One day in the mid-1960s, Dr. Kenneth Bird found himself caught in a miserable traffic jam in Boston's Sumner Tunnel. At the time, only 1 tunnel connected the city with Logan Airport, and the 2.7-mile trip often took more than an hour. Bird made the trip regularly as a physician working at Massachusetts General Hospital (MGH) and in Logan's medical station. On this particular day, the standstill led him to dream of a system of communicating with patients over the airwaves, eventually leading to the introduction, by early 1968, of a microwave-based television system connecting MGH with the airport.
Bird's son, Greg, told this story during the inaugural Kenneth Bird Lecture at the Eighth Annual Meeting of the American Telemedicine Association (ATA) in Orlando April 27-30, 2003. Using Bird's system, physicians at MGH took a patient history and remotely controlled a camera trained on the patient. Nurses at the airport used electronic instruments to measure and transmit to the hospital blood pressure, heart and lung sounds, ECG, and x-rays. According to Greg Bird, his father examined his first long-distance patient, a man with an acutely swollen left knee, and asked the man about the experience. The patient replied, "Doc, it was just as if you were here."
The discussion of the field's origins preceded a talk by Joseph F. Coughlin, director of Massachusetts Institute of Technology's Age Lab, about how its leaders have sowed the seeds of its "creative destruction." Such contrasting concepts, between beginnings and ends and between cutting-edge technology and practical answers to daily problems, characterized this year's annual meeting. Coughlin credited economist Joseph Schumpeter (1883-1950) with the notion of "creative destruction," the idea that, when done right, a new field will attract new ideas, new players, and new models of doing business that will reinvent it. According to Coughlin, telemedicine is largely a set of technologies in search of a market. The field is trapped within medicine's model of reimbursement for services, a model that must change if telemedicine is to reach its potential, he said. The focus must shift from building leading-edge technologies to exploring how to manage chronic care, he said.
He described 4 visions for the future of telemedicine, each representing a new set of entities now entering the field. The first would occur in retail pharmacies and might take the form of a wired kiosk where customers could receive answers to health and treatment questions. The second model, already in practice, allows patients to use wireless devices equipped with sensors to give themselves "a checkup a day." Following this model, patients gather data themselves and, if necessary, send it to a medical center for review. Such monitoring would allow patients to focus on their own behavior, "really engaging people in what they're doing." The third model would involve creation of service networks for care. Such networks might eventually build around homes reconceived as health stations. A fourth model might begin with employers interested in monitoring their employees' health. Coughlin described a company that has placed pedometers on employees' feet to determine how much they walk while on the job. According to this model, work places become "where you're not just paid, but where you're checked," Coughlin said. Each one of these models suggests a different group of players and a different business model from existing telemedicine, he said.
Other presentations focused on telemedicine applications that can be put into practice today. Dr. Michael Ricci, MD, described preliminary results of the Vermont Tele-Trauma Project, an effort to provide video consultations to doctors in rural emergency rooms in Vermont and upstate New York. Vermont is an ideal location for testing rural telemedicine because it ranks 49th in population in the United States, has 68% of its population living in rural areas, and patient transportation often is hindered due to weather conditions. Ricci, a vascular surgeon, said that rural patients are about twice as likely to die from trauma-related injuries as urban patients with similar injuries. The reasons include less access to specialized care, physicians with less practice handling certain types of injury, and longer transportation times. It can take 1-4 hours to transport patients to Fletcher Allen Health Care in Burlington, the major teaching facility for the University of Vermont. This compares with about 20 minutes in Miami, Florida, Ricci said. "We thought that maybe we could help by using telemedicine and bringing a trauma surgeon virtually into a rural hospital. That was our premise. I think what we learned from that is that we get just as much out of it as the rural doctor does." He said that doctors in rural areas get the benefit of a specialist's knowledge, while the specialist gets better continuity of care and has a better sense of the problems before the patient arrives at Fletcher Allen.
