The heart of an American Indian on the Pine Ridge Reservation in South Dakota is beating via satellite in the ears of a Mayo Clinic cardiologist 350 miles away.
In rural Wabasha, Minn., waste is draining from the blood of a 70-year-old man with kidney failure. A Mayo nephrologist in Rochester, Minn., 40 miles southwest, is watching the dialysis on interactive video. "Harold, how are you doing?" the physician asks. "Are you getting outside?"
These demonstrations, financed by NASA, illustrate how the latest communications technologies link physicians with distant patients. It's all part of the show-and-tell of telemedicine.
Medical centers across the country are scrambling after government telemedicine grants. Congressional interest in the information superhighway has spilled over to telemedicine. The government will devote at least $25 million to telemedicine this year and many millions of dollars more to projects that support it.
Much is said about the potential of telemedicine to make healthcare more accessible to patients, particularly in rural areas, while saving money. One controversial but often-cited study said telemedicine and other advanced telecommunications could reduce U.S. healthcare costs by $36 billion annually.
Although vast sums of money have been spent in years of demonstrations, telemedicine still hasn't proved its worth. Prodded by powerful payers, researchers are just beginning to sort out when telemedicine makes sense and what it will cost.
How rigorously it's evaluated will signify how seriously the healthcare system has taken the public debate over medical technology's costs and benefits. Telemedicine underscores a fundamental challenge. "Some technologies diffuse into medical use because of good, solid scientific evidence. Some technologies diffuse because people like them," said Alan Hillman, M.D., director of the Center for Health Policy at the University of Pennsylvania.
An old dream.Telemedicine is the delivery of healthcare through interactive audio, video or data communications. Experiments in it began in the 1950s.
Hype about it started long before. A 1924 issue of Radio News magazine-three years before the invention of television-depicted a boy sticking out his tongue for a far-away physician, watching him, essentially, on interactive video. The article was titled "The Radio Doctor-Maybe!"
Today telemedicine is fact, not fancy. Satellites and telephone lines are transmitting radiology images, pathology slides, echocardiogram readings-almost any form of clinical information-as well as the sight and sound of patients and physicians. The same systems aid long-distance administrative conferences and physician education.
The field boasts dozens of vendors. Many will display their wares at the Radiological Society of North America annual meeting this week in Chicago.
But will healthcare embrace the "virtual" doctor? Maybe.
"I am actively involved with telemedicine, and I've been a proponent of it," said Michael Wood, M.D., a Mayo orthopedist. "But I must admit with telemedicine there's sometimes more furor than fact."
Telemedicine advocates contend the technology will improve medical care and save money because rural patients and big-city specialists won't need to travel to see each other. Sparing some patients transfers to urban medical centers, they argue, will help financially ailing rural hospitals and, thus, the rural community.
A hesitation to pay.Medicare and many private insurers, however, are hesitant to pay for telemedicine. It might be used unnecessarily. They fear that telemedicine, like too many technologies, will run up their bills without clearly improving patients' health.
"Telemedicine is moving so rapidly, we haven't had a chance to say, `What is this doing for me? Or is it just creating a problem?'*" said David Berkowitz, vice president at ECRI, a technology assessment firm based in Plymouth Meeting, Pa. "We don't know if it changes anything. We don't know if anybody is going to pay for it. Why are we rushing into this?"
Yet, telemedicine networks of urban medical centers and rural providers are springing up rapidly, fed by federal, state and industry dollars. In 1993, 10 networks brought physicians and patients together through video conferencing, according to Telemedicine Today, a monthly newsletter. At least 60 more networks are being formed.
Money is flowing from federal agencies. A partial list includes the Advanced Research Projects Administration, the National Telecommunications and Information Administration, and the Rural Electrification Administration.
Federal telemedicine grants will top $25 million in fiscal 1994, according to the Center for Public Services Communication. The Arlington, Va.-based firm tracks federal telemedicine projects for NASA, but its total doesn't include one of the biggest spenders, the Department of Defense, which hasn't provided figures.
In all, Congress dedicated $1.1 billion in 1994 to build the backbone of the nation's information infrastructure, high-performance computing. Such projects, though not specific to telemedicine, will further its development, according to the Center for Public Services Communication.
States enter the fray.The gush of federal money for telemedicine might slow now that recent elections have changed the makeup of Congress.
