Using Telemedicine to Improve Health Care in Distant Areas J ane Preston,

M.D. Frank W. Brown, M.D. Bette Hartley, M.L.S.

Many users consider telemedicine a partial solution to problems of delivering health care to remote areas orareas underservedby cmicians. Current telemedical technology benefits from recent developments such as the decreased cost and improved quality ofthe coderdecoder (codec) equipment used in interactive digital video systems and the expansion of fiber-optic cable nettcorks. The authors outline some pioneering telemedicine programs of the 1960s and 1970s anddescribe two recently activated systems in Texas. One network, serving the western two-fifths of the state, links faculty members f rom four campuses of Texas Tech University Health Sciences Center with almost 40 rural communities. The other connects the state hospital and three other facilities in Austin with four health care sites in the town ofGiddings, 65 miles

away. Besides servingpatients, the systems provide continuing medical education and support to reduce the isolation of rural health care professionals. Primary goals indude evaluation and certification oftelemedical training and analysis of the cost feasibility of telemedical services.

Dr. Preston is clinical associate professor of psychiatry at Baylor College of Medicine in Houston and former chair ofthe American Psychiatric Association’s committee on telemedical services. Her address is 4030 Braker Lane, Suite 550, Austin, Texas 78759. Dr. Brown is assistant professor in the department of psychiatry at Emory University School of Medicine in Atlanta and a member of the APA committee on telemedical services. Ms. Hartley is an information specialist in the department of psychiatry at the University of Wisconsin in Madison.

For the past three decades, physicians and other health care professionals in the United States and Canada have been exploring the use of telecommunication techniques to link health care professionals with isolated areas for diagnosis, treatment, consultation, transfer of medical data, and education (1). Experiments in telemedicine have ranged from using closed-circuit television to bring medical care to patients a few miles away to using satellites to provide medical advice and training to health care professionals in another country. Telemedicine has been considered a partial solution to the problems of delivering medical care to remote areas or to areas underserved by physicians or health care specialists (214). Telemedicine has also been incorporated in inner-city health care delivery (15-17), in continuing medical education (4,18-20), and in the provision of health care to prisoners (2 1 ). Medical specialties such as radiology, psychiatry, dermatology, and speech therapy have used telecommunications effectively (22-26). Various projects have demonstrated that a wide variety of cliical tasks can be successfully accomplished via television, telemetry, and voice communication systems. The need for telemedicine is obvious in the face of major obstacles to providing a high standard of health

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care. First is the grossly unequal geographic distribution of health care manpower and resources. Second is the need for health care providers to efficiently keep up with a rapidly changing body of knowledge (27). It is not economically feasible to locate medical specialists, the highest-technology equipment, and major information resources in every hospital and clinic. One partial solution to these problems is to give health care providers access to specialists and information via telecommunications at the time they need help. In this paper, we approach telemedicine as a health care delivery system, a system appropriate for addressing problems in areas in which distance or maldistribution of resources hampers or precludes highquality medical service. First, we outline the technology of telemedicine, emphasizing live two-way visual and auditory exchange. Second, we describe some of the pioneering programs. Third, we describe two major telemedical demonstration systems now providing service in Texas. Finally, we discuss broader issues for research. “Telemedicine,” as used in this paper in relation to current operations, is telecommunication that connects a patient and a health care provider through live, two-way audio, two-way video transmission across distances and that permits effective diagnosis, treatment, and other health care activities. It is often called interactive telemedicine. This definition puts the focus on delivery of services across distances with a sense ofrespectful intimacy. It is this intimacy, directed toward resolution of disability, that is the heart of health care.

25

equipment set and the transmission set. The equipment set encompasses the hardware and software that capture visual images, sounds, and data; transform them into an information stream that can be transmitted over long distances; and then convert them back into visual and auditory images and records at another site. At the heart of the equipment set is the codec (the acronym for coderdecoder), which transforms the analog signal to a digital one at one end of the network and back again at the other. To transmit live video images, a video camera is needed at each site. It is augmented by a microphone to pick up speech or other audible information. So that those on each end can see and hear what is being sent, each site needs a speaker and a color video monitor; an ordinary television set will do. If text-such as patient records,

