Despite Successes, Telemedicine's Future Is Clouded With Questions

by Terry Costlow

America’s veterans are used to charging into the unknown, but for years they’ve been leading the charge in an unexpected area that blends technology and medicine to provide remote medical care. The Veteran’s Administration (VA) is the country’s largest user of telemedicine, which lets patients access remote specialists without traveling.

Futurists foresee a time when patients in remote areas will talk to renowned experts over the Internet, doing such things as diagnosing problems that general practitioners can’t evaluate. Though the VA and others have established the beachheads for that vision, myriad legal and technical challenges must be overcome before telemedicine will gain a foothold in the general population.

The VA has succeeded because it has control over its doctors, patients and its technology. Standard hospitals must deal with such issues as licensing and payment, not to mention slow phone lines and balky Internet connections.

On the technology front, the VA has a high-speed, wide-area network (WAN) that links all of its hospitals. As far back as 1999, VA physicians performed 300,000 remote consultations. Although uncounted since then, that number has soared as doctors and patients have become more comfortable with the idea that the doctor and patient are in different states.

“It’s no longer just a project; it’s now part of standard practice,” said Adam Darkins, chief telemedicine consultant at the Veteran’s Administration. Darkins expects telemedicine use to soar in the next 18 months, with the opening of a handful of VA centers of excellence, which will be staffed by experts in different maladies. Patients will be able to access these specialists from remote areas, reducing the stress and expense of travel.

Nation’s Prisons Are Reaping Benefits

Although the VA is a telemedicine leader, it’s not the only place with the controlled environment that lends itself to defining the future of distance medicine. In a vastly different setting, the nation’s prisons are taking advantage of the cost savings of telemedicine. Transporting prisoners to hospitals and doctors' offices is quite costly. It’s far cheaper to set up video links so doctors can examine inmates without travel.

“A lot of prisons have installed videoconferencing over plain old telephone lines. The University of Texas at Galveston does thousands of (related) consults per year,” said Nancy Brown, project director at the Telemedicine Information Exchange, a Portland, Ore., group that monitors telemedicine activity for the National Library of Medicine.

Obstacles Continue to Hold Telemedicine Back

Bandwidth

The technologies used for veterans and prisoners are as different as their image among the populace. In traditional videoconferencing, for example, the clinician has no way to access patient files unless they’re sent to him before the teleconference. The VA overcame this problem when it began using its broadband WAN, which has the bandwidth to carry such data-intensive files as X-ray images, along with the videoconferencing images. Remote specialists can now have as much information available immediately as the patient’s regular doctor has.

Reimbursement

Bandwidth is but one of the issues that is keeping telemedicine from emerging beyond the project/study phase. Another key concern is reimbursement. Some insurance companies won’t pay for remote consults, and others pay for only very limited types of interactions. None pay more than for a face-to-face visit, so physicians must bear the equipment costs.

Licensing

Another issue is licensing. Each state has its own licensing requirements, which limits the opportunity for physicians to treat distant patients. “If you fly to Texas, I can treat you,” said Yadin David, a Houston-area biomedical engineering director, who is president of the Center for Telemedicine Law. “But if you stay in your home state, where I’m not licensed, it’s a violation of federal law for me to treat you.”

Standards and Protocols

Yet another design concern is the lack of standards. Medical files, such as X-ray images, must be presented in formats that physicians are used to seeing, but there aren’t many standards yet for digitizing the hardcopy images and sending them over the Internet.

Even the standard protocols used for Internet communications pose something of a problem for videoconferencing and sending huge medical image files. “The Internet is designed for sending e-mails and large files with error checking. It’s not made for sustained synchronous links,” said Scott Simmons, co-chair of the American Telemedicine Association’s technology group.

Will Tradition Be Replaced?

Whatever telemedicine’s application, ease of use will be a key. Many patients are elderly people who are unfamiliar and uncomfortable with technology, and even computer-literate users often have maladies that require simple human interfaces. It’s a safe bet, therefore, that while telemedicine will continue to gain popularity and use, it will not replace traditional, face-to-face meetings between doctors and their patients.

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Terry Costlow has written about the electronics industry for more than 20 years, covering a wide range of technologies and topics.