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'Telemedicine' allows patients to get second opinions in just one visit

HONESDALE, PA. — HONESDALE, Pa. -- It was a routine medical consultation, with a 21st Century twist.

Marcellus A. Walker, small town doctor, shined a light into Betty Tuleya's ear and peered in with his otoscope. Harold A. Harvey, a renowned cancer specialist, watched as his colleague examined their patient, who was receiving a follow-up examination after successful surgery for a rare tumor on her adrenal gland.

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When he finished, Dr. Walker did not pass the instrument over to Dr. Harvey. There was no need. The specialist had seen everything Dr. Walker saw -- and just as clearly. It would have been a tough handoff anyway. Dr. Walker was in Wayne County, in the rural northeastern corner of Pennsylvania. Dr. Harvey was more than 150 miles away at the Milton S. Hershey Medical Center in Hershey, near Harrisburg.

The electronic collaboration of Drs. Walker and Harvey was made possible by a telephone network called PA HealthNet -- an ambitious state project that is bringing the expertise of large teaching hospitals to small towns such as Coalport, Emporium, Coudersport and Honesdale.

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The year-old Pennsylvania project is one of several regional networks that are beginning to change the way medicine is practiced in rural America. Telemedicine, the marriage of medical science and advanced telecommunications technology for diagnosis and treatment, is bringing the Mayo Clinic to Marcus Welby.

"It might be one of the most affordable ways to provide medical care," said Dr. Eric Tangalos, clinical and administrative director of telemedicine at the Mayo Clinic. "It also arguably puts practitioners at any point on the continent in touch with any specialist anywhere in the world."

'Growing like wildfire'

For those reasons -- and many others -- telemedicine is expected to emerge as one of the leading uses of the so-called "information superhighway."

John Linkous, who runs the Washington office of the American Telemedicine Association, said there are telemedicine projects in the works in about 30 states. By next year, he said, there probably will be projects in all 50 states.

"It's a cutting-edge field that is unbelievable. It is growing like wildfire," Mr. Linkous said.

Nobody knows just how much economic heat that fire will generate. Sales estimates of telemedicine equipment are hard to come by because often the same equipment used for medical purposes is used for other applications, such as education.

But clearly the potential is enormous, as shown by a sizable roster of medical equipment manufacturers, software writers, electronics companies and telecommunications carriers scrambling for a piece of the market.

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For Pennsylvania's project alone, the vendors included Bell Atlantic Corp. as systems integrator, Medical Televideo Inc. as a supplier of monitors and medical equipment, and Compression Labs Inc. as a provider of digital compression computer technology.

Advocates contend the nation's health care system can realize enormous savings through telemedicine. Mr. Linkous estimated that the more efficient use of time and resources could save $15 billion to $20 billion by the year 2000, not counting the money patients could save in reduced travel costs.

The key to the future of telemedicine is the vast amount of medical information that can be transmitted in digital form. From the sound of a patient's heart murmur, to an X-ray image, to the pattern of an electrocardiogram, medical data can be instantly transmitted over telephone and cable television lines to specialists hundreds or thousands of miles away.

"The only disadvantage is they can't touch and feel, but we're finding that's not critical if you have someone who can touch and feel on this end," said Dr. Walker.

The 36-year-old Chicago native is perhaps the main reason that Honesdale, a bucolic town of 5,000 where the parking meters on Main Street accept only dimes and nickels, has emerged as a hotbed of advanced medical telecommunications.

Pennsylvania officials say Honesdale has been the most active of the six "remote" sites on the network, which also includes teaching hospitals at Hershey, the University of Pittsburgh and Temple University in Philadelphia. Of the 21 cases in which the network has been used for referrals, 11 have come from Wayne Memorial Hospital, all but one of those Dr. Walker's cases.

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Dr. Walker said his electronic consultations work better than more traditional alternatives, such as calling a specialist by phone or referring a difficult case to a larger hospital.

"It's a better dynamic because the consulting doctor is on the other end, the primary doctor is in the room" with the patient, he said. At the same time, the visual connection helps create a bond of trust between the specialist and the patient, he said.

New uses envisioned

Dr. Walker said he can envision uses for the HealthNet system that go far beyond routine consultations. With portable cameras, he noted, small hospitals can transmit images from operating rooms in real time, making it possible for specialists to assist less experienced surgeons during emergency procedures.

