GAVESTON — Dr. Michael Davis, sitting at what looks like a helm on the bridge of a starship, places a pair of headphones over his ears.
On the flat-panel screen in front of him, a nurse presses the end of a stethoscope against a prison inmate’s chest. Loud and clear, the drumming rhythm of his heart pulses across the network, covering the 70 miles between Richmond and Galveston in, literally, a heartbeat.
Doctors such as Davis at the University of Texas Medical Branch have used telemedicine for years to treat patients far away in the Texas prison system, corporate clients, rural Texans, and even researchers in Antarctica — all without leaving their hometown.
Davis and the other doctors who manage and use the medical branch’s Electronic Health Network envision wider applications for the technology that had roots in the 1960s but, until the last decade, was still largely relegated to the realm of science fiction.
Obstacles remain. Patients tend to like to have their doctors close by, and insurance companies are still skeptical about potential cost savings.
But as telemedicine technology gets smaller, cheaper and more refined, the government and insurers are paying close attention.
The potential of the technology ranges from chronic disease management — easy, in-home monitoring of patients to prevent expensive trips to the emergency room — to robotic surgeries controlled by physicians half a world away.
“The future of telehealth depends less on technology than it does politics: telecommunications laws, privacy laws, insurance reimbursement, licensure,” said Will Engle, director of the Association of Telehealth Service Providers, an international group based in Portland, Ore.
Progress In Prisons
The telemedicine program at the medical branch is among the largest and most highly regarded of more than 250 programs identified by the association in a 2005 survey, Engle said.
When an inmate in any Texas prison unit needs medical services beyond what an on-site primary care physician can provide, a medical branch specialist is just a teleconference away.
Multiple videoconferencing screens allow both the patient and doctor to see themselves and each other. The patient can zoom in on the doctor’s face, where expressions can speak volumes. And the doctor can see how his own face appears to the patient, a plus when delivering bad news, for example.
Self-adjusting cameras provide far better definition than the Web cam you’ll find at an electronics store, and they allow doctors to see the entire room, or a section of skin as large as a deck of cards.
A laryngoscope, used for viewing areas not fit to mention in print, transmits a large, crisp image of the word “trust” inscribed on a dime inside a doctor’s pocket.
In the 1990s, when the medical branch accepted the challenge of providing care for the entire prison system, one of the biggest problems was handling the reams and reams of medical records. Faxing unwieldy charts and patient histories was slow and prone to errors.
Now the records system is entirely electronic, down to the voice recognition system that takes dictation for doctors. It can handle those nonsense prescription medicine brand names and phrases like “prosthetic aortic valve replacement” without missing a beat.
With its 30 to 40 telemedicine studios, the medical branch was on pace to conduct 70,000 patient visits in 2007. During each visit, a registered nurse, emergency medical technician or other licensed medical professional was by the patient’s side to help the doctor assess the patient.
“A lot of people think that it is not a personal form of medicine, that it’s like a Coke machine that you walk up to and stick a credit card into it and a doctor appears on the screen,” said Dr. Glenn Hammack, executive director of the Electronic Health Network at the medical branch. “That’s really not anything we’ve been involved in nor do we advocate.”
From Refrigerator To Suitcase
One of the earliest exercises in telemedicine came in 1967 at an airport, of all places.
Hammack said there were concerns that Logan Airport, at the edge of Boston Harbor, would be too isolated from medical care in a disaster. A black-and-white closed-circuit television network connected nurses and patients at an airport medical station to physicians at Massachusetts General Hospital.
When the medical branch started to provide care in Texas prisons, the initial goal was to reduce van rides. Telemedicine stations were installed in 10 percent of prisons. The installation was bigger than a home refrigerator and cost more than $250,000.
Today, all prison units have a telemedicine cart, and the medical branch’s reach now extends around the globe. A “suitcase system” contains all the elements of the carts used in the prisons. It runs for hours on batteries, transmits information over standard wireless networks, and it fits in an overhead bin on an airplane. Mobile systems have been deployed to infectious disease research centers in countries around the world.
Obstacles
Many private insurers won’t reimburse for telemedicine visits. But some states, including Texas, have passed laws requiring reimbursement just as if the consultations were face-to-face.
“I think insurance companies are just sort of conservative when it comes to looking at new policies,” Engle said. “They’ve been waiting for the evidence to mount up that there are cost savings.”
Health care providers and the telecommunications industry are aggressively seeking to provide such evidence.
A 2001 report to Congress by the U.S. Department of Health and Human Services said that, while a few small studies demonstrated cost savings from telemedicine, the benefits haven’t been systematically evaluated on a large scale.
A 2007 study, funded partly by AT&T and released in November by Boston-based Partners Healthcare System, found that nationwide use of telemedicine systems in emergency rooms, prisons, nursing homes and doctors’ offices could save $4.28 billion annually.
The study was also funded by the AT&T Center for Telehealth Research and Policy at the medical branch and by grants from the Dallas-based O’Donnell Foundation and the Galveston-based Kempner Fund.
Besides convincing insurance companies, telemedicine advocates will have to ease fears about malpractice liability and licensure problems.
In many cases, doctors can’t legally treat patients across state lines using telemedicine.
In California, state investigators charged a Colorado doctor with a felony after he prescribed antidepressants over the Internet to a teenager in California. The teenager later killed himself.
In 2007, an appeals court ruled the state was within its rights to prosecute an out-of-state doctor for practicing in California without a license, even without setting foot in California.
On the other hand, patient satisfaction and worries about extending the technology to rural areas are proving to be less of a problem than some thought.
Surveys routinely show patients are satisfied with the quality of telemedicine visits versus face-to-face encounters, especially when they would have had to travel far to reach a doctor.
And the federal government is dishing out more money to extend high-bandwidth telecommunications to rural areas specifically for telemedicine. In 2007, the Federal Communications Commission announced a three-year, $417 million program to help rural health care groups build high-speed networks. The program includes roughly 6,000 hospitals, research centers and clinics in hard-to-reach places.
All of which may mean that the waiting room will one day be brought to your living room.
“You’ll have access over the Internet,” said Dr. Oscar Boultinghouse, chief medical officer of the network at the medical branch. “You’ll have a set-top box, and we’ll be channel 500 on your cable.”
