Telemedicine & Technology

Most often, telemedicine refers to the use of electronic communication technologies in the delivery of clinical care. Broader definitions include health related activities including professional education, community health education and continuing education for health professionals. The technologies used in telemedicine range from use of the fax or telephone to share information through the transmission and evaluation of still images via computer, to fully interactive video-conferences. The widespread availability of video cameras combined with computer technology and the Internet have been a major factor in the advancement of telemedicine evaluation and implementation.

How Telemedicine Can Improve Access to Care
Imagine that a patient in a small town in Iowa goes to his primary care physician about a lesion on his arm. The physician decides to refer him to a specialist in dermatology to determine if the lesion is malignant. But the nearest dermatologist is in Des Moines, at least 100 miles away.

Not so long ago, the patient would have either had to take the 100-mile journey or miss out on an accurate diagnosis. But today, telemedicine can make getting to the specialist a lot easier. The primary care physician simply has to set up an appointment with the dermatologist and forward the patient’s medical information. Then, on the day of the appointment, the patient and primary physician consult with the dermatologist through interactive television.

“With the use of telemedicine, the dermatologist can evaluate the lesion and make a diagnosis, the primary care doctor gains valuable information from the consult, and the patient doesn’t have to take a trip,” said Paul Maaskestad, administrative director of the Midwest Rural Telemedicine Consortium. The Consortium is a 30-member network of health care organizations that is funded by the Centers for Medicare and Medicaid Services and the Health Resources and Services Administration (HRSA), of the U.S. Department of Health and Human Services.

Defined as the practice of medicine at a distance, telemedicine can involve a range of technologies, including telephones, computers, videoconferences and diagnostic cameras. The most common clinical uses of telemedicine are diagnostic consults and medical data transmissions, according to the report, Exploratory Evaluation of Rural Applications of Telemedicine, released by HRSA’s Office of Rural Health Policy (ORHP) earlier this year. The report, which is the first comprehensive survey of rural telemedicine programs, reveals results of a two-year study of more than 2,472 rural hospitals in the United States. Radiology and cardiology were cited as the most common clinical applications of telemedicine, followed by orthopedics, dermatology and psychiatry.

The practice of telemedicine is not new; it was first introduced more than 30 years ago. What is new is its growing popularity, due largely to increasing federal support of telemedicine projects and increasing attention to telemedicine’s success.

Telemedicine has great potential to improve access to care for minorities by reducing language barriers between patients and doctors, according to Maakestad. “More and more Latin Americans are coming to Iowa to do seasonal work. And in many rural communities, there are not a lot of human resources to deal with language differences. So telemedicine could play a valuable role in improving the way we communicate,” he said.

There is no question that some innovative telemedicine projects are improving minority health. For example, the Indian Health Service (IHS) is linking up with a number of medical schools to provide eye care through teleoptometry. For one project that serves the Yupick, Athabaskan, and Aleut tribes in Dillingham, Alaska, doctors digitize retinal images of the patients. The images are then sent to the University of Southern California School of Optometry, where retinal specialists evaluate them and return them to the local optometrists. “This is impressive because a specialist can be accessed in minutes, with the patient still in the room,” said Mark Thomas, a clinical engineer with IHS. “The patients can see what their eyes look like on large computer monitors, and that usually prompts them to ask lots of questions. So they end up getting more involved in their health care than they might have in a traditional eye exam,” Thomas said.

“Teleoptometry appears to be more cost-effective and less complicated than one might think,” Thomas added. The equipment used for the Dillingham project can run around $25,000. The process involves attaching a video camera to eye exam equipment and linking the video camera to a computer. The image of the retina is then transmitted through the Internet.

Telemedicine especially holds promise for parts of Alaska and other rural areas that have long distances between towns, shortages of medical personnel, lack of public transportation and harsh weather conditions.

Central to the success of telemedicine is the acceptability of these electronic office visits to patients, according to researchers at the Rural Telemedicine Project at the University of North Carolina. The project, which receives funding from ORHP, conducted focus groups and in-depth interviews with residents of a poor part of eastern North Carolina who had been linked through interactive video to the university’s school of medicine in Chapel Hill. Findings from the study were generally positive. Many patients actually preferred telemedicine because they felt more comfortable and less intimidated by the doctor. Some also felt more involved in their medical care.

But like other modes of health care delivery, telemedicine is not without glitches. For example, there are no uniform reimbursement policies in place. According to the ORHP report, less than 25 percent of hub facilities surveyed were reimbursed by insurers for services delivered through telemedicine. Other concerns include legal and regulatory uncertainties, such as whether a professional is credentialed to provide services in a rural facility across state lines. And is the local doctor or the specialist miles away responsible for the patient?

A Joint Working Group on Telemedicine, consisting of representatives of all federal agencies with active telemedicine programs, has developed a work plan that addresses several areas of concern in telemedicine. The Working Group collaborates with non-governmental groups such as the Center for Telemedicine Law, and follows federal activities that affect telemedicine. A new plan adopted by the Federal Communications Commission, for instance, will make discounted telephone and Internet rates available for schools, libraries, health providers, non-profit and public rural health clinics. This directly affects telemedicine “because transmission costs will be reduced for rural areas that traditionally had to pay a lot for these services,” said Dena Puskin, Sc.D, Chair of the federal Joint Working Group on Telemedicine.

Telemedicine will never completely replace in-person interaction between patients and health care providers. But rural health facilities across the country are embracing this innovation. Supporters of telemedicine hope that once this technology overcomes its drawbacks, it will reach even more people who otherwise would not have access to care.

by Michelle Meadows. Originally published in the November, 1997 issue of Closing the Gap, a publication of the Office of Minority Health Resource Center. Used with permission.

Funding for Life Support is provided by a grant from USDA Rural Development