by Melvin H. Nutig, MD
Melvin H. Nutig, MD, is an orthopaedic surgeon in private practice, a member of the California Telehealth/Telemedicine Coordination Project, a state-wide organization; the American Telemedicine Association; and is Telemedicine Project Coordinator of Cedars-Sinai Medical Center, Los Angeles.
At a time when there seems to be virtually no good news about the practice of medicine, or the future of medical specialists, there comes a potential solution to many of the problems we all face.
The political and economic climates in America call for downsizing of medicine with an emphasis on primary physicians, who in the end will still need to rely on the expertise of specialists such as orthopaedic surgeons. The social climate now seeks to ensure that those who are directed to managed care will still have access to good quality specialists. The medical climate of managed care wants health care to be delivered better, faster, and cheaper, and just when all of this is happening, along comes the technological breakthrough of telemedicine-a perfect fit for all of these new imperatives.
Telemedicine is not a new specialty, but rather a new tool for the practice of medicine. It uses all forms of modern telecommunications technology from telephone and fax to live two-way interactive video to allow a physician in one location to consult with a patient in another. It gives the physician with the vision and the willingness to step into the 21st century the same opportunities that any reasonable businessman would ask for when faced with shrinking markets, i.e., the opportunity to export out of the geographic confines of our practices.
This is not a world of the future, but rather it is here now, and has been here for some time. In the late 1950s telemedicine had its earliest starts in such programs as the University of Nebraska Department of Psychiatry's interactive program with their state mental institution and the federal government's participation in the STARPAHC program, in cooperation with several medical schools. (STARPAHC is an acronym for the Space Technology Applied to Rural Papago Advanced Health Care, a program to test the use of telemedicince for providing health care in rural areas as a model for space travel.)
There are now telemedicine programs in almost every state in the nation and in every part of the world. The number of new programs coming into existence continues to grow at an enormous rate and telemedicine has gained wide acceptance from almost every area of medicine, including surgery and its subspecialties. Two peer-reviewed journals began publishing this year dealing with the many applications of telemedicine.
The technology, thanks to the advent of compressed digital image transmission in the 1980s, has brought us to the point where with standard "off-the-shelf" equipment we can communicate with each other in real time with face-to-face discussion and transmission of all of the medical data a physician would ever need to make a diagnosis and recommend appropriate treatment. These images are sent over standard telephone lines with broad bandwidth capabilities, or via satellite.
A medical specialist at one end of the communication link is in touch either with another physician such as a primary doctor or another orthopaedist, or even a physician's assistant or a nurse. The patient is with that primary care giver and, via video monitors, the doctor and patient at each location can see and talk to one another.
A full history and physical exam can be carried out, and when needed, any "hands on" can be easily accomplished by the caregiver who is with the patient. Radiographs can be transmitted at the same time and even annotated much the same way that John Madden explains the movement of the offensive line after a football play.
Skeptics are wrong to believe that without the ability to actually touch the patient, they will not be able to complete their exam and without an in-person encounter, they will not be able to communicate with their patients.
There are already many years of published literature to show that from the point of view of the physician, this technology works very well, without any detriment to the quality of care which might otherwise be delivered. In the case of an orthopaedic examination the health care giver who is with the patient can palpate, prod, and poke. If a patient needs to be splinted or casted that also can be done by trained personnel under your supervision. And if your expertise is needed in person for a closed or open procedure then arrangements can be made for that to be done in a timely and convenient fashion. The doctor and patient travel only when necessary.
Communication is not a problem. From the patient's point of view, several studies have shown that when given the choice of repeating a telemedicine consultation, or traveling a great distance to get to the specialist, most patients were satisfied enough to opt for another opportunity with telemedicine.
Finally, from the point of view of those paying the bills, this solves the problem of how to get the specialist from where he or she is to where the patients might be in some remote part of their state. It also eliminates the need for costly trips into town, away from work, to see the specialist or for ambulance or helicopter transport of a patient who could be appropriately cared for in his or her local hospital, had he had adequate triage.
The potential applications of telemedicine in orthopaedic surgery are numerous. Just think of how this could bring efficiency to your daily life.
In addition to those applications already alluded to, including consultations and triage, postoperative follow up visits can be done easily and conveniently, especially for those patients who might otherwise have to travel a great distance to get back to the surgeon's office.
Telemedicine also works well in a variety of educational situations. Tele-proctoring of arthroscopic surgery, for example, by an expert instructing someone with less experience, or even real-time intraoperative second opinions are possible. CME courses can be arranged so that large groups of physicians do not need to travel to one central location for a course or meeting when all the information could more easily, and more cheaply, be shared using the same teleconferencing technology which is currently being used in many industries on a routine basis.
Lest you get the impression that the implementation of a telemedicine program is as easy as picking up the telephone, it should be pointed out that there are a number of "barriers" which must first be overcome in order to be successful.
Reimbursement Currently neither the Health Care Financing Administration (HCFA) nor any of the private insurers are paying for anything other than teleradiology or telepathology, but that is expected to change. Several test programs are underway, funded by HCFA, to look into this technology and make some determinations about payment. Until then, a sound business plan will have to be formulated before you embark on a telemedicine program to take advantage of those venues where revenues can be generated to pay for the somewhat costly equipment, i.e., managed care, the military, prisons, and foreign markets.
Licensure In most states, intrastate use of telemedicine is not a problem. It is considered to be part of normal medical practice. In those situations where consultations are across state borders the issue has not been fully settled. Some states (Texas and Kansas) have stated that telemedicine consultants into that state need to hold a full and unrestricted license. Realizing the hardship that presents to practitioners, the Federation of State Medical Boards has proposed model legislation which would allow interstate telemedicine consultations with a limited license which would be more easily obtained from the individual states. That legislation is now in review across the country.
Malpractice This issue has yet to be resolved since to date there have been no malpractice claims brought in a telemedicine interchange. Most legal specialists in malpractice issues feel that this technology should not present any additional legal burdens or risks to the consultant assuming that sound medical principles are followed.
The story of telemedicine is much more than can be told in the space allocated for this article and I would encourage those interested to look into its implementation through the vast bibliography which already exists.
Model of Advanced Communications Technology Satellite (ACTS). Photo from National Aeronautics and Space Administration.