Demands for better care, cutting costs spur telemedicine's growth - part 1

Telemedicine supports three critical medical missions: 1) Delivering medicine where conventional medical care is unavailable, 2) Serving as an adjunct to conventional medicine, and 3) Providing an educational role via simulation, reducing the cost and increasing the skill of physicians - particularly in some surgical specialties - by allowing them to learn by practicing in a simulated environment.

All three roles have both civilian and military applications, and all three were discussed at the recent Telecon and Telemed II conferences. Those conferences were the platform for the introduction of many new products and technologies, ranging from network computing to distance learning. Concurrently, the National Aeronautics and Space Administration sponsored Technology 2006, which showcased new technologies from agriculture to telemedicine.

Telemedicine is being driven by the growth of managed care (capitated payment), rising costs and inadequately served patient populations - all trends likely to continue. One technology emerging is interactive video television for the delivery of health care services in remote areas. Legislation is paving the way for wider application of this technology across the U.S. There is need for medical services in specialties like cardiology, dermatology, and psychiatry in remote areas, but an inadequate supply of qualified practitioners. Where hospitals do exist in such areas, they generally are small, and have no specialists. This is one place where telemedicine has a definite and key role to play.

Differing views of market size

Estimates of the size of the U.S. telemedicine market were as low as $77 million in 1995, coming mostly from the sales of equipment to telepathology, video conferencing, and to a lesser extent, teleradiology applications, which are active in at least 40 states. Expenditures are projected to grow to more than $283 million by the year 2000. However, when military and other peripheral expenditures are included, the estimate looks more like $750 million, according to Alex Linder, editor of Global Telemedicine Report.

To overcome the scheduling and management problems that have plagued many early telemedicine programs, the conference stressed better management, organization, and planning as keys to success, particularly in building the telecommunication infrastructure on which the medicine is practiced.

The widespread acceptance of telemedicine applications has straggled against several formidable obstacles over the last decade, including state medical practice laws (often requiring doctors to be licensed in every state where they practice or provide telemedicine consulting services); expensive telecommunications infrastructure, which makes the transmission of radiology, live video and other types of medical data relatively expensive in many areas of the U.S., and generally unavailable (except by satellite) in many areas of the world; and the general complexity and non-standard nature of a telemedicine system.

Much is now changing to overcome several of these obstacles, and will continue to change after 2000 due to new technologies on the World Wide Web which are just coming on-line. As that occurs and costs of care in general rise, telemedicine will look like a better deal, and insurance reimbursement policies should change to encourage delivery of care by this means.

Telemedicine has so far proven itself in applications where it is less expensive to bring the specialist, via telemedicine, to the patient rather than to bring the patient to the traditional health care facility or specialist. Some of these traditional applications for telemedicine include: psychiatry, dermatology, prison medicine, and medical education. In other applications telemedicine is straggling to gain more widespread acceptance. With the birth of virtual reality, telemedicine is expanding into remote maintenance, medical practice simulation, and medical education. Such services are not just useful to remote U.S. hospitals, but also to underdeveloped countries.

Existing telemedicine systems use everything from plain old (analog) telephone service to dial-up, multi-megabit/sec data links. The telecommunication infrastructure underpinning telemedicine varies widely already. Telemedicine has benefitted during the last two years from the more widespread availability in the U.S. of ISDN links suitable for store-and-forward imaging and video telemedicine applications. GTE (Phoenix, Arizona) has offered new types of high-speed transmission in some areas of the country and that has assisted in creation of telemedical PACS systems.

Some states are investing in telecommunication infrastructure. North Carolina and Texas have been leaders in making high-capacity, digital wide-area networks available statewide, and now hospitals in Florida are working with Sprint to develop statewide telemedicine and teleradiology along with networked voice, image, video, and data service over an optical network. Massachusetts General Hospital (Boston, Massachusetts) and Howard University Hospital (Washington) are linking hospitals as far away as the Caribbean to provide consults and eliminate travel costs.

The National Library of Medicine (Bethesda, Maryland) also is involved, awarding research contracts of $2.8 million this past November to Beth Israel Deaconess Medical Center (Boston, Massachusetts) to develop a home-based, two-way video conferencing link for parents of SIDS-vulnerable newborns, so they can get help around the clock. In conjunction with Continuously Available Medical Care (CAMC) home stations, telemedicine allows the attachment of stethoscopes, pulse oximeters, and other monitors to be attached in the home setting and monitored remotely in the hospital. The CAMCs also can work the other way, allowing parents at home to watch their premature babies as they are cared for in neonatal ICUs. In all, 15 hospitals are participating in a federal research program to demonstrate the value and cost-effectiveness of such monitoring.

