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Telemedicine untethers the doctor Improving patient care and outcomes while simultaneously cutting costs might seem mutually exclusive goals, but that is exactly the promise of telemedicine. The term telemedicine covers an ever increasing number of techniques that put patients in touch with medical expertise over great distances. Ophthalmology has embraced the benefits of telemedicine for remote screening, diagnoses and treatment. Screening for diabetic retinopathy and glaucoma are the most widespread applications of remote ophthalmologic care, with projects throughout the world. In the US, it even takes place in shopping centres. The University of Maryland's School of Medicine runs a screening programme using a non-mydriatic fundus camera in a Baltimore shopping mall. It targets African-Americans, who are at increased risk from glaucoma as well as diabetes. A trained nurse takes a picture of the retina and gives the patient a unique ID. The digital picture is sent, on a CD with hundreds of others, to the ophthalmology department at the University of Maryland's School of Medicine for analysis. Two weeks later the patient can ring up and get their results using their unique ID number. There is also talk of introducing a state-wide screening programme for diabetics in the US southern state of Georgia. Emory Eye Center, MCG Health System, and the Georgia Department of Human Resources (DHR), are sponsoring a pilot project. "This is potentially a very important project," says Maria Aaron MD, the programme's medical director at Emory Eye Center. "Its beauty is two-fold: we can save the precious sight of thousands of Georgians if they are screened early, and we can also save the state money in terms of what they would have to cover in the future eye treatment of diabetics." If the pilot programme is successful, the sponsors want to extend it to all diabetics in the state. This is the promise of telemedicine - cheaper, better quality health services. Large numbers of people are scanned and analysed by experts, all for minimal cost. "Ophthalmology lends itself to telemedicine, especially when you're checking for diabetic retinopathy. Many clinicians would assert that retinopathy is eventually an almost certainty for those with diabetes so diabetics need to be constantly screened, because blindness can be prevented if the condition is spotted early enough. Teleophthalmology allows regular, low-cost screening to happen," Jonathan Linkous, Executive Director, American Telemedicine Association told EuroTimes. Canadian ophthalmologists took the concept one step further, using a satellite uplink to deliver images from the aboriginal areas of northern Alberta province to a full service hospital in Edmonton. This system allows for identification of patients who need urgent attention, and spares others the need for unnecessary travel. The success of a pilot program led to a more extensive program called Screening for Limbs, I-Sight, Cardiovascular and Kidney (See EuroTimes May 2003).The potential for teleophthalmology beyond diabetic retinopathy is also great, according to ophthalmologists Rosa Ana Tang MD and Jade S. Schiffman MD. The two participated in a six year teleophthalmology programme at the University of Texas, Medical Branch (UTMB), in Galveston, Texas. Over 30 medical specialities were involved with weekly video-conference clinics in the UTMB programme. There were about 30,000 telemedical visits from inception, in 1994, to the first quarter of 2000. It provided care and support in the diagnoses and treatment of pterygium, cataract, trauma and glaucoma. Their video-consultations were used for verification of referring diagnoses, treatment decisions, surgical decisions and surgical consents, and follow-up dispositions. It also provided a means for resident ophthalmologists to 'sit-in' remotely on a consultation, improving education. The service proved enormously popular with patients: 93% felt adequately informed about what to expect with telemedicine, while an impressive 71% felt that telemedicine was the same or better than a face-to-face encounter. But most importantly, 74% preferred telemedicine to travelling to Galveston for a visit. The researchers also note ongoing problems with telemedicine, notably unreliable computer hardware and software. Technical limitations constrain growth in the field. However, it may be 'people problems' that are holding back telemedicine, says Linkous: "The barrier is not the technology. The big issues are acceptance by doctors and consumers, payment, liability and standards," he says.Telemedicine is slowly becoming mainstream. For example, at the recent annual meeting of the ESCRS in Munich, the sessions broadcasting live cataract and refractive surgery by satellite link were all standing room only.One can get an idea of where the field is going by looking at telemedicine applications in other medical specialties. Applications range from basic medical advice to remote telerobotic surgery.In Ball State University, Muncie, Indiana, an interactive TV network allows students to consult a nurse anonymously for advice. In Rochester, New York, staff at a crche consult with a physician when a child falls sick. Without telemedicine, parents would have to leave work when their child felt unwell. Now, parents are only called when the condition is serious. Telemedicine is certainly not limited to North America. In Norway, for example, researchers are testing applications ranging from automatic monitoring of blood glucose levels in diabetics to preventing tuberculosis. At Norway's National Centre of Telemedicine current research programmes are investigating diagnostic care to ships at sea, and to people beyond the Artic circle.In the United Kingdom, telemedicine is proving its worth as a way to maintain care while saving money. "A big development in the UK recently is video conferencing to support accident and emergency cases. For tricky cases, these departments get video-conference support from consultants at the nearest A&E hospital," explained Jim Briggs PhD, a computer scientist based in Portsmouth UK and architect behind the online UK Telemedicine Information Service.Teledermatology in the UK took off to combat a specialist shortage, according to Briggs. Now, a trained nurse takes pictures of patient conditions, which are then analysed by consultants remotely. The service provides triage, specialist referral and treatment support for local GPs. Simple cases can be treated by the GP with advice from the consultant, while difficult cases are shipped to the nearest specialist for consultation."Waiting lists in Kent fell from months to weeks since the introduction of teledermatology," said Dr. Briggs.Over time, these kinds of services are likely to extend to the home. "It's already here," said Mr. Linkous, "You can take pulse oximetry, and electro-cardiogram, blood-sugar, weight, and even test pacemakers in the home. It's individual self-care. It's not ubiquitous yet, but it will be. Vital signs equipment in homes will become as common as microwave ovens. It's the future of disease management." These systems are typically deployed in care homes in the US and Japan, where the data is observed remotely by a specialised nurse. One US company, PDSheart, even offers 24-hour heart monitoring and contacts emergency services if there is a problem. Consumers are slowly moving towards the sort of constant remote monitoring only previously experienced by astronauts.Even applications straight out of science fiction, like robot-assisted surgery and telesurgery, are old news. In 2001, surgeons in New York successfully removed the gall bladder of a 68-year-old patient in France."There are now 150 hospitals using robotic surgery right now, and in Toronto one surgeon performs operations on people 100 miles away every week," said Mr. Linkous. Jonathan Linkous Jim Briggs PhD
Maria Aaron, MD
Rosa Ana Tang MD
Jade S. Schiffman MD
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