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The American Telemedicine Association in Washington, DC, describes telemedicine as the transfer of medical information (such as graphics, video, and audio) among patients, physicians, and other health care providers who are at distant locations. It includes the use of telecommunications to link the players in the health care spectrum for diagnosis, treatment, consultation, and continuing education.
While just beginning to make substantial inroads into mainstream medical practice, telemedicine already has proved its value in the care of patients who live hours from medical care and those who can be transported only with great difficulty and at high cost.
Telemedicine may even allow ambulatory patients to continue living at home rather than move into a nursing facility. A telemedicine unit permanently installed in a patient’s home can supplement in-person visits, since hands-on care, while certainly an integral component of home health, is not always essential, such as when the objective is to educate family members about the care of a patient. In emergencies, telemedicine can provide quick and direct access to health care providers.
Approaches to and technologies used for telemedicine are diverse and include real-time full-motion video transmissions, still images, audio exchange and, more recently, the use of the Internet. (See story, p. 77.) Research in the field is widespread, involving not only private health care providers but those in the military as well. Because telemedicine relies on a communications infrastructure, it raises major issues regarding regulation and control.
Among the better known telemedicine systems currently in use — but certainly not the only one — is the Picasso Still Image Phone, originally manufactured by AT&T. The Picasso system consists of an analog phone that allows the interchange of audio and full-color, high-quality images with another Picasso unit. The Picasso phone can be plugged into existing modular phone jacks and runs on standard electrical current. A speakerphone allows group discussions among patients and providers. Images can be viewed on a built-in screen, a television, or a personal computer monitor. Almost any videocassette recorder or electronic camera can be used to capture and send images, and special lenses allow for extreme close-ups.
The still images can be transmitted in quick sequence, creating fragmentary movement. In addition, images can be stored and viewed at a later time or converted to photographs for inclusion in the patient’s record. Some systems can be complemented with equipment that monitors and transmits blood pressure, pulse rate and heart rhythm.
The second generation of Picasso systems is expected to be on the market soon, and production is now handled by Lucent Technologies.
The highly visual nature of telemedicine makes it a natural fit for wound care. Once the home health nurse, who operates the remote telemedicine unit, is in contact with the evaluating physician, the physician can request images of a wound from any angle or distance. A typical telemedicine episode might transpire as follows:
The system also can be used for diverse tasks such as looking at a diabetic patient’s syringe to see if it has been filled with the proper amount of insulin. Physicians and nurses at medical centers are encouraged to transmit images of themselves to their patients to increase the level of comfort and create a semblance of intimacy in the remote relationship.
Priority Professional Services, a home health company in Dallas, regularly uses mobile telemedicine to care for patients. "We’re not trying to replace doctors’ visits, but some patients are very debilitated, and it takes an ambulance just to get them in for routine care," says Jamie Mozingo, BSN, RN, MBA, formerly Priority’s chief executive officer. "With the telemedicine system, we don’t have to take these patients in as often, and this makes coordinating care for patients much simpler."
When a Priority nurse or aide sends an image to a clinical supervisor, the image is added to the patient’s record, which makes it an important quality assurance and outcomes measurement tool, Mozingo adds. Patient confidentiality is protected by covering the patient’s face and using only patient identification numbers when images are transmitted. In addition, patients sign a standard release form giving permission for image transmission.
Mozingo says that minimal time is required to train staffers to use the equipment. Nurses and aides in the office needed only a few weeks to learn how to use the telemedicine system. They then took the system home and practiced sending images to the office before taking it into the field.
Kaiser Permanente Health Care, based in Oakland, CA, also has experimented with telemedicine for home health visits. A project known as Tele-home Health is one facet of the health care network’s Interactive Technologies Initiative. The program’s goal is to compare the standard of care for in-person home health visits and telephone home health visits with a telemedicine model. Two hundred patients are participating in the program.
One interesting outcome of the study is that even with the constraints of a small video screen and slow transmission time, the patient/nurse relationship "seems to take over," says Jill Deuser, RN, MBA, senior project manager with Kaiser Permanente. "We’re finding that you feel that you’re in the same room with the person," she says. "Technology doesn’t seem to get in the way."