Healing the online patient

Tuesday, December 19, 2000
By Jim Mathews ,
Washington Techway Staff Writer

URL: http://www.washtech.com/news/biotech/6095-1.html

Date accessed: January 8, 2001

Even the simplest forms of medical interaction - refilling a prescription for asthma medication or finding out whether a child with a fever needs to be seen in a pediatrician's office - so far have failed to take off in the online world. Obviously, the problem awaits just the right kind of electronic magic to make it all work, right?

Wrong.

"Telemedicine is no longer a technology problem in any category," declares Dr. David C. Kushner, the medical director of the telemedicine program at Children's National Medical Center of Washington, which is finding new ways to expand and extend telemedicine's reach. "It really is financing and how medical care is structured and paid for that's slowed it to a stop."

Some 15 years ago, when people first started doing serious thinking about telemedicine, the technological challenges were formidable, and mostly boiled down to bandwidth. About 10 years ago, satellites solved the bandwidth problem, but expensively, pricing remote telemedicine out of the reach of all but the military and other large institutions, and limiting other applications to small patches of geography.

Today, spurred on by ever-rising consumer demand for new experiences on the World Wide Web, Internet bandwidth has grown to where it's a cost-effective alternative to satellite time for all the enormous files doctors and hospitals can create - images generated by computerized axial tomography scans, high-resolution X-rays, magnetic resonance imaging scans and even volumes of data in patients' charts.

Though it's demonstrably cost-effective, most large insurers aren't convinced. So far, most of them only pay for teleradiology and tele-echocardiology, two subsets of telemedical practice.

"Those two specialties took about 15 years to evolve," Kushner says, which can happen "in an environment where reimbursement was available for service providers. That is not true of other areas of telemedicine. If a physician wants to practice telemedicine today, he has to do it for free."

And that's why real, widespread telemedicine for everyday medical practice still waits in the wings. Only those physicians who don't have to worry about fees can afford to advance telemedical practice, which is why the bulk of what would conventionally be called telemedicine is being done in the military and in prisons. Here the frontiers of telemedicine are being advanced - doctors in uniform don't have to worry about rent, paying office staff or malpractice insurance.

An aircraft carrier offers the perfect example of the usefulness of telemedicine. Deployed to the open waters of the Pacific Ocean, a carrier is about as remote a workplace as there is on Earth. Ordering a cardiology consultation on a sailor is hugely complicated and expensive, involving not just a referral form and a trip to someone else's office, but often a flight off the ship to an onshore hospital. The trip alone can cost the Navy as much as $5,000, apart from any medical care that's delivered, or the loss of the use of a sailor.

But, as Kushner explains, "the issue is who saves the money, in whose pocket does it stay, and what do they spend it on."

For those outside the large institutions, it's the insurance companies that would save money, and for the moment, "the problem is the people who potentially could save money haven't been convinced," Kushner says. This despite the fact that "one visit to the ER by an adult with congestive heart failure far outweighs the cost of putting a telemedicine workstation in their home and providing a nurse-practitioner three times a week."

If that situation is going to change, it's Washington-area businesses and institutions, at the center of efforts to prove telemedicine's utility and cost-effectiveness that will change it.

With help from local companies such as Northern Virginia's ViTelNet, District-based Allied Communications, and a neighborhood partnership group, Kushner is nearly ready to roll out a pilot program that would put a telemedicine suite in the Brookland Manor complex of urban Washington D.C.

"What we've got currently is a T1 connection, and we've done several demonstrations to see that it works," Kushner says.

Brookland Manor, the only digital-subscriber-line powered, community-based telemedicine node in the Washington region, is serving as a national model on how to combine needs and revenue streams to make telemedicine affordable for underserved communities, explains Allied Communications President Curtis White.

Allied focuses on urban, residential areas around the United States that are scheduled for rehabilitation and revitalization - places like Washington, Richmond, Miami, Houston, Los Angeles and Chicago. The Brookland Manor project grew out of Allied's work with Fannie Mae and Riggs Bank to create a model smart home community in the District, wiring the rehabilitated buildings so they can handle broadband traffic.

"We've teamed up with PeoplePC to put computers in all of the units," White says. "What you have is a fully networked broadband community that fits out here. That then makes it very easy to provide the connectivity to content providers" such as "health care providers, educational institutions that want to [begin programs in] lifetime learning, and the financial community" supplying financial services to these traditionally underserved areas.

Combining health, education and finance helps attack the cost of installing the broadband capabilities needed for telemedicine, by "leveraging the activity from a number of different industries," White says. "That has been one of the problems with telemedicine. There's a perception that the market will not support the cost. In our case, we think if we can parse together revenue streams from a number of different sources, we can" make it work.

In telemedicine, Allied is working with six redevelopment sites in Washington, representing a total of some 2,500 units, "indirectly 6,000 or 7,000 living units," White says. "In these instances if ... there were broadband nodes that [telemedicine partners] they could drop into, then the cost is not a prohibitive cost for them," he says. "The only thing you have to deal with then is the cost of the doc's time and the nurses' time."

Kushner, White and others think they've put all the pieces in place at Brookland Manor, and if it works, they can pick up those pieces and replicate them in communities across the United States. The idea is to work with a local developer and partners to drop the network into place, then team a local university with a hospital to construct a telemedicine course.

Residents in these communities, perhaps with some medical background, such as licensed practical nurses or home health aides, get certified to use the telemedicine peripherals, so that "they can actually be paid by some payer" - a health maintenance organization or other insurance carrier, White explains.

Many of the residents can be seen in the telemedicine suite for everyday management of chronic problems, such as asthma, high blood pressure or diabetes, at considerably lower cost than would be incurred by ignoring those problems until they become acute emergencies - and expensive emergency-room visits. The benefit in the community is not only healthier residents, but "indirectly, some job development and creation," White notes.

Thanks to a lot of hard work, support from Children's Hospital and Providence Hospital and a few grants, most notably from the Cafritz Foundation, after four years of conversation "there's a place, there's a wire, and people are interested," Kushner says. "But the whole project will stall if there's no way to pay for the nurses or physicians who will staff it. We've gotten right to the end of the diving board, but we've held back in building a major program until we're certain we can pay for it."

Home monitoring, triage and examination of the patient is a solid first step toward proving the economic sense of adoption of telemedicine, says Allen Isadpanah, president of Reston-based ViTelNet, acknowledged as a leader in telemedicine technology.

"Before we go doing surgery" remotely, it's important to look at more routine, but ultimately more economically attractive, applications, Isadpanah says. For example, "we can use a pocket PC to monitor a patient with diabetes from home ... I don't want him to come to the hospital every day."

But he points out that even though telemedicine's broad acceptance so far is hampered by insurance issues, connectivity issues within buildings and a focus on large-scale projects, "telemedicine has been growing 40 percent annually" as a market segment for electronics equipment makers.

"We have an increase of 100 percent annually in the use of telemedicine" among ViTelNet's clients, says Isadpanah. "We are one of the few making money in telemedicine. In a couple of years, we will see a big increase in that 40 percent, and I've always said that by 2005 hospitals will make at least 50 percent of their revenues through telemedicine."

Jim Mathews/jmathews@aviationnow.com is an online editor for the McGraw Hill Companies in Washington.

Reported by Washington Techway .

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