interoffice correspondence, or curriculum material-will be transmitted, it is desirable to include a laser printer and &x at each site. The codec makes it possible to create, send, jointly annotate, and even draw on documents, x-rays, or photographic images from both sites simultaneously. A videocassette recorder allows transmission of teaching videotapes and other material such as echocardiograms. Further, any image on the monitor screen, such as a video image ofa skin lesion or a text file, may be stored on the computer’s hard disk for subsequent review or timely comparisons. Additional hard disks may be used for extensive storage. Many of the codecs available today allow the user to choose from a variety of transmission speeds. Such adjustments alter the rate at which the digital bit-stream is transmitted, effectively selecting the size of the “pipeline” (properly called the band width) used for transmission. High transmission speeds and the broader band widths they require cost more per hour of use than slower speeds and narrower band widths. The ftstest speed readily available with current digital technology is a rate of 1 .54 megabits per second, which requires a band width commonly referred to as Ti. When lower speeds are chosen, the user will notice some anomalies in the visual field, the “echoes” ofmotion. For example, with ordinary telephone line transmission, at 56 kilobits per second, the echoes appear as a marked discontinuity of motion or as a less sharply defined image. (Some manufacturers choose to preserve image definition at the slower speeds, sacrificing some fluidity of motion; others choose to preserve the appearance of natural motion while accepting a certain amount of blurriness.) Most users find that a speed of half-Ti or one-fourth Ti is acceptable for any application. They find that slower rates are effective for most transmissions in which there is a limited amount of motion in the visual field, such as educational conferences. The transmission speed is impor-

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The technology of telemedicme Interactive video transmission is easily understood. Currently, two transmission modes exist, analog and digital. The analog mode (transmitted in the form of waves) is the technology of broadcast television. Among its advantages are the high resolution of the images transmitted and its familiarity; its disadvantages are the extreme expense associated with transmission and the size and complexity ofthe required hardware. The digital mode takes advantage of developments in computer science, transmitting in the form of a digital bit-stream of Os and is. Its advantages are lower transmission costs, reduced equipment size, simplicity of operation, and easy interface with computers and with computerized systems for storing and retrieving images and data. A relative disadvantage ofa digital system is the shadowy “echoes” of motion that appear at slow transmission speeds. This disadvantage is being eliminated with alacrity by the U.S. telecommunication industry. All modern interactive video systems use digital transmission because of its lower cost, its utility, and its potential for expansion. The working components of interactive

video

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tant in the telemedical evaluation of physical symptoms and signs, including tremors of, for example, tardive dyskinesia. The ability to select the speed gives the system user control both ofthe clinical situation and of the expense of the transmission. At present the hands-on user must “dial in” to a central telecommunication operator to select the transmission speed, but equipment allowing the user such control is expected to reach the trial stage by early 1992. This equipment should also make it possible for financially strapped community agencies, such as mental health and mental retardation centers, state psychiatric hospitals, rural general hospitals, and prisons, to participate in line-sharing and timesharing. The transmission set refers to the method by which the digital output of one codec is delivered to another. The digital bit-stream may be transported by a variety ofmedia. Many long-distance phone carriers can transport the signal over fiber-optic lines or specially conditioned copper cables. Such terrestrial transmission is the least expensive to operate on an hourly basis, but ofcourse is limited to areas linked by the lines. Satellite transmission transcends these geographic limitations, which means that interactive video systems could reach almost any location. However, satellite transmission costs roughly eight times as much per hour as terrestrial alternatives. The cost of satellite transmission is cxpected to decline markedly as more satellites are established in orbit and more satellite time is made available to the public on an as-needed basis. Yet the rapidly expanding fiberoptic network guarantees that terrestrial transmission will cost less for the foreseeable future. Finally, where topography permits line-of-sight transmission, microwaves have been used to carry digital signals over substantial distances. However, this kind of transmission is more susceptible than other kinds to atmospheric disturbance, and maintenance is costly under certain weather conditions. Currently, technological progress in two areas-improvements in the

