Laptop Magazine, July 2002

The Virtual Doctor

Telemedicine Provides Anytime/Anywhere Health-Care

By John Edwards

 

Not many people have heard of Falcon Heights, Texas, a tiny enclave nestled against the Mexican border, about 125 miles northwest of Brownsville. But Falcon Heights residents, like people living in other rural locations nationwide, can be certain that they'll receive immediate, high-quality medical attention. All it takes is a phone call and some advanced computer technology.

 

As mobile devices become capable of handling increasingly sophisticated and specialized tasks, an array of products and services are arriving to revolutionize the way health care is provided to people who can't travel to a central medical facility. Telemedicine, the use of telecommunications to provide medical information and services, is giving caregivers the power to diagnose and monitor a wide range of conditions across distances ranging from just a few miles to the other side of the world.

 

In Falcon Heights, homes are sparse and street signs rare, which can make it difficult for paramedics to locate someone in distress. In such a place, a telemedicine system can mark the difference between life and death. "We had a patient with congestive heart failure, and ambulance workers would have a hard time finding his home in the middle of the night," recalls Elizabeth Huerta, director of nursing for Nurses That Care, a McAllen, Texas, health-care services provider. To forestall the need for a perilous emergency call, Nurses That Care installed a remote monitoring system inside the patient's home. The system collected heart rate, body temperature, and other key data, and then transmitted the information back to the health-care provider's monitoring center. "We were able to see when he was having problems and we could tell him, 'You need to go to your doctor because there's a problem in your vital signs.'" For the patient, says Huerta, it was like having a skilled clinician in constant attendance at his bedside.

 

Under the Umbrella

Telemedicine is an umbrella term that encompasses a wide range of technologies. A telemedicine session may be as simple as two health professionals discussing a case over the telephone, or as sophisticated as a satellite videoconference between providers at facilities on two continents. Regardless of the technology involved, telemedicine can save lives. "Maybe a patient can get access to a nurse practitioner, someone who is in their neighborhood, but if they need to see a cardiologist or some other specialist, telemedicine helps them access services without traveling," says Maryann Lombardo, an electronic health-care analyst for Datamonitor, a business research firm located in New York. "Especially if you have an ill person, traveling can be a burden.

 

Until recently, telemedicine systems capable of remotely diagnosing and monitoring patients tended to be expensive, complex systems that required constant attention by a skilled technician. But laptop computers, PDAs, and a growing number of easy to use portable medical devices are redefining telemedicine, allowing health-care providers help patients regardless of their location. "It's definitely becoming a more popular way of accessing information," says Lombardo.

 

Besides providing enhanced health-care to faraway patients, telemedicine vendors are hoping that their systems will prove to be the perfect antidote for HMOs, insurance companies, government agencies and health care service providers, all of which are struggling to control rapidly rising costs. Health-care service providers, in particular, are finding themselves financially squeezed. The 1997 Balanced Budget Act cut funding for home health care agencies, replacing payments for each home visit with a predetermined sum covering 60-day periods. "This has forced organizations like ours to look for more efficient ways of serving patients," says Nurses That Care's Huerta.

 

Home Health Monitoring

Home health monitoring systems are leading the way toward low-cost, pervasive telemedicine. "That's where a lot of the emphasis of telemedicine has been, says Datamonitor's Lombardo, who adds that the market for such systems is growing rapidly.

 

The HomMed system used by Nurses That Care consists of a portable instrument console collects patient health data, such as heart rate, blood glucose levels and body temperature. Once collected, the information is sent via the SkyTel pager network (a wireline connection is available as a backup) to a central station--located at a hospital or clinic--where a clinician reviews it.

 

The system is fully automated, vocally alerting its user to the need to take vital signs and then providing step-by-step guidance through the process. "The device is programmed to come on first thing in the morning at a predetermined time," says Herschel Peddicord, president and CEO of Brookfield, Wisc.-based HomMed. The system can speak to its user in English, Spanish, or any other language that HomMed has programmed into it. The multilingual capability is particularly important in places like Falcon Heights, where many users are fluent only in Spanish.

