Communications Revolution Program #5-94: "Trends in Hi-Tech health Care" KPFA Radio - January 19, 1994 Panelists: Janice Rylander, Jim Grigsby Project Director and Host: Jude Thilman Executive Producer: Bari Scott Associate Producer: Carol Klinger Managing Editor: John Rieger Associate Editor: Claire Schoen Feature Producer: Steve Tokar Introduction by Jude Thilman Tele-Banking, Tele-Commuting, Tele-Therapy, now we have Tele-Medicine. You may never see or talk to a lived human being again! Health care through computer networks - I'm Jude Thilman and this is the communications revolution. In rural Oklahoma, it used to take four to six days to have your X-rays read. Now it takes 60 minutes -- thanks to sending X-rays by computer. Two-way interactive video, real-time 3-D images, digital sound sent back and forth between your doctor and a far away specialist -- it's all part of the growth industry called Tele-Medicine. But what will the cost be to an already over-burdened system? We are joined by two people involved in this new field. With us in the Berkeley Studios of KPFA from Pacific Bell's Health Care Market Group, Marketing Director Janice Rylander. And from station KCFR in Denver, Jim Grigsby, Senior Research Associate at the Centers for Health Services and Health Policy Research Our look at Tele-Medicine begins with this report from producer Steve Tokar. Feature by Steve Tokar Dr. Defacto: Mrs. Norell? Mrs. Norell: Dr. Defacto? Dr. Defacto: Yes, sorry to keep you waiting, I have to go again, but I'll be right back. While I'm gone, I'd like you to take a few minutes to verify your medical records... Mrs. Norell: ...but, uh... Dr. Defacto: It's very simple, Mrs. Norell, Egbert will take you right through it. Don't worry, I'll be back. Mrs. Norell: I rush down here to be on time, and look at all the good it does me. And now I get to wait for Edward. Egbert: Egbert, Mrs. Norell, I'm right here. Mrs. Norell: Where? Egbert: On the computer screen in front of you. Mrs. Norell: You're in the computer?! Egbert: No, I AM the computer. Egbert 5000 the Doctors' Computerized Patient Record System. Mrs. Norell: What?! I have no idea what you're talking about young man, young machine, whatever you are. Egbert: I'm talking about computerized medical records Mrs. Norell. Look, here it is 2014 and it has been about 20 years since you have seen a doctor, right? Yes. August 2, 1994 - a funny rash that cleared up on its own. Mrs. Norell: And I haven't missed much since then, from what I can tell. Egbert: On the contrary, you've missed a lot. It might help if I filled you in. Mrs. Norell: But Dr. Defacto... Egbert: Won't be back for a while, believe me. Alright. Back in 1994 when you last saw a doctor, automobiles were still powered by gasoline. The ozone hole was confined to the South Pole and most medical records were kept on paper, hospital charts, lab results, all of that. But a growing number of health professionals were envisioning a national, computerized patient record system. Mrs. Norell: Whatever for? Egbert: I thought you'd never ask. Let's go to the Data Archives for an excerpt from a 1994 interview with Dr. Martin Findlater on the Board of Trustees of the National Rural Health Association. Ah, here it is: There's a great deal of waste in, shall we say, the bureaucracy of medicine and so, this will help reduce the bureaucracy simply by being able to reproduce the same information on multiple occasions. Egbert: Not only that. Say your doctor orders a laboratory test for you and writes a prescription: I can enter that information on a computer and, with existing technology, that information can be transmitted to the pharmacy, to the lab, and you can save some steps that way, and it will also reduce the number of mistakes that are made. Mrs. Norell: Hah! Egbert: Well they were optimists back then, and sometimes they were right. Back to the data archives - 1994 again. Suzanne Henry, a Nursing Professor at the University of California: What it might mean to you if an individual patient, coming in for a visit, that rather than being asked -once again- to list all of your current medications, your drug allergies, what diseases you may or may not have, you may be asked instead to just verify. Egbert: Which is what I would like you to do. Just use the electronic pad and stylus there. Mrs. Norell: Hmm. It says here that I'm allergic to aspirin - that's not right. Oh, it must be because I was born in Aspen, Colorado. Egbert: Why not change it? Mrs. Norell: I'm trying, but nothing happens. Egbert: Ahem, well, I'll change it for you later. Now the next technological breakthrough was to link all those computerized records into one big national database. And this allowed you to start analyzing the information compiled so that today you could do a national study on, say, the effectiveness of two different drugs on a particular type of patient. Mrs. Norell: That rash I had back in '94? Egbert: Exactly, your doctor could have done a data search and found out that the cream he prescribed was useless in cases like yours. Mrs. Norell: My marigolds loved it though. Egbert: Oh really? I'll add that to the database. Ah, and then there were the on-line support groups - which are run by patients themselves. Mrs. Norell: What's that? Group therapy on the computer?! Egbert: Not exactly. They're clearing houses for information on the latest treatments and drugs and study results. Mrs. Norell: Oh. Egbert: Let's see, a 1994 interview with Wendy Hoechstetter, a System Operator for an on-line support group for