But state governments also are anteing up research dollars. Georgia, for example, is providing $8 million to link 59 healthcare facilities with interactive video. Oklahoma plans to spend $4.3 million to bring teleradiology to 39 rural hospitals. Iowa recently decided to let healthcare providers tap into its $182 million statewide fiber-optic network.
Private industry, however, might be the biggest sugar daddy of them all, observers said. It's just quieter about the size of its contributions.
BellSouth Telecommunications and GTE, for example, supported a telemedicine project at the University of South Carolina. Meanwhile, Raytheon Co., the maker of the Patriot missile, formed a telemedicine venture to bring experts from Houston's Texas Medical Center to the world.
If telemedicine takes off, count among its beneficiaries the Baby Bells, radiology equipment manufacturers and defense firms searching for new private-sector markets.
Its benefits to patients and the healthcare system aren't as clear.
"It's our understanding that the folks paying for telemedicine are spending the money because they believe it will bring them more money later. That's the American way," said William Decker, a policy analyst for the American Association of Retired Persons, a consumer advocacy group. "Our question is, Who are those costs going to be passed along to?
"We think telemedicine has some potential to improve access, and it should be examined further and, if useful, used," Mr. Decker added. "There's an awful lot of stories now, but not a lot of evidence."
Return still small.So far, the return
on investment in telemedicine has been small in terms of patient care. In 1993, interactive video linked physicians and patients about 2,250 times, a Telemedicine Today survey said. This year, about 50,000 radiology images will be transmitted between U.S. facilities using telemedicine. Their interpretation will amount to the work of five full-time radiologists, said Ace Allen, M.D., editor of Telemedicine Today and an assistant professor of medicine at the University of Kansas Medical Center.
Few telemedicine programs perform more than 100 interactive video consultations a year. Many hospitals also use the systems for administrative meetings or medical education.
At those usage rates, years will pass before researchers gather enough data to authoritatively state if and when telemedicine is a good idea, said Douglas Perednia, M.D., director of advanced telemedicine research at Oregon Health Sciences University in Portland.
Galvanized, Drs. Perednia and Allen helped put together a not-for-profit agency to coordinate telemedicine research so data from different programs would be comparable. Six telemedicine programs are using its research protocols, Dr. Perednia said. Fifty others are interested.
A single government agency coordinating public and private grants would do the job better, Dr. Perednia said. The Center for Public Services Communication also is urging the government to adopt a more systematic research program.
"The problem with telemedicine is that there is very little good information about it," Dr. Perednia said. "Virtually all these programs are vendors working closely with people who say, `We can't provide services like we should, so we'll try something different.'
"They don't know if it's cost-beneficial, but it doesn't matter because someone else is picking up the tab. If telemedicine were clearly a good idea, you'd think people would start to spend their own money on it."
Rural uses stressed.One often-heard argument for telemedicine is its potential to buttress rural hospitals and communities.
Since 1991, some 365 patients have been seen through a telemedicine network financed by the state of Georgia. It originally linked 502-bed Medical College of Georgia Hospital and Clinics in Augusta to 94-bed Dodge County Hospital in Eastman, which are separated by a drive of at least two hours.
A third hospital, 70-bed Emanuel County Hospital in Swainsboro, was added in March 1993. Georgia now is expanding the network to 59 healthcare sites.
"It's just beyond anything we ever expected it to be," said Barbara Bivins, R.N., Dodge County's telemedicine coordinator. "The majority of your census in rural areas is elderly. If your patient is Penny, who's 74, then it's usually her 72-year-old brother who's driving her to these distant hospitals. I get to see patients smile when they walk out of here because they don't have to make a trip to another town."
Telemedicine is doing good for Dodge County, too. Because experts examined patients over interactive video, the hospital kept 85% of the patients once transferred elsewhere, said Jay Sanders, M.D., telemedicine director at the Medical College of Georgia.
That's a healthy dose of revenues for struggling rural providers. Every patient added to the average daily occupancy of a rural hospital means $150,000 more in annual revenues, Dr. Sanders said. Meanwhile, every job at a rural hospital equals 2.25 jobs elsewhere in the community, according to a University of Oklahoma study.
Other rewards accrue. Telemedicine might make it easier to recruit physicians, nurses and others to rural areas because they'll feel less isolated.
Physicians gain.If rural physicians watch urban specialists in action, they might not need to consult with them as often. "If telemedicine does what it is supposed to do in terms of professional education, it will hardly ever be needed," Dr. Sanders said.
Legislators from some rural states maintain that those advantages ought to count in any analysis of telemedicine's costs and benefits. It is an argument rejected by others.
