Telemedicine
                              
            (Introduction to Medical Informatics)
         (http://www.cpmc.columbia.edu/edu/textbook)

LAST REVIEWED:  8 October 1996

attempt to improve medicine through communications
     
     widen patients' ACCESS to health care
          bring consultant, transport records
     
     improve the QUALITY of specialists available
          public health monitoring, reduce time to treament
     
     reduce COST of care
          reduce travel, improved preventive health

survey of rural hospitals (Gaumer, 1995)
     340 / 499 hospitals have some telemedicine
     67 % have only teleradiology
     only 10% have > 1 consult / day
     median = 12 sessions / month
     up to half of sessions are nonclinical

examples:

1. insurance - try to reduce administrative costs
     
     NYS HEALTHCOM
          all 272 hospitals, 635 nursing hm, 59 county offc
          eg, hospital is given 386 unix PC, 2400 baud modem
          email (UUCP)
          medical discharge summaries
          birth certificate registry
          cancer registry
          congenital malformation registry
          universal insurance billing form
          results: 95% compliance, 75% more accurate,
               faster reimbursement, cost savings

2. public health - identify and track public health threats
     
     French Communicable Disease Network
          Minitel on toll-free line
          500 volunteer GPs report diseases
          databases for viral hepatitis, viral illnesses,
               HIV, Lyme, Rabies
          early epidemic detection, map disease spread

3. rural physician assistance - consult on less common cases
     28 million people in underserved rural areas
     rural hospitals are closing, stopping acute services
     fewer insured, older, more outpatient, long distances
     need more GPs, RNs, specialists
     but telecommunications can help: obtain results,
          read X-rays, consultation, monitor hardardous
          therapy, reduce isolation (colleagues, literature)

SYNAPSE (Nebraska)
     305 professionals
     literature, email, specialty BBSs, drug info,
          QMR (diagnosis), insurance, organ retrieval,
               patient education, events

4. text and digitized image - remotely read X-ray, pathology
     
     Glomerular Disease Collaborative Network (10 states)
          150 nephrologists
          microscope image of renal biopsy sent to expert
          dual viewing of image (true consultation)
          had to be low cost:
               486 PC, data compression, phone (56 Kbit)
          640x496 image takes 15 seconds
          switch between image and voice

     telepathology study (UNC, 1996)
          8-bit color (256 colors) just as good as 24-bit color
             (16 million colors)

5. video consulting - face to face patient interviews
     
     psychiatry consulting (Austin, Texas prisons)
          4 sites (hospital, dialysis, prison, clinic)
          expensive to move prisoners
          2500 consultations in 3 years
     general consultation:  UTMB (Galveston) 1996
          69 units across the state
          1800 telemedicine visits since 10/94
          advantages:  security; decreased cost

challenges:
     no insurance reimbursement for telemedicine
          key issue for rural areas
     slow physician acceptance
     lack of medical informatics teaching
     lack of network standards
     costly high-speed networks
     lack of coordination among counties, states, agencies
     legal = e.g., cross-border licensing; malpractice liability