Turn On, Boot Up… Say Ah-h-h!

The School of Medicine explores the frontiers of telemedicine and how it can better serve patients in Indiana.

In a perfect world of health care delivery, all would have equal access to timely, high-quality hospital and clinical services. But in our not-so-perfect world, many live in rural or remote areas far from large population centers where health care, particularly specialty services, is more readily available.

In recent years, medical schools and health care delivery systems, including Indiana University School of Medicine and its Clarian Health partners, have been using telemedicine to help narrow the access gap. Telemedicine is the electronic transfer of high resolution images, live video, sounds and patient records from one location to another. Among the tools used to make such transfers are satellites, desktop PCs with videocards, videocameras and microphones, high resolution monitors, interactive software and, of course, the Internet.

Specialized and adaptable equipment also is available including electronic stethoscopes, endoscopes, otoscopes and ophthalmoscopes. When connected, these devices can send real-time images; using special sensor devices, a patient's pulse, respiration and blood pressure can be measured, transmitted and stored.

"Telemedicine is not some phenomenon looming on the horizon. It has arrived and is becoming a part of the health care and education landscape," says IUSM's Stephen J. Jay, MD, associate dean of continuing medical education and chairman of the Department of Public Health. "Telecommunications technologies allow a primary care physician in a remote area to connect with specialists in a larger urban center to consult, diagnose and treat a patient."

You can't get more remote than the South Pole, nearly 12,000 miles from downtown Indianapolis. The School's best known use of telemedicine occurred last summer when Dr. Jerri Nielsen, a physician at the Amundsen-Scott research station, discovered a lump in her breast. She performed a biopsy on herself and sent the images via computer to oncologists at IUSM, who confirmed the cells were cancerous. In July, medical supplies and chemotherapy were airdropped to the frozen outpost.

Kathy Miller, MD, assistant professor of medicine, who specializes in treating breast cancer, regularly consulted with Dr. Miller via videoconferencing and the Internet, and oversaw her series of chemotherapy treatments. In October, Dr. Nielsen was able to leave Antarctica and receive further treatment at IU Hospital.

But you don't have to travel to the South Pole to understand the value of this new medium. Telemedicine, as Dr. Jay suggests, is not a neonate in terms of technology or use. In the 1940s and 1950s, scientists pioneered sensor technology to measure test pilots' vital signs. In the 1960s, NASA expanded the use of sensors to gauge not only the physiological conditions of astronauts flying in outer space, but also the environment within the spacecraft. These might have been small steps for NASA at the time, but a giant leap in how the technology could be transferred for the delivery of health care.

Beginning in the late 1960s, emergency medical specialists relied on telecommunications to communicate with ER physicians. In the early 1970s, several remote villages in Alaska were equipped with satellite television hookups to permit simultaneous medical consultations. By the end of the following decade, telemedicine consultations using one-way video, voice and faxes allowed American physicians to assist doctors in Soviet-controlled Armenia tending to earthquake victims.

Back home again in Indiana, advocates continue to seek ways to take full advantage of all that telemedicine has to offer Hoosiers. Dr. Jay, along with Julie J. McGowan, PhD, director of the Ruth Lilly Medical Library and of Information Resources, is working with others at the School of Medicine to help define and steer telemedicine into the 21st century.

"You have to define the needs of patients, physicians and medical facilities throughout the state," says Dr. McGowan, who has written extensively on telemedicine and taught on the subject at the University of Vermont College of Medicine. "You need a clear road map of where you want to go."

Indiana began such a journey in the mid-1960s when IUSM established a statewide system of medical education, sometimes referred to as the Indiana Plan. The program trains first- and second-year medical students at eight campuses throughout the state who complete their last two years at the Indianapolis medical campus. Today, all of the campuses are more closely linked with continuing and distance education activities, using the Internet and videoconferencing.

At the Indianapolis campus, videoconferencing, administered through the Medical Education Resources Program (MERP), has become more commonplace. Interactive lectures in dermatopathology and nutrition and dietetics have been beamed to other medical campuses, as have courses in other medical specialties.

"The School of Medicine continually looks at ways to use videoconferencing as a tool to strengthen students' education and support the activities of practicing physicians," says Jonathon Barclay, assistant director for program development and communications at MERP.

In early 1998, Clarian and IUSM financed and implemented a two-way interactive distance learning link through videoconferencing. It's the internal medicine "noon conference," a one-hour session that allows residents at Emerson Hall to interact with residents at Methodist Hospital's Wile Hall several times each week.

Telemedicine advocates continue to narrow the distance. A Department of Agriculture grant helps support a project involving Terre Haute's Union Hospital, IU School of Medicine, Clarian Health, Indiana State Department of Health and the Midwest Center for Rural Health.

"This is a great public and private collaboration that serves rural western Indiana," Dr. Jay says. The program provides obstetric teleconsultations for high-risk patients and also establishes an electronic medical records network at rural health care sites, designed to ensure consistency and continuity of care.

The startup and maintenance costs to operate telemedicine systems can be daunting. An Office of the Rural Health Policy report three years ago found that more than half of the nation's main and secondary telemedicine sites spent more than $100,000 just to get their programs off the ground. Depending on the technology and services rendered, a telemedicine session may range from $50 to $500.

"Providing patient care and all of the other uses of telemedicine falls under the rubric of how do you pay for it," says Dr. McGowan, who will be teaching a class in telemedicine for the Regenstrief Institute Medical Informatics Fellowship Program. "In most environments, there is no single use that could justify the costs. It's vital that telemedicine applications and potential funding streams be broad-based."

Indiana, as Dr. Jay views it, has a compelling need to develop telemedicine applications, particularly in rural areas. More than sixty percent of Indiana's ninety-two counties are designated as non-metropolitan counties, and a third of the state's six million residents reside in rural areas. He estimates that thirteen percent of Indiana's active primary care physicians serve in rural areas.

In testimony before Congress earlier this year, Dr. Jay detailed the need and benefits of expanding telemedicine's many uses throughout Indiana.

"Accessibility to quality health services for many Hoosiers is limited and the rural population is disproportionately poor and older," Dr. Jay said, speaking before the Senate Agriculture, Nutrition and Forestry Committee, chaired by Richard Lugar, R-Ind.

Enhanced delivery of telemedicine in rural Indiana has three key benefits. First, past experience demonstrates telemedicine cannot only improve health care, but reduce travel time, costs and delay in care, increase access to specialty care, and improve capacity for community-based care. Second, telemedicine can strengthen community-based health professions, education and training. Third, telemedicine has the potential to expand data collection, research and prevention-based public health programs in Indiana.

In January, IU School of Medicine and its partners submitted a proposal to the Department of Health and Human Services for Indiana Area Health Education Centers. Its goal is to build academic-community partnerships in rural and medically underserved communities; its success will hinge largely on the integration of telecommunications technology.

"Medicine has evolved to the point where no one physician or group of clinicians can be an island, cut off from the rest of the world in diagnosing and treating their patients," Dr. Jay says. "The technology exists today; the challenge is how do we use it and where do we intend to take it. Telemedicine can improve the quality and length of human lives and eliminate disparity of who receives care and who doesn't."