Wayne Memorial's telecommunications hub is a small room with a pair of oversize monitors and a bank of electronic equipment the size of a family room home entertainment center.

During a recent demonstration attended by Pennsylvania Gov. Robert P. Casey, a camera mounted on one of the monitors transmitted a video image of Dr. Walker and Ms. Tuleya to Hershey, while a camera in Hershey brought Dr. Harvey's face onto one of the screens in Honesdale. As the examination proceeded, the camera in Honesdale zoomed onto Ms. Tuleya's hands to show the patchy pattern caused by a skin condition.

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While the hospital itself is wired with high-capacity fiber-optic cable, the information superhighway hasn't been extended to Honesdale quite yet. Once they left the hospital the images and sounds of Ms. Tuleya's examination were sent by the electronic equivalent of a two-lane county road: copper telephone wire.

The two-way, real-time video connection over copper is made possible by a powerful computer called a Codec, made by Compression Labs, that uses digital compression to squeeze the information stream through the lines.

The results were not perfect. The image from Hershey arrived with a slight delay, and there was a herky-jerky quality to the image of Dr. Harvey, but the Hershey specialist pronounced himself satisfied.

"As a consultant, I would feel very comfortable with the quality of this data in rendering an opinion from a remote location," he said.

Pioneering Pennsylvania

With vast stretches of forest and farm between its urban centers, Pennsylvania is a natural candidate to be a pioneer in telemedicine. According to Governor Casey, the state will expand its telemedicine network by 50 percent over the next year, adding four more rural hospitals.

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George J. White, automated technology policy manager in the governor's office, said Pennsylvania's system is the first in which a state government has pulled together competing teaching hospitals to join in a single telemedical network. In other states, universities have generally taken a leading role.

The projects in those other states have demonstrated the wide variety of potential uses of telemedicine:

* In Oregon, crisis response teams use RODEO NET, a program linking 13 rural communities, to provide outpatient mental health care.

* In North Carolina, the East Carolina School of Medicine in Greenville conducts remote examinations of prisoners at a state penitentiary in Raleigh.

* In Nevada, nine rural hospitals have 24-hour access to four radiologists at the University of Nevada.

* In Texas, a Texas Tech University-sponsored system called MedNet provides continuing medical education services to family physicians, nurse practitioners and physician assistants in rural West Texas.

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* The University of Washington School of Medicine uses teleradiology to help medical personnel at rural clinics in Washington, Alaska, Idaho and Montana decide whether to treat patients locally or refer them to a larger hospital.

As a relatively compact, highly urban state, Maryland has had less impetus to create a statewide telemedical network than other states. Perhaps for that reason, the state's major teaching hospitals are not as far along in finding uses for telemedicine as many others.

But physicians and scientists at both Johns Hopkins and the University of Maryland Medical Center are beginning to take a serious look at possible projects, including some that might reach patients on the Eastern Shore and in Western Maryland.

Steven Fritz, a professor of radiology at Maryland, said the hospital is about to launch a trial of a system under which physicians at the hospital will be able to send X-ray images directly to a computer in a radiologist's home for a consultation.

Dr. Richard J. Johns, a medical professor at Hopkins, said the world-renowned medical center institution is very interested in extending its reach through telemedicine -- "not only regionally but also at greater distances."

Dr. Johns said one important priority for Hopkins is to establish a telemedical link between its main complex and its Bayview campus in Southeast Baltimore. Another is home health care. A third is connecting the offices of Hopkins' extensive health maintenance organization.

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"If you have an enrolled population of patients in an HMO and you want to have a cost-effective HMO, being able to get easy, inexpensive access to consultation when you need it is a great way to go," he said.

Shouldering the burden

There are still some hurdles to be cleared before telemedicine can play a larger role in health care. The stickiest question: Who pays? Physicians, hospitals and insurers haven't figured out how to bill for long-distance services.

For now doctors on both ends of the Pennsylvania network are contributing their services gratis.

"At some point we've got to come back to reality," said Mike Stershic, Wayne Memorial's vice president for community relations.

One group that seems to have few difficulties with the system is the patients themselves.

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Mary Beth Wood, a young Honesdale woman who suffers from a painful neurological condition, said a video consultation with a specialist spared her an agonizing eight-hour trip to Hershey and back at a time when she probably would have had to be transported by ambulance.

"Dr. Walker was sitting right beside me during all this. There's a lot of comfort to be taken in that too," she said.



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