From maximum-security prisons in Texas to a remote outpost in Antarctica, health care is delivered virtually by a successful telemedicine program operated by the University of Texas Medical Branch (UTMB) in Galveston.

Physicians and administrators for the Texas state prison system initially began the Correctional Managed Care program in 1994 to deliver cost-effective care to Texas prisons, said Dr. Glenn Hammack, assistant vice president and executive director of the UTMB Electronic Health Network (EHN).

As technology costs fell, the UTMB EHN extended telemedicine services to underserved areas in Texas, as well as to many commercial customers. Physicians typically work in the Galveston area, while patients themselves are distributed across Texas, Kentucky and even Antarctica.

For patients in underserved areas, distance medicine is the only treatment option they receive. At this time, 75 percent of telemedicine visits serve prison inmates, with the remaining 25 percent assisting noncorrectional visits.

The average patient receiving distance medicine services lives 100 miles from Galveston, while the farthest lives more than 8,000 miles away in Antarctica.


Typical Visit
A typical UTMB telemedicine visit is like a traditional doctor visit, except the physician and patient aren't in the same location. Video conferencing lets physicians and patients see each other, and clinical encounters occur in various locations -- county health program offices, corporate nursing offices, rural medical clinics, prison medical clinics and medical clinics at scientific research stations.

A staff person, called a presenter, is usually on hand to walk the patient through the visit and perform the examination. The presenter might be another on-site physician, nurse or paramedic using electronic examination equipment, such as a stethoscope or a handheld fiber-optic camera to examine the ears, nose, throat and skin, Hammack said.

After the exam, the presenter records notes in the patient's electronic medical record that is accessible from anywhere on the EHN's private telecommunications network, which covers 80 percent of Texas.

In some cases, the UTMB EHN uses store-and-forward technologies in place of real-time data exchange. For instance, medical images of diagnostic studies from distant locations might be stored and later viewed during a diagnostic evaluation back in Galveston.


The T-Cart
At its off-site locations, the UTMB EHN installs a telemedicine cart (t-cart). All electronic devices required to operate the virtual physician office are on the cart, as is a complete medical video-conferencing system, including video monitors and a remote-controlled pan/zoom camera that provides diagnostic-quality images.

A light table lets the physician view X-rays or EKG results. A handheld medical camera, complete with fiber-optic halogen lighting, is used to look into the patient's throat and ears, and to examine the skin closely. An electronic digital stethoscope-sending unit is also included.

The cart carries a complete electronic medical record workstation, giving the presenter at the remote site access to patient medical information housed in a large mainframe data center running Oracle 10g in Galveston, with a mirror site in Huntsville, Texas. Connectivity can be provided through broadband Internet and VPN, or via a private T1 line.

Depending on customer preference, the EHN leases or sells the remote, costing about $40,000 per unit, installed and supported. Leasing a cart for one location costs approximately $9,500 annually.


Case Examples
Nearly every medical specialty has adopted telemedicine in some form to better reach all ages, races, needs and locations.

KUHF Houston Public Radio reported that the UTMB EHN is partnering with the University of Texas Health Science Center in Houston to provide mental health services to students in the Houston Independent School District. Such services account for roughly 30 percent of the 60,000 annual telemedicine encounters.

In these cases, the patient interacts directly with the doctor via video link. One senior psychiatrist said the sessions are so real