In an article about the system, Ricci described several technical requirements for rural teletrauma care. These are:
a short response time from the consulting physician, meaning that doctors must have convenient access to videoconferencing equipment, even at home;
a system simple enough to operate at both ends without technical support;
remote control of cameras by consulting physicians, leaving ER physicians' free to provide care;
a small "footprint" for video equipment placed in cramped emergency rooms;
equipment flexible enough to be used for remote educational sessions; and
adequate audio transmission.
Consulting surgeons also found the ability to view radiographs very useful.
In addition to technical requirements, Ricci said physicians on both sides must put aside their skepticism and think of their relationship as a partnership. "I think the biggest lesson for us was -- I confess -- that we probably went into it with a paternalistic attitude: that big brother was going to help out. But it turns out that it's a symbiotic relationship." He said that the system has helped doctors in rural hospitals and at Fletcher Allen develop relationships. "But also we jointly take care of patients."
From April 2000 to November 2002, physicians at Fletcher Allen completed 41 teletrauma consultations, primarily for long-bone injuries, closed-head injuries, liver and spleen injuries, and lung contusions. Among the dramatic cases, Fred Rogers, MD, talked a doctor through a surgery to establish an airway in a head injury patient. After the consultation, both referring providers and trauma surgeons answered questionnaires. Of trauma surgeons, 61% felt that the teletrauma system improved patient care and 67% felt that consultations would not have been as effective over the telephone. Referring providers had even stronger positive reactions to the system: 83% thought the consultations improved patient care and similar proportions felt that the telephone would not have been as effective.
One type of procedure now being investigated by the group at Fletcher Allen is the possibility of providing consultations even for some neurosurgeries, such as release of pressure buildup in head injuries. "It can be a life-saving procedure, but you only have a very short period of time. It's pretty hard even for a physician to take a drill to somebody's head... It's dramatic to me. It's not the easiest thing to do." Rural physicians used to perform these types of procedures, but they have become the domain of specialists, he said. Other uses for video-conferencing systems might be obstetric and pediatric emergencies. The Vermont system initially consisted of 3 dedicated ISDN lines, video cameras capable of remote operation, and ordinary personal computers, though dedicated video-conferencing systems now provide better results. The program initially was funded by a grant from the Department of Commerce's Technology Opportunities Program and was then expanded using funds from Office for the Advancement of Telehealth (part of the US Department of Health and Human Services). Fletcher Allen has provided about $300,000 a year in telecommunications costs. Ricci also said that the program has received strong support from US Sen. Patrick Leahy (D-Vt).
In contrast to the high-tech video conferencing used by Fletcher Allen, low bandwidth is the rule for the most remote places of the world, said Charles R. Doarn, MBA, executive director of Medical Informatics and Technology Applications (MITAC) at Virginia Commonwealth University in Richmond. Doarn gave a presentation on his organization's efforts to do telemedical consultations in Romania, parts of Russia, the Amazon interior, Ecuador, and Kenya. MITAC is developing remote telemedicine in partnership with NASA, which wants to find applications useful for space travel. Doarn said that earthbound telemedicine can be accomplished using satellite telephones and other low-bandwidth technologies, but care providers must lower their expectations for perfect communications because such devices are prone to static and intermittent transmission. "If you look at the picture of the world lit up at night, the lights don't signify where most of the world's population lives," Doarn said. "With limited bandwidth, it becomes a big challenge to try and deliver quality healthcare if it's designed around high-capacity Internet or if it's designed around high-speed phones."
