Friday, January 5, 2001

University Medical Centers Expand Reach With Telemedicine By KATHERINE S. MANGAN Galveston, Tex. "Can you see me good, Doctor?" the burly patient asks as he lifts his shoulders, one at a time, to demonstrate a hitch in his right shoulder socket. The doctor, Jason H. Calhoun, examines his patient not in person but on a 40-inch video screen. The patient himself is 50 miles away, in a prison in Sugarland, Tex. Dr. Calhoun's video monitor, meanwhile, is part of a futuristic control center at the University of Texas Medical Center here. An array of computer monitors displays the patient's medical history and digitized x-rays. Dr. Calhoun decides he needs more x-rays to determine why the patient, whose shoulder was smashed in a prison brawl, isn't recovering faster from his surgery. "If it weren't for telemedicine, we would have to bring these patients in here for all of these follow-up surgical visits, along with several guards," says Dr. Calhoun, who is an orthopedic surgeon. "The security can cost more than the medical treatment." Over a period of a few hours, Dr. Calhoun will examine 15 patients, all prisoners scattered throughout the eastern half of Texas. He will check their x-rays and medical records and review rehabilitation exercises with them, and -- with the help of on-site nurses -- poke and prod them to pinpoint their medical problems. He keeps up a comfortable banter with his patients, who generally seem unperturbed by the fact that their physician is talking to them from miles away. The medical center's CyB-R Care system, as it is known, is one of the most advanced telemedicine programs in the United States. In fact, it's in prisons that many telemedicine programs have found their toehold. Although telemedicine was touted in the late 1980's as a way to reach people living in remote towns, many programs found too few patients there to justify the expense of setting up the equipment, which can cost $30,000 or more at each examining site. Making matters worse, insurers often balk at reimbursing physicians for their cybercare treatments. Medicare, for instance, only reimburses physicians under certain conditions, such as when the patient lives in a rural area with few doctors and is accompanied by a physician's assistant or nurse practitioner, rather than a registered nurse. Because of these roadblocks, some programs have had to shift gears. "Many telemedicine programs started out with demonstration grants to serve rural areas," says Jonathan D. Linkous, executive director of the American Telemedicine Association. "When those grants disappeared, the programs were difficult to sustain because of the small populations involved and the lack of reimbursement." Neither is a problem when the patients are behind bars. "Prisons offer a captive population that needs our medical services," says Rashid L. Bashshur, director of telemedicine at the University of Michigan Health System and president of the American Telemedicine Association's board of directors. "Once you have the equipment in place, it's extremely cost-effective." Prisons are required to provide health care to inmates, so doctors don't have to twist any arms to get their expenses reimbursed. "Prisoners are one of the only populations with guaranteed health care," says Mr. Linkous. "It's considered cruel and unusual punishment if it's not provided." There is no shortage of medical problems in the nation's prisons. Inmates are more likely than the general population to be afflicted with hepatitis, H.I.V., communicable diseases, and chronic conditions like diabetes. Many prisoners also have a history of inadequate health care. They're also prime candidates for psychiatric care, and for telemedicine programs aimed at curbing smoking or alcohol abuse. Despite the advances in telemedicine, and the opportunities provided by prisons, many medical faculty members remain leery of treating patients from a distance. Julia Nunley, an assistant professor of dermatology at the Medical College of Virginia Campus of Virginia Commonwealth University, is one of those skeptics. "I think the best way to treat a patient is in person," she says. "When I check a lesion, I need to know the color clarity and whether it's palpable or flat. I can't touch or feel a lesion in telemedicine." She says that she is also worried about being sued. "What if I make the wrong diagnosis because I'm working with incomplete information?" she asks. "We are trying to stretch the almighty dollar, and it's the patients who are losing." Still, a growing number of medical schools have started to offer programs in prison telemedicine. They include the University of Texas' medical branch in Galveston and Texas Tech University, which together are responsible for the health care of nearly all of the state's more than 200,000 inmates. Texas Tech, which serves 33,000 inmates, is also developing a telemedicine course. The course will teach students such skills as diagnosing from a distance and establishing rapport with patients. Other universities offering telemedicine health-care programs include Ohio State University, the University of Rochester, the State University of New York at Buffalo, and Louisiana State University. Among the nation's larger university telemedicine programs: Physicians at the University of Arizona treated about 1,000 prisoners in 1999 through telemedicine, and officials there expect the number to at least double annually for the next few years. Before telemedicine, prisoners had to be driven as far as 500 miles across the desert, escorted by guards, to the state's only lockup hospital, in Tucson. The program also serves thousands of rural residents each year. Physicians at East Carolina University's School of Medicine consult with inmates in three prisons statewide in 32 specialties, including dermatology and psychiatry. The telemedicine network is linked to dozens of sites in homes and rural towns, where