Microsoft, Netscape leading the way

The biggest factor for the future may be the rapid standardization by Microsoft (Redmond, Washington) and Netscape (Mountain View, California) on newer Internet transmission protocols that support real-time data transfer across the Internet. The moves by those companies and others may also benefit telemedical applications by standardizing the processing and hardware platform they require, reducing the number and complexity of the unique components of telemedicine systems and providing some off-the-shelf solutions to major parts of the application problem. That will reduce the logistical support (and therefore the cost) of configuring current systems. Making systems work together harmoniously and seamlessly is not a trivial (or inexpensive) task, and telemedical systems often require a fair level of expertise to troubleshoot difficulties that arise.

Teleradiology or remote PACS systems are applications which still challenge telemedicine. While the concept is viable, the amount of data required to be sent for medical X-rays is substantial, translating into wideband telecom channels and substantial transmission costs to transport the image, and costly high-resolution CRTs to view the transmitted image. Teleradiologists often have to settle for store-and-forward images, rather than real-time image transmission.

Despite problems, interest grows

In spite of cost and logistical and equipment issues, interest in telemedicine is growing rapidly, spurred not only by newer and more cost-effective core technology, but by the drive to reduce costs induced by the change to managed and capitated care delivery systems in the U.S. There is particular interest in enterprise-wide access to longitudinal medical information on patients by caregivers, as well as in building telecommunication networks which include physician offices and home health care providers.

A key issue common to all telemedicine applications is the cost and availability of adequate digital bandwidth to support medical data transfer needs, which range from fairly low for voice transmission to very high for image transmission in real-time. The Internet has become a hotbed of interest for medicine in general and telemedicine in particular, as it provides a relatively high-bandpass, digital channel at a very low, fixed cost (essentially free) from an applications point of view. The Internet connects nodes with T1 or better service, which is fine for medical records, digital voice, and some limited real-time video image transmission, and quite adequate for the transmission of small color pictures typical of those required for pathology and dermatology applications.

For years the transmission protocol on the Internet has been TCP/IP (terminal control program/Internet protocol), a mechanism that defines packets and how they are handled to assure transmission from one site and arrival at another. TCP/IP, however, has several serious limitations for some types of real-time medical data transmission, not the least of which is that it does not assure that data packets received at a node are in the same time sequence as they were transmitted. When data arrives out of time sequence, it makes the applications which process the data go to much extra work to reconstruct it into the correct time sequence.

New Internet protocol developed

The problems with TCP/IP have resulted in a newer protocol being developed for the Internet, one which better meets the transmission needs of real-time data transfer. The new protocol is real-time protocol, or RTP, which provides support for applications with real-time properties, including timing reconstruction, loss detection, security, and content identification. RTCP provides support for real-time conferencing for large groups within the Internet, including source identification and support for gateways and multicast-to-unicast translators. RTP was approved by the International Engineering Standards Group as an Internet proposed standard, and subsequently published as RFC 1889 and RFC 1890.

A year ago, Netscape unveiled Netscape LiveMedia, a standards-based framework for bringing real-time audio and video to the Netscape open software platform. Netscape's LiveMedia framework is based on the Internet RTP and other open audio and video standards such as MPEG, H.261 and GSM to enable products from these and other companies to work together, providing users with a range of real-time audio and video capabilities.

Intel (Hillsboro, Oregon), Microsoft and a consortium of more than 100 technology vendors vowed to build an open platform based on existing standards to make video, voice and data communications over the Internet as commonplace as a simple telephone call. The International Multimedia Teleconferencing Consortium, the group pushing for an open Internet communications platform, said its implementation will be based on International Telecommunications Union (Geneva, Switzerland) standards and Internet Engineering Task Force (IETF) specifications, including T.120 for data conferencing, H.323 for audio and video conferencing, and the RTP/RTCP and RSV specifications. Microsoft said last March that it would include RTP capabilities as part of its ActiveX Technologies in future releases of Windows and associated developer kits.

These developments promise to dramatically reduce the cost and complexity of transmitting live patient voice, data, and video information between the local patient site and the remote consulting site (where the medical specialist is located). When fully implemented, it will reduce the required software to a common Internet browser, like Netscape's Navigator or Microsoft's Explorer, and use the Internet as the low-cost data channel for the transmission of medical digital, vitals, and voice data.

Microsoft is making rapid strides. It unveiled its NetMeeting Conferencing Software (currently available as a beta release to Internet Explorer), which provides voice and data Internet communications on the World Wide Web, including standards-based, multi-user software support from 20 major companies. NetMeeting communications and collaboration software provides true multi-user application-sharing and data-conferencing capabilities. It makes voice and data communications over the Internet as easy as a phone call and workgroup collaboration as effective as all participants being in the same room.