Rather than using such high-bandwidth technologies, MITAC employs satellite telephones that make use of low-bandwidth orbital satellites, but which also have the advantage of being available almost anywhere in the world. He said that a recent transmission of a trauma course between Richmond, Virginia, and Ecuador succeeded using satellite telephones, but transmission was choppy. Doarn, who used to work on space medicine for NASA, said that the space program faces similar problems because of long transmission times and other challenges. This is leading the space administration to develop more on-site technologies for treating people in space, including training systems and other technologies that probably will have applications on Earth. The biggest challenges, Doarn said, are to encourage people to consider how earthbound medicine and earthbound physics will change in space. "It becomes very much a challenge to get a quality healthcare link to the (orbital) space station. It's not quite as robust as it could be in 2003. You would expect that there would be a lot of bandwidth. There is. But the amount dedicated to healthcare is 13 or 14 kb, which is...nominal. A lot of the bandwidth is for station keeping and down-linking of science and teleoperations...We've been able to use low bandwidth to do a lot of different things. You can do a lot with less, but you have to have the expectations."
A cluster of telemedical applications designed for veterans reflected Bird's notion of telehealth as a resource for communities. The Department of Veterans Affairs took up a large corner of the exhibit space with a group of 15 small exhibits showing telehealth initiatives developed by individual veterans hospitals. The displays included mental health initiatives, home care, retinal screening, hospice care, neurology, Parkinson's disease, and speech pathology. Donna Ferro, RN, a nurse with the VA hospital in Huntington, West Virginia, showed off a screening system for neurology and Parkinson's patients. The Huntington hospital, an 80-bed facility in rural West Virginia, uses teleconferencing technology to connect patients with a VA medical center in Lexington, Kentucky, and the Parkinson Disease Research Education and Clinical Center in Richmond, Virginia. Patients doing the remote screening can cut their visits to Richmond down from an average of 5 to just 2, once for surgery, Ferro said. For a Parkinson's screening, for example, a physician in Huntington will perform an initial exam. Those results then are reviewed and a telemedicine session with a neurologist in Richmond can be arranged and information from the session transmitted back to Huntington. At that point, doctors in Huntington can arrange treatment or send the patient for more specialized treatment. The system uses secured lines, which Ferro said ensure patient privacy. It also takes advantage of patient records that are shared throughout 173 Veterans' hospitals, the nation's largest health system. Ferro said that the ability to electronically share records across several VA hospitals provides an essential backbone for the system's telemedicine initiatives.
Carol Jordan, RN, a coordinator for remote palliative care at the VA hospital in Indianapolis, Indiana, showed off a herd of teddy bears with heart-shaped bibs sown on their chests reading "telepal," which stands for "telehealth delivery and palliative care." Jordan's group provides chronically ill or dying veterans with a home-based monitoring system, a store-and-forward device the size of a breadbox with a small screen and a camera on top. The device connects to an ordinary telephone and collects information about health measures, such as patient fatigue, pain, and endurance, and forwards it to the hospital once a day. It has attachments, such as a blood pressure cuff and a stethoscope, so that nurses or doctors can check blood pressure or listen to heart and lung sounds. "It lets us know whether we're managing their symptoms or not," Jordan said. "If their pain score is 7 [on a scale of 10], then we're not doing our job. It sends a red flag and we call them." The system allows palliative care nurses to set up appointments with social workers, clergy, dieticians, nurses, doctors, and others involved in holistic patient care. Jordan said that the home-based monitoring system has reduced the number of emergency room visits for enrolled veterans and helps identify the need for hospice care a bit earlier. Each veteran enrolled in the program receives the monitoring device and a teddy bear, she said. "It allows veterans to take some control of the disease process, to feel like they're participating in their own care."
