Video Vexations

A series of unresolved issues, ranging from affordable access and regulatory barriers to cultural resistance, threaten to slow down the increasing use of telemedicine and distance learning

by / August 31, 1995
Sept 95 Level of Gvt: State Function: Education, Medicine Problem/Situation: Video technology is being slowed by telecommunications expense as well as regulatory and turf roadblocks

Solution: Streamline existing state regulations that affect access costs and review regulations and laws regarding remote medical diagnosis and criminal arraignment to account for new technologies

Jurisdictions: Georgia, Iowa, California, Kansas, Maine, Montana, North Carolina and Oklahoma

Contact: Dennis Bybee, associate executive officer of the International Society for Technology in Education, 703/351-5243

By Tod Newcombe News Editor Hoping to take advantage of distance learning's technological prowess as a teaching tool, the University of Maine decided to build a new campus that would rely almost exclusively on two-way video for teaching. Instead of buildings and professors, the campus would simply deliver courses to students via video broadcasts from the university's seven other campuses

Eventually, some students would receive degrees from the video-networked campus

But in April, J. Michael Orenduff - the university's chancellor who led the way for the video campus - resigned when faculty objected strongly to the idea. According to a report in The New York Times, the incident has raised "questions about the extent to which technology will displace college professors ... and is seen as a forerunner to conflicts at other colleges." Cultural resistance to distance learning is but one issue of many that threatens to slow down the widespread use of video technology as a tool for education, as well as medicine and criminal justice. Concerns about affordability, legal issues and regulatory constraints have cropped up as federal, state and local governments expand their use of interactive video as a tool to help doctors, educators and judges do more while public resources shrink

Applications of varying sizes involving distance learning, telemedicine and video arraignment are under way in virtually every state and many large urban locations. Iowa is implementing its own $100 million statewide network, with a heavy emphasis on distance learning. Georgia has invested more than $50 million in its Statewide Academic and Medical System

Oklahoma announced last year the start of a $3.4 million telemedicine network. The list goes on

Driving this growing investment in state-of-the-art telecommunications is a desire on the part of government executives to make their states economically viable. Without distance learning and telemedicine reaching into every urban and rural community, states fear they may strike out in terms of attracting new businesses, jobs and people

CONNECTION COSTS Building a statewide video network is an expensive undertaking, and the payback is considered long term by a number of educational and medical experts. One of the major objections to distance learning by the professors at the University of Maine was its relatively high cost for a tool that teaches few students. The $13 million network was expected to serve approximately 3,000 out of the 25,000 students in the university's seven campuses. Georgia has spent the equivalent of $250,000 for each site on its 200-node video network

Equipping a classroom with video cameras and monitors, sound equipment, computers and software can run from $90,000 to $150,000. The American Medical Association estimates that between $40,000 and $60,000 is needed to equip a hospital room for remote diagnostics and examinations. Costs per site for court video arraignment run about $40,000, according to the National Center for State Courts

Another major cost for any two-way video application is the bandwidth necessary to transmit the images. Annual user fees can easily hit $40,000, though Georgia reported that it pays $1,000 per month to link its high school classrooms using a half-T1 line

Educators and medical experts are concerned that the high cost of video transmissions and the discrepancy of costs in urban and rural areas will impede widespread development. The American Medical News (April 10, 1995) reported that the hodgepodge of regulations governing telecommunications has resulted in some telemedicine systems spending as much as $10,000 per month for T1 service while others pay as little as $400

The same situation affects distance learning. "The prime impediment to distance learning is the cost of access," said Dennis Bybee, associate executive officer of the International Society for Technology in Education