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codec and expansion of fiber-optic transmission networks-has put interactive audiovisual telemedicine within reach of smaller facilities if they plan carefully. Because of vigorous research by various companies, the size of the codec equipment has dropped dramatically over the past ten yearsfrom equipment that would require two flatbed trucks and five persons to transport to equipment that can be lifted by one person. The decrease in the codec’s size is paralleled by a decrease in cost, which is now about $20,000. The codec’s reliability and quality, which have been criticized in telemedical applications in the past (1 1 ,i4), also have improved. A 1987 report noted that reliable, although expensive, systems can now be constructed (28). The cost of additional plug-in equipment desirable for certam uses in a telemedicine systemfaxes, fiber-optic endoscopes, laser printers, videocassette recorders, and the like-is stable or declining, and the quality is improving. However, it is the declining cost and increasing quality of codec equipment that make it possible for a small hospital to hook into transmission networks capable ofsupporting telemedicine. The second improvement is the expansion of fiber-optic networks. Five years ago it appeared that satelIke, microwave, or radio transmission would be required for all longdistance applications and that because ofthe expense ofthese systems, video interactive systems would be used primarily in urban areas. Dedicated satellite time is prohibitively expensive for most medical uses, certainly for rural communities. Microwave and radiowave transmissions require relay equipment and maintenance, again more expensive for rural applications. Fiber-optic cable is a relatively inexpensive, high-quality method of transmission, but it requires a codec, which until recently was very expensive. With the technical and cost breakthroughs for codecs, the potential market for telemedical transmissions to rural areas became evident. Regional telephone companies responded by rapidly installing fiber-

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optic cable along railroad right-ofways. Because telephone lines have been traditionally installed along railroad right-of-ways, fiber-optic installation was expedited. Fiberoptic networks provide the ideal current technology for all telemedicine and should facilitate the delivery of medical care and education to small communities located along railroad lines.

.

Pioneering systems American references to telemedicine date from 1959, when the University of Nebraska began using two-way closed-circuit microwave television for medical treatment and education (29). The first application was transmission ofdemonstrations involving neurological patients and case informarion to freshman medical students in laboratories across the campus (4). Other applications at the University ofNebraska followed, including a two-way closed-circuit microwave television system between the Nebraska Psychiatric Institute (the university’s department of psychiatry) and Norfolk State Hospital, an isolated ftcility 1 1 2 miles away. For six years the system was used to provide neurological and other consultations to the hospital, ward administration services, education and training for both facilities, and research collaboration (4). Other notable early applications of telemedicine were STARPAHC, a program that delivered health care to residents ofthe Papago Indian Reservation in Arizona, and Massachusetts General Hospital’s link with a mcdical station at Logan Airport. STARPAHC, or Space Technology Applied to Rural Papago Advanced Health Care, was a joint project of Lockheed, the National Aeronautics and Space Administration, and the U.S. Public Health Service beginning in the late 1950s (30,31). Its purpose was twofold, to carry out research in using audio and audiovisual telecommunication to provide medical service to astronauts in space and to provide general medical service to communities on the reservation. In the STARPAHC program, a van was outfitted as an examining room, with a variety of medical equipment including x-ray and

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electrocardiograph, and was staffed by two Indian paramedics. The van was connected by two-way microwave television and audio transmission to a Public Health Service hospital and to a second hospital with a variety of specialists. The project, which successfully provided medical care to remote sites on the Indian reservation, died a slow death about 20 years after its inception due to lack of maintenance funding and of system management. In 1968 an interactive television microwave link was established between Massachusetts General Hospital in Boston and a medical station at the city’s Logan Airport (32-34). The telemedicine link included an electrocardiograph, stethoscope, and voice transmission capability. Cornparisons of diagnoses made over the video link by a hospital physician (with the help ofa medical assistant at the medical station) and study diagnoses made by a physician at the airport medical station showed that only 1 or 2 percent ofthe video diagnoses were not satisfactory (35). Of the uses by various medical specialties ofMassachusetts General Hospital’s telemedicine system (35), the application of psychiatry was among the most successful. Initially, clinicians hesitated to try psychiatric consultation at a distance because face-to-face proximity was thought to be the significant factor in the intimacy needed for discussing personal matters. However, psychiatric consultations were successfully carned out at the Logan Airport mcdical station, beginning with airport employees or family members who presented as psychiatric emergencies and later extending to patients from outside the airport population (i 5). Massachusetts General Hospital also provided telepsychiatric services to the Veterans Affairs Hospital in Bedford, Massachusetts, beginning in 1968. In the i970s services were expanded to schools and courts in the community and to a nearby prison. For some patients-young children, adolescents, and certain patients with schizophrenia-communication by interactive television was found to be easier than contact in the same room (36).

