- The Washington Times - Sunday, October 4, 2009

The field of telemedicine has come a long way since a Harvard professor figured out a way to examine patients via television cameras so he wouldn’t have to fight traffic in a long car ride each day.

Dr. Kenneth Bird, a Harvard professor affiliated with Massachusetts General Hospital, was moonlighting as medical director at Boston’s Logan Airport in the late 1960s when necessity became the mother of invention. Tired of making an hourlong drive between the airport and hospital, a route that took him under the Charles River, he suspected there was a better way.

Informal as it was, he is credited with being the father of civilian telemedicine in the U.S. by using television to send black-and-white digital images that linked his medical station at the airport with the hospital when he needed help with diagnosis and treatment.

Today, telemedicine — the treatment of patients by remote means in many forms — is a “virtual” phenomenon in every sense of the word.

“The breakthrough is your mobile phone, the house call of tomorrow,” says Dr. Jay Sanders, a protege of Dr. Bird, referring to the possibility of sending images from a high-tech personal digital assistant device.

Dr. Sanders, president emeritus of the American Telemedicine Association and professor of medicine at Johns Hopkins University, sees telemedicine enabling technology to address many of the health care needs we have.

Beyond the mobile telephone, minimally invasive surgery performed by robots controlled from a remote location is being tried in Europe, according to David Balch, a technology consultant and former board member of the American Telemedicine Association.

Laparoscopic surgery using robotic devices already is done in the U.S. This allows a video camera to be positioned inside a patient’s body, becoming the surgeon’s “eyes” and eliminating the need for a large incision to see inside the body directly.

Duke University engineers are working on how to get a computer to direct robotic surgery on patients in dangerous situations such as a battlefield or in remote locations, such as outer space.

“Telemedicine is a pretty fast-paced industry,” Mr. Balch says. “What is interesting is what is coming — devices such as wearables, whereby patients with identified chronic illnesses will wear monitors and be remotely tracked and where you can set parameters so doctors are paged when necessary. Clearly, technology is ahead of the practice of medicine.”

Applications are expanding across the board — and borders — often in surprising ways, at both high and low ends since telemedicine, or telehealth, can refer to any kind of distant communication connecting patients with medical professionals or health personnel with their peers.

Inova Health System in Northern Virginia is an example of a major medical center that has taken advantage of up-to-date communication technology. Intensivists — doctors specializing in critical care — and a team of experienced critical care nurses work 12-hour night shifts, keeping tabs on 127 patients in five hospitals from a high-rise office building as far as 15 miles away.

The program, called EnVision eICU, allows personnel to monitor hospital ICU units from behind six computers at each workstation where they also have camera and phone access to duty nurses on-site as well as the patient. Inova expects to have two-way video capability in the near future.

Like air traffic controllers, their eyes are fixed on multiple signals snaking across the screens — patients’ vital signs — similar to those on view in the hospital room. They are ready to intervene if they, or the machines, detect something unusual. “It’s the small things that are the telling factors,” says Theresa Davis, eICU’s operations director.

“It isn’t a substitute for bedside care,” insists Dr. William Jackson, 37, eICU’s medical director. “It’s a safety net for the most vulnerable, the sickest patients in the hospital.”

To prevent complications, patient needs are being continually assessed. If a patient is sick enough, Dr. Jackson consults with the patient’s private physician directly. Both the doctors and the eICU nurses, including a day team, spend time bedside on a regular schedule as well as making virtual rounds.

“We’re definitely pioneers,” says Rosemary Brindle, a critical care nurse for 41 years. She recalls the time when she caught a family member wanting to remove a patient’s oxygen mask to give the patient some water. “I calmly intervened to tell them the water could go into go into her lungs and make her choke.”

While outwardly expensive — installation can range between $2.5 million and $3.5 million — and, to some, a seemingly excessive measure, the off-site support operation has shown itself in studies to be cost-effective in a relatively short period of time. Recovery of patients was faster, mortality rates in ICUs were lower, patients’ stays were shorter, thereby shaving hospital costs by 24.6 percent, and fewer intensivists were needed.

At the “high end” of telemedicine, the wealthy can virtually bring the hospital to them. Guardian 24/7, a new Winchester, Va., company in business since January, offers installation in homes, yachts and private planes of what they call a ready room. In its ultimate configuration, dubbed a “Presidential Ready Room,” it resembles a high-class hospital room with luxury trimmings.

These offerings are only the latest, and possibly the most ambitious, of so-called boutique or concierge medicine, whereby clients usually pay a fixed annual fee in order to receive services and amenities beyond the capabilities of most private medical practices.

Clients signing onto some of the most expensive Guardian 24/7 packages can, with the push of a button, activate hospital lighting, a sterilization machine, medicines, measuring and therapeutic devices — even a custom-fitted ambulance, if desired. The physician on call is available by two-way video with all pertinent medical histories at hand.

“We aren’t trying to do away with emergency medical services, the kind that paramedics provide,” says Brian O’Mara, vice president of business development for Guardian 24/7.

“We can provide for that vital 10-minute black hole, to make sure a person stays alive and doesn’t kill the heart tissue.” Potential clients respond to that appeal, he said. “They don’t want to die, and they don’t want to have to go to a local emergency room for reassurance they are just having indigestion.”

Monitoring equipment in the home allows the doctor to direct a patient or a health aide to help with the diagnosis by doing an EKG, Mr. O’Mara said. The patient puts the belt across the chest, allowing the doctor to diagnose an acute heart attack and obtain a chest X-ray.