Attention Deficit Disorder, or ADD: People definitely come away knowing far more than they had ever imagined, in far less time. Or we'll get people who say, "I have been ADD all my life, and I've learned more in the past day, reading this forum, than I knew in all that time." Mrs. Norell: Well, really, I have missed a lot in 20 years. Egbert: And I haven't even told you about Tele-Medicine yet. Mrs. Norell: Tele-Wha--? Egbert: Tele-Medicine. Say you don't live in San Francisco, but hundreds - or even thousands - of miles away. You and your local doctor can still consult with Dr. Defacto over a two-way interactive video system. Dr. Defacto would examine you on camera without leaving his desk. You could see him too. Mrs. Norell: You mean I would actually get to see the doctor? Egbert: Patience Mrs. Norell. Mrs. Norell: Oh, I would see patients... Egbert: Never mind. Back to the Clinton era, 1994. Sheri Hostetler, Executive Editor of Tele-Medicine Magazine One of the big tenets of Clinton's Health Care reform is increased access to health care. Of course, increased access is one of the big reasons why people implement Tele-Medicine projects because you have a lot of folks living in rural, or otherwise remote, areas who don't have a lot of access to, sometimes, even any health care at all. Certainly not any kind of specialty health care. Egbert: Ah, the idealistic '90s.... Mrs. Norell: Egbert if you aren't' a machine I'd swear that you are being wistful. Egbert: Well, Vivian, let's be Frank. Computers can do great things, but we can also be used for other purposes. 1994 Data Archive. Dr. Rick Peters, Head of Corporate Development for Oceania, a medical software firm: Computer systems are going to make people more efficient, there's no question about it. They are going to eliminate a lot of steps in the process. Egbert: And as it turned out, they eliminated a lot of nurses. Computerized records allow fewer nurses to take care of more patients who were sicker. Which means more machines and fewer people. And it is a harsh reality that I think is a shame because the administrators are looking at that and they are looking at automation making nurses more efficient rather than looking at automation eliminating middle managers, administrative overhead, and all of the red tape and bureaucracy that doctors and nurses have to deal with to take care of patients. Egbert: And then there's the question of secondary uses... Mrs. Norell: Uses of what? Egbert: Medical data... [static]... Excuse me. Jody: Hi Mrs. Norell, I'm Jody from Operations Unlimited, an overseas corporation. As a patient of Dr. Defacto, you qualify for our frequent surgery plan. If you have 10 operations, for whatever reason, we'll give you the 11th free! Just call 1-... [static] Egbert: Hi, I'm back. Case in point, Viv, that's a secondary use. Mrs. Norell: They can break in, just like that? Egbert: Security is never perfect. Which is another weakness in the system of course. But there you are. Dr. Defacto: There you are Mrs. Norell. Sorry to keep you waiting so long. An unexpected Tele-Medicine consultation. Mrs. Norell: Oh, you have rural patients? Dr. Defacto: Rural? I should say not! A clinic about two miles away. Not a neighborhood you would actually want to be in... if you know what I mean. Mrs. Norell: Uh-huh. Dr. Defacto: Now let's see your chart.... 'Allergic to Aspen trees.' That's interesting. Now Mrs. Norell, the procedure you have been recommended for is a total hip replacement. I'm not sure how much you understand about what's involved... Mrs. Norell: Wait a minute - you said hip replacement? Dr. Defacto: Yes, the entire left hip. Now a woman of your age.... Mrs. Norell: But my hips are fine! It's my big toe, I sprained it a few weeks ago. Dr. Defacto: Then, why have you been referred to me, Mrs. Norell? Mrs. Norell: Darned if I know. I thought those nice young kids at the clinic knew what they were doing. Dr. Defacto: Egbert! Egbert: I found the mistake doctor. The technician transposed two numbers when Mrs. Norell was first treated and the error just multiplied - as usual. Dr. Defacto: You know Egbert, just once I'd like to get through a day without a screw-up like that. Jody: Hi Dr. Defacto, I'm Jody from Operations Unlimited.... Defacto: Egbert! Egbert! .... (narrator) Jody, Egbert, Mrs. Norell and Dr. Defacto are fictional creations. All interviews in Egbert's Data bank took place in 1994 with real people. This is Steve Tokar for the Communications Revolution. ****** Host Jude Thilman: Mistakes made worse by the power of computers. Janice Rylander, (Marketing Director for Pacific Bells' Health Care Market Group). The feature we just heard makes the future sound frightening, Don't you think? Where you get fewer nurses, mixed up patient records and less contact with doctors. Is this an unfair caricature, in your opinion? Janice Rylander: Well I think change is always fearful or causes fear in people, and I think that is what we're looking at here is sort of revolution, call it the "information revolution." And just as people were fearful of a car, instead of a horse-and-buggy. I think you can concentrate on that, but I think there are a lot of benefits here. I think that we're still not talking about eliminating the human reaction in all of this, so I'd like to just characterize it as normal fear of anything that is different. Host: Well, one thing we want to do is sort out what fears are based in possible realities and what aren't. Just this last notion that mistakes could be multiplied by computer, some claim