Wednesday, April 9, 2008

Telemedicine's Role in the Future of Health Care

Telemedicine is, quite simply, the use of telecommunications in clinical medicine, where medical information is exchanged for the purposes of consulting, or for remote procedures and examinations. It can obviously break down barriers related to geographical location, but it can also help alleviate some of the pressures of time by allowing a specialist to attend to several hospitals in one day. I would like to argue that it may be able to play a valuable role in the (not so distant) future of health care.

According to some, the first telemedicine application was a transmission between West Chester and Philadelphia in 1948. Radiological images were shared via telephone over a distance of 24 miles. Fast forward to today and find the well established Ontario Telemedicine Network as one of many that pop up in search results.

So telemedicine is definitely taking root. This means that at least some progress toward overcoming the challenges surrounding its use must have been made:
  • Cost. This one is the most obvious. I suspect this is less of an issue now that the price of technology (especially bandwidth) has decreased so much over the years. Still, we tend to always want to come up with something bigger, better, faster; the costs can't be falling too quickly as we move ahead like this.
  • Evaluation. We need a good way to evaluate the quality of health care that is achieved from using telemedicine. Are patients faring better, and if so, how much? Enough to justify the cost?
  • Digitization. Patient records are not only on paper, but often scattered about several hospitals or doctor's offices. For telemedicine to realize its full potential, these records should be consolidated into one electronic database.
  • Security. Digital patient records obviously need to be kept secure and confidential.
  • Legalities. Consider problems like this one: Suppose there is a physician licensed to practice in, say, Ontario, but not British Columbia (I don't even know if that is how it works here in Canada, but bear with me anyway). She works from her office in Ontario, but treats a patient in B.C. with the help of telemedicine. Is this legal?
  • HCI. In many cases, patients would be required to interact directly with technologies they may not be familiar with. Designing devices that are easy enough for, say, seniors to use comfortably in their homes is certainly a challenge.
  • Telecommunications. While things have improved dramatically in this regard since that first telemedicine communication in the 40's, we still can't push high quality video and audio across the country in real time.
Let's turn our attention for a moment to a place where many (or all) of these challenges are much greater than they would be here in the developed world. In the late 1990's, South Africa had less than 50 doctors per 100,000 people, and less than 6 per in Central African Republic [source]. The potential good telemedicine could do is obvious.

As the author of an article entitled Telemedicine in Africa: potential, problems, priorities puts it: "Up and running and paid for, it would be wonderful, of course. One envisages a novel form of continuing education for medical personnel, new possibilities for long-distance consultation with specialists, rapid image-rich exchanges of knowledge and ideas." The article then goes on to outline all the reasons why this probably isn't possible, or even the right thing to do right now, citing the more fundamental needs for potable water, reliable electricity, and basic education.

Still, I have read articles (like this one) that have shown successful applications of telemedicine on a smaller scale. For instance, a project in Mozambique made use of low-cost teleradiology equipment and a digital microwave transmission link between two hospitals. This allowed patients to have specialists to examine their radiological images from a distance. So I do have hope that the technology of telemedicine could help improve the lives of many Africans, even now.

Now that I've tugged on your heart strings a bit, let's bring our attention back home again. Here in Canada, many residents are concerned about unreasonably long wait times. Sure, politicians continue to say they are working to improve the situation, but things just seem to keep getting worse. Since allowing some private health care clinics take the load off the public system isn't an option for many, and since the baby boomers are rapidly reaching retirement age, we need some new ideas. Here's where I think telemedicine could help.

One of the reasons for the problem is the shortage of health care workers. Telemedicine may help alleviate the pressure by enabling those we have to see more patients in a given span of time. Instead of traveling between hospitals and even cities, specialists could work from one central location and consult patients via video conferencing. Patients could visit satellite clinics in their own hometown with somebody trained to use the equipment and collect data needed.

The shortage of hospital beds seems to be another large problem. If patients that need relatively minimal monitoring are taking up space in hospitals, perhaps they and their monitoring could be moved to the home. The OTN has a whole section on Telehomecare, showing that it's possible to bring equipment to the patient even today.

