Teleradiography implementation and adoption in Boston-area hospitals

Teleradiography

COMPUTER TECHNOLOGY and MEDICINE

Revolutionary Combination

The recent fusion of state-of-the-art computer technology and medicine, called teleradiography, has excited radiologists for its capabilities. The 2002 Akmerican Heritage Stedman's Medical Dictionary describes teleradiography or teleroentgenography as a procedure, which is performed with the tube held approximately 6 feet from the body and then sent to a distant site.

The choice of hardware depends on size and speed of the image and licensure if it will be sent from one State to another. On the other hand, the major criteria for the choice of a printer are cost, output resolution, paper requirements, and gray scale. For accurate output resolution, a 600 dos per inch printer should produce an image at approximately 12 1p/mm. For the purpose, some printers need special paper. Cost is also an important criterion when the cost/benefit ratio of the use of the radiographic digital imaging system is considered. And the printer should produce an image with 28 or 256 shades of gray.

Through teleradiography, physicians can use computer networks to share images among themselves or with students within an area. This enables them to achieve the highest possible level of collaboration in conducting a diagnosis or determining treatment. This is done by digitizing data from magnetic resonance imaging or MRI, CAT scans and some digital x-ray machines. For example, a radiologist can transmit x-ray images of fractures to a practitioner anywhere in the world. All that teleradiography requires is a standard UNIX terminal, which is connected to the internet.

Unified Medical Systems is a Brookline company that creates and uses digital images. The use of teleradiography at United Medical has been limited but its founder, Dr. Julius Pearlman, has encouraged more doctors to use it. He says he and those who do receive and send medical images all over the world right at home. Other area hospitals have responded. Radiologists at the Brigham and Women's Hospital, for example, have been experimenting with network-linked magnetic resonance imaging and CAT scans. Director Ethan F. Fener of the radiology information systems said that 30% of the hospital's almost 2000,000 radiology exams were digital. He also said that almost all the exams are entered into computer file servers and are available for sending throughout the department, the hospital and the medical community. CAT scans are transferred through the network to Dana Farber Cancer Institute for radiation therapy planning. The therapy is then sent back for implementation.

But some hospitals hesitate to use it because of certain disadvantages, such as cost and speed. Doctors at Massachusetts General Hospital, for example, do picture archiving of digital images in large quantities instead of using teleradiography. Other doctors encounter difficulties with computer terminals. Some computer screens have limited space, intensity and brightness. Director Fener also finds the use of teleradiography expensive in the face of overwhelming demand. Dr. Pearlman, however, believes that the advantages in using the procedure outweigh the disadvantages and justify the cost. It integrates information from different images and allows the user to view them through different texture and intensity ranges, which are otherwise invisible. Director Fener foresees that images will be more widely accessible to physicians and that data conveyed by teleradiography will be used for analysis, therapy and intervention.

Telemedicine and Teleradiography

Health care professionals who work in distant areas and others who work under conditions of isolation can now take advantage of telemedicine in performing their tasks. Telemedicine has been defined as any medical activity, which utilizes telecommunications. Its most common techniques include telephones, fax machines and the basic computer skills. Its applications cover and include direct patient services, supervision, education and research. Teleradiography or teleroentgenography is considered the most established of the new technologies.

Computers have been used to create and examine images and translate CT scans, sonograms, magnetic resonance images and even some x-ray images. This has enabled the rotation, enlargement and comparison among images. Radiography develops the image and places it into the digitizer. The digitizer is, in turn, connected through a computer to a telephone line. The image is sent to a remote computer, which translates the digital file into a diagnostic x-ray image. Using this series of equipment, a technician from one end can shoot the film and a radiologist at a distance on the other end can receive and view it almost simultaneously and make a diagnosis right there and then. This new technology allows the primary care provider in remote areas to make needed consultations, hence improve the delivery of patient care.