"The healthcare system has so many problems already, if we start to take on the problems of rural economies, we're going to be in more of a mess," said Dr. Hillman of the University of Pennsylvania.
Even Dr. Sanders, whose program is used to support the "rural economy" rationale, agrees to an extent. "Our focus as a healthcare system is not to save doctors and hospitals but to save patients," he said.
What makes analysis of telemedicine so enigmatic, however, is that the technology's benefits are rarely stacked against its costs.
A 1992 study by Arthur D. Little, funded by a consortium of telecommunications companies, is the only estimate of telemedicine's effect on the nation's medical bill. Better use of telemedicine and other advanced telecommunications could reduce healthcare costs by more than $36 billion a year, it said.
Costly systems.Unfortunately, the
study didn't account for the cost of installing and operating telecommunications equipment, and the authors didn't estimate how much that might be. Prices vary so widely, the study's authors said, and the costs of building a telecommunications infrastructure will be shared by so many industries.
The problem is the Little study's optimistic conclusions often show up in testimony before Congress for federal funding of telemedicine, without an accompanying caveat about the systems' costs.
"There is no study of telemedicine's cost-effectiveness," said Jim Grigsby, who reviewed the results of current telemedicine programs for Medicare and Medicaid.
"If telemedicine does increase access, it is going to increase total expenditures for medical care. The debate then becomes, `Is it worth the benefits?"' said Mr. Grigsby, a researcher at the Center for Health Policy Research at the University of Colorado Health Sciences Center in Denver.
In general, complete interactive video systems run $50,000 to $100,000 per site. Teleradiology systems cost $40,000 to $75,000. Hospitals also must pay for training, maintenance and telephone-line access. Monthly line-access charges range widely-$100 to $8,000-depending mainly on location and volume, Mr. Grigsby said.
In the end, the value of telemedicine depends on how it's used, said Jane Preston, M.D., president of the American Telemedical Association and director of the Texas Telemedical Project.
The Texas project connects healthcare facilities in Austin to a hospital, a prison, a renal-dialysis center and a mental health institution in rural Giddings, 65 miles away. It's served 2,700 patients since 1991.
Costs and savings are so difficult to track, "you're asking a question I can hardly answer," Dr. Preston told MODERN HEALTHCARE. Nevertheless, she contends that telemedicine is "not just cost-feasible, it's cost-effective" as long as networks cluster several services, as is the case in the Texas project.
HCFA, Medicare's overseer, doesn't share her conclusions yet. Like most insurers, it pays for teleradiology because it's billed just like other radiology services. Most other telemedicine services, such as video conferencing, aren't reimbursed.
Most current uses of telemedicine appear "safe and effective" and therefore reimbursable, Mr. Grigsby told HCFA in his report. He urged further study, however, because traditional practices might be more medically effective in some cases. Meanwhile, available information doesn't reveal how telemedicine will affect utilization of services or total costs.
In response, HCFA set aside about $7.5 million for studies at East Carolina University School of Medicine, Iowa Methodist Medical Center and Mercy Hospital Medical Center in Des Moines, Medical College of Georgia and West Virginia University Health Sciences Center.
The speed with which HCFA decides how to reimburse telemedicine will depend, in part, on how rapidly providers adopt it, said Michael Hupfer, a HCFA division director.
Private efforts to evaluate telemedicine continue. For example, Mayo is seeking government support to test telemedicine with a Minnesota rural facility next year.
In the mid-1980s, Mayo set up a satellite network to connect physicians at its Rochester clinic to those at newly opened clinics in Jacksonville, Fla., and Scottsdale, Ariz. Over time, the clinics developed their own expertise, and the demand for telemedicine consultations dropped. Educational and administrative uses, however, also justify the $4 million system.
Today, the need to integrate with primary-care providers in its region is stirring Mayo's interest in telemedicine, said Dr. Wood, chairman of Mayo's communications committee.
"What I expect to learn from these tests is for what specific applications it is reasonable to use telemedicine and for what applications it is inadequate," he said.
Despite all the studies, one question is likely to remain forever unanswered. Could America achieve the goals of telemedicine, such as increased access to care, at a lower cost if it spent its money differently?
"How about just collaboration? People are seeing that there is a basic need for communication between people in geographically separate areas," said Steve Rushing, a partner in the Atlanta office of Andersen Consulting. "A lot of attention gets paid to this high-tech part of telemedicine, but I think e-mail, for example, will impact the healthcare system sooner."