THE MEDICAL MIRACLE OF TELEMEDICINE
With a little high-tech wizardry, television turns into telemedicine and can become something of a medical miracle.
Written by Sally Logue Post
Some people call television the idiot box, but when combined with a little high tech wizardry, television turns into telemedicine and can become something of a medical miracle.
Telemedicine, as practiced at the Texas Tech University Health Sciences Center, has saved a newborn child’s life, has kept asthmatic children out of the emergency room, and has saved nursing home-bound senior citizens from costly and traumatic ambulance rides to the hospital.
The concept of telemedicine began at the Health Sciences Center in the late 1980s. During its first trial run, in June 1990, a routine post surgical follow-up consultation suddenly turned into a life-saving situation.
James Luecke, M.D., was on one end of the telemedicine conference in Alpine, Texas, 300 miles away from Ted Hartman, M.D., at the School of Medicine in Lubbock. Three hours before, Luecke had delivered a little girl. Now, Aida was having trouble breathing. Suspecting heart trouble, Luecke asked if a neonatalogist was available. Marian Myers, M.D., was summoned to the telemedicine consultation room. After asking a few questions and looking at Aida’s X-rays and laboratory work, Myers diagnosed acute respiratory distress due to aspiration pneumonia. She recommended emergency treatment that Luecke administered. Two hours later, Aida was stable. Today, she’s a healthy 12-year-old, doing well in school and taking dance classes. And her mother isn’t shy about telling everyone that telemedicine saved Aida’s life.
"I didn’t think my daughter would make it," said Mary Porras. "Sometimes I stop and think, it makes me shiver, what would have happened if they hadn’t had telemedicine."
While no stories have been quite as dramatic as Aida’s, telemedicine continues to grow and aid the Health Sciences Center in providing more and better health care to Texans.
Telemedicine is basically about overcoming distance and improving access to health care. And in rural West Texas, people often lack medical access and have plenty of distance to cover between small towns and big city hospitals.
An internal matter of distance gave rise to telemedicine at the Health Sciences Center. When the school of medicine was established in 1969, campuses were opened in Lubbock, Odessa, Amarillo and El Paso. The decentralized concept presented communications problems. To help solve those issues and better utilize faculty, the School of Medicine began using teleconferencing between its campuses. Third- and fourth-year medical students are spread out among the four locations.
E. Jay Wheeler, M.D., the former associate dean of the School of Medicine, and Ted Hartman, M.D., then the dean of the School of Medicine, began thinking the same concept could be used for primary care. "We knew we had to do something to help rural communities, but we didn’t have a firm thought," said Hartman. "It was really Jay Wheeler who had a sense of what we could do in the way of primary care, even if it was just over ordinary telephone lines."
Wheeler won’t take all the credit. He insists the early success of telemedicine was a joint venture. "We had every reason to believe this would work, and it has," he said. "Once we had created the network between the four campuses, we were sure we could use that backbone to extend into rural communities."
In the late 1980s, Health Sciences Center officials convinced U.S. Sen. Lloyd Bentsen of Texas that telemedicine had real potential. "Sen. Bentsen managed to include $2 million as part of the rural health policy budget and that’s how telemedicine really got started," said Hartman.
With that first federal appropriation, and donated equipment from AT&T and support by Southwestern Bell, telemedicine was on its way.
The concept is simple and is known as a TeleDoc. On a mobile cart are a camera and microphone so the specialist at the Health Sciences Center can see and hear the patient and the health care provider. The remote location also can see and hear the doctor. The camera can zoom in on specific areas, such as a burn or a surgical scar. Instruments allow the specialist in Lubbock to look into the patient’s ears and throat. Medical records and X-rays also can be transmitted.
One of the first challenges faced by this new technology was how to combine bulky cameras, monitors and medical equipment into a portable unit. The Health Sciences Center already was conducting classes by teleconference and recently had begun producing and distributing continuing education programs to hospitals in the region.
Hartman and Wheeler took their ideas to Jeff Cowan, the engineering manager at HealthNet, and his colleagues.