a reduction of mistakes when using electronic databases will happen, and some claim more mistakes will happen. What's your opinion? JR: Well, my personal opinion is where ever you have a human being, you also have the possibility of mistakes and that includes as humans interact with technology. But I think you have a lot more consistency that is passed on through technology and I think that the benefits are there. But please believe that I don't believe that the human factor should ever go out of it. Especially when you're talking about something like medical care, that's important for all of us. Even people who are involved in the technological revolution are still human beings and understand the importance of that. Host: Alright, let's go over some of the benefits, as you note, of this new technological revolution. What are some examples, Janice Rylander, of the sort of Tele-Medicine technologies that you're familiar with, that are being implemented now? Let's identify, what's going to become a household word, in the future, like the word X-ray has become? JR: Well, maybe we need to step back and explain why Pacific Bell is involved in this first. There's really two ways. First of all, I belong to a health care market group that is really working with the health care community in identifying how telecommunications and technology can assist them, both in the efficiency of their operations from an administrative viewpoint and a clinical viewpoint. And the other one is just bringing from the Pacific Bell perspective the benefits of the information age to the home. Host: Give us an example. JR: Well, Pacific Bell has invested $16 billion in putting the infrastructure into California. By the end of 1996 we should have 1.5 million homes connected to what is being called the Super Information Highway. Which is really an advanced method of putting voice data and video into the home. Those two really converge together, in health care, through a program called CALREN and that is a research and education network trust fund that Pacific Bell set up. The Information Super Highway is going to be only as useful to people as applications are developed. So one of the things we did was develop some applications through a trust fund, or, we didn't develop the applications. We had companies -- health care organizations -- come together and develop health care applications. Host: These are pilot projects, right? JR: Pilot projects that use the technology that will be on the Information Super Highway. Host: These sound like a big investment for something that is going to happen in the future, and let's come back what the investment will look like in a minute. But in terms of what's already being implemented, I understand there are already some 20-25 projects or sites for Tele-Medicine going on around the country. I would like to bring Jim Grigsby into the discussion. Jim Grigsby, you were the principal investigator on a grant from the Health Care Financing Administration (or HCFA) -- the agency that actually administers Medicare -- to study the effectiveness of Tele-Medicine. So you took a look at these sites that are currently operating around the country as opposed to things that are projected to come down the pike. Give us your sense of what the successes were and what some of the down side was. Jim Grigsby: Well, there is quite a bit of variability among these Tele-Medicine programs. In fact, right now, there are probably just under 20 that are relatively active. We visited eight of them, and I've spoken with people who run or work in a number of others. They are found in a variety of different places, for example Tripler Army Medical Center in Oahu provides medical care to, essentially to the whole Pacific. At the current time, they only have one program operating and that's between Tripler and an island about 2,200 miles away called Kwajalein, which is inhabited primarily by U.S. defense contractors and their dependents. In an area like that where there aren't very many flights between Oahu and Kwajalein, where it is very expensive to evacuate people by air for medical reasons, it appears that this approach to Tele-Medicine is not only very innovative but has the potential to save quite a bit of money and quite a bit of time. Host: Tell us exactly what they do in Oahu. JG: Well, they've got a variety of different programs that are available. The bulk of the work that they have done so far is involving dermatology. There are a number of skin conditions that are fairly common in the South Pacific and therefore the need for dermatology is relatively high. So using interactive television it's possible to see a patient, video tape that patient, or rather take a live recording of that patient on Kwajalein that can be seen in real time ... you can transmit that to Oahu, or a dermatologist can examine the patient with a high resolution monitor, and in many cases make a diagnosis that might mean that the patient doesn't need to be evacuated or doesn't need to have specialists come out and see him. Host: I imagine travelling from island to island could be quite expensive. Now, the other big victory, or success story, I should say, for Tele-Medicine is supposed to be in rural areas which similarly to islands has patients at quite a distance from their health care providers. Can you give us an example of how it has worked in a rural area Jim? JG: Yeah. It has worked variably. In some areas it's worked quite well, in that people who live in remote areas no longer have to get into their car and drive