Broader Use of Teleradiography Needed for Accurate CT Scan Reading

Schriger and associates tested and evaluated three groups of physicians' accuracy in interpreting cranial CT scans to determine thrombolytic therapy in patients with acute stroke. The three groups consisted of radiologists, neurologists and emergency physicians. The authors concluded that many of the physicians who routinely performed the task did not have the needed skills to recognize hemorrhage on cranial CT scans. It was noted that the three hours given to administer recombinant TPA required skillful interpretation of cranial CT scans. The authors recommended advanced training in CT scan interpretation or a broader use of teleradiography in order to improve the accuracy of cranial CT scan interpretations.

Treatment of acute stroke now includes recombinant tissue plasminogn activator or TPA for select patients within three hours of acute ischemic stroke. Patients with intracranial blood on CT scan should not be given this therapy. Results of the study showed that while the surveyed physicians scored almost perfectly in identifying both easy and difficult hemorrhages, 78% of them had incorrect readings of the CT scans. Hence, the authors recommended advanced training in CT scan interpretation or the broader use of teleradiography in order to improve reading accuracy.

Teleradiography as telehealth technology has been shown to be effective in treating diseases, such as diabetes and congestive health failure. Less than a decade ago, the medical community thought it was too experimental to fully use and fully endorse. Today, telemedicine or telehealth activities have seeped into mainstream medicine, mainly through the efforts of the American Telemedicine Association. For all the brilliant results of studies on its efficacy, however, internet medicine has not been as readily incorporated into traditional medical. One reason is that telehealth equipment was expensive and not focused on specific patient need. Another reason has to do with payer issue problems. And a third is telemedicine's greater emphasis on technological efficiency than cost-benefit ratios.

Early telemedicine equipment was durable but large and costly in adjusting it for home use while maintaining high profit margin. In the early 90s, these were in fact so costly that even pilot telemedicine studies were hard to launch. The profit margin was also so stiff that it could have wiped the telemedicine concept completely if grants did not provide the funds for early telehealth studies. At first, healthcare organizations retained the old and stiff profit model. Under this model, the profit margin was the same for a patient who was monitored at home as if he were in the hospital. The same hospital-grade monitoring equipment and same level of medical expertise were used. Despite the findings of initial telemedicine studies that remote patient monitoring improved outcomes, insurance companies were not convinced about costs getting saved. They found no reason to strongly endorse telehealth activities. The developers and healthcare providers of telemedicine, however, grasped the possibility of improving the quality of life of chronic sufferers of disease. In time, most payer organizations, such as Medicare, acknowledged the potential but without the cost potential. There is currently a need for hard data to weigh the program costs against its benefit. Evidence must clearly demonstrate that telemedicine technology will significantly improve the overall organization, especially on labor costs.

A recent ATA survey, however, found that of 141 active telemedicine programs in the U.S., 72 make billable services available. According to the findings, program payers have been reimbursing in at least 25% States. They are following the lead of Blue Cross and Blue Shield rather than the lead of Medicaid/Medicare. Elderly patients and other patients in the rural areas have been viewed as sticking it out with Medicare. Nonetheless, ATA predicted increasing federal support for telemedicine in the form of congressional appropriations and initiatives. These included Medicare Telehealth Validation Act of 2003, which would make healthcare more accessible in rural America. Another indicator of progress was the creation of low-cost, modular remote patient store-and-forward monitoring equipment. It is easy to use and non-threatening to older people who resist new technology. Experts interpret Medicare's decision to reimburse for telemedicine activities as the ultimate force, which will eventually bring remote patient monitoring to the masses. Despite obstacles, developments in the realm of telemedicine in the last eight years indicate progress in the struggle to reduce the costs of home care.

