When health care is delivered from a distance

Technology bringing specialists closer to patient and physician

For The Sunday Gazette

House calls are taking on a new look as health care catches up with available telecommunications technology.

Physicians - with the help of a telephone hookup and digital camera - now can inspect a wound, check a heartbeat and monitor water weight gain through face-to-face visits with patients over a large computer screen.

This new frontier of long-distance treatment promises to improve patients' access to medical assistance, particularly for those in remote areas, while holding down costs, health-care providers say.

Others, however, say that concerns over confidentiality, reimbursement and the qualifications of online providers will slow down this march toward what is commonly called telemedicine.

"There are a lot of things under development right now," said Jeannie Cross, spokeswoman for the Healthcare Association of New York State. "There unfortunately also are some barriers."

She cited federal regulations governing patient confidentiality, which may make it difficult to transfer medical files electronically between providers, and state professional licensing regulations, which could restrict physician consultations across state lines.

Questions of reimbursement also hinder the delivery of long-distance care, Cross said. How does a physician or hospital get reimbursed for valuable educational information posted on a Web site or offered in an e-mail correspondence? If a small health-care facility transmits a patient's lab results to a specialist in a larger hospital, how do both institutions get paid for their work?

A telecommunications partnership between Albany Medical Center Hospital and rural hospitals in central New York and the Adirondacks is exploring these issues while actively trying out new possibilities with available technology.

Branching out
Under the umbrella of the non-profit Adirondack Area Network, a teleconferencing and telemedicine system that serves a wide variety of educational and health-care facilities, Albany Medical Center is transmitting its continuing education courses and demonstrations of the latest surgical practices to sites in Cambridge, Oneonta, Plattsburgh and Burlington, Vt.

The partnership also is venturing into electronic transmission of medical X-rays and images from the smaller facilities to Albany Medical Center for consultations with specialists and emergency room personnel, according to David Bonner. He is director of Sage Technology Initiatives at the Sage Colleges and president and chief executive officer of the Adirondack Area Network.

Such video consultations can save patients drives of up to a couple of hours each way to meet with a specialist in person, and avoid having to send an ambulance out in dangerous winter conditions to the more distant, larger facility, he said.

"It really turns us into a community center, not just a hospital," said Robin Hetko, manager of information systems and communications at Mary McClellan Hospital in Cambridge, Washington County.

The hospital's rehabilitation department, for instance, is using teleconferencing technology to transmit classes featuring live patients to Herkimer Community College, she said. Similar distance learning programs also are being set up for Adirondack Community College in Queensbury, Hetko said.

Mary McClellan, meanwhile, is tapping into the expertise of Albany Medical Center Hospital's staff by exploring teleconsultations between the two facilities' emergency room staffs.

"The hope is to be able to get their expertise," especially from specialties not represented on the hospital's staff, such as cardiology and obstetrics, Hetko said of a relationship with Albany Med.

The U.S. Department of Agriculture in 1998 provided the Adirondack Area Network with funding to purchase the videoconferencing equipment, which costs up to $ 1 00,000 per unit, Bonner said. Verizon, the telecommunications company, provided additional start-up money for the project.

"Soft funding is very good to get started," Bonner said. But ongoing reimbursement from insurance companies for telemedicine, just like for any other method of treatment, will be needed to make regular use of the technology, he added.

Easier to use
Meanwhile, improved telecommunications services and rate structures are making use of the technology more efficient, Bonner said.

Hospitals and other facilities can use the same access lines for telemedicine, long-distance continuing education, Internet service and long-distance phone calls, he explained. And hourly rates of $ 1 00 to $300 per hour are changing to flat monthly rates of $2,000, allowing the facilities to stay online continually.

The federal Veterans Administration hospital system has weighed in in favor of investing in new telemedicine technology after considering both patient care and cost efficiency, area providers say.

Video hookups at rural VA-run clinics and group homes allow home-care physicians and psychiatrists at the Stratton VA Medical Center in Albany to monitor patients'health and prescribe appropriate medications without driving up to two hours away, and incurring overnight costs, to visit just a handful of ill veterans, they say.

"We can very quickly identify a problem ... and initiate treatment," said Dr. Roberta Miller, who since spring 1999 has been testing a telemedicine computer system with veterans living at the Ingersoll Home for elderly men in Schenectady. "It may prevent me traveling the 23 miles out there to get the same thing done."

This year, she plans to begin placing the system - which features a computer screen, keyboard and equipment for listening to a heartbeat and recording blood pressure rates and weight over the telephone hookup - in the homes of veterans living in remote areas who frequently require hospital care.

Miller said she expects that more regular monitoring of these patients, made possible by this technology, will reduce the need for more expensive hospital treatment.

Dr. Bruce Nelson, a behavioral health manager at the VA Center Hospital, is using a similar system for psychiatric evaluations at outpatient clinics in Elizabethtown and Plattsburgh.

The system features digital cameras at both ends of the telephone line for face-to-face interviews over a large computer screen. It has allowed the hospital to expand services to veterans without incurring the expenses of hiring high-priced professionals for low-volume sites or of sending psychiatrists 21/2 hours each way for a short visit with a patient, Nelson explained.

Plenty of potential
The system also provides more timely evaluations for patients, by allotting to the clinics regular time slots each week for electronic psychiatric visits, Nelson said. Previously, patients sometimes had to wait months for a psychiatrist to drive up to a clinic.

As the technology improves and costs drop, Nelson said he expects eventually to install the system in all 12 of the hospital's outpatient clinics.

Bonner and Dr. Henry Pohl, vice dean for academic administration at Albany Medical College, also see plenty of potential for the Adirondack Area Network system.

The system is used now mostly for educational programming, such as joint ethics committee meetings between the teaching hospital and other, smaller facilities, videoconferences during live operations to introduce other professionals to the latest in surgical techniques, and hospital emergency department training of volunteer EMT squads in the Adirondacks, Pohl said.

He envisions eventually having hometown family physicians working with specialists in Albany on a patient's treatment plan without requiring the patient to travel. He envisions electronic follow-up visits after a patient's release from the hospital.

Bonner envisions teleconferencing visits between patients at Albany Med and their family and clergy offering support from hospitals hooked up to the network in the home community.

"The technology has proven itself for continuing medical education and online reading of X-rays," and now is ready for expansion of services, he said. He acknowledged, however, that more than funding stands in the way of fully implementing the system.

Questions of physician licensing over state borders - and even between countries - will become tricky as telemedicine expands, Bonner said. He also said that the technology and its use also hasn't been licensed, and practitioners are grappling with ways of ensuring that safety mechanisms are in place in case a critical telecommunications connection fails.

"When you start to get dependency on the technology in patient care, it becomes an issue," he said.

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