for four to six to eight hours in order to see a specialist instead that can often be seen in a community health clinic or community hospital. The image is transmitted to a medical center elsewhere, and their conditions can often be taken care of. In some cases, patients with chronic illnesses, for example, have been monitored over time. Followed regularly by a specialist to make sure that their medical care is proceeding properly. Host: We still have to have a description here of exactly what images or what exactly the technology is that one doctor is seeing at one end and one patient is providing on the other end. What exactly is the doctor looking at when they see their patient 60 miles away? JG: Well it depends on the exact specifications of the system. In some cases what's used is a still image, so that essentially -- let's say for example that a patient has a skin lesion of some sort, it's possible to take a still, digitized photograph of that lesion and transmit that. In fact there are telephone systems, picture-phone systems, that will allow transmission of these still images. In other cases it's a live interactive image so that the physician can see the entire patient, see a provider with the patient do an examination, if necessary. The patient may be looked at from different angles, can use different cameras so that you can get a macro lens and get a good close-up or, if necessary for example, a neurologist may want to watch a patient walking across the room. Host: It really raises a question in my mind whether I want a doctor to diagnose a lesion on my skin by looking at a picture of it without being able to touch it, probe it, I don't know -- smell it (smile), all of those kind of things. JG: Well, it raises a question in some dermatologists minds as well. While a number of people are very enthusiastic in their support of Tele-Medicine, it is clear that there is still a fair amount of skepticism. And part of the reason for that is that there has not been sufficient research to demonstrate the effectiveness of Tele-Medicine. Part of our study was to try to review the research literature to find out exactly what we could say about its effectiveness, and apart of the use of Tele-Medicine to transmit radiology images (so X-rays and CT scans and things of that sort) outside of that there really isn't a lot of good evidence that Tele-Medicine is effective. Host: Janice Rylander would you agree that there's not much evidence to support Tele-Medicine's success? JR: Well, I think we're just now learning about what's going on, so I would agree that probably all of the data isn't in. I think one area where Tele-Medicine can be effective is in the second opinion also. Where you are in a situation where you are still with the doctor and that second opinion is valuable and can be done through Tele-Medicine as well. Because, again, eliminating that human interaction as we all know is very important to us with our doctors, is a very scary thing. So the second opinion I think plays a big role and would certainly reduce the costs and aggravation for the individual and hopefully reduce overall health care costs. Host: In point of fact, the Tele-Medicine projects that are currently operating haven't provided that much patient care, is that true Jim Grigsby? JG: Well, that's right. There's an oncologist at the University of Kansas named Ace Allen who did an informal study last year and found that in all the Tele-Medicine programs in North America, if you don't count sort of very brief consults with a specialist about people who are on dialysis for kidney disease, fewer than a thousand consultations were done in all of North America. A lot of programs have had really a great deal of difficulty getting going. One very large, well funded program, for example, has expended $1.6 over the last year and a half -- two years, and has seen, I believe, a total of 16 patients. Host: Not cost effective I would suggest. JG: No, at $100,000 per patient it's not very cost effective at all. Other programs, though, have been able to increase patient volume, and use the system reasonably well. But even in those programs you find that they still may only be seeing 10-11 patients a month. Host: I think it is helpful to hear this and put some perspective. People are afraid, for instance, that their patient files are going to be on huge databanks. But currently fewer than one percent of this nation's hospitals even keep their records electronically. So, a lot of these fears are projections of what might come down the road in the future. In fact, a lot of health care providers, physicians particularly, are reticent to involve themselves in Tele-Medicine projects, isn't that true Jim Grigsby? JG: Well, that's true, and there are a number of different reasons for that. For one thing, because the research literature doesn't have a lot to say about the effect of Tele-Medicine, many people are concerned about whether or not the technology works. Generally the people who are involved in Tele-Medicine programs are believers or we assume they wouldn't be very involved. But it looks as though Tele-Medicine is reasonably effective, but for certain applications it's not always clear. So they're concerned about liability. They're concerned about providing quality medical care and they're not certain that they can do it, at least a certain percentage of providers. Others are really concerned about how it is going to affect other aspects of their practice. Right now Tele-Medicine is generally not reimbursed so that people