Telemedicine reaches individuals

Telemedicine provides virtual medical services from the hospital, in physicians' offices and at home. Now, "virtual hospital" teleconferencing systems, once available only in big hospitals, are now reaching down to individual practitioners' offices. Meanwhile, the fastest-growing segment of the business is end-user devices for home care. And although today's federal programs will not pay for home care, in 2001 telemedicine's market share is expected to increase when government medical programs begin to use a new payment formula that is expected to spur the market.

Typical of the business-to-business segment is Apollo Telemedicine Inc., Falls Church, Va., a pioneer in building diagnostic networks for hospitals. The company announced last month its eHealthStat turnkey program for individual physicians. Those who join the eHealthStat network can consult physician-to-specialist just as the big hospitals do. The result, according to the company, is that a diagnosis and treatment plan takes shape only hours after a patient is seen, rather than days or weeks later.

"EHealthStat creates a virtual hospital environment in which physicians can interact with other specialists over the Internet-we let physicians focus on their primary business of diagnosis and treatment, while leaving administrative concerns to the health administrators," said Mark Newburger, Apollo's chief executive.

The program uses Apollo's remote control microscope , which permits consultants to view over the Internet biological samples taken from the patient. The company claims that its telepathology systems have been clinically proved in more than 3,000 diagnostic case studies.

Still, the end-user business is growing fastest. One of the leaders is American Medical Supplies (Miami, Fla), which boasts 1,700-plus installations of its telemedical devices in 41 countries. It supplies everything from videoconferencing systems for physicians consulting with specialists to remote control stethoscopes for patients at home. President Mark VanderWerf said, "Right now we can give patients a dedicated device to remotely read out each of the normal diagnostic measures such as blood pressure, pulse rate, temperature and so forth, but you have to buy the devices yourself. Once Medicare starts paying, the device will just come as a free part of the service of monitoring you at home."

The company sells four types of remote control stethoscopes, including its Phone-Steth that passes high-quality heart and lung sounds (what physicians call auscultation) over phone lines for real-time assessment of patients. The companion Ausculette has output ports for up to five listeners for real-time consultations among attending physicians, and the Simulscope transmits the signal to local physicians via infrared. The granddaddy stethoscope, e-Steth, connects to the sound card of a patient's PC to digitize heart and lung sounds as well, creating a simultaneous multimedia phonocardiogram and automatically e-mailing it to a physician. For institutions, AMS provides complete vital sign monitors as well as remote control versions of all the normal diagnostic instruments. For instance, take the device that the doctor sticks in your ear, called an otoscope. AMS' remote control version allows a nurse to insert one in your ear, nose or mouth while a doctor at a remote site views its image on a computer screen.

All-seeing scope

Likewise, there's that device that the doctor aims at your eye from way too close, called a Welch Allyn diagnostic scope. AMS' remote control version allows a nurse to illuminate your retina, the head of your optic nerve, your retinal arteries and even your vitreous humor without dilating your pupil. The focus in the eyepiece, made by the nurse, is equal to the image remotely viewed on a video monitor by the doctor.

For diagnosing skin conditions, AMS also markets a remote control dermascope that a nurse holds against your skin surface. The integrated microscope has a built-in millimeter scale on its contact plate, allowing the doctor to measure any lesions right on his remote video screen.

For home use, AMS has inexpensive models for blood pressure, weight and various electrocardiogram monitors. They all use internal digitizers and modems to automatically send their readings to your doctor over the telephone.

For many of AMS' devices, two versions are available. The higher-priced models use two dedicated U.S. Robotics modems souped up for AMS by 3Com-one at home and one at the doctor's office-to transmit the real-time signal from its remote control instruments. The less expensive store-and-forward model records a vital sign, digitizes it and then uploads it to a dedicated IP server port over standard telephone lines. The physician can then view the record of the examination when he or she is ready.

The advantage of the dedicated modem route is that the doctor can direct the patient's helper to move the stethoscope to specific spots. The advantage of the store-and-forward model, besides price, is that it automatically sends the readouts to the correct doctor on the Web.

The ultimate in remote control medicine, surgery, has already been successfully performed by SRI International (Menlo Park, Calif.) under a contract with the U.S. armed forces. The successful prototype, called the Telepresence Surgery System, has been installed as a teaching tool at the Uniformed Services University of the Health Sciences (Bethesda, Md.).

SRI's interconnect provides physicians with 3-D vision, dexterous robotic surgical instruments and force-feedback so that surgeons can "feel" the amount of drag as the scalpel slices. The surgeon sees a virtual image while the robot on the battlefield mimics the surgeon's movements.

Within the next year, SRI hopes to demonstrate an updated battlefield version of the system that allows surgeons to stay safely behind the lines while medics set up the surgery tent right on the battlefield. The deployed system will replace a fiber-optic connection used for the demonstration prototype with a wireless connection between the doctors and the robotic surgery tent.

