Telemedicine: Solving the Inequities of Healthcare

The doing of doctoring over America's telephone lines would be a powerful prescription for the dilemma of universal coverage

In Georgia, 5-year old Jennifer awakens with a cough, fever and rash on her chest. Her father dials the interactive telecommunication connection to reach Jennifer's doctor, and describes his daughter's symptoms. The nurse on the other end of the line tells him to connect special probes to Jennifer's chest that measure her temperature, blood pressure and pulse.

The nurse listens through an electronic stethoscope and examines the rash through a high-resolution television monitor. Then she tells the worried dad what he should do, while the system automatically sends a record of the transaction to the family's medical file, to the community databank and, of course, to the family's insurance company for payment.

Sound far-fetched? Or will the privacy of home replace busy hospital clinics and crowded waiting rooms? Actually, an electronic return to the house call is much closer to reality than the American public realizes. The obstacles are less technological and more legislative, regulatory and economic.

Before long, the sick who inhabit even the most rural backwaters should be able to receive ministrations from top-flight physicians at the most prestigious hospitals around the country. Rural healthcare providers will be able to keep up with current techniques through on-line continuing education programs, obtain instantaneous second opinions, and interact with home-bound patients.

Megabits of vital medical data and images will be instantly accessible and transportable to any point on the network, and interactive video will allow experts thousands of miles away to conduct "live" consultations with primary care physicians and their patients.

Perhaps just as importantly, during a time when healthcare costs devour trillions of dollars annually and nobody can agree how to remedy the situation, telemedicine may play a crucial role in reforming an industry known for overcharging and underperforming.

To date, telemedicine has been confined largely to joint trials between major telecoms and hospitals. NYNEX, Bell Atlantic and BellSouth have all tested networks in their service areas to facilitate everything from the transmission of X-ray images to interactive video consultations.

GM Hughes Electronics hopes to get into telemedicine via its "Spaceway" project, a plan to deliver interactive communications services via ultra-small aperture terminals -- satellite dishes -- beginning in 1998.

"As citizens and taxpayers are concerned about healthcare, we imagine the need to reduce medical costs and link remote clinics will be facilitated by Spaceway in several respects, including interactive teleconferencing, and rapid transmission of data and images such as CAT scans," said Ed Fitzpatrick, vice president of Spaceway.

Spaceway, he said, is not trying to tailor itself to fit any of the healthcare bills struggling through Congress, but rather, is being dictated by logic and common sense. "Any bill will want to control costs and make benefits available to every person in this country," he said. "Telemedicine is appealing both intellectually and economically, and will be an unavoidable part of the picture."

Jay Sanders, director of telemedicine at the Medical College of Georgia, warns that telemedicine's accessibility may be a liability. He explains that although telemedicine would probably decrease the per-patient cost of healthcare, it could conceivably increase the overall cost, since any system that improves access will have to care - and pay - for the 40 million people currently uninsured.

Despite this, he says "there is no question that telemedicine will be one of the riders of the information highway." Rising healthcare costs, insurance coverage and uneven quality are driving the health system to a cost-conscious, competitive, market-based managed care environment where information systems linked to the National Information Infrastructure are destined to play a central role, he said.

"A lot of attention is being paid to healthcare. It's not the sole driver of the NII, but it is an important component," said Jack McGuire, vice president, healthcare technology group with Science Applications International Corp. "We need to support multiple capabilities, not just electronic commerce," he said.

Before telemedicine can be widely put to work, some significant questions must be answered, including: How should federal and state regulations be changed to facilitate development of telemedicine systems? What should insurers consider in developing payment policy for telemedicine consultations? How should studies be designed to evaluate the quality of telemedicine outcomes? and how can data be secured as it passes through widely used networks?

Meanwhile, federal agencies, states and private companies are beginning to test telemedicine's boundaries. In the next four months, Georgia will be hooking up residential television sets with technology that will allow doctors across the state to test vital signs of patients.

Over the past two years, the Peach State has spent $8 million for 60 such public sites that have reduced the number of hospital visits by chronic patients and provided medical treatment to patients in rural areas.

In Pennsylvania, Bell Atlantic is building an interactive video network linking 10 urban and rural hospitals. Remote diagnostics, teleradiology (the transmission of images), and distance learning will all be possible with this network.

While the Baby Bell views this project as an important step in demonstrating the viability of telemedicine, it will also lay the groundwork to bring medical services into the home through its emerging video-dialtone network.

"We see a bigger market as we deploy more of a broad band network to the home," said Andy Mekelburg, director of external affairs with Bell Atlantic. "Home healthcare is a bigger business opportunity."

While deployment of a fully interactive network to customers remains years away, he said, Bell Atlantic plans to use its video dialtone network to carry a number of telemedicine applications, from healthcare programming to electronic house calls.

Eventually, he said, patients may be able to leave hospitals earlier and be monitored by their physician from home via an interactive link to the hospital.

"Most of that technology exists today, we just need the fully integrated network," explained Mekelburg.

Until then, barriers exist, not the least of which is approval from the Federal Communications Commission for video-dialtone networks. Mekelburg said it took the FCC two years to approve one such network for the company in New Jersey.

Other issues are tied up both in telecom and healthcare reform bills currently being debated in Congress.

Mekelburg identified four specific issues delaying telemedicine:

Under current healthcare Financing Administration rules, physicians may not be reimbursed for telemedicine consultation under Medicaid or Medicare. HCFA sets the standard for the private sector, and is thus halting the process, he said.

A second issue concerns liability of network providers. If a telemedicine consultation or data transmission glitch results in a faulty diagnosis leading to sickness or death, is the carrier liable for malpractice?

Funding is also a major concern. Telemedicine equipment is expensive, and somebody will have to pay. The problem is that those who can most benefit from telemedicine -- the 55 million people who live in rural areas -- can afford it the least.

Finally, he said, the prohibition of local exchange carriers from offering long-distance service will keep telemedicine artificially expensive until all carriers are given free reign to compete in both local and long distance markets.

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