In the not-too-distant future, when the a visiting nurse comes to call on a homebound patient, she'll use a telephone.
The nurse will do the same kinds of exams she would have done in person: take the patient's blood pressure, listen to the heart and lungs, record body temperature, take other vital signs and give the patient a visual once-over. But the nurse could be dozens, hundreds or even thousands of miles away.
Telemedicine is on the horizon. A virtual visit can now be done with computerized devices and a standard phone line. With the blend of telephone and television, computer connections and the Internet, the idea of medicine at a distance has steadily matured. While much of the work remains experimental, the future vision has clarified enough for federal agencies to form the Joint Working Group on Telemedicine. Members include the Departments of Defense, Agriculture, Commerce, Health and Human Services, Justice, and Veterans Affairs; the Office of Management and Budget; the Appalachian Regional Commission; and the National Aeronautics and Space Administration.
The vanguard of telemedicine includes devices that provide communications among patients, physicians, and other health-care professionals. Such combinations include tele-radiology, in which images such as x-rays, sonograms, and CAT scans are sent digitally from one location to another; interactive videoconferencing, which allows several doctors to confer simultaneously with access to the same images; and tele-cardiology, in which electrocardiographic data is transmitted to experts for interpretation.
Telemedicine focuses on direct patient care, specifically linking the patient to the health-care provider, transmitting medical information from the patient to the nurse, doctor or other health-care professional. With a telemedicine device installed in the home, a nurse can complete an exam without the person ever having to go out. The medical information is transmitted from the testing devices directly to the health professional.
The Food and Drug Administration regulates some aspects of telemedicine. For example, when a digitized image is compressed for transmission, FDA requires that the manufacturer indicate on-screen whether the compression caused any data loss. The agency also oversees the diagnostic devices attached to the system.
FDA cleared the Kodak LifeView Care Station, one of the newest telemedicine devices, for marketing in February. The device includes a television monitor and camera--so the patient and health-care provider can see each other--blood pressure cuff, stethoscope and thermometer. It enables health professionals to view and communicate with patients between office or other in-person visits. The station is set up in the patient's home by a nurse or by a caregiver trained by a nurse.
To start a telemedicine appointment, the patient calls the health professional on the phone and then switches on the machine. The videophone, connected by a standard telephone line, transmits readings from the stethoscope, thermometer and blood pressure cuff during the phone conversation. The station also lets the health professional monitor pulse rate and listen to sounds from the patient's bowels, heart and lungs.
Images and data are transmitted to the medical professional, then dated and stored. The units cannot be used if a patient or the patient's caregivers are physically unable to use it, if they don't have the ability to operate the device or if their language skills are not sufficient to communicate with medical personnel. Kodak expects the first units to be available through home health-care providers by the end of September.
Other telemedicine projects are ongoing across the country using approved medical technologies with electronic communications. Although it has been around for a while, telemedicine has been held back by "three big problems," says William Decker, senior policy advisor with the Public Policy Institute of the American Association of Retired Persons.
The first of these is third-party reimbursement.
"Medicare will pay for certain applications, such as tele-radiology," he explains, but insurers do not cover all telemedicine patient applications. The main problem, Decker says, is the lack of data showing that patients benefit from these technologies. There are also questions about whether these technologies will ultimately save money.
The second big problem, he says, is "ensuring patient confidentiality and privacy," especially in applications involving satellite uplinks and downlinks. "Encryption," he notes, protects privacy, but it "drives up costs."
Decker says the third problem is that physicians are licensed by each state separately. A doctor licensed in California can't practice on a patient in Pennsylvania, even though telemedicine technology could easily allow it. Some work is being done on telemedicine licensing, but this is in its very early stages.
Because of this licensing limitation, many telemedicine projects are conducted within a single state. Many of the early studies have focused on rural health, where distances often make it difficult for patients to get to a health-care professional. For example, Texas Tech University has several rural health-care telemedicine projects, such as a project to connect clinics in several remote areas with each other and with experts at the university. Another project with a school health clinic links the school nurse, who is the only health-care provider in the small town of Hart, Texas, with specialists in Lubbock, saving patients and their families miles of driving.
The University of California at Davis sponsors a rural clinic program using videoconferencing and electronic transmission of sounds and images to enable patients to consult with specialists unavailable in their communities. The number of these consultations has increased 300 percent since 1997. Practitioners in more than 17 medical specialties are available, including dermatology, endocrinology, nutrition, pain management, rheumatology, organ transplantation, and pediatrics.
Though the focus of telemedicine is usually local, sometimes it expands internationally. Alaska is participating in a working group to share information about telemedicine that includes Russia. Alaska and parts of Russia are similar in their remoteness and terrain. The Alaska Telemedicine Project, along with the University of Alaska and the State of Washington, plans to work with the international group to present a telemedicine model for giving rural health-care providers access to e-mail, other Internet and computer-based information technologies, and medical imaging transmission.
"Telemedicine," Decker observes, " has real promise."
For more information, visit The Federal Telemedicine Gateway at www.tmgateway.org
This article is excerpted from the May-June 2000 issue of FDA Consumer Magazine.