Telemedicine: How does it work?
Telemedicine uses a hybrid technology incorporating elements of television, telecommunications, computers, and engineering. Services can be delivered on a combination of technologies with a variety of equipment. Most telemedicine applications require interactive voice and video, the quality of which varies according to the delivery system. At the lowest end, several companies make a slightly more sophisticated version of the telephone which allows audio and still images to be sent between sites via conventional telephone lines through the use of a handset, a camcorder, or a built-in camera at one end and a monitor at the other. The Internet also provides a platform for sending data, text, still images, and limited full motion video.
At the higher end of the technology scale are dual monitor videoconferencing systems (one monitor displays the sending image and one the receiving image), which are equipped with microphones, built in cameras, a video codec which compresses the video into digital form and a user interface. Digital scanners, microscopes, VCRs, telestrators (annotators), and electronic medical instruments such as stethoscopes and otoscopes can be added to these systems as required. The speed of transmission largely determines the quality of the picture. On telephone lines these systems can run at speeds from 112kbs to 1.544 mbs (a full T1), all at 30 frames per second. A codec compresses the video signal at one end and decompresses it at the other. Videoconferencing at speeds of 1/2 T1 or higher give full motion, real time, nearly broadcast quality video. Full broadcast quality (uncompressed video) can only be achieved using a satellite.
There are three major vendors of videoconferencing equipment, and there are numerous desktop conferencing packages. Standardization is still being developed in the industry. Presently, communication between different types of equipment (e.g. desktop and video codec) and different manufacturers is possible, but with decreased performance. The transmission speed defaults to the user with the slowest speed.
The lower end technologies such as still image videophones (about $3,000 per phone) and the Internet (the price of a PC) are excellent for data and voice transmission, but image transmittal is still slow and cumbersome. With patience, however, and a narrow, well-defined agenda, some useful medicine can be accomplished at this level. For example, a 3-month trial was conducted this spring using still image phones between the dermatology departments of Yale and the VA Medical Center. A Yale dermatologist successfully supervised surgical decision-making and technique on patients at the VA. Residents were guided through excisional surgery of malignant lesions. This saved hours of travel time for both dermatologists and residents (who typically shuttle back and forth between the two sites several times a day, a 15 minute trip each way), and improved patient care by allowing residents and less experienced clinicians immediate access to Yale's dermatologic surgery faculty.
Developing a reliable delivery system has been slow, which contributed to the cautious pace of telemedicine in the early 90's. Reliability is still an issue for some aspects of some technologies. Redundancy of equipment and/or personnel protects data and ensures patient safety. Although the technology appears as simple and as familiar as turning on a TV set, in fact multiple technical elements are involved and users must be trained to operate the equipment. In our experience telemedicine projects require broadbased planning, installation, and operational support.
Telemedicine: Its importance
Well-developed telemedicine programs have been around in Nebraska and Iowa since the 1960's, but telemedicine became a hot new concept only very recently when it was evident that health care reform was underway. Health care cost containment has become a national priority, and the failure to pass federal reform has spurred local changes. There were 10 telemedicine programs in 1992, 20 in 1993, and it has been reported that in 1995-96 most US hospitals plan to implement some form of telemedicine program for clinical and/or administrative purposes.
Telemedicine breaks down geographic barriers and certainly it will save a lot of dollars very quickly by treating many patients on site rather than in an expensive hospital setting; it will improve patient care by giving health care providers access to teaching medicine resources; and it will target services to populations that have been hard to reach (remote rural areas), expensive to serve (prisons, mental institutions), and historically neglected (urban poor).
In many countries outside of the US the fiscal realities of health care are equally compelling. Three countries in the Middle East - Saudi Arabia, Kuwait and Abu Dhabi - spend $60-100 million a year each to send their citizens abroad to receive health care. A telemedicine relationship with Yale would significantly reduce those costs. At the other end of the scale, money is being provided by many organizations for telemedicine to underdeveloped countries, to improve health care by connecting local practitioners with distant help.
The Yale Telemedicine Center
<http://info.med.yale.edu/telmed/>
;The Yale Telemedicine Center disseminates educational activities at Yale to a wide variety of universities and health care institutions and provides interactive clinical consultations in every specialty. This summer we participated in a project at the Special Olympics connecting the Smilow Field House with the Emergency Radiology Department at Yale New Haven Hospital. Physicians at the Field House used teleradiology equipment to transmit X-rays in as little as 10 seconds each to Yale for consultation with radiologists.
There are a number of current and pending telemedicine projects at the School of Medicine: the Saudi-US Universities Project (SUSUP), the NASA Spacebridge Project, and other projects connecting Yale to other hospitals in Connecticut and nationwide.
The SUSUP links Yale with Duke, University of Virginia, Texas Childrens Hospital, George Washington University and King Faisal Hospital in Riyadh, Saudi Arabia. Each site is supplied with a dual monitor videoconferencing system, a digital X-ray scanner, a teleradiology workstation (computers and high resolution monitor), and a telepathology workstation (digital microscope and computers). The US universities are connected to Washington via a dedicated T1 telephone line. In Washington, the signal is transmitted to Riyadh via satellite. Three days a week the participants share clinical and professional educational information.
The NASA Spacebridge Project links Yale with Fairfax Hospital in Virginia, LDS Hospital in Utah and the Clinical Hospital in Moscow via the Internet. The project will develop software to enable participants - both medical students and physicians - to share clinical information about difficult cases using text and image transmission on the MBONE (the multicast backbone on the Internet).
Another project links Yale with hospitals in Detroit and Honolulu. This project focuses on telementoring, a process whereby a Yale surgeon guides or "mentors" a less experienced surgeon at a distant site during a laparoscopic surgical procedure. Fewer than 10% of US surgeons perform advanced laparoscopic surgery (operating through several one-inch incisions in the abdomen as opposed to opening the whole abdominal cavity). There is an estimated failure rate of up to 43% on initial laparoscopic procedures; telementoring sharply reduces or eliminates failures. Later this year several other applications including interventional radiology procedures, multidisciplinary case presentations, and grand rounds will be showcased on this network.
A project linking the School of Medicine with the VA Medical Center will begin in a few months, making Yale's combined faculty available to all VA patients for clinical consultation in radiology, pathology, psychiatry, internal medicine and surgery. Inquiries for other projects have come in from Greece, Mexico, Argentina, Jamaica, China, Kuwait, Russia, and the Philippines.
Telemedicine: the future
These technologies will transform the way medicine is practiced, eventually bringing significant elements of health care directly into the patient's home. We are just beginning to define the full scope of telemedicine, but it's future will be driven primarily by the new economic imperatives which are dramatically changing health care delivery. Telemedicine will not only allow physicians and other health care workers to take better care of patients, but will provide patients with tools to allow them to take a much more active and effective role in taking care of themselves.
To discuss a telemedicine project, please call Lindsey Holaday 7-5279 or Henry Swett, MD, 5-2688.
Henry Swett, MD, is Director of the Yale Telemedicine Center, Assoc. Prof. Diagnostic Radiology, Dir of Emergency Radiology, and Clincal Dir of PACS/Teleradiology at YNHH (Phone: 5-2688)