"We thought we could basically use what we were using in the classroom setting," says Cowan, associate director of telecommunication service at HealthNet. "We gathered up everyone’s ideas and needs and pulled together the equipment we’d need."
The hardest part proved to be finding a cart to make the whole thing portable. "We ended up designing a tank," Cowan said. "It weighed 300 pounds, but you could roll it around and it was durable."
The TeleDoc concept is still in use today. But this so-called medicine of the future first appeared in surprisingly similar detail on the cover of Radio News magazine in 1924. The picture of this "radio doctor" shows a large box that resembles a giant console television showing a doctor in one place examining a child in another place. It’s worth noting that this audio–video hook up came a few years before the first television broadcast.
While the principal is very similar to the TeleDoc first built at the Health Sciences Center, Cowan says he didn’t know about the magazine picture until he was interviewed for VISTAS.
The next major advance in the use of telemedicine came in the mid-1990s when the Health Sciences Center signed a contract with the Texas Department of Criminal Justice to provide medical care to some of the state’s prisons.
"There was explosive growth in the prison population during that time," said Don McBeath, director of Telemedicine and Rural Health. "Most of the time
when an inmate needs medical care, he or she must be transported long distances to a hospital. The logistics and manpower needed to take an inmate of a prison for sometimes two or more days at a time can be staggering and expensive. The people at Texas Tech thought telemedicine had significant potential to save a lot of time and energy and improve care."
Between 1994 and 1998, telemedicine units were installed in several prisons. "Our doctors can see the patient and determine if he or she really needs to go see a specialist," said McBeath. "It’s also a tremendous tool for post-surgical follow-ups."
The work in the prisons has helped Health Sciences Center experts learn to better utilize telemedicine. "It has helped us understand how to do telemedicine well," McBeath said. "We better understand when it is appropriate. We have learned how to better train the presenter, or the person at the remote site who is talking to the doctor. The time spent in the prisons has helped advance the program as a whole."
Health Sciences Center doctors next trained their sights to small town schools, and Hart, about 75 miles northwest of Lubbock, was the target.
No physician lives in the small town of about 1,100 people. The closest doctor is 15 miles away. While that may not sound far, it can be a huge obstacle to parents who must take a half day off from work and lose pay, to take a child to the doctor.
The Texas Tech School of Medicine Department of Pediatrics had established an on-site clinic on Wednesdays in the school. In 1998, it seemed a natural choice to use telemedicine to supplement that care. So, a telemedicine clinic was added on Fridays.
The heart of the Hart project is Retta Knox, R.N., the school nurse. "Retta is the secret of the success of this endeavor," said Richard Lampe, M.D., chairperson of the Department of Pediatrics.
Knox, who’s been the Hart school nurse for 29 years, says the extra access to physicians is a huge benefit to her community. "This keeps us from being so isolated," she said. "The county hospital is 15 miles away, the nearest family practice doctor 30 miles away. To take a child to the doctor is a major undertaking. A parent has to take time off from work, often losing pay they can’t afford to lose."
As for the success of the project, Knox points to an asthma education project that was started last year. The program focuses on teaching the children, and their parents, how to use the medicine and how to recognize symptoms. The bottom line? "It kept these children out of the emergency room," said Knox. "Of the kids in the program, four out of five had never gone a year without going to the hospital or the emergency room. With this project, they didn’t have to do that."
As for the kids? "They like being on TV," says Knox. "And it’s been a good thing for the parents as well. I can show them the same picture of, say, an infected ear that the doctor in Lubbock is seeing. When the parent sees how red and ugly that ear looks, they
better understand why the child should take all of the medication and not stop in a couple of days when he stops complaining."
Lampe says seeing a patient on the TeleDoc is not really different than an office visit. "I try to behave the same as I would in the office. Once you get over the little bit of self-consciousness that you’re on TV, it’s okay."
Lampe also believes the TeleDoc may heighten communication during the exam. "You realize that you’re talking to a group. The patient is there, maybe a parent or a spouse and the care giver is there," he says. "You want to be real careful in giving your instructions, so that everyone is hearing the same thing."