I'm sure this is just the beginning of the potential uses of telemedicine might have in tomorrow's world. I know I will be watching its progress as I age, with hope that it might play a role in improving our health care situation.


Unknown said...

Think about this: a virtual hospital! I'll get to that in a moment.

Wow, did you research all this out of interest/curiosity? You came up with a good compilation of the pertinent issues. I didn't know you had this blog going, it's great! As a little aside, I especially like the aesthetics of the banner at the top ;)

Innovations such as telemedicine and home care are hot topics in my courses. It is unfortunate that medicine may be moving to a place where personal contact is excluded from the patient/physician relationship; yet at the same time I understand that such a reality is becoming increasingly necessary, as it is the lesser of two evils.

An interesting issue for your field is the public-private mix. Our current system is publicly funded privatized care (public tax dollars fund care in privatized hospitals (most don't realize a hospital is a business from which people gain profits). As you mentioned, there are a handful of government-funded initiatives (such as the Ontario Telemedicine Network) but the software or technology developed for these purposes may be developed through governement funding, or can be purchased from a private developer. Taking this idea further, if you are a large operation you could potentially set up and implement such a network by yourself. Doctors work for private businesses (hospitals), so I'm pretty sure a software or technology company could set up their own virtual hospital. The condition is that they could not charge patients (as is the case for hospitals), but there are still ways to profit (just as hospitals do). Could have some interesting implications...

There would be privacy issues with medical records, but release of such information is up to the patient's discretion. There are still issues with electronic security but from my understanding the progress on that front is pretty good. If anyone is interested in this type of stuff, health informatics is a good field to look into.

Wow, my brain is running in all directions with this virtual hospital idea... all we need now are some investors!

Gail Carmichael said...

Wow Anu, thanks for such a great comment! I learned a lot from it. The reason I wrote about this is that I did a presentation about it in a medical computing class I am taking this semester (we look at various issues in terms of technologies and algorithms, but not generally social and other implications). I didn't know that hospitals were actually for-profit businesses. I could definitely see virtual hospitals popping up - especially since you can even do telesurgery today! How would it make money? (How do current hospitals make money?)

Unknown said...

Well I'm glad you're broadening your scope to look at implementation!

I looked up the stats and over 95% of Canadian hospitals are non-profit (however, the directors of these hospitals still take home hefty 6-figure salaries). The federal government funds hospitals by leasing them for periods of 25-30 years at a time. It also pays set fees for each service a physician performs (eg. physical exam, follow-up, surgery, etc).

In a private practice, a doctor would take home income per service. However, hospitals usually pay their doctors a salary or on another established pay structure. The government is still paying per-service, so the difference between all the doctors' per-service claims and salaries is surplus that goes towards the hospital (which is fine for physicians, because practicing in a hospital means not paying overhead (no lease, no equipment to buy, no staff to hire). Of course, the hospitals put their surplus into the aforementioned expenses. Now, a hospital that is smart and money-wise will have more leftover money than one that is not (hence the 'business' aspect -you know how there is an MBA? Well the hospital equivalent is an MHA). Additionally, there are certain medical services that are not funded by provincial health plans (varies by province), so these services are also income.

A virtual hospital could make money in the same ways. Of course the range of services would be much smaller than that of a hospital. A hospital also brings in money through research (again, government-funded). This touches on an issue I have with the academic machine, in that public tax dollars fund research that can be turned into personal profit through patents and inventions. Also, the journals that publish research articles are inaccessible to the public that funds them (often subscriptions are required, and the language is not comprehensible to lay-people). BUT, I digress...

I'm sure if you think about it, there are novel ways to bring in profit for a virtual hospital... I'm not going to list any because they are inherently evil (healthcare should not be a profit margin!). I just couldn't resist a thought exercise in picking out the loopholes of our system ;-)

I think this idea (the non-profit version) is a real probability in the future. Maybe as virtual medical offices, or as regular hospitals that have 1 or more units that are virtual.

Anonymous said...

The information we have found in this blog is wonderful that explains about the tele medicine's role which is easy to provide and maintain the medical patient record .

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