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Phone and the Internet have helped extend medical services Into remote areas



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LUBBOCK, Texas - Before telemedicine, John Griswold's burn patients would drive four or five hours to the Texas Tech University Health Sciences Center, enduring painful rides and missing days of work for a 20-minute appointment.

Today, without leaving his office in Lubbock, the burn specialist and chairman of the department of surgery can visit them at clinics in their hometowns, with a little help from modern technology.

First, it's an 8-month-old whose blistery, bright pink foot was seared by boiling water. Then there's a young man whose leg was skinned in a motorcycle accident. An elderly man burned in a house fire, followed by a young woman who caught her hand in a dry cleaning press.

Telemedicine - long-distance care over the Internet, phone lines and video cameras - has spread during the last decade from rural to urban communities, and into schools, prisons and nursing homes. It has entered emergency rooms and hospital intensive care units, and dentists, psychiatrists and pharmacists have joined the ranks of those using the technology to reach underserved populations.

For many in the industry, telemedicine is the future of health care - an efficient, cost-effective way to meet the needs of an aging population and an imminent nursing shortage. In a matter of years, they say, many Americans will communicate in real time with physicians from the comfort of their living rooms, through cable channels and affordable video cameras.

Not everyone is sold, however. For many doctors, the verdict is still out on the quality of care that is, by its nature, less personal and more reliant on technology. Legislators have stopped short of granting their full support. Medicaid and Medicare offer only limited reimbursement for care delivered through telemedicine, making the care expensive - and, in some cases, impossible - for even the most determined physicians.

And it hasn't been as quick to take hold in North Texas, where doctors come in high numbers and few people are more than an hour's drive from health care.

A CHECKUP FROM EL PASO

Dr. Griswold feared that his patients wouldn't adjust to the technology. But he says they picked it up faster than he did.

"Not only do they like it, they prefer it," he says. "They don't feel like it's lesser care."

With telemedicine, a registered nurse or physician can take vital signs such as blood pressure and heart rate, visit with a patient and prescribe treatment from afar - all over broadband connections.

And the convenience has made a real difference. Griswold says that before telemedicine clinics, if patients couldn't find someone to drive them to faraway appointments, they would stay home, getting so sick they had to be readmitted to the hospital.

"It has been a dramatic improvement," he says. "We're seeing the patients sooner, with almost no complications or readmissions. And they're so much happier."

Maria Torres can attest to that fact. Her 9-year-old, who uses a wheelchair, was hospitalized twice in the last year after water from a hot iron scalded his thighs. The El Paso family took time off work and school to drive to Lubbock, the nearest burn clinic, for skin grafts, spending many hours on the highway.

Since the surgeries, Torres' son has had follow-up appointments from an El Paso clinic through telemedicine. While she would rather have a hands-on doctor, she says, long-distance care is a close second.

"At first, I was thinking, `We're going to have to travel five hours back and forth every time he has another appointment,'" Maria Torres says. "We're very fortunate. Our family is in a difficult circumstance, and this service has been wonderful for us."

A GROWING TECHNOLOGY

Telemedicine was just an expensive toy for Texas universities in the early 1990s. But a lawsuit against the state prison system in 1994 gave the technology the boost it needed.

As part of the suit, the prison system contracted with Texas Tech and the University of Texas Medical Branch at Galveston to provide health care for prisons across the state - and a total of more than 160,000 patients.

Before, it was costly and time-consuming for inmates to receive medical care. But with state-funded telemedicine, doctors could beam care directly into prison units, gaining experience that would help them apply the technology to other fields. In years to come, it expanded from rural schools to nursing homes, and everywhere in between.

In Dallas, Texas A&M's Center for Telehealth at the Baylor College of Dentistry uses videoconferencing technology to diagnose dental problems and control disease among rural children in the Rio Grande Valley. Lars Folke, the director of the center, set up long-distance dental clinics in several schools in the early `90s and has expanded his practice to monitor diabetes, obesity and asthma in recent years.

And at Cook Children's Medical Center in Fort Worth, Texas, hospital administrators started their first telemedical experiment this spring, connecting doctors to children with genetic disorders in Abilene.

Richard Lampe, Texas Tech's chair of pediatrics, knows the impact telemedicine can have on families. From a lab in Lubbock, he asks the flushed, smiling child on his TV screen to say "ahhh," revealing a pink mouth and a sticky tongue. "Jacy, you must have had milk for lunch," says Lampe.

For the last decade, he has used telemedicine to forge strong ties with the children of Hart, Texas, a town nearly two hours north of Lubbock.

"In a town of 1,200 people, we are their doctors," Dr. Lampe says. "It keeps the children in school."

Lampe says that from the get-go, kids responded better to telemedicine than to in-person doctors. And parents learn their own health lessons from the appointments, taking on-screen tours inside their children's ears, throats and noses.