 

Another popular home health monitoring technology is made by Philips Medical Systems. The Philips' Interactive Healthcare Services (IHS) system is targeted at people with congestive heart failure. The product uses battery-operated wireless measurement devices, such as weight scales and blood pressure cuffs, that can be placed anywhere inside a patient's home. "Our primary goal is to minimize hospitalization by watching for measurement trends and reacting early, before an emergency hospital visit is necessary," says Dan Barton, director of marketing for Philips Medical Systems, which is located in Andover, Mass.

 

Since congestive heart failure patients tend to be very sick, it's important for the devices to be easily accessible at a bedside or other convenient location, says Barton. The IHS devices allow patients to gather daily measurements, such as weight, blood pressure, pulse, and heart rhythm, that are vital to the ongoing management of congestive heart failure. The data is sent wirelelessly to a "home hub" box, which collects the information and automatically transmits it via a phone line to a health-care facility for examination. "The devices give the care manager or clinician accurate daily results, flagging patients that need immediate attention and allowing quick intervention via phone to get the patient back on track," says Barton.

 

Although home health monitoring's primary emphasis is on serving patients in remote locations, the technology can also be used to assist people who live in more densely populated areas. This includes patients who are too sick to leave home and people who live in urban areas that are poorly served by overcrowded or otherwise inadequate local health-care facilities.

 

A key reason HomMed is using wireless technology is that 12.5 percent of its end users don't have a home phone. This is particularly true when working with inner city and indigent patients. A lifestyle benefit provided by HomMed's system is that it can be taken on the road and used in a hotel room or a vacation home. This makes the technology especially useful for 'snowbirds' who travel to winter homes in places like Florida and Arizona.

 

Remote monitoring technology also promises to save payers money by cutting the number of patient visits to hospitals and critical care centers. "It can reduce costs by catching something at an earlier phase, preventing big, catastrophic circumstances," says Lombardo. According to statistics compiled by HomMed, monitoring devices reduce the need for emergency room visits by 99 percent and hospitalizations by 92 percent. HomMed estimates that it costs an average $5 to $10 per day to equip a patient with a remote monitoring system. Emergency room visits costs an average $900. A visiting nurse costs about $100 per day. "Being treated at home is very inexpensive health care," says Peddicord. "And patients don't like going to the hospital, either."

 

Improved accuracy is another benefit provided by remote monitoring technology. More reliable results can lead to better patient health and allow physicians to fine-tune prescription treatments, reducing the need for costly pharmaceuticals. Peddicord says HomMed's system provides a 97.8 percent compliance rate, compared with the 30 percent compliance that's achieved by requiring a health professional to phone patients and inquire about their vital signs. "People are often confused by device readings; technology never is," he says.

 

Clinical Research Monitors

Telemedicine can also help pharmaceutical and other companies engaged in medical research. A growing number of researchers are turning to handheld systems to conveniently and accurately gather information about patients and their experiences with specific drugs.

 

Medical trials for new pharmaceuticals and other treatments can take years to complete. Companies also need to monitor approved drugs for long-term safety and efficacy trends. In either case, getting full and accurate patient records is difficult. Mobile devices allow researchers to signal patients that it's time to complete their daily, weekly, or monthly notations. Additionally, unlike hand-scribbled notes, the technology automatically places data into a computer-readable form, allowing researchers to quickly access and analyze data.

 

A major provider of clinical trial/safety surveillance monitors is Cambridge, Mass.-based CRF Box, which calls its system the Comprehensive Patient Connectivity Technology (CPCT). The system allows patients to fill in clinical diaries by using a mobile phone or Palm PDA. A Public Key Infrastructure (PKI) security architecture protects transmitted data against prying eyes. Timo Ahopelto, CEO of CRF Box, expects virtually every pharmaceutical company to switch to electronic trial monitors by 2004.

 

Once CRF Box’s electronic patient diaries capture clinical patient-generated data, the information becomes available for review by researchers, physicians, and other clinical study team members. The approach allows information to be collected continuously, rather than in drips and drabs over several weeks or months. Besides accelerating the monitoring process, real-time data collection and review gives doctors the ability to assess a patient’s health and immediately address any potential safety issues. "The doctor can, in real time, follow the results via the Internet and in that way adjust the treatment to fit the patient's needs," says Ahopelto. "That improves the treatment outcome and then makes the patient feel better--which is the ultimate need of the physician."