"If we don't resolve the problem, the momentum toward distance learning will be adversely affected." Bybee's organization is pushing an amendment to the Telecommunications Reform bill in the Senate that will allow "schools, libraries, healthcare providers and rural telemedicine projects to have telecommunication access at rates that are affordable and not more than the incremental cost to the providing carrier." Bybee said that the telecommunications carriers are up in arms about the amendment, but without some sort of guarantee of affordable access for government, educational and medical institutions, he believes the country "will just end up with pockets of innovation." OTHER REALITIES Besides infrastructure and access costs, state and local governments must also contend with the economic viability of distance learning and telemedicine. The Health Care Finance Administration (HCFA), which administers the country's Medicare and Medicaid programs, in general does not cover telemedicine examinations or diagnosis

That's because telemedicine is still considered experimental, according to Bernadette Schumaker, of HCFA's Bureau of Policy Development. Current HCFA policy requires face-to-face contact between doctor and patient for a visitation to be reimbursable, explained Schumaker. However, HCFA does give carriers some leeway on this matter, so it's possible for some coverage to occur. HCFA is conducting its own research of telemedicine's viability, but has given no indication that it intends to change its current policy any time in the near future

The short-term economics of distance learning is also unclear. Some proponents of distance learning tout its cost savings by allowing one teacher to instruct as many as six classrooms at once. But an article in The New York Times on distance learning (July 20, 1994) quoted several teachers as saying their ability to teach and for students to learn diminishes as class size grows. Several teachers who worked with the technology said they could not handle more than 30 students at any single time without losing personal contact

Schools may also need a technician to run the equipment and manage the video classrooms, as well as teaching assistants to provide help for students. Then there is the limitation on what can be taught via distance learning. In Georgia, school educators found that advanced classes, such as foreign languages and mathematics, were best suited for video, not remedial English

Certain legal issues also compound some of the problems of using video technology. A number of criminal justice agencies have begun looking at ways to use videoconferencing in the courts. However, lawyers and judicial experts have raised legal issues concerning the use of videoconferencing for witness testimony and video arraignment

Legal procedural issues and concerns about a defendant's access to counsel may scuttle attempts to use videoconferencing in courts for witness testimony and arraignment, limiting its use to pre-trial meetings between lawyers. (see "Courting New Technology" Government Technology June 1995)

In telemedicine, legal precedents for remote liability and medical licensing across state lines have not yet been established, according to a report in the Journal of the American Medical Association (February 8, 1995). "When a telemedicine consultation crosses state lines, does the provider have to be licensed in one state, the other, or both?" ask the authors, Douglas A. Perednia and Ace Allen. They add that, "today's patchwork of state regulations, accreditation, and liability is clearly incompatible with the widespread use of electronic medical services." FUTURE VISIONS In North Carolina, high school students 200 miles away from the Atlantic Coast can take a course in oceanography through distance learning. In Georgia, thousands of students who have never been to a zoo are able to see and hear the latest about exotic animals at Zoo Atlanta via the state's video network. In rural Kansas, a telemedicine network links country doctors with specialists they never had access to before

Video technology does work. Early innovators, such as Iowa, North Carolina, Georgia and numerous others have been willing to take a risk with the technology to see whether they can extend certain educational and medical benefits to people who need them the most

But it's clear that states need to work carefully at helping to resolve certain issues if video technology is going to flourish. They need to support efforts under way in Washington that guarantee some form of affordable access to high bandwidth telecommunications in poor and rural locations. At the same time, they should also work at streamlining existing state regulations that affect access costs

Regulations and laws concerning remote medical diagnosis and criminal arraignment should be reviewed and, if necessary, changed and brought up to date, so as to allow the medical and legal community better access to video technology

At the same time, however, state and local governments need to be asking what their citizens really need. Does every school district in a state truly need expensive, full-motion video for distance learning, or will education be better served by giving some schools video and others access to the Internet? Does every rural telemedicine location need two-way video? Would one-way video and two-way audio - which costs less - suffice? Video technology provides states and localities with an opportunity to change the way government provides some very basic, but vitally important services. The challenge will be to adopt and use the technology in ways that cities, counties and states can afford, both financially and socially