Despite the success of telemedicine, it will never replace the old fashioned way of a doctor seeing a patient face to face. Nor is it meant to do that.
"As far as the ability to verbally and visually interact with someone, the TeleDoc is about the same as a face-to-face visit," says Lampe. "The magnification you get with the camera is excellent. But it’s not the same as being able to touch someone, and that’s an important part of what we do."
Richard Homan, M.D., dean of the School of Medicine, agrees. "Telemedicine is not the be all and end all," he says. "It will never replace a doctor seeing a patient in person. It will never replace being able to look them in the eye, hold their hand, provide a comforting shoulder for them to discuss their closest concerns. However, it is a useful tool in extending care to select patient populations in order to improve access and reduce costs."
As for the future, everyone involved in the project sees the potential for growth.
The Health Sciences Center recently has launched a burn treatment system that allows
burn patients in El Paso to receive follow-up care. This is another use of telemedicine to overcome the problems caused by distance. There is no burn center in El Paso. Without the telemedicine follow-ups, patients must make the 600-mile round trip to Lubbock every month.
The Health Sciences Center in El Paso also has started the Telemedicine Diabetes Education Program. The goal is to educate diabetic patients in four colonias around the border city. Clinics associated with the Health Sciences Center already are located in these colonias. The telemedicine program will give people who would have to travel several miles better access to education to help them better manage their condition.
The field of geriatric medicine also shows promise for telemedicine. "I think there is a big opportunity in geriatric medicine," says Homan. "It can be scary, not to mention costly, to transport a frail, elderly patient to the emergency room. If we can do an assessment with telemedicine first, then we can cut down on a lot of those trips."
Homan, as chairperson of the Family Medicine Department, last year instituted a telemedicine project with the Carillon Senior Living Campus for just that use. The new Garrison Geriatric Education and Care Center also is wired for telemedicine. "Even though the Garrison is across the street, and Carillon is maybe a mile away, using telemedicine for initial assessment will cut down on those traumatic and expensive ambulance trips to the emergency room. Our goal is to demonstrate its usefulness in caring for patients in rural long term care facilities."
The growth of telemedicine has, of course, brought bureaucratic problems to solve. "Our technology is way ahead of our policy," says Patti Patterson, M.D., vice
president of rural and community health and medical director for telemedicine. "States, the federal government and most insurance payers are struggling with what to do with telemedicine charges."
Traditionally no payment could be billed if a physician did not see a patient face-to-face. "There has been some liberalization of what Medicare and Medicaid are willing to pay for, but it’s still restrictive," she said. "Until telemedicine becomes a normal part of medical practice, we’re going to struggle with this issue."
Another issue Patterson sees is privacy. She insists that all telemedicine should be done over dedicated phone lines to ensure privacy. "One of the key parts of the Texas Tech System is that we are extremely conservative in what we do," she said. "This is not some kiosk in a shopping center somewhere."
Despite the money issues, Patterson and Homan agree the future for telemedicine is unlimited. "Who knows what we’ll be doing in 10 years," says Patterson. "We’re not limited by the technology, only by creativity and how the system will pay for it, how we’ll incorporate it into the good practice of medicine."
As for the pioneers of telemedicine at Texas Tech, Ted Hartman and Jay Wheeler both say they are pleased the system worked as they thought it would.
"I think telemedicine is something the Health Sciences Center can take a great deal of pride in," said Wheeler. "We had a chance to play a leading role in the nation in developing this system."
And the Health Sciences Center will continue to have a role in the future of telemedicine.
Homan says letting students in all disciplines at the Health Sciences Center become familiar with how to use telemedicine is critical. "These students are the next generation that will use telemedicine," he says. "They are the ones who will find new applications that we haven’t even thought of yet."
In Alpine, Mary Porras is just glad someone thought of telemedicine at all. "Maybe if they didn’t have telemedicine, I wouldn’t see my daughter play or dance," she said.
James Luecke agrees. "It’s fair to say that the telemedicine consult saved Aida’s life. I saw Aida just a few months ago for a regular check up. She’s doing fine; she’s a healthy growing girl."
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