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Another important study came out of the long-term use of two-way audiovisual telemedicine in critical care provided by Massachusetts Gencmi Hospital to a VA hospital. In one 18-month study of the project, almost 400 patients received approximately 1 ,500 telemedical consultations (28). The system involved a stationary television unit at the consultant’s hospital and a mobile television unit located at the distant hospital. The consultant examined the patients via a 29-inch color monitor. Transmission was by helium-neon laser at first, and later by a more reliable microwave system. The major problems were organizational rather than technical, including difficulties scheduling physician-to-physician consultation and transmitting the consultant’s recommendations to the attending physicians. However, in spite of its successes, the Massachusetts General Hospital system was silent by the mid-i980s. In the early 1970s a total of 1, telemedicine sites were receiving federal funding (37). They included Dartmouth Medical School’s Impact project, which provided services to isolated villages in Vermont and New Hampshire (38). It also oftred a model for continued medical education to a variety of health care providers until the mid-i980s.

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The growth of the telemedicine literature in the i970s, with major contributions by the STARPAHC, Massachusetts General Hospital, and Dartmouth programs, was not repeated in the 1980s; the sparseness of publications until the late 1980s reflects a decade of near-inactivity in the field. Currently, telemedicine is showing new signs of enterprise. Still to be solved, however, are problems with terminology and the old challenges of organization and management, some of which apparently contributed to the decline of the earlier systems. The recent literature reflects continuing confusion in terminology. Although for many writers “interactive telemedicine” means live, twoway audiovisual communication between patient and provider, or student and educator, it is often used to

28

describe educational transmissions that incorporate two-way audio but only one-way video transmission. (That is, a medical center transmits a lecture or demonstration to a remote area, and clinicians in that area can ask questions, but they cannot transmit images ofpatients or scans back to the center for visual consultation.) In some instances, the telemedical application may involve live twoway audio and video transmission, but the transmission speed may be slow and thus not suitable for general medical use. “Interactive” may also be used to designate interactions with a computer rather than with another person. In addition, there is no clear definition of telemedicine as a system of services. During the 1980s, equipment technologists who were associated with eight ofthe 15 federally funded programs operating in the early 1970s uniformly described similar patterns of how the systems were used (personal communications with the senior author). User satisfaction by providers and patients was high, yet the systems died ofattrition. Seen over time, two deficits are now apparent. First, telemedicine was then an information system operating in a climate and time innocent of information systems and of system management. Second, health providers of that time largely failed to usefully exploit the system or its components. Time-hungry physicians seemed naive about how to apply the systems’ power as a personal tool to better engineer their time. In addition, they only rarely used the systems to improve clinical skills. Organizational or management structures for telemedicine services were not recorded. Because provision of telemedical services fell in no one department of the medical schools involved, lines of authority and responsibility were unclear or absent. Telemedicine seemed to be considered only a communication device, not a medical tool to augment existing services and procedures. This lack of system management is likely one of the reasons that the early telemedicine systems fell silent. The literature does show relatively brisk telemedical activity in

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Canada through the i980s, although it is largely audio networking or the use of systems with two-way audio and one-way video capabilities (2,3, 8,11-13,18-20). The Canadian activity may reflect the political thrust of socialized medicine joined with the country’s great expanse of land, much of which is sparsely served by health care providers. As for telemedicine systems in other countries, systems in Italy (9) and India (1 0) were reported in the mid-i980s. More recently, telemedicine programs have been reported in China (5), Norway (6,39), and Australia (7).

Two

Texas

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Two current telemedicine projects unusual in their geographic or service-system scope are located in Texas, an appropriate laboratory demographically and geographically for studying the problems and opportunities afforded by telemedicine. Both projects offer consultations and oversight of care, provide continued medical education and support to reduce the isolation of rural health professionals, and have the goal of improving rural health. One system, Texas Tech University Health Sciences Center’s MedNet services, extends more than 500 miles to cover roughly the western two-fifths of Texas and uses the center’s faculty members as health care providers. The other, the Texas Telemedicine Project in Central Texas, reaches 65 miles from the city ofAustin to all points ofentry into the health care system in the rural community of Giddings, a town of less than 4,000 people. uses a mix ofpublic health and private providers from four sites in Austin to serve four facilities in Giddings. Both projects have substantial additional goals. MedNet’s respected academic resources are directed toward evaluation and certification of telemedical training and evaluation ofequipment. The Texas Telemedicine Project is also concerned with making cost feasibility analyses; establishing procedures for credentialing health care providers, for quality assessment, and for peer review; and evaluating community acceptance of telemedicine services.

