Many trends are creating the perfect storm for tremendous change in the delivery of healthcare. Baby boomers are now aging and with an increased life expectancy, but there is a shortage of healthcare workers. That same shortage has a huge impact on rural areas, especially when it comes to availability of specialty caregivers. Healthcare costs are increasing, yet healthcare providers need to stay profitable, so there is competition to deliver quality and depth of service. Then there is the trend toward green. AV and IT technologies are at the forefront in addressing these challenges in the form of telemedicine.

Telemedicine is not all that new. NASA may have been the first to use it in order to monitor astronauts’ health while they were in space in the 1960s. Two-way closed circuit TV and two-way microwave-based telemedicine systems were also used as early as the 1960s for pilot and experimental programs, as well as for actual delivery of healthcare.

But now — right now — is considered the boom. Spending on healthcare technology is expected to dramatically increase, owing to the economic stimulus law that President Obama signed earlier this year. That initiative includes $20 billion for health information technology, of which analyst firm Pike & Fischer forecasts 25 percent or more being applied toward broadband-enabled telemedicine.

Daniel Kurywchak, CEO of Telemedicine.com, trains physicians in the city of Parintins, Brazil, on the use of a general examination camera being used for teleopthamology and teledermatology. The image is transmitted live to a remote specialist located at the nearest hospital, which is an 18-hour boat ride up the Amazon River.

“About 15 years ago, your average telemedicine system for doing live video consultation cost in excess of $100,000, requiring four BRI ISDN lines running on Windows 3.1,” says Daniel Kurywchak, CEO of telemedicine

consulting firm Telemedicine.com, Inc. of Cameron Park, CA. “So needless to say, it was not very stable. It also required separate components in a mobile 20-space rack. Now, the videoconferencing piece of telemedicine is a small set-top box appliance that either sits on top of a monitor or can be mounted utilizing far-end camera control, using pan/tilt/zoom, and providing higher resolution in video quality.”

According to Kurywchak, the three major ways telemedicine technology has changed are “the quality and reliability of the equipment, the reduced cost of equipment, and having access to high speed broadband.“

TELEMEDICINE IN ACTION

Telemedicine delivered via videoconferencing technologies are used by healthcare providers in several different ways. One is traditional videoconferencing. Videoconferencing among administrators provides the usual benefits of faster decision-making, reduced travel, and reduced carbon footprint. Another use is for education. Recorded training videos can train staff at all levels. An organization also may wish to share audio and video of live procedures in order to train those in remote facilities. The third use, and the one that is evolving most quickly, is actually delivery of healthcare.

Telemedicine technologies are sometimes used in surgery, says Kurywchak, as well as those procedures that use an otoscope, nasal pharyngoscope, sigmoidoscope, etc. because the telemedicine system simply connects to the video output of any endoscope camera. “The most common uses are videoconferencing in conjunction with the use of medical peripherals for telepsychiatry, teleneurology, teledermatology, teleotolaryngology, trauma, and surgery assistance,” he says.

Telepsychiatry is considered to be the most prevalent use of telemedicine, and is one of the services offered by Preferred Family Healthcare (PFH). Kirksville, MO-based PFH is a behavioral health non-profit organization providing substance abuse treatment/prevention and mental health services throughout Missouri and San Antonio, TX. Andrew B. Greening, LCSW, RTC, says PFH uses telemedicine for videoconferencing with clients.

“We implemented it about five years ago to provide our psychiatrist the opportunity to see consumers many miles away without having to travel,” says Greening, who is also PFH’s vice president, behavioral health. PFH’s setup is a Polycom videoconferencing system with a 27-inch Vizio HD widescreen LCD monitor on a portable cart, and a dedicated encrypted line. “It also allowed one psychiatrist to serve many sites from one location. We also at one time were providing telemedicine services to veterans and were connected with the VA Hospital in Columbia, MO.”

“Doctors that use it find it quite efficient,” he says. “One psychiatrist took her system with her and saw our consumers while on extended vacation.” The portable Polycom system consists of a camera, a monitor, and speakers. Greening said the primary issue wherever the system is used is the availability of an encrypted (encrypted is necessary as confidential information is being discussed) internet connection that provides sufficient bandwidth that supports picture clarity over time. This is usually available from cable providers with proper arrangements.

