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The Big Sell: Telling Doctors About Telemedicine
The new Office of Telemedicine goes the distance

Alex Nason demonstrates a consultation via videoconference.

With a remote control, Alexander Nason sends commands via the Internet from a videoconferencing station near Wolfe Street to a camera in a hospital room in Ethiopa.

For newcomers,” he says, “telemedicine is something that needs to be experienced, not talked about.” He zooms in on some instruments in the Ethiopian hospital, killing time while waiting for a teleconference with Ireland to begin. Minutes later he has simultaneous live connections with pediatric hospitals in Cork, Dublin and Belfast. Doctors there make convincing eye contact from three squares on the screen, and Nason greets them from a fourth.

This is a rehearsal for tomorrow’s exhibition teleconference, when a couple of Hopkins physicians will consult with Irish doctors before an audience of Irish political figures, including the Minister of Health, who will be tuning in to see what the telemedicine buzz is all about. The audience will see high-resolution digital images—a fetal sonogram, perhaps, or the inside of an eye—and the doctors on either side of the pond will be able to mark up and manipulate the images even as they consult.

Welcome to the world of telemedicine: clinical care, consultation and education delivered via communication technology. Nason, a Johns Hopkins International senior manager for education and outreach, has made it his personal mission to awaken Hopkins doctors to the possibilities. These range from the commonplace, such as consultation by phone or e-mail, to the seemingly far-fetched: telesurgery on a patient in another country—or even in space. The middle ground encompasses radiology consults on home computers, lectures broadcast in real time by satellite, home health care by videophone, centralized intensive care monitoring, travel-free prison health, and late-shift international outsourcing.

Some of these things are happening now at Hopkins, but not enough, and not cohesively enough, to satisfy Nason. With a background in hospital strategies and a knack for the long view, he heads the new Office of Telemedicine. Its mission is to serve as a clearinghouse and technical resource for divisions interested in developing their own programs.

Nason’s task is half technical, half financial—and two-thirds public relations. Monthly meetings bring together a small band of believers, including Bill Ruby, the infectious disease specialist who provides HIV care by videoconference to Maryland’s prison population, and Louis Kavoussi, the urologist who does hospital rounds by remote-controlled robot and has performed robotic telesurgeries from Baltimore on patients in places like Rome and Singapore. The biggest challenge in bringing others on board is getting doctors who are strapped for time—and possibly skeptical—to come and see for themselves.

If Hopkins on the whole has been slow to grasp that being in the same place at the same time is a luxury that’s getting harder to afford, others have caught on in a big way. The NIH-funded Telemedicine Information Exchange lists over 200 programs in the United States.

Off-camera at the Ireland teleconference is vendor Tim Kaufman, CEO of Second Opinion Software. With a product that integrates videoconferencing and asynchronous, or “store-and-forward” technology (storing information digitally and forwarding it, as in e-mail), Second Opinion dominates the industry in the South and West, where telemedicine is already big business. The Irish network, linking 29 pediatric hospitals, is the company’s—and the world’s—first national telemedicine system.

The point, says Kaufman, is to reduce or eliminate travel and increase access to care, particularly in places where specialty care is hard to come by and where demand is high. He cites the case of seven ophthalmologists responsible for 3 million people in South Central Los Angeles. They can see more patients by not seeing them—that is, by replacing office visits with images taken by technicians and delivered to their e-mail in-boxes. Hopkins ophthalmologist Ingrid Zimmer-Galler conducts screenings this way between Frederick and Cumberland, Md. Otolaryngologist David Goldenberg will be studying the potential of telemedicine in rehabilitating patients using real-time video technology. The list of fields in which pictures may soon replace office visits is long.

Reimbursement and licensure remain thorny issues. Outside of radiology and telemedicine to rural communities, store-and-forward consults are generally not reimbursible, and while a number of states have made legal provisions for telenursing across state lines, few such allowances have been made for doctors.

Hence the need for persuasion (read, lobbying) on many fronts. But with the meeting grounds of the modern era becoming entirely virtual, the writing is on the wall. “We can choose to be involved now at the cutting edge,” Nason ventures, “or we can wait and play catch-up later.”

Rosemary Hutzler



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