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The two projects share information and support, especially through links between Texas Tech University and Telemedical Interactive Consultative Services, Inc., the nonprofit corporation that manages the Texas Telemedical Project. Texas Tech MedNet Texas Tech’s MedNet is a three-year demonstration project, partly funded by a $1.9 million grant from the U.S. Public Health Service, that began operation in January i989. Health care practitioners in hospitals and clinics in 37 rural communities in West Texas are electronically linked by various technologies to Texas Tech Health Sciences Center’s four campuses in Lubbock, Amarillo, Odessa, and El Paso. Four kinds of services are provided by MedNet: Clinical consultation using point-to-point interactive digital video. Primary care physicians in rural locations can communicate with physicians in larger hospitals or medical centers on the four campuses for consultation and diagnosis. For instance, patients in Alpine and Fort Stockton can be seen through live video at the Health Sciences Centers in Odessa, Lubbock, or El Paso. The two-way interactive audio-graphicsdata systems use digital Ti links. They also are fully compatible with the Texas Tech Techlink network that provides interactive video cornmunication between the four campuses. Static video imaging systems using telephone linesfor transmission. These systems allow exchange and analysis of high-resolution x-ray images, pathology images (in color), and other still images between the rural hospitals and campus sites. They also allow transfer of administrative material such as spread sheets, appointment schedules, and billing information. Engineering studies of input devices and resolution requirements, essential to the success of the technology, are also being carried out. Continuing education using satellite uplink technology. Since late 1989 the Health Sciences Center in Lubbock has provided two weekly live continuing education programs

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especially tailored to rural health care practitioners. Grand rounds, case conferences, seminars, and similar programs are currently offered to 37 rural hospitals. The systern, which is one-way analog video with two-way audio, allows telephone questions from participants. Medical information and consultation byfax. Physicians in the rural hospitals found they could use fi3.x machines, originally installed to receive documents from Health Sciences Center libraries, for consultation on fetal monitoring. More than 90 percent ofthe fetal-monitoring images sent by fax revealed abnormalities that could be managed by telephone consultation. Nineteen sites are currently on the fax network. The MedNet system offers numerous benefits to rural health care providers, such as increasing their diagnostic resources through teleradiology, telepathology, and longdistance clinical examination and case review; setting up consultations between physicians, including twoway visual consultation, without geographic limitation; and delivering more specialized medical care to patients in their own communities. Through the delivery ofcare locally, the health care revenues of the local communities are increased. In addition, the system gives rural health care providers efficient access to current medical information. They can participate in continuing education programs without the costs of travel and of hiring temporary staff to cover for them, and their professional isolation is decreased. The telernedicine system can also be used for public education, legal hearings, and administration of

Texas Telemedicine Project The Texas Telemedicine Project (which is directed by the senior author) began in April 1989 with a feasibility study of the economic, operational, and institutional aspects of a telemedical network to deliver medical services to a rural community. The study, funded by the Hogg Foundation, was notable because earher telemedical systems included virtually no studies ofcost feasibility nor ofoptimal design considerations that might help developers of future networks. Actual operations of the system began in April 1991. The telemedicine project uses a fully interactive two-way audio and two-way video network that connects four sites in Austin-Austin State Hospital, the state headquarters of the Texas Youth Cornmission, the Austin Diagnostic Clinic, and the Texas Telemedicine project office-with the community general hospital and three other sites in Giddings. The Giddings sites indude the 26-bed Lee Memorial Hospital, a Texas Youth Commission maximum-security unit, and the Giddings Regional Dialysis Clinic. The Giddings Community Mental Health Clinic, located behind the general hospital, shares the hospital’s equipment and time. Each site is equipped with a Video-Telecom CS300 unit that includes video, audio, and high-speed data transfer channels; ports for a fax and a laser printer; and two 20-inch color monitors, two video cameras, two microphones, and a speaker. The sites are linked with each other on schedules based on the projected workloads ofeach f.cility. For instance, the general hospital is connected with the Austin Diagnostic Clinic during the night, when automobile wrecks on a nearby highway may require emergency triage by clinic physicians. That connection gives way at 8:45 each morning to a link between the Austin Diagnostic Clinic and the Giddings dialysis center so that a clinic nephrologist can check the first group of dialysis patients as they are taken off dialysis and check the next group as they are put on. The management component, Telemedicine Interactive Con-