patients are trained to use desktop videoconferencing equipment, which includes electronic blood-pressure monitors, provided by the program. Corrections officials in Virginia are trying to get all the state's major prisons connected to a single telemedicine network that would bring together physicians from the University of Virginia and the Medical College of Virginia. Even in states that have successfully used telemedicine, hurdles remain. "If we had the money to install the equipment and plenty of specialists willing to use the service, we'd install it in all of our prisons," says Angelo Cisternino, a financial analyst for Virginia's Department of Corrections. "But there aren't that many specialists who are comfortable using telemedicine to provide medical care." While cost has been a major hurdle for many universities, equipment prices have been dropping rapidly. Equipment varies widely among programs, and few have setups as elaborate as Galveston's CyB-R Care system. Even here, though, prices are coming down: Equipment for one CyB-R Care examining room that cost about $60,000 a few years ago costs only about half that today. The system, with its ability to transmit x-rays and other medical information, is gradually replacing the lower-tech telemedicine applications in Galveston's network, which covers nearly all of Texas. The system relies on satellites and high-speed telephone lines. Using the Internet would be far less expensive, but wouldn't ensure confidentiality. Dr. Calhoun's morning of exams is fairly typical for a cyberdoctor at Galveston. When he arrives, he reads over the exam schedule that a receptionist has prepared electronically. As each appointment time arrives, the patient is brought to the CyB-R Care satellite station in a prison clinic. A nurse practitioner at the prison signals that the patient is ready to be seen. A technician at the headquarters makes video contact and pulls up the patient's electronic medical records. When Dr. Calhoun gives the signal, the inmate's image appears on the screen in front of the doctor's workstation, a curved, high-tech command center. Using two-way-interactive video, Dr. Calhoun examines the patient. By zooming in, he takes a closer look at a scar to see how it is healing. Another physician might use the system's electrostethoscope to listen to a patient's heartbeat, or a dermascope to examine a rash. If necessary, Dr. Calhoun can call in a faculty specialist in any number of medical fields for a three-way videoconference. One patient, who arrives wearing shackles, practically pleads for surgery to repair an aching backside. The high-security-prison inmate seems less menacing when he explains how he was injured, not in a fight, but from falling off a crate while getting a haircut. "It's been three months, and I can barely walk. I have to walk on my tiptoes," he complains. "The pain is always there, from the time I wake up until I go to bed." Dr. Calhoun asks prison guards to remove the patient's shackles so he can point to the areas that hurt. The doctor instructs the nurse to move her hand up and down the patient's heavily tattooed leg, until she presses the point that causes him to wince and double over in pain. The physician zooms in on the patient's x-rays and examines his medical chart. The verdict? Nothing is broken; the injury produced bursitis and arthritis that don't require surgery. "Honestly, the only way we can treat it is with anti-inflammatory medicine, time, and gentle stretching exercises," the doctor tells the patient, whose face clouds over. "I guess I don't have any choice," he mutters. "You can refuse treatment." "Oh no, I really want to get better. I'm tired of walking silly." Dr. Calhoun prescribes the stretches and medicine. If it weren't for telemedicine, the patient would have been transported to Galveston, along with at least four guards, at a cost of hundreds or maybe thousands of dollars. Because he is confined in a high-security area of the prison, guards have to take special precautions when taking him anywhere. In asking state lawmakers for an expanded telemedicine program, Texas prison officials estimated that they spent about $5-million transporting prisoners for medical exams in 1998. Telemedicine could cut that amount by at least half, they reasoned. "Only one of every 13 patients we see in our private clinics ends up going into the operating room," Dr. Calhoun says. "The other 12 didn't even need to come in. They could have been treated by telemedicine." Even the most ardent advocates of telemedicine concede that it's not right for every patient. "There are still patients we need to put our hands on, particularly someone who is in an acute or life-threatening situation," Dr. Calhoun says. Medical schools that offer prison telemedicine hope that the experience they've gained will help them branch out into other applications, such as rural and home health care. And even though several medical schools' initial forays into rural telemedicine were disappointing, they are making another go at it. Texas Tech and the University of Texas' medical college in Galveston have begun expanding their rural networks, and are making plans to expand the scope of their practices into other venues. Already, beneficiaries have included workers on off-shore oil rigs and chronically ill children. In the not-too-distant future, telemedicine advocates envision a patient being examined by a doctor from a desktop computer in the patient's home. "Over the next few years, there will be a great opportunity to expand telemedicine into rural areas and nursing homes," says Don McBeath, director of telemedicine at Texas Tech. "We'll take what we learned in prisons and apply it to other populations." Dr. Calhoun couldn't agree more. "We don't want to be kept in prison with this technology," he says. Easy-to-print version E-mail this article

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