ACCESS TO SPECIALISTS

A critical and widely-acknowledged need is access to specialists. Patients in rural areas must travel great distances, which is difficult when the patient is ill or experiencing financial difficulty. With the shortage of specialists, even those patients in populated areas sometimes have lengthy waits for appointments.

Consulting with specialists is an application that is skyrocketing. For example, a general practice physician in a rural area can teleconference with an ENT from a city hundreds of miles away. Or a doctor at a small hospital can wheel a videoconferencing system into a patient’s room and conduct a post-surgical consult with her dermatologist.

“A community hospital has a need to import medical talent,” says Joe D’Iorio, manager of TeleHealth for videoconferencing vendor Tandberg. “A university of medical center, which may have paid to get someone trained in that talent, has a need to export that knowledge. Video becomes the enabling mechanism. You have a patient with his doctor in one room and a specialist on the other end of the videoconference, and the doctor in the room facilitates the dialog among them. It’s about bringing the right talent to the right place at the right time.”

Sometimes the need for a consultation is more time-sensitive. D’Iorio explains that while trauma doctors have a broad range of skills, they can’t do everything. Imagine a situation where the police bring a person to the hospital who is presenting psychiatric symptoms — you need a psychiatrist. “It takes two behavioral health specialists to sign for involuntary commitment, and this person may be disrupting the hospital. So time is a critical factor to locate not one, but two psychiatrists. Videoconferencing is the perfect mechanism to bring that talent where the decision is needed.”

Another example of bringing the right talent to the right place at the right time is an initiative called TeleStroke, a rapidly spreading trend that uses telemedicine to determine methods of treatment to patients presenting stroke-like symptoms.

“One cause of a stroke is a blood clot that is not allowing blood to flow, and another cause is an aneurysm, which can rupture, causing bleeding in the brain,” D’Iorio explains. “So if the patient has a clot, they need a blood-thinning agent. If they have an aneurysm, a bloodthinning agent is the worst thing you can give them. So a neurologist has some critical decisions to make in terms of taking one course or action or another.”

Few emergency departments have 24/7 access to a neurologist, especially in remote areas. TeleStroke, which is a grass-roots effort initiated by regions, hospital groups, companies, and other types of organizations, provides stroke teams that are on call around the clock via telemedicine to reduce the time from arrival to evaluation and treatment. It is so successful that the American Heart Association announced findings this year that TeleStroke consultation is “as effective as bedside workups.”

THE TECHNOLOGY INTEL EMEDlCINE

Today's AV and IT capabilities are helping healthcare providers in ways they never could before.

“Cameras and displays are some of the AV technologies that have evolved greatly to significantly assist healthcare,” says Carl Belawske, CTS, audio/visual technician for the education department at Finger Lakes Health. Finger Lakes Health, located throughout four counties in central New York, is a community-owned, not-for-profit healthcare provider for those who live in the central Finger Lakes region.

“Cameras have shrunk to the point where they can go into a body and transmit images in great detail,” says Belawske. “Displays have evolved from large and limited technologies to products that display high definition sources in a very compact, full-featured package. The capabilities of the latest display technologies and cameras have allowed healthcare to collaborate not only within an organization, but around the globe.”

Finger Lakes Health uses AV and telemedicine for patient/family education, staff education, and conferences and special events. Two schools of nursing — LPN and RN programs — use AV technologies for classes and in hands-on instruction. Their most frequent use of telemedicine is in the form of collaboration within and outside their network of facilities, which Belawske says helps them diagnose cases more accurately, better educate patients and families, better educate staff, and reduce travel time and costs.

“This technology also allows me to remote manage virtually every aspect of an AV system installed anywhere in our organization from anywhere,” Belawske continues. “This reduces my travel costs and improves response times. The technology allows me to take a more proactive approach to potential problems because most AV components can send an email or page me informing me of a potential problem.”

Jim Mountain is president of Secure TeleHealth, a Pittsburgh, PA-based company providing PC- and internet-based videoconferencing services since 2007. The systems connect behavioral health professionals to their clients in the clients’ homes or communities, and are marketed to states where Medicaid reimburses client-encounters via telemedicine.

“The good news is that interest in telehealth videoconferencing in the behavioral health field is exploding,” says Mountain. “Good clinical outcomes have been reported by early adopters of this technology. The cost of using this technology has dropped dramatically, especially when used on the public internet. For the first time, telemedicine is sustainable without grants.”