public agencies. The MedNet project was begun as a cost-participation project under which the Health Sciences Center was required to fund all equipment and to demonstrate and negotiate its cost participation annually. Administrators plan to fund the network’s ongoing operation by generating income from the system and by obtaining some ftmds from a Health Sciences Center line-item request for project staff and operations

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sultative Services, Inc., makes daily 30-minute management “rounds” of each setting. As part of the ongoing research activities incorporated into the project, each interactive meeting with users is fully documented, now in a computerized system. The documentation includes data on diagnosis, treatment, disposition, and planning; insurance information; and demographic data. Also recorded are the salary range ofthe providers, whether travel would have been required without telemedicine, estimated time saved, and user satisfiction or dissatisfaction. One aim is the development of an economic template for evaluating the cost feasibility of future telemedical services to rural areas. During the first three months of the project, the number of medical, educational, and administrative transmissions was limited by the need to develop management lines of communication, experiment with the equipment, and refine quality control procedures and software. Even so, 164 transmissions were recorded, five of which dealt with emergencies. The first emergency was a psychiatric one, involving a legally required reevaluation of the suicide potential of a patient held under emergency commitment at the general hospital in Giddings. A consulting psychiatrist at Austin State Hospita! was able to adequately evaluate the patient through the telemedical system, even though it was the first time the psychiatrist had used the equipment. Thus the telemedical consultation saved a day’s travel time from Giddings to Austin State Hospita! for a state policeman, a case worker, a hospital attendant, and the patient. The findings enabled the physician who had requested the reevaluation to release the patient, who was to be followed as an outpatient. Also during the first three months, the development of continuing education programs for physicians and nurses was begun. Such programs will alter community services significantly; for instance, training nurses to provide neonatal

30

Telemedicine

Library

Health care professionals interested in specific aspects of telemedicine may contact the Telemedicine Library, a bibliographic retrieval system initiated by the American Psychiatric Association’s committee on telemedical services. The library, 1cated in Madison, Wisconsin, collects and makes available information on the use of telecommunications for patient care and for administration, education, and research. The library currently contains more than 600 citations. The Telemedicine Library can provide data base searches and can arrange for access to the library by computer. For information, contact Bette Hartley, M.L.S., Telemedicine Library, Department of Psychiatry, University of Wisconsin Center for Health Sciences, 600 Highland Ayenue, Madison, Wisconsin 53792; telephone, 608-263-6170.

care will enable physicians to deliver babies at the community general hospital again. Training will also be offered to nursing home attendants in the care ofthe seeing impaired. Early experiences with the Austin-Giddings links suggest that the technology is equal to the task of delivering medical and mental health services to distant areas. Struggles with the technology, fairly severe initially, centered on rapid switching between sites; however, technical problems seemed to be solved within the first three months. With rare exceptions, users of the system, even those who were most reluctant beforehand, uniformly reported the experience as positive. It appears so ftr that rapid and accurate communication and steady management may be the keys to success. Telemedicine’s

future:

research issues With each new development in health care, whether a medication, a new procedure, a technological advance, or a change in patterns of service delivery, ethical and legal issues must be considered. What approach