The room, when outfitted optimally for a million dollars or more, is capable through such interactive computer linkage of performing nearly everything short of surgery that is done in any emergency room, company officials say. When a nurse is present, as will happen in some millionaire and billionaire client homes, it’s possible to do blood analysis electronically on the spot with a special diagnostic tool. After a few drops of blood are applied to a strip inserted into a hand-held device the size of a cell phone, it can print out the analysis on a screen within five or six minutes. The screen produces a printed piece of paper and also fits into a special docking system in a computer.

Client associates or their family members are trained ahead to handle lesser equipment, such as a blood pressure cuff, under the doctor’s direction. In certain cases, they might own a defibrillator and be trained to use it to stimulate weakened heart muscles in the event of a heart attack.

“We don’t do stitches,” says Jonathan Baker of Charlottesville, Guardian 24/7’s executive vice president. “And our physicians are licensed in each state where we have patients.” Buyers often are people afraid of an accident at the wrong time in a faraway place and others who don’t like to deal with emergency rooms and are aware of hospitals’ poor treatment records in transmitting infections.

Attracted by the convenience of not having to make frequent trips to hospital emergency rooms for scrapes and sniffles with his five children, Alex N. Vogel signed up for an annual high-five-figure contract. Chiefly for telephone contact, the package provides medical advice around the clock, from any location on the globe.

A resident of the Middleburg, Va., area, he is a busy man — a Washington lobbyist whose wife is a Virginia state senator with a law practice on the side. The savings in time that would have been spent going to local hospital emergency rooms for family ailments is worth it, he says.

“It’s comforting and handy, plus, we travel a lot and the idea of being accessible to world-class medical care on a full-time basis is intriguing,” he says.

To some people, this latest venture into privatized medicine is yet another example of how medical resources are being used to pamper the wealthy who already have plenty of advantages when it comes to getting good health care. Guardian 24/7 owners assert that their operation is a model for the future when developments in technology bring costs down.

But telemedicine’s reach to everyday uses for people of all levels of monetary means is extensive. Much already is happening.

Some 32,000 clients in the Veterans Administration’s pioneering home health program regularly report on their vital signs via computer or a telephone messaging machine, to a nurse or social worker panel responsible for monitoring them. Patients in turn get advice or are put in touch with physicians as needed — if a medication needs changing or hospital admission is required, for example.

More advanced forms include videoconferencing from two locations, making simultaneous consultations and the transfer of digital images possible with technology that, in some cases, is even less than that of an iPhone. The VA has 49,000 clients utilizing this method and 145,000 received care through what is called “store-and-forward” of digital images. Since beginning telehealth in 1977, the VA has seen a satisfaction rate as high as 95 percent and a 25 percent reduction in hospital admissions.

A grant from the National Science Foundation in 1969 established the first telehealth project in correctional facilities, now found in many states such as Georgia and Texas, as well as in Virginia.

“There are 16 prisons in Virginia, and we can get to all the prisoners at far less cost than bringing them in person to a hospital,” says Dr. Ronald Merrell, editor in chief of Telemedicine and eHealth and professor of surgery at the VCU School of Medicine.

“A patient can sit in a facility and talk to a doctor with secure color videoconferencing. With the help of a nurse, he can relay his vital signs.” Heart sounds picked up by an electronic stethoscope can be heard by the doctor at a distant location.

In addition to holding a two-way conversation, the patient often can zoom in on the doctor’s face and see his expression, and the doctor can see how his own face appears to the patient. This allows both parties to be aware of the subtle, unspoken emotions that are part of a routine exchange on any sensitive topic such as a person’s mental and physical well-being.

Programs in home health care as well as the construction of high-speed networks for rural and underserved areas are being spurred in part by billions of dollars from the federal government. In August, the administration announced $1.2 billion in federal grants directed to improving health record keeping by switching to electronic systems.

In April, the Federal Communications Commission approved $35.6 million under its Rural Health Care Pilot Program for telehealth networks in nine states to link hospitals regionally. A smaller sum went to a telehealth project in Alaska.

Typical of forward-moving projects, a nonprofit Ohio group called the Telehealth Video Resource Center in April launched a Web site to make its videoconferencing services available to doctors and medical educators worldwide.

George Washington University’s Maritime Medical Access program has provided medical care this way around the clock by telephone, fax or telex since 1989 to oil rigs, shipping vessels, private aircraft and yachts for nearly 20 years. Lack of availability of broadband width is generally the only limitation to service.

When the container ship Maersk Alabama was boarded by pirates off the coast of Somalia last year, the Remote Medical Program, part of George Washington University’s Maritime Medical Access service, had emergency room doctors on hand to offer advice on treating problems, should any have arisen.

Their reach has been extensive. Clients currently include a Raytheon company outpost in Antarctica.

United Health Group and Cisco Systems, a technology firm, recently announced a partnership operation of what they call “the first national telehealth network,” expected eventually to connect 600,000 physicians and 5,000 hospitals nationwide. As part of the effort, an 18-wheel mobile van equipped with the latest in videoconferencing equipment and suitable clinical tools is scheduled to undertake several pilot projects.

First up is a visit to rural New Mexico this summer, in conjunction with Project HOPE, to tackle diabetes and other chronic diseases. The van also helped with back-to-school immunizations in Baltimore in early September.

“It’s the first time a private payer has really come out in a big way and endorsed telemedicine. … The insurers are starting to say yes,” notes Jonathan Linkhouse, CEO of the American Telemedicine Association. “Telemedicine doesn’t have to be high tech. There is a huge benefit in terms of keeping people out of hospitals.”

• Ann Geracimos can be reached at agericamos@washingtontimes.com.

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