He says AV and IT developments are driving the company’s growth, as is the availability of encrypted AV over the public internet. “HIPAA [the federal Health Insurance Portability and Accountability Act] and common-sense dictates that all doctor-patient encounters should be properly safeguarded to ensure privacy and confidentiality,” says Mountain. “This is especially true in the behavioral health field. To conduct clinical sessions over the public internet, robust encryption algorithms such as AES128 are crucial.”

The increase of broadband access in rural areas and new and improved AV compression technologies are also factors to which he credits his company’s success. “Echo-cancelling technologies have obviated the need for headsets, which were not well-received by some of our clients,” he adds. “The ability to conference with up to 12 participants on the same screen has allowed us to create virtual therapy groups, where some or all members participate remotely.”

Another technological development, high definition imaging and display, are acknowledged as desirable, but sometimes impractical. “High definition is the most important in surgical procedures such as cornea transplant, where a cornea can be reviewed by physicians ahead of time, and pathology for reviewing microscopic images,” says Telemedicine. com’s Kurywchak. He believes, though, that in day-to-day telemedicine, it is more of a want than a need, because medical peripherals used in dermatology, ENT, etc. are still in standard definition. “And the current requirement for a standard definition video signal in order to transmit a native video format requires only 384 kbps; however a 1080p HD telemedicine consultation requires 3 mbps, which is still a challenge for most locations,” he says.

Kurywchak also suggests that LCD is preferred over plasma for “store and forward” telemedicine (still images captured, then sent to a specialist for diagnosis) since an LCD’s higher native resolution is better for still images.

Audio also needs to be of high quality. “One of the most popular uses of telemedicine worldwide is psychiatry,” says Kurywchak.  “Within this specialty, sound is equally as important if not more important than the video quality because the patient must feel as though the psychiatrist is in the room with them.  Having tinny sound in psychiatry just does not work for a successful consultation. In locations such as pediatric intensive care, ER, OR, etc., the transmission of high-quality heart and respiratory sounds are critical.”
 
He also warns against using low-end webcams, online video conferencing services and the Internet for reliable live diagnostic procedures.  These products generally utilize smaller video resolution sizes than SD, such as QCIF, which is a quarter of the size of a standard video resolution.  “It is a fallacy to believe that a physician can accurately diagnose from such a tiny image resolution and would be willing to risk his medical licensure,” he says. “Telemedicine requires a high quality SD or HD video conferencing transmission for proper diagnosis, and the internet in most of the U.S. today simply cannot yet reliably handle continuous high bandwidth 2-way full duplex video calls for long periods of time without dropping frames or dropping the call completely.”

Ron Emerson, director global healthcare markets for videoconferencing vendor Polycom, says the video quality that we see now is up to 11 times better then it was even six or seven years ago and at much lower bandwidths. He says the industry continues to develop solutions that require less bandwidth to deliver better quality. He also sees telemedicine systems becoming more comprehensive solutions as opposed to a collection of connected devices.

“For the future, it’s about turnkey solutions that integrate patient health records, medical imaging systems, video, and medical peripheral devices,” says Emerson. “We’ll integrate that into a seamless system so that, regardless of where the patient or clinician is located, a high-level assessment and interaction can occur.”

St. Joseph Hospital in Orange County, CA, uses 60-inch LCD monitors to display the continuously updated status of each patient in the operating and treatment areas.

Emerson says another trend is telementoring, when a surgeon in one location watches and guides a surgeon performing a surgery in another location. Communications with patients will continue to evolve, too. “People are leaving the hospital sooner, so using telehealth and video technologies to increase contact from the clinician to the patient in the home environment will continue to grow,” says Emerson.

He says 3G cellular technology will facilitate that trend. “Advancement of 3G will allow quicker seamless integration of video into home environments for clinician-patient interaction,” says Emerson. “When someone goes home from the hospital, the healthcare must continue, but if the patient is elderly or lives in a remote area, they may not have DSL or other broadband connections.”

He says that, in that case, the home health nursing agency will likely install a 3G cellular system for the patient. “The nurse just walks in, plugs a 3G card into a device like the Polycom business media phone, and, boom, you have video. It’s pretty impressive. 3G in telemedicine will be huge.”

Denise Harrison, a writer and marketing communications consultant, has managed publications in a variety of industries, including commercial and consumer audiovisual.

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