Telemedicine may be demonstrating its viability as a tool to diagnose and treat people in rural areas, but it has a long way to go in proving it's practical for medical practice.
A recently released study for the federal Office of Rural Health Policy found that the combination of high start-up costs, steep transmission fees and low volume made the typical electronic consultation an expensive session.
But the study also found anecdotal evidence that once telemedicine programs are in operation for several years, they can attract enough participation to bring down costs and improve access to care.
The study by Abt Associates, a Cambridge, Mass.-based research and consulting firm, targeted 353 rural hospitals and 205 associated medical facilities-from rural clinics to urban medical centers-participating in telemedicine programs as of early 1996. Abt identified those facilities from an initial screening survey it conducted in mid-1995 of all 2,472 nonfederal hospitals outside metropolitan areas (Feb. 12, 1996, p. 26).
The 558 facilities with established programs were questioned in detail about how they use the capability.
Of the 499 facilities responding, 340 reported using telemedicine only to send or receive diagnostic images such as X-rays and computed tomography scans.
Of the 159 others that used telemedicine capabilities more broadly, such as for interactive consultations with specialists, two-thirds were using their equipment fewer than four times a week.
Low volume, combined with start-up and transmission costs, ballooned the median unit cost of a "teleconsult" to $1,181 for a central "hub" site and $476 for a connected "spoke" site, not including any reimbursement to clinicians.
Telemedicine is supposed to make medical expertise more accessible in rural areas. But managers are discovering they first must make their programs more accessible to physicians trying to manage whirlwind schedules, says Andrea Hassol, Abt senior researcher and co-author of the study.
When clinicians at both ends of a telemedicine connection operate at a fixed location, such as in emergency medicine, a teleconsulting capability can be worked into the routine (April 1, 1996, p. 47).
But in general practice, a rural doctor juggles a schedule that can cover broad territory and change at a moment's notice because he or she is perhaps the only physician in town to handle a first-priority medical case, Hassol says.
Yet a teleconsulting appointment requires a rural doctor to coordinate schedules with a patient and a distant consulting physician and then assemble at a precise time in front of the camera and video screen.
Physicians typically have a hard time staying on schedule under normal conditions, Hassol notes. And they spend much more of their time practicing out of an office building rather than at a hospital, even at a tertiary medical center, she says.
But telemedicine equipment usually is in a hospital, which means busy specialists and rural doctors are pulled from their normal schedules and locations to keep the appointment.
In addition to the inconvenience, many physicians are reluctant to take risks with a new practice medium for which no clinical standards have been established, the report says.
An exception is radiology, which is visually oriented, not usually dependent on having a patient present and bolstered by standards of practice established within the specialty. But Hassol says no other specialty has compiled the research and standards necessary to encourage telemedicine.
As a result, "there's nothing to let (specialists) know if what they're doing is acceptable or not," she says.
After radiology, cardiology was the most common clinical application of telemedicine, followed by orthopedics, dermatology and psychiatry.
The tools are there for those who want them. The study found most telemedicine operations were taking full advantage of available technology, including full-motion interactive video for live interviews, meetings and educational sessions.
But the initial investment is high, and line charges add significant ongoing expense (See chart, p. 118).
Hassol said the technology requires high-performance telecommunication lines such as fiber optics that have to be dedicated to the network at costs ranging from $1,000 to $4,000 a month, in addition to usage charges of at least $25 per hour.
Hospitals gave financial support to a majority of sites, and federal and state grants were common sources of funding for telemedicine programs, the report says.
While initial figures laid out in the report seem bleak, they summarize an application of technology in the earliest stages of development. More than 40% of the telemedicine programs surveyed had been providing teleconsults for one year or less.
The report says telemedicine systems improved with age, increasing their utilization as facilities gained experience.
Telemedicine also figures to become more attractive once healthcare networks become responsible for the health of rural enrollees under managed-care contracts, Hassol says.
The power of telemedicine to bridge distance is demonstrated in a small way by the report's examination of Allina Health System's network of 15 facilities linked by telemedicine equipment.
In Elbow Lake, Minn., near the North Dakota border, a physician and his heart patients "meet" with cardiac specialists at Allina's Abbott-Northwestern Hospital in Minneapolis, conducting pre-surgery consultations in a two-way video session.
For decades, the doctor had been sending heart patients to Fargo, N.D., an hour away. But now he sends them all to Allina's specialists.
Through the video sessions, he now feels he knows the specialists in Minneapolis and has learned a lot just by listening in, Hassol says.
And although patients have to travel farther, "when they get to the big city, there's going to be a face that they've seen before."