Also, Johns Hopkins University demonstrated a hookup, facilitated by a hardwired connection, where a surgeon remotely controlled a laparoscope held by a staff member.

Smart operating rooms

Companies like Computer Motion (Goleta, Calif.) are already offering commercial versions of those research prototypes. It has adapted the remote control surgery concept to what it calls the smart operating room of the future. There, surgeons will never touch the patients, but instead control a robot with voice commands to make the actual incisions. Robotic control guarantees a minimally invasive surgical procedure because each incision is exact to a precision impossible with unassisted human hands.

"You never have to worry about your hand shaking or slipping, and the enhanced dexterity and precision reduces patient pain, trauma and recovery time-these new minimally invasive procedures just are not possible without robotic assistance," said Robert Duggan, chairman and chief executive.

Computer Motion announced early in July the first successful robot-assisted gall bladder removal. It was performed by surgeon Baki Topal at the University Hospital Gasthuisberg in Leuven, Belgium. Topal completed two robotic laparoscopic cholestectomy procedures to remove the gall bladder through three 5-mm holes with the Zeus Robotic Surgical System from Computer Motion. The machine has already logged over 500 endoscopic radical prostate removal procedures, but the gall bladder was its first major organ removal.

These robotic surgical assistants have proved the concept of remote control surgery for telemedicine, since the doctor operates the robot from controls that could be located off-site. According to AMS, it won't be long before these robotic surgeons will be operating over broadband remote control connections. "If you can operate the robot from 10 feet away, then you can operate it from 10 miles or 10,000 miles away with the proper data connections, which it is our business to provide," said AMS' VanderWerf.

Opportunities abound for entrepreneurial engineers to design instant remote patient care devices, especially for the developing home market for telemedicine.

A few companies have already jumped into the home market using devices that depend on patient reports. They then transmit that textual information over regular telephone modems. For instance, LifeChart.com Inc. (Mountain View, Calif.) has services for diabetics, asthma and cardiopulmonary patients. For instance, its AirWatch Asthma Monitor helps the user record the frequency and other factors when he or she breathes into a handheld device, which uploads into a remote logging computer. The physician then has access to the patient's entire history. But even without the physician, the company claims, the patient using its online software can more easily perceive the factors that trigger asthma attacks.

Still, the AirWatch does not even attempt to collect sound or image data from patients, but depends on their reports keyed into the handheld unit. But as the low-bandwidth restriction of telephone lines is ended and with embedded broadband, the last major restriction to full-service at-home telemedicine will be removed, enabling devices that actually measure progress rather than depend on reports.

As high-speed interconnections become more common, AirWatch-like devices will be able to collect data and send it to remote servers automatically. At the beginning of June the Federal Communications Commission allocated a new spectrum for wireless medical telemetry services, allowing potentially life-critical equipment to provide interference-protected wireless connections for medical equipment, ending dependence on the telephone. This type of service will permit physicians to monitor patients' progress anywhere-at work, in the ambulance or at home.

As broadband-such as fiber optics, DSL and cable modems-becomes integrated into every home, enough bandwidth will be available to provide inexpensive land-line devices that enable diagnostic medical procedures remotely in the home. Today, devices are already available for the most common biometrics, and patients pick the mix that matches their malady.

"We usually see patients [who already have a diagnosis] using telemedicine at home, so they usually know which devices they need to monitor what," said VanderWerf of AMS. However, with broadband's entry into the home, opportunities will abound for new real-time devices that take advantage of the increased bandwidth to offer ad hoc diagnostic modes as well as monitoring functions. Plus, multiple-mode devices could measure biological parameters such as glucose level, instead of individual biometrics such as temperature, pulse rate and blood pressure.

According to AMS, the biggest challenge to engineers designing future remote controlled medical devices lies in integrating them into malady-specific devices that meld multiple types of media, yet utilize a consistent network.

"Right now, we have to require that each unit be standalone, with its own internal digitizer and modem, plus each type of [medium]-sound, video and text-has to go to a different port on the Web server. But that is unnecessarily complex. What we really want entrepreneurial engineers to design instead are units that put all three types of media together, interconnect with FireWire and share a modem talking to a single IP port," said VanderWerf.

With devices that meld the media, AMS hopes to have turnkey products for the emerging home telemedicine market-such as glucose monitors for the millions of diabetics worldwide-that transmit regular multimedia reports on the user's progress to his or her doctor. Many other widespread maladies could benefit from regular monitoring. With Medicare paying for home devices, industry observers believe that the millions of "shopping channel" viewers will buy many of those new telemedicine home care devices.

"We are poised on the brink of an exploding telemedicine market. We don't build our own devices, but depend on entrepreneurial engineers to come up with innovative designs for which we provide the marketing expertise. So I don't have an engineering department, but if I did, I'd be thinking remote patient care," said VanderWerf.

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