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'Doctors on Call'
Telemedicine Under Way At the Clinical Center

By Carla Garnett

On the Front Page...
It used to be a big problem if you were here and your doctor were there. One or the other would have to travel for you to get the best care. What if you were too sick to travel, or your doctor couldn't leave other patients, or you needed a specialist halfway across the country? An extension of the technology that gave birth to face-to-face video conferenced business meetings is quickly becoming a solution.

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Called telemedicine, the new field can bring the best medicine to you, wherever you happen to be. It gives new meaning to the words "doctors on call."

Now NIH is nearly ready to extend the concept by bringing the latest medical research to the bedside of people taking part in clinical trials, who might be too ill to come here, or who may require frequent follow-up and monitoring.

"We will actually interview patients and examine them, see their x-rays, pathology, and laboratories [tests] simultaneously with the doctor on the other end," said Dr. Steve Holland, an NIAID investigator who soon will use telemedicine facilities at the Clinical Center to conduct a clinical trial of people with tuberculosis. "For experimental therapies, I think this offers a chance to do new and innovative things under an expert's observation over a great distance. Just think of the difference between a simple phone call describing a work of art and being able to see the picture at the same time."

A specially designed ophthalmoscope is connected to the transmitter shown in the background. The Clinical Center, which already uses such transmission equipment, will be outfitted with similar instruments in about 6 weeks. Telemedicine technology enables clinicians to reach patient populations otherwise inaccessible to them.

"Telemedicine technology is beginning to reach people who may never have had access to the care they needed or to the benefits of NIH's medical research," said Audrey Kelly, telemedicine manager at the Clinical Center. "This expands the knowledge base doctors can share with each other and it broadens the capability for physician consultation and patient monitoring. The future benefits of telemedicine are truly unlimited."

Dr. John Gallin, CC director and chief of the Laboratory of Host Defenses, has been a vocal enthusiast of telemedicine and has encouraged members of his own lab to explore its applications.

The Clinical Center currently has several telemedicine projects in progress or under development to support clinical research trials: Dr. Peter Choyke of the diagnostic radiology department uses telemedicine as a teaching tool. Each month he conducts training with medical students at the Navy Medical Center, displaying radiological images that are transmitted over video lines. Each resident is asked to diagnose the condition displayed on the remote monitor. Choyke can interact with the radiology resident in this online setup, showing, annotating, reviewing and expanding on the resident's diagnosis and recommendation.

CC surgeons are interested in using telemedicine in the operating room to view laparoscopic procedures being performed at distant locations and to demonstrate to others procedures they are performing themselves. Telemedicine used in surgical training can become a powerful tool to teach and monitor complex surgical procedures at distant medical facilities.

An international telemedicine project is under development that will involve investigators in Australia, South America, Thailand, and South Africa collaborating with NIAID investigators at the CC, Kelly said.

In his first patient telemedicine trial, Holland and collaborator Dr. Terri Lightner, a physician at South Texas Hospital, will administer interferon gamma, an immune stimulating cytokine, to patients with multi-drug resistant tuberculosis.

"The initial phase of the trial is simply to assess drug tolerance and toxicity," he explained. "But subsequent phases will look at whether interferon gamma can accelerate or enhance the clearance of TB." Lightner, whose facility for transmitting patient data over phone lines is already in place, will actually administer the drug in Texas, while Holland oversees and advises from a CC video facility. In about 6 weeks, a facility will be outfitted with new medical examination devices that will allow Holland not only to observe but also to participate in the actual examination.

While Holland's joint effort with Lightner will be his debut patient trial using telemedicine, he said that he was turned on to the technology's benefits last fall, as a method of solving another type of long distance consulting problem. A serendipitous result was meeting Lightner and other physicians more deeply involved in developing telemedicine projects.

"I got interested in data-sharing," Holland said, "through my collaborator Jim Cook, chief of infectious diseases at National Jewish Hospital in Denver. We were trying to jointly manage patients seen both here and there and found it difficult. Jim already initiated contacts and work with Los Alamos National Laboratory in New Mexico that was directed at creating a graphical patient record with embedded microbiologic and radiologic data. When I met Dr. Lightner, she was already involved in using teleconferencing for patient management in her practice. As we developed a collaboration with her, it became clear that telemedicine was a natural way to keep up with the data and patients. Since she has done an enormous amount of preparation and implementation with her collaborator in San Antonio, it just seemed appropriate to jump on the bandwagon and try to incorporate patient studies as well."

While there are the obvious advantages of time saving, convenience and increased patient accessibility, there are several concerns that will have to be worked out before the technology comes into widespread use. Holland noted the top two -- confidentiality and user comfort. "I don't think these confidentiality questions are any different fundamentally than telephone or fax transmissions," he said, "and doctors, nurses and patients will need to develop a level of comfort and familiarity so that they know what to expect."

Current video equipment that is used to hook up NIH researchers with other facilities across the country requires tying up the equivalent of six telephone lines. The charges for this are similar to the costs of six long distance telephone calls between the locations. The video equipment costs per site are about $40,000 for a state-of-the-art video unit that includes the necessary coder/decoder devices. The specially designed medical instruments, such as stethoscope, ophthalmoscope, or otoscope, can increase the equipment charges anywhere from $8,000 to $30,000. Still, a typical telemedicine unit could pay for itself soon enough in travel expense savings of both physicians and patients.

Kelly also said that the telemedicine industry must develop minimum standards so that all units correspond at the same speed and speak the same language. Measured in kilobits, the quality of the transmission improves with higher kilobit settings. Improving picture quality also increases the number of phone lines in use, and thereby raises the cost of the connection.

"Video conference users seem to have settled into 384 kilobits as an acceptable transmission speed," she noted, demonstrating about a half-second time delay between an actual movement and the movement seen on the monitor.

"Interest in telemedicine is increasing daily," she concluded. "Dr. Gallin is enthusiastic about the opportunities that telemedicine offers for improving care and research. NIH will be a pacesetter for using telemedicine in research, especially in an environment that draws patients from every state and many other countries. During Dr. Holland's trial, NIH will be documenting and comparing the cost/benefit factors of alternative treatment approaches. The key to acceptance of telemedicine is proving its clinical, academic, and economic benefits to the medical community. Telemedicine will improve both the quality and efficiency of care at the Clinical Center."