Talking and working together in real time will clearly be the next big thing on the Web. Microsoft NetMeeting supports application sharing and conferences among more than two people, and international standards for the broadest possible interoperability. The application-sharing capabilities in NetMeeting allow two or more people to simultaneously share virtually any existing Windows operating system-based application across the Internet, a corporate LAN, or the public telephone network. Since almost all clinical information and electronic patient records software applications are now appearing as Windows 95 or NT software applications, the communications channel for applying them at the point of care could potentially be NetMeeting customized by some application-specific scripts written by the medical application vendors.

Microsoft NetMeeting is the first software shipped on the Web to support International Telecommunications Union standards for multi-user data conferencing, facilitating a truly interoperable multi-vendor Internet conferencing world. NetMeeting supports open, international standards from both the ITU and the Internet Engineering Task Force. The ITU T.120 data conferencing standard enables real-time, multi-user collaboration and file transfer over the Internet, intranet, or telephone network. NetMeeting also supports real-time protocol from the IETF, used to transmit and synchronize real-time streams over the Internet.

NetMeeting is based on the ActiveX technologies conferencing platform, announced at last spring's Microsoft Professional Developers Conference, with support from over 120 companies. Developers can easily add conferencing capabilities to their products using a software development kit that also is available on the Web.

More than 20 companies have announcing shipping or planned delivery of conferencing products and services compatible with NetMeeting. Some of them are listed in Table 1 on page 4. One such supplier is Incite (LOCATION?), whose new Medcite product, introduced last month, allows high-quality video, voice, and data service to be supported concurrently, through specialized hubs and advanced multimedia servers and client software over local (LANs) and wide area networks (WANs). It also features store-and-forward communications, a popular modality for telemedical applications.

Netscape has its own coalition

Microsoft's big rival on the web is newcomer Netscape, a public company which has announced its own coalition of almost 40 application vendors who will cooperate in providing an audio and video standard which allows the Internet to be the transmission vehicle for broadcast of voice and data images that will compete with television. The group includes plenty of big hitters, such as IBM (Armonk, New York), Apple Computer (Cupertino, California), Sun Microsystems (Mountain View, California), Digital Equipment Corp. (Maynard, Massachusetts), Hewlett-Packard (Palo Alto, California), and Silicon Graphics, all high-end suppliers with stakes in the UNIX operating system, a rival to Microsoft's Windows 95 and NT computing environment. This new protocol is called real-time streaming protocol, or RTSP. Software compatible with this protocol allows the standard PC to become a virtual TV which can receive "broadcasts," something with obvious medical educational implications for both patient and staff training.

Apple has said it is committed to supporting international standards for conferencing and collaboration over the Internet. Its support for these standards is a key element of the strategy for ensuring a robust environment for conferencing and collaboration over the Internet between Macintosh and Windows-based platforms. Given Apples recent alliance with Netscape and Sun Microsystems, and the interoperability which Sun is designing into its popular Solaris (UNIX) operating system, the benefits of real-time data transmission across the Internet could be extended to UNIX and Apple applications running on these platforms as well.

These new technologies open the Internet for broadcast audio and video applications, allowing the capture of digital video onto any workstation connected to the net. With the increased power of the new Intel multi-media instruction PC, scheduled to begin appearing this year, the video received from the Internet can be displayed in full screen, rather than postage-stamp-sized displays, at higher frame rates than generally possible at present.

Things will get even more interesting as cable and telephone companies begin competing in earnest to bring higher-speed data conduits into the average home and office, and as the notion of networked computers grows. Both Microsoft and Netscape are striving to facilitate the development [TABULAR DATA FOR TABLE 1 OMITTED] of such services as an integrated part of their web browser products, providing the user with a single, integrated, and generally transparent user interface for all of these various underlying technologies. Once these new technologies are in place, the job of integrating a medical telemedicine site will be greatly simplified.

Feds in a go-ahead mode

The U.S. government also is signaling the states to open up the communication pipelines. The Federal Communications Commission's Advisory Committee on Telecommunications called on federal and state commissioners to help implement sections of the Telecommunications Act of 1996 that impact telemedicine. Under that act, health care providers in rural areas are to pay rates for telecommunications services used in the delivery of health care that are commensurate to rates for similar services in urban areas. That should give rural hospitals access to service levels able to support a wide range of medical services, including the bandwidth-hungry teleradiology applications. The full report of the committee is available at http://1/41/4www.fcc.gov and can be obtained by non-browsers from the FCC's Patricia Chew at (202) 218-0260.

These industry moves and announcements do much to assure a more robust Internet protocol for the transmission of real-time voice data over the Internet, and can just as easily be used for medical applications including: live patient physiological waveforms and vital signs information derived from patient monitors being used in the skilled nursing facility, physician's office or home health care setting, for patients transferred there from acute care hospital settings to reduce the costs of in-patient care. It remains to see how individual medical equipment and system suppliers will use this new technology in actual commercial applications.

