - it can potentially save both care providers and patients a tremendous amount of time and money. Users also see its educational factor as a way to increase the quality of care.

The physician in the rural area can get Continuing Medical Education (CME) credits, said Anderson. "If the rural doctor is there during the consultation and then discusses the case with the physician afterwards, he is given credit for it. Instead of closing down his office for a week for a conference, he can obtain his CME requirements throughout the year. The community doesn't have to loose their physician for that time."

This CME arrangement is also something that has been worked out in Georgia but has not yet been formalized nationally.

Virtual medical communities, virtual multidiscipline practices, virtual hospitals serving hundreds of square miles and virtual examinations are all possible and already happening. Even though some basic issues need to be resolved nationally, the industry doesn't seem to be waiting. But when something comes along that saves money, increases productivity and improves the quality of patient care, it is reasonable to assume the medical community is going to take an interest.

Some might say telemedicine is just what the doctor ordered.

David Aden
David Aden is a writer from Washington, D.C.