"The kids have grown up with TV and computers, and this technology is second nature to them," he says. "Everyone thinks it's really cool."

THE HUMAN FACTOR

Some doctors, however, say nothing beats personal care.

At Inova Fairfax Hospital in Virginia, administrators are implementing a $5 million e-ICU - an intensive care unit where patients' vital signs and comfort levels are monitored by videoconferencing equipment - to provide a safety net and prevent avoidable death. But for Barry Dicicco, chief of pulmonary medicine and vice chairman of the department of medicine at the hospital, it's debatable whether it will make a difference.

"It's been tremendously controversial," Dicicco says of the system, which is in place at only four hospitals across the nation.

Dr. Dicicco says telemedicine is like any technology - it can be used for great good or great harm. If it takes the place of physician-patient interaction, it will have done a disservice, he says.

People are being led to think technology can save the day, he says. "It's not like running a plane on autopilot. You still need a physician interpreting and making decisions."

Dicicco's sentiments are shared across the medical community.

Even Houston's M.D. Anderson Cancer Center, which opened the SBC Telehealth Center in 2002, uses its facilities for long-distance education, as opposed to one-on-one patient consultation.

AN EARLY SUCCESS

But for Maria Porras, telemedicine was the only option.

The young mother will never forget the terror she felt when doctors at an Alpine, Texas, hospital swept her newborn from her arms. No one expected Aida, born in severe respiratory distress, to live. But thanks to an experimental videoconference, Texas Tech doctors saved her life, marking her as telemedicine's first baby.

Aida turned 14 in June. And the eighth-grader shows no signs of her precarious first days. The spark plug with squinty brown eyes and a bright smile is a fledgling softball pitcher who loves math and social studies.

"Everyone called her the miracle baby," Maria Porras says. "Telemedicine saved my daughter's life."

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GETTING EQUIPPED

High-definition televisions, camera scopes and lightning-quick broadband Internet offer images so clear that telemedicine participants feel as if they're on two sides of a window. And the best part? It gets cheaper every year.

When Don McBeath, Texas Tech's director of telemedicine and rural health services, first bought telemedicine equipment, a single machine cost $80,000. Today, he says much-improved systems cost $30,000 and could cost $15,000 within several years.

For patients, owning home systems can cost from $500 to $6,000, depending on the technology. But much like computers and DVD players, those prices should drop as the equipment becomes more mainstream. Experts say that before long, parents will be able to purchase $100 to $200 camera scopes and show their child's eardrum or scraped knee to a practitioner over a cable network.

THE RESEARCH

While anecdotal evidence supporting telemedicine is strong, the research available is limited. In a University of Tennessee experiment with dozens of congestive heart failure patients from 2000 to 2003, the number of days spent in the hospital annually decreased 80 percent, from 6.2 days to 1.3 days. The average annual cost per patient decreased 50 percent - from $10,000 to $5,000 - including the price of the telemedical equipment.

And in a three-year study of an e-ICU, an intensive care unit where individual patients' vital signs and comfort levels are monitored by videoconferencing equipment, published in 2004 in Critical Care Medicine, mortality decreased 27 percent and length of stay dropped 16 percent. Individuals paid less per visit, and the hospital increased revenue because administrators were able to fill more beds.

AN URBAN EXPERIMENT

In urban Los Angeles, the nearest hospital may be a mere five miles away, says Richard Baker, executive director of the Urban Telemedicine Centers of Excellence. But if it means taking four buses and trekking through gang territory, the five miles might as well be 5,000.

To combat this, and the undermanned nature of Los Angeles' public hospitals, the ophthalmologist received a grant to open remote clinics in public housing projects across the city. With the same technology used to send crystal-clear images back from Mars, Dr. Baker was able to bring his practice waiting list down from six months and to tackle the worst problems right away.

But Baker's practice is limited by an important factor: In Los Angeles County, telemedicine is not covered by federal health care. Currently, Medicare and Medicaid cover the costs of telemedicine in hospitals and clinics only in counties deemed "medically underserved," or with populations of 50,000 or less. Urban communities and schools, nursing homes and teledentistry are excluded from this funding.

For the urban sites, legislators think, "High-quality centers are not that far away," Baker says. "But if you look at it in terms of time, it's not a big difference if it takes three hours to go 200 miles or three hours to go four miles."

Baker says he is trying to get Medicaid and Medicare to reimburse telemedical appointments. For him, it's a no-brainer. But there are many who still aren't on board.

"It saves money, provides better care, is appropriate to what patients need, and gives access to those who previously didn't have access," he says. "It's better for everyone."

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(c) 2004, The Dallas Morning News. Distributed by Knight Ridder/Tribune News Service.

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