doctors and other health care professionals gathered in ... Today the bulk of telemedi- cine communication ... units and electronic mail", he says, and health care ...
I Technology
Telemedicie: The best is yet to come, experts say Evelyne Michaels A patient in a remote community dons a special cap and his brain waves are transmitted via telephone to the electroencephalogram centre at a major teaching hospital. Twenty physicians in half a dozen cities confer about the latest infornation on AIDS testing and management without having to leave their respective towns. Medical students on the East Coast view x-ray images on a television screen and discuss their impressions with a Vancouver radiologist.
rTs hat is the reality of telemedicine in 1989, but experts in this still-
growing field say the
best is yet to come. More than 50 doctors and other health care professionals gathered in Toronto recently to learn more about this advanced form of communications technology which allows clinical data and educational programs to be exchanged over long distances. The keynote speaker was one of Canada's telemedicine pioneers, Dr. Max House, and he said thousands of Canadians now use or benefit from various forms
of the technology. But, he added, it has yet to reach its true potential. House, a neurologist and associate dean of professional affairs at Memorial University in St. John's, Nfld., believes that as the cost of medical education and health care delivery rises, telemedicine will be viewed with greater interest by administrators, educators and physicians themselves. Today the bulk of telemedicine communication occurs over
long-distance telephone lines, with three main modes of signal transmission: satellite, microwave and cable. Other methods can be used - for example, television but these are quite expensive. Canada currently has two major
telemedicine networks - Telemedicine Canada, which has 535 locations, and the Telemedicine Centre at Memorial. Dr. Colin Woolf, a senior chest physician at Toronto General Hospital who sits on Telemedicine Canada's board, says the organization ran some 800 programs involving 100 presenters last year, most of them in the area of continuing medical education. Memorial's Telemedicine Centre operates a 130-site audio network which is available for programming around the clock. Most of the sites are in health centres, although some are in universities, community colleges and government buildings. About
"So far only a tiny percentage of physicians have ever taken part in some aspect of telemedicine."' Dr. Max House
Evelyne Michaels is a freelance writer living in Toronto. 612
CMAJ, VOL. 141, SEPTEMBER 15, 1989
half of the centre's programs consist of continuing health education, community information and medical data transfer, with the remainder being presented by government and other professional groups. Both networks are self-supporting, relying on the fees charged to cover costs. Current technology allows for a variety of services and programs: * Electrocardiogram tracings can be transmitted via telephone lines and a printer hookup within 30 seconds. Last year 800
electroencephalograms (EEGs) were transmitted through the Memorial network - the patient wears an electrode-equipped cap and the signals are transmitted to an EEG centre where they can be interpreted. This saves the patient time and money. 0 X-rays and still photos of the body can be transmitted using a system called "slow scan". The images are sent via telephone and received on a television screen. In Newfoundland, this system has been used to diagnose and manage illness on
offshore oil rigs. Recent technologic advances have greatly improved picture quality. 0 Medical schools use telemedicine to provide lectures and other educational material that might not be available otherwise. For example, educators and students in remote communities can gain access to faculty from hospitals and medical schools across the country. Telewriters allow for the exchange of freehand writing and computer graphics; the use of specially adapted personal computers also
Main enemy of telemedicine may be doctors' reluctance to use it Dr. Max House thinks only two factors can limit telemedicine's future - the distance technology can go in expanding and improving the system and the number of doctors and other health care workers who will take advantage of all it has to offer. House has combined his interest in neurology with a fascination for other communication networks, including early work on satellite transmission in Newfoundland. His eyes sparkle when he talks about potential applications: * Home monitoring of patients via phone and television will allow doctors to observe certain physical signs such as heart rate, blood pressure and even blood chemistry by using transdermal patches that are already available. "Everyone will soon have a VCR and eventually telewriters, fax units and electronic mail", he says, and health care will become part of this information explosion. Even today, he says, some communities are experimenting with "lifeline" programs in which the elderly or disabled wear a panic-button device which, when activated, automatically summons emergency help. Pacemakers and cardiac monitors are also being tied into sophisticated
communication equipment to transmit vital data. * For the physician practising in an office setting, telemedicine will play an all-important role - case histories, lab reports, medical articles from hospital or university libraries, even billing forms, will be available at the touch of a button. * Telemedicine could also help control spiralling health costs caused by the ever-growing demand for expensive, high-tech devices such as CT scanners. A relatively small number of these devices could be employed for diagnostic purposes, with the results being transmitted to and interpreted by experts in other locations. * Eventually, holograms three-dimensional images could become a part of telemedicine technology. Images of a beating heart could be used to educate students, and surgeons could use holographic models to "rehearse" procedures. Health care in space the ultimate in long-distance care - will demand even more elaborate systems for transmitting data and delivering treatment. While much of this may seem impractical or farfetched, says House, doctors who prac-
tised a century ago could not have imagined much of the technology that is routine today. The question, he says, is whether physicians will ever become receptive to telemedicine. "So far attitudes have been less than positive and only a tiny percentage of physicians have ever taken part in some aspect of telemedicine", he admits. He thinks doctors are normally quite reluctant to change practice methods and often don't have the time to explore new ways of employing technology. Another important factor is the refusal of paying agencies to reimburse doctors for telephone consultations, which discourages them from expanding this aspect of their practice. While professional groups such as nurses and hospital administrators have reacted more positively, major medical associations, like the physicians they represent, have shied away from taking advantage of telemedicine technology. But both House and Dr. Colin Woolf of Telemedicine Canada believe telemedicine will come of age by the year 2000. "It may be that finally everyone else has caught up to us and are ready", says House. CMAJ, VOL. 141, SEPTEMBER 15, 1989
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Turnout for telesymposium: 80 doctors expected, 1 showed up ] elemedicine allow- tr, broadcast of up-to- date itnformation tc) remote parts oet he c'ountry, but when it is used. t promote pharmaceuticall. products the results inav not be quite 'hat organizers atiCtpated. An example i...a recent ..telesymposium sponsored Lvv G.D. Searle & Co. to pro-mote a new use for one (of its products, Cytotec (misopros tol). Organizers sent 14 000 in vitations to attend the live- narional broadcast and estimr.ate that about 650 general practi tioners and specialists attend-ed. Attendance varied wvidely. though. At the Ottawa (ovL. Hospital, where 80 docwor.v had been expected, onlyv m,-)e showed up.