 

Ahopelto estimates that it costs a pharmaceutical company anywhere from $500 to $1,200 a year to equip a patient with a trial monitor, depending on the person's location, the type of mobile device being used, and the type and amount of data being collected. "If you have 20 countries and seven different languages, you need to operate a help desk with all the different times and languages," he explains. "It becomes more costly than a simple trial conducted on the West Coast or the East Coast in a relatively small area."

 

Mobile Medical Information

Another way telemedicine can improve patient care is through mobile medical information delivery. UCLA researchers, for example, have developed Global Care Quest (GCQ), a system that's designed to connect hospital-bound patients to their health-care providers. GCQ, which is designed to run on a wide range of PDAs, allows healthcare professionals to conveniently view patient information, x-rays, CT scans, clinical documents and a wide range of other material. Wireless connectivity provides instant access whenever and wherever this data is needed--during rounds, at home, or even at a resort hotel thousands of miles away.

 

Currently undergoing beta testing by surgeons at the UCLA Medical Center, GCQ promises to revolutionize the way health-care providers access patient information, says Dr. John Frazee, clinical professor of neurosurgery at the university's School of Medicine. "Time is crucial, and if I have to walk around to different places to view images it's incredibly inconvenient." Frazee notes that having patient information at his fingertips allows him to make a decision in a snap, expediting the delivery of health-care services. "I can discuss treatments with a resident by phone and say 'Okay, this patient needs to go to the operating room,'" he says.

 

UCLA has also developed a consumer version of GCQ--Best Care Quest (BCQ)--to provide helpful information to authorized relatives of critically ill ICU patients. Like GCQ, BCQ works with a wide array of wireless PDAs. The system is designed to translate complex medical data into meaningful information for non-expert users. The material provided by BCQ can include patient-specific clinical data originating from various hospital information and monitoring systems. It can also provide relevant articles culled from health and medical publications as well as general-purpose hospital and local area information.

 

BCQ's developers believe that making clinical and support information easily available to a patient's relatives marks an important step toward improving the overall hospital experience. The technology can reduce the need for time consuming verbal communication between the caregivers and relatives and improve the effectiveness of critical care by promoting the free flow of information. "It's pretty hard to show this to somebody and not have them get excited about it," says Frazee.

 

Obstacles

     While few doubt telemedicine's potential to cut costs and improve patient care, the technology is meeting some stiff resistance from physicians. "Doctors are really busy, and they don't necessarily have time to sit down and read the book on how to use a Palm device," says Datamonitor's Lombardo. As a result, despite the promise of long-term payoffs, physicians need to be coaxed into using telemedicine systems. "It's very easy for them to scratch some notes on paper," says Lombardo.

 

Government oversight is also slowing telemedicine's progress. This is particularly true of clinical trial systems, where monitoring software must pass exacting Food and Drug Administration scrutiny. The FDA's validation process is time consuming and adds significantly to the cost of developing and implementing a new telemedicine system. "It's not really the cost of the device, it's the cost of implementing and validating the software," says Lombardo. In Europe, where government regulatory agencies tend to be more flexible, telemedicine system makers face a much lower cost hurdle.

 

Like Science Fiction

Despite the lingering roadblocks, telemedicine's prospects appear to be as unlimited as the technologies that are driving the field. As mobile and wireless technologies mature, falling prices could make remote monitoring devices less of a financial gamble for health-care payers and more available to patients. Currently, telemedicine's price is high enough that it's critical to decide just who should get these systems. In the years to come, lower prices could make this decision something of a no-brainer.

 

Inexpensive telemedicine systems would help move the technology directly into the consumer mainstream. As wireless medical monitoring takes off, even relatively healthy people may begin demanding such systems, believing that the technology will help keep a mild or moderate condition from degenerating into something more serious.

 

Telemedicine's long-term future has an almost science fiction-like aura. As monitoring devices get smaller and smarter, sensors could someday be built into pacemakers and other internal medical devices, allowing critical data to be transmitted to a pager-sized wireless transmitter and then to a central monitoring station. Tiny sensors could also be implanted directly into people to provide a continuous stream of data on various bodily functions. Such technology would be great news for people who, because of their location or physical condition, can't regularly see a doctor. "Telemedicine is the wave of the future," says Nurses That Care's Huerta. "It's something that will affect everyone."