In the opposite corner of the Orlando exhibit hall, displays from contractors with the US Army's Telemedicine & Advanced Technology Research Center (TATRC) created a high-technology military presence within the exhibit hall. Half of the TATRC exhibit space was filled with a genuine army hospital tent filled with new battlefield technologies, including litter-pulling robots, for treating and transporting wounded soldiers. But the TATRC display area also contained displays from several technology initiatives designed to serve rural and undereducated areas. In particular, representatives from the Center of Excellence for Remote and Medically Underserved Areas (CERMUSA) presented several technologies built from personal digital assistants (PDAs) intended to provide more diagnostic technologies to remote physicians. One such technology was a Hewlett-Packard iPAQ equipped with leads that turn it into a miniature electrocardiograph. Another, more sophisticated version of the same device had 12 leads and could be synched to a computer to transmit data directly to the patient's record. These $1200-$1500 devices are mobile and inexpensive, said Vicki Pendleton, RN, who works with CERMUSA through St. Francis University in Loretto, Pennsylvania. Pendleton, an emergency nurse, was particularly excited by an iPAQ-based emergency room toolbox that the center has developed. The kit contains all the mathematical formulas needed to calculate fluid drips and other dosages necessary for emergency and critical treatment. "It gives you the recipe," she said.
TATRC, which funds many research efforts in advanced medical technologies, wants to integrate simulation and other technology efforts nationwide to begin to create a cohesive field from many scattered efforts, said J. Harvey Magee, TATRC's project officer for medical modeling, simulation, and advanced medical technologies. "We don't want to own it all," he said. "But we want to integrate simulation efforts on behalf of the country."
Another TATRC-funded effort on display was a smallpox inoculation teaching kit completely contained in a cardboard tube. The kit, called SITU, for Smallpox Inoculation Training Unit, will become part of the nation's bioterrorism defense initiatives. The US government has identified the disease, which was declared eradicated in 1980, as a potential bioweapon following the events of September 11, 2001. Researchers at the Center for Integration of Medicine and Innovative Technology (CIMIT) in Cambridge, Massachusetts, developed the training kit for the army in just 10 weeks, presenting it for the first time at ATA.
The tube can be shipped anywhere in the world and stored indefinitely, said Steve Dawson, program leader of CIMIT's simulation group. It stands 16 inches high and 4 inches in diameter, and contains a simulated arm that looks and feels like a fleshy upper arm, complete with 3 subdermal packs of simulated blood that will ooze or drip out when punctured. The kit also contains a vial of simulated vaccine, 4 bifurcated, smallpox inoculation needles, an instructional CD, and a platform to hold the vaccine. The purpose of this self-contained kit is to revive knowledge of a vaccination technique that has not been practiced on American civilians since 1977, Dawson said. The technique is simple, he said, but differs from standard muscular injections because it requires practitioners to pierce patients' skin up to 15 times, just enough to draw a dot of blood, but not so deep that the puncture bleeds freely, which would flush out the vaccine. The tube contains everything needed to teach the inoculation technique, as well as proper handling and disposal of live vaccine and dressings, which are biohazardous. The simulated vial of vaccine actually contains an inert powder, developed in MGH's pharmacy, that can be reconstituted using the same dilution mix as actual smallpox vaccine. Thus, a practitioner can practice the steps of preparing the inoculation, puncturing an arm that bleeds realistically, and disposing of the resulting hazardous waste. By the end of April, 33,000 people nationwide had received smallpox vaccinations. Some time in early 2004, about 200 million doses of vaccine will become available to the public.
Nearly 2000 people attended the Orlando meeting. The President's Award for the Advancement of Telemedicine went to the Missouri Telehealth Network based in Columbia, Missouri, and to Dr. Lloyd M. Aiello, director of the Beetham Eye Institute, Joslin Diabetes Center, in Boston. The Maxwell Thurman Award for leaders in telemedicine and advanced medical technologies went to Major General John Parker. The American Telemedicine Association will hold a fall forum on remote telemonitoring and home telehealth from September 14-16, 2003, in Fort Lauderdale, Florida, and the next annual meeting will be held in Tampa, Florida, from May 2-5, 2004. For more information visit ATA's Web site.
Medscape Technology & Medicine. 2003;1(2) © 2003 Medscape
Cite this: Highlights From the Eighth Annual Meeting of the American Telemedicine Association (ATA) - Medscape - Jul 14, 2003.