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best serves the patient or client? Is confidentiality protected? The telemedicine technology itself carries answers to some of these questions. Digitalized messages are f.r more difficult to break into than telephone lines. Videotaping of cliical sessions incorporated into the patient record should have the same legal protections ofconfidentiality as the chart does. Patient decisions about therapy or medication should of course be informed decisions, and risk factors should be reviewed. What is the role of telemedicine here? Is the patient who is taking a medication with side effects that require close scrutiny safer if telemedicine makes expert examination instantly available? Or is the same patient in a riskier position because he or she is at a geographic distance from that expertise ifthings go awry? Research on these and related questions is obviously needed. It is important to note that many of the basic issues were well researched and documented in the i970s, including the replicability and reliability of telemedical diagnoses, patient response by treatment specialty, and user satisfaction, including the satisfaction ofpatients, referring physiclans, and consultant physicians. The Telemedicine library (see the box on this page) extensively documents such research. Minimum standards for transmission technology need to be developed to ensure that equipment is reliable and that it accurately portrays the condition of the patient. Research is needed to determine what procedures and consultations can and cannot be carried out safely and effectively by telemedicine-and what the risk of telemedical consultation is for the patient compared with the risk either ofdoing without the consultation or of transporting the patient elsewhere. Good research design will also incorporate measurement of the risk and cost of the patient’s being away from family and home. Also important is research on the therapeutic impact of obtaining consultation and diagnosis promptly by telemedicine compared with the

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usual time delay. Which approach is more effective, and under what circumstances? What are the related morbidity and mortality risks, and the costs of each approach? As for telemedicine training programs, can “bedside” training of mental health and mental retardation caregivers substantially raise the standards of care in isolated institutions? Can it also reduce staff turnover? Sociological research can also be valuable. If the impact of telemedicine on a rural hospital is to stabilize the hospital’s continued existence, what are the additional effects on the community as a whole? If telemedical education is being added to mcdical services, what is the effect on the community, on family life, and on overall community health? Several legal matters are of interest. Because physicians are licensed state by state, licensing issues immediately arise. Under Florida and Arizona law, any physician transmitting telemedical services to those states must be licensed in both the sending and the receiving state. What ifa natural disaster occurred in a state for which medical or psychiatnc services could be provided more rapidly by telemedicine from a neighboring state than by providers within the state itself? Might state licensing law preclude obtaining telemedical treatment from distant supportive medical centers? More broadly, if a state hospital or mental health center consistently lacks adequate staffing or stafftraining, could the state be held liable for not providing telemedical services to improve the situation? Another legal issue relates to whether prescriptions transmitted by telemedical systems can be honored. A pharmacist can fill a prescription only if it is signed by a physician licensed in the same state. But if a manic-depressive patient who is traveling loses his medicines, can telemedicine help? What if, through telemedicine, a pharmacist in the state in which the patient is traveling witnesses the patient’s physician in another state signing a prescription? In what state did the professional services occur? Can the prescription be filled?

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Conclusions Telemedicine cuts the cost of health care, and it improves its quality. Telemedicine puts the specialist where the specialist is needed, when the specialist is needed. It brings the medical educator and primary health care provider together at the dcctronic examining table, and it enlivens continuing medical education with bedside teaching. Telemedicine now offers the U.S. another tool for crafting a vigorous and prudent health care delivery system.

the Papago Reservation. Medical Care 17:59-68, 1979 Dwyer iT: Telepsychiatry: psychiatric consultation by interactive television. American Journal of Psychiatry 130: 865-869, 1973 StrakerN,Mostyn P, MarshallC: The use of two-way TV in bringing mental health services to the inner city. Amencan Journal of Psychiatry 133:12021205, 1976 Muller C, Marshall CL, Knashen M: Cost factors in urban telemedicine. Medical Care 15:251-259, 1977 Lindsay PA, Davis DA, Fallis F, en a!: Continuing education through telemedicine for Ontario. Canadian Medical AssocianionJournal 137:503-506, 1987 Scott AA, Boehm LA: Continuing edu-

15.

16.

17.

18.

19.

cation

References 1 . House AM: Telecommunications in health and education. Canadian Medical Associationjoumal 124:667-668, 1981 2. Dunn EV, Higgins CA: Telernedicine in Canada: an overview. Dimensions in Health Service, July 1984 3. Higgins CA, Conrath DW, Dunn EV: Pmvider acceptance oftelemedicine systems in remote areas ofOntario. Journal ofFamily Practice 18:285-289, 1984 4. Wittson CL, Benschoter R: Two-way television: helping the medical center reach out. AmericanJoumal of Psychiatry 129:624-627, 1972 5. Wang SC: [A new nursing milestone: telemedicine services in the Penghusj. Hu Li Tsa Chinese Journal of Nursing 37:65-69, 1990 6. Hjorth PS: Trends in Norway: telemedicine in a local community. Sygeplejersken 89:10-16, 1989 7. WatsonDS: Telemedicine. MedicalJournsA ofAustralia 151:62-71, 1989 8. House M, Keough E, Hiliman D, et al: Into Africa the telemedicine links between Canada, Kenya, and Uganda. Canadian Medical Association Journal 136:398-400, 1987 9. Rotondo G: [Evolution and current uses of telematics in medicine: future prospectives

