Telemedicine faces tough hurdles

WASHINGTON - Even though tele- medicine is going to be a tough sell for providers and users alike, no other coalescence of technologies holds as much potential for solving major problems in the military and civilian sectors.

Apr 1st, 1997

by John Rhea

WASHINGTON - Even though tele- medicine is going to be a tough sell for providers and users alike, no other coalescence of technologies holds as much potential for solving major problems in the military and civilian sectors.

And that`s what the physical dimension of telemedicine is: a coalescence of advanced telecommunications and information-processing technologies, all readily available from commercial suppliers, to deliver medical services where and when they`re needed. The hardware and software are here now. The only (only!) job left is to integrate them into systems that will work reliably under real-world conditions.

Technological issues, however, are only the beginning; the cultural dimension is another story. The users will need persuading. This means the doctors who will have to operate the system and, in the case of the military, the soldiers who stand to benefit it it.

Both groups are digging in their heels.

Doctors are inherently suspicious of anything that disrupts their traditional routine. As Dr. Jay Sanders, president of the American Telemedicine Association, pointed out at last month`s telemedicine forum sponsored by the Association of the U.S. Army (AUSA), the doctors weren`t keen on stethoscopes at first. They felt they needed the intimate contact of putting an ear to a patient`s chest and that a cold, metallic device broke that contact.

The troops in the field are equally suspicious of any abrupt change and for the same reasons; they`re also in a business where lives are at stake.

One Army Special Forces captain probably sums up their attitude. This officer told me there was no way he was going to have some self-styled expert back in the continental U.S. looking over his shoulder when he was conducting his business.

That`s what the current field tests sponsored by the Army Medical Research and Materiel Command at Fort Detrick, Md., are all about: to determine whether a telemedical system can deliver enough benefits at an acceptable cost to overcome this resistance. Keep in mind these are prototypes and they`re supposed to fail. When Thomas Watson Jr. was president of IBM he said he measured his company`s success by the number of its failed research projects.

What is new is the enabling technologies, particularly the Internet and powerful, rugged, deployable processors. For the first time, it`s possible to deliver medical services to the users rather than requiring them to physically transport themselves to the health care providers, Sanders points out.

Yet he says this is only the beginning. For the future, Sanders says he envisions "ATM-type kiosks" where anyone can insert a personal medical card, use the equipment in the kiosk to measure physical conditions, and upload the information to a primary-care physician and then on to a specialist.

The last piece in the technological puzzle is the individual user`s smart card, which enables the whole system to work. As reported at last month`s AUSA telemedicine forum, Data-Disk Inc. of Sterling, Va., has delivered the first prototype cards and readers as part of the Medi-Tag system to be tested by the Army (see story page one).

At the current prices for the necessary components - $75 for each card and $500 for the reader interface to the computer and on to the Internet - of course the cost is prohibitive, admits Data-Disk CEO Thomas Clark.

But those prices won`t last long if the idea catches on. They`ll go down the experience curve

In a way it`s a hopeful sign that military officials are taking the lead in this area. For openers, the battlefield has to be the worst-case environmental scenario for a demonstration. If the tags and readers work in jungles and deserts, they`ll likely work in most American suburbs. Also, in the more structured military society, there`s a different relationship between doctor and patient than in the civilian world. And, best of all, the military represents a steady market to build up the production base and drive down prices.

In today`s age of commercial off-the-shelf (COTS) technology, which is the main reason telemedicine is possible at all, it`s also useful for the operational experience to flow from the military to the civilian sector. This is a case of a "spin on" becoming a "spin off." The net result is a sustainable dual-use technology.

As is common among COTS technologies, the potential of the civil market dwarfs the military. The soaring cost of health care is the number-one economic problem in this country. It accounts for a trillion dollars out of our annual gross domestic product of about $7 trillion, some four times the cost of operating the entire Defense Department for a year.

Delivering medical services to patients electronically instead of tying up costly medical personnel and facilities can make a big dent in those costs. Telemedicine could be an integral part of Medicare and Medicaid. As a new sexagenarian myself, I`d welcome a system in which Medicare participants automatically got a smart card with their entire medical history and direct access to the best specialists in the world. And, economic considerations aside, there would be an inestimable value in saving lives in emergency situations.

Assuming virtually universal access to the Internet - on the order of the percentage of homes that have telephones and television sets today - and successful demonstration of the enabling technologies in the Army`s Medi-Tag field tests, the telemedicine infrastructure should soon be in place. All that`s left is convincing the likes of the American Medical Association, which has opposed every previous innovation in medicine, and the cantankerous Special Forces captains.

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