One patient monitoring company anticipating the trend is Criticare Systems (Milwaukee, Wisconsin). Its new MPT (multi-parameter telemetry) transceiver includes the necessary telephone hookups, dialers, and applications software to provide real-time data transmission over telephone lines from the patient's home to a remote site - such as a home health care agency, skilled nursing facility, or acute care hospital - which can monitor the patient's vital signs, and even remotely initiate non-invasive blood pressure readings on its monitors. The MPT is the most advanced telemetry unit to date for non-hospital monitoring. Because the bandpass required for vital signs is low (less than 10 Kbytes/second), even conventional analog telephone lines and asynchronous modems are all that's required.

Marquette Medical (Milwaukee, Wisconsin) also has been busy re-engineering the concept of medical telemetry, as noted in the November 1996 issue of BBI. Marquette's integration of infrared patient and staff locators, and cellular communications in portable nursing stations carried by nurses as hand-held personal data assistants will change the face of in-patient telemetry monitoring just as Criticare's introduction of the MP transceiver and telecommunications connections will extend monitoring into outpatient, physician office, rehab, skilled nursing facility, and home care settings.

Another company working outside of the traditional in-patient care setting is Protocol Systems (Beaverton, Oregon). In a joint project with Fairfax Hospital (Fairfax, Virginia), Protocol has helped the hospital equip a "virtual" home unit, actually a specially designed area of the hospital which is set up to simulate the home environment. This is a three-phase technology demonstration project managed at the hospital by Jay Ionetti, MD, to determine if hysterectomy patients requiring patient-controlled analgesia can be managed by their families in the home care setting on the same day as surgery, through a portable monitor networked to the hospital, with the assistance of a responsive paramedic group in the event difficulty arises.

Providing distant medical care

Bringing care to patients at home under managed care may become a growing imperative and means of further reducing hospital length of stay and in-patient expenses, but telemedicine also is moving ahead slowly in its more traditional role of bringing medicine to patient populations and locations where other medical choices and providers are either very limited or non-existent. One such location is Alaska, which covers an enormous area but has a population of less than 600,000 - the vast majority of whom are proximal to a few moderately sized cities, while the rest of whom are in an area 250% larger than the state of Texas.

Health care in Alaska has three major challenges which are ideally suited for a telemedical solution: how to provide cost-effective care across the distances represented by that enormous state, and doing so despite frequent long periods of adverse weather conditions. All of these challenges translate into a very high cost of delivering health care. While the cost of living in general is 25% higher in Alaska than in the U.S. as a whole, the cost of medical care is almost 90% higher.

Providing consistent, high-quality medical care to Alaska residents is a challenging proposition. The military plays a large role in health care delivery in the state, as it accounts for more than 70,000 state residents or family members on active duty and another 160,000 associated with other agencies. Military personnel and dependents who need medical care beyond what has been available in Alaska usually are transferred to Madigan Army Medical Center (Ft. Lewis, Washington), but that is a significant expense, and it separates patients from their families. It also is one not generally open to Alaska's non-military population. While Alaska attracts many construction and adventurous types, doctors (particularly medical specialists) generally are not among them. Alaska ranks 49th of the 50 states for the lowest ratio of physicians to population.

In 1995, a new telemedicine initiative was begun in Alaska under the auspices of Elmendorf Air Force Base near Anchorage. This initiative is one of many military initiatives in telemedicine, which we will discuss more fully in Part 2 of this series. The initiative includes video conferencing, and store-and-forward data for patient care. The U.S. Department of Defense spent around $300,000 per site for MD/TV store-and-forward systems, which provide a variety of audio and (half motion) video services using relatively low bandwidth channels. The combination of video conferencing with store-and-forward capabilities can work well for many applications. In Alaska, use of the tele-medicine systems suggests that the greatest utilization will be by those services which have been the most scaled back, or which are in the most need in a particular market.

Medical specialists who used the system, which linked clinics in four remote areas of Alaska, included physical therapy (for patients recovering from knee surgery), dermatology (for diagnosis of rash and lesions), internal medicine (for patient histories, physicals and follow-up visit consultation), emergency orthopedic care (to transmit digital photographs of fracture X-rays), and dental practice (for oral surgery and orthodontic consults). Not all of those applications proved successful, due to the low resolution of the systems installed. For improved use in dermatology and ear, nose and throat applications, a higher-resolution camera would be required, with camera stands to prevent motion blur of the images captured and transmitted.

Alaska is an example of cooperation between military and civilian uses of telemedicine in a community in which both parties win. However, the military is an important user of telemedicine by itself. We will explore what's happening in that area in next month's BBL.

COPYRIGHT 1997 A Thomson Healthcare Company
COPYRIGHT 2004 Gale Group