of

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77:67-77, 1986 10. Desai AB, Bhargava 5K, Mehta DK, et al:Telemedicine:afeasibilityexperiment for national application. Indian Pediattics 21:773-775, 1984 1 1 . Roberge FA, Page G, Sylvestre J, et a!: Telemedicine in Northern Quebec. Canadian Medical Association Journal 127:707-709, 1982 12. Dunn E, Conrath D, Acton H, et a!: Telemedicine links patients in Sioux Lookout with doctors in Toronto. Canadian Medical Association Journal 122:484-487, 1980 13. Carey LS, Russell ES, Johnson EE, eta!: Radiologic consultation to a remote Canadian hospital using Hermes spacecraft. Journal of the Canadian Association of Radiology 30:12-20, 1979 14. Fuchs M: Provider attitudes toward STARPAHC: a telemedicine project on

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29.

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through

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Management and Residential Placement Problems of Patients With HIV-Related Cognitive Impairment Alicia James

A. Boccellari, Ph.D. W. Dilley, M.D.

The Neuropsychiatric AiDS Rating Scale, which classifies HI V-relatedcognitive impairment alonga six-stage continuum, was used to explore the relationship between the severity of impairment and management and residential probkms among 318 persons in San Francisco with suspected Hi V-related cognitive impairment. Nearly half of the sample were in the moderate, severe, or end stage of impairment. One-third of the 318 persons, most ofwbom were in the moderate and severe stages, were reported to present residential placement problems. The manage-

ment problems most associated with placement d:fficulties were home safety, wandering, confusion, and memory d:ffwulties. More than afourtb ofthe moderately to severely impaired patients were living alone with no outside help or were homeless and living on the streets. Results of this study support the development ofspecialized residentialprogramsforpatknts with HiV related cognitive impairment.

Dr. Boccellari is director of the neuropsychology service at San Francisco General Hospital, 1001 Potrero Avenue, San Francisco, California 941 10. She is also assistant clinical professor of psychiatry at the University of California, San Francisco, School of Medicine. Dr. Dilley is project director of the AIDS Health Project and associate clinical professor of psychiatry at the University of Callfornia, San Francisco, School of Medicine.

Neurological complications frequently accompany AIDS and advanced HIV infection (i-i 1). The most common is a syndrome that has been variously referred to as AIDS dementia complex (1) and HIV-iassociated dementia (1 1); in mild cases, the term HIV- 1 -associated minor cognitive/motor disorder has been used (1 1). Neurobehavioral symptoms associated with AIDS dementia complex include motor symptoms such as generalized slowing and behavioral complications such as social withdrawal, apathy, confusion, and difficulty with independent living skills (i,i2-i4). Patients who suffer from these complications provide a special challenge to the AIDS health care delivery system. Attempts to assess the incidence and prevalence ofHIV-related cognitive and behavioral changes have

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been plagued by a lack ofclear diagnostic guidelines and by other methodological problems (i 5-47). Some have estimated that at least twothirds of individuals with AIDS will develop significant clinical symptoms of AIDS dementia complex during the course of their illness (1 8). Others have suggested that clinical evidence of AIDS dementia complex will develop in only i2.8 percent of those with AIDS (19). They further estimate that a total of i 3,i44 patients with AIDS dementia complex will be living in the U.S. by the end of i99i. Investigators have focused primanly on identifying neurobehavioral abnormalities in HIV-infected persons and secondarily have attempted to estimate the frequency of these abnormalities. We are aware of no published data on the relationship of HIV-related cognitive impairment to complications in the management and residential placement of HIV-infected persons. Specific problems associated with HIV may require different management and treatment options than for patients with other dementing illnesses, such as Alzheimer’s dementia. In San Francisco and other urban areas with significant numbers of persons with AIDS, the problem of providing outpatient care is a daily

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Community

Psychiatry

Using telemedicine to improve health care in distant areas.

Many users consider telemedicine a partial solution to problems of delivering health care to remote areas or areas underserved by clinicians. Current ...
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