"Certainly
In ttaw a (i)n
tnere weren't many people and I think the highest number [anywhere] was 20'. said Dr. Malcolm Champion, associate professor at the UniversiVt of Ottawa and one of five e:>xperts available to answer questions during the broadcassI t. un.d.erstand they had a lot more people [attenA in British. Columbia. Givern a potential audien-ce of 7000. I think getting 10%/o of GPs andi specialists out at that hour of I.the morning is fairly goodl.He said speeches present.ed during the broadcast had been prerecorded anid -w4,ere beamed from Toronto to three different time zones. Ques*tions were presented live from thel participating hospitals. "I
permits the simultaneous transmission of voice and data on the same telephone line. These are interactive systems, emphasized Woolf: "Participants are able to question the presenters who can supplement their programs with predelivered packages containing written material, slides and vi-
deotapes." Gerard Mercer, Telemedicine 614
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thought: t was ian interesting distinguish the live broadcast and fairlyv gooci exercise t ff rom stand.ard CME videoportray a.ifferen.t means -f t-apes andL, according to Hall, C>ML- talthough the Iu.rn1'touLt vould be used more effectiveIV for futre programs similar among the hospi .tals w. as quite variable Cha mpior -aid ' tht ione rganized for .) p -w be v %erl.; .M: u The interaction rIlOI!)VV¾bv d,ot wahat the medlunmi ill tapes is about. In goodC qauaipi, e sr)which are ofpromoted by future, we will break the taped Searie, butt th E! vid.eotapes sections into smaller periods wvere no.t. nbiased. with '10-minute discussions TI- e telesym posiurn. m. was .-.I between. them. variation of earli er ones Hall maintained that a Ico r instance, nati onal grand short lead time for the January tounds for obst£etricians and event - - planning did not' ' gynecologists. B ut while the .5 - wav begin until N oxv 15 hos, of' t.rhat exiperiment Dr. responsible forn- the poor turn E;arl Pi.unkett of t the Unive-sit-i out. 'When asked if he thoughi i; -. oronto, was only able ..ophysicians w%ere reluctan.t. to) N "Sad thei1. tihe pote:ntial aud.i.ec' ihow p because Searle was tor those broad. nasts incldudeid the sponsor, he responded: all Ibut a few phaysicians il Far from lt. The program. that. C-an adia, organizEers of Searle's Searle supported was 1000/5 evernt wX;ere all toi o aware of the scientific. Searle provided the difference betw4 een potential grant to make the educational audience andc actual attenproduction possible. Of about dance 100 doctors who commented Media Ente rprises Inter o3n the proceedings, only about national Inc. (ME 1) handled. a: twXo said there was an.y bia, rangements tfio the Janruar. and mo st were impressed bx telesy mposium and follJoxed t1he inueupy. We delivered. ar, anTl approach simi lar to the m educational p-rogramn: no it offers regular 1v across the Jr huug pro-)motion. ortLnrrv, albeit on. a .>.n.smaller O1rganizers would not re s.c.ale. klanz lHalt 'ILthe com.paveal. how' miuch the event cost, II.7 vitce-preside. nt for marketbut an. indication is offered by ing, :said that of 58 hospitals some of the items required tLo receivinig the Sea rle broadcast, produce it: satellite dishes had 12 subscribe tc) viEI program to be installed temporarily atming. it comes mainly from 46 hospitals at a cost of $600 the AmericanIRehabilitation each, satellite time h.ad to be Educational N1 etwork and purchased for $787 an hour MIanagement VPicsion, and' atl catering and advertising had to be prov?ided, and promotionai programi-s incitLcle a; W.1a"J.i-ii-n component. miiaterials and a media kit proThe two-wE ay exchanges duced L
vv
i
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Canada's manager, says the range of programs is virtually unlimited. For example, recent programs have served doctors in emergency medicine, orthopedics, psychiatry and family practice. Nurses have also conducted programs, and allied health professionals have used telemedicine to transfer information among social workers, food-service work-
ers, pharmacists and rehabilitation therapists. The University of Toronto uses the network to provide courses in health administration, while the Canadian Bar Association has offered programs in health and the law and the Federal Centre for AIDS has run special programs linking experts across the country.u