The Internet and Medicine

The internet is clearly the medium of choice for telemedicine as well as other medical applications, although web site creation has been proceeding rather slowly. Statistics show that only 2% of hospitals have their own web sites. IBM and other vendors, however, have assured that the pace will pick up and make the creation of medical web site simpler, faster and cheaper. More than 95% of hospitals use the internet for email, medical discussion groups and FTP services. Of this number, 30% intend to increase the internet for marketing and promotional uses and 44% of them for manpower recruitment. At present, the internet is used for medical literature research at 40% but much less for online patient assessment at only 12% and only 1% for the transmission of patient records. These data translate into almost 2/3 of health care providers in the U.S. As not using the internet for clinical use despite its low and fixed cost. A third or 31% of these health care providers use other telecommunications modes, such as the old telephone system, dial-up lines or dedicated ISDN or TI lines. But the shift to the internet has been perceived by expert observers to become the trend. They predict that it will replace most of the old telephone and other telecommunication channels and services. The primary reasons for this are cheap cost and the integration of the required tools into the operating systems by Microsoft. Dr. David Warner, chief information officer of MindTel, disregarded historical barriers to the widespread use of telemedicine. He expressed optimism on the unparalleled potentials of telemedicine in the next decade. He specifically mentioned the case of the Malaysian "super corridor." It links government and private company services, including health care and telemedicine, with the global community. It will test the merits of telemedicine in health care delivery to the most remote parts of Malaysia. This Malaysian project has been attracting worldwide attention and a lot of American corporate support.

Communications technology has been modifying conventional biomedicine and opening up a decidedly new era in medicine. It has enabled virtual reality and surgical techniques to perform medical procedures over minute video technology through the internet in unprecedented ways. Physicians, patients, administration records-keepers and insurers can interact securely with one another in real-time over the internet. This can be done by means of a system, which will allow for multiple-user, real-time and synthetic intelligence-enhanced medical practice online.

Many States have shown enthusiasm over some telemedicine programs. One such program is prison medicine, which has proved to be cost-saving. The patient can be managed via telemedical examination at much less cost than transporting him to outside medical facilities and providing security during transport. Telemedicine programs also respond to situations when the care is needed in remote, thinly populated areas and the transportation is too expensive or unavailable. In England, the use of teleradiology for certain-sized images was reimbursed by health plans, as the case was with telepathology and teledermatology. In the case of teledermatology, 41% of the 52 million patients who consult for skin problems in the U.S. every year are not seen by dermatologists.

A annually are not seen by dermatologists. As a consequence, many melanomas go undiagnosed and many lives are lost because of delayed recognition and treatment. Telemedicine presents the solution of allowing family practitioners who see patients with suspicious skin conditions to be viewed by expert dermatologists through the teledermatology system. Teledermatology can also be less expensive. A recent study conducted by the University of Tennessee, which used interactive video systems, found that primary care physicians who performed the exams without telemedicine spent $294 per patient at two visits. In comparison, telemedicine-assisted exams cost only $141 per patient at an average of only 1 visit. A properly established in-office or mobile telemedicine facility will also incur less driving time, increase teaching opportunities, and increase the number of patients. These patients can receive better-quality local professional care. Dermatology exams in remote or rural areas can also be performed in 12 minutes by telemedicine. In comparison, a camcorder may be adequate as an input device. The old telephone or ISDN may also provide adequate bandwidth. The old telephone may likewise be cheaper than ISDN and works well with the new modems.

The U.S. Department of Defense has led in the use and promotion of telemedicine applications. It has been developing telesurgery, teledermatology and teleradiology. Two projects by the Commonwealth of Virginia Telemedicine Network ar the Commonwealth of Virginia Department of Corrections Prison Project and the Southwest Virginia Alliance for Telemedicine. Physicians at the University of Virginia Medical Center can examine inmates at the Virginia Department of Corrections without leaving the correctional facility. Its telemedicine program has reduced inmate transportation cost, security risk, has increased efficiency through block scheduling of consultants and effectiveness of patient record tracking and has reduced public view of the inmates at the Center. The University received a grant by the U.S. Department of Commerce in the amount of $412,269 to fund the Southwest Virginia Alliance for Telemedicine. It was to benefit the four medical sites attached to the University of Virginia Health Systems.