can get paid for it. It's also not clear to a lot of rural provider whether or not these programs are really intended to steal their patients away from them. So there is the fear that it will undermine their practice or undermine the network of referrals that they have developed over the years. Host: You're listening to the Communications Revolution. You can contact us via E-Mail at kpfa@well.com, kpfa@well.com, or if you'd like to join today's discussion and talk about today's topics on-line, just join us on the Internet, on our IRC channel which has the name, trp5. Janice Rylander, even the Health Care Financing Administration noted recently that they are concerned that companies such as Pacific Bell and others are going to have a very entrepreneurial rather than patient care priority in implementing Tele-Medicine projects. Entrepreneurial in the sense that they are going to go in and swoop and scoop patients away from rural physicians and center their care in large urban medical centers and thereby break the personal connection between doctor and patient. What is your response to that fear? JR: Well first of all recognize that Pacific Bell won't be delivering health care to people. It would be our working with doctors, hospitals, clinics, to be able to help them deliver the type of health care that is appropriate over telecommunications. I think, again, it just goes back to there is a fear and a fear of change. And right now doctors are probably the ones who are being squeezed the most, not only in terms of acceptance of telecommunications, but also in what's happening in moving our health care system -- in terms of reform, putting it from a fee for service into a managed care environment. So there are lots of fears there that are justifiable in terms of their own personal careers and what's happening to them. But telecommunications, really, can assist in both the administrative portion of their business, and really provide some cost effective ways to address administrative bureaucracy of health care. I think the clinical part of it, as Jim says, is a little bit more nebulous... Host: It's been problematic. How about the question of patient empowerment. There is certainly some indication that having huge on-line databases of health care information will help empower patients to learn more about their own health and their own diseases, if you will. Do either of you know of examples of this happening? JR: Yes, we certainly do. I think just through technology that exists today with interactive voice mail, many of the HMOs and the various health care providers are using, within interactive voice response kinds of systems, the ability to have people gain information, to be able to answer their questions about routine health care that can assist when a young child is running a fever and the mother doesn't know what to do to bring that fever down, but yet all indications are it is not at a critical stage. But just something that empowers them to access that information from the home and that's as simple as your touch-tone pad, in some cases, right now on your telephone. So we do see ways that people can gain more information and I think those ways will increase in sophistication as home health applications develop. We're in a situation right now where we're moving from a sickness model to a wellness model and in doing that we've seen care move from the hospital as the central focal point to outpatient clinics and ultimately moving closer and closer to the home. Telecommunications can play a role and I think it plays a big role in the education and empowerment of bringing information readily available, easily accessible into the home. Host: All via your telephone of course. JR: Absolutely. Host: We're discussing Tele-Medicine: Will it promote patient empowerment or will it drive up the cost of health care, or both? You've been hearing just now from janice Rylander. She's Marketing Director with Pacific Bell's Health Care Market Group. You're also hearing from Jim Grigsby. He's the Senior Research Associate at the Centers for Health Services and Health Policy Research. I'm Jude Thilman and this is the Communications Revolution. We'd like to hear from you right now. Give us your thoughts on High-Tech medicine by calling 1-800-848-2298. That's 1-800-848-2298. We'll be right back. ****break**** Host Jude Thilman: We're talking about the ups and downs of Tele-Medicine. Whether a day will come when computers care for you more than your doctor. Call us with your questions and comments at 1-800-848-2298. We do have callers waiting on the line. Let's hear now from Rob in Petaluma. Hello Rob. Caller #1: Hi. I was wondering what the role of alternative medicine and natural medicine would be in the process of all this. Is it just being left out of the discussion or, you know, what part is it going to play at all? Because it seems that the alternative medicine is very helpful for a lot of people and it often is left out and in the health care reform, it is not even a topic. So I was just wondering what people on the panel had to say about that. Host: Thank you for your call Rob. It does seem to me, in what I've read about Tele-Medicine, the legislation that's been introduced has to do with, "will Medicare reimburse?" There are concerns about liability issues, as you brought up Jim Grigsby. Everyone's concerned about mainstream medicine and how Tele-Medicine is going to be a part of the new health care reform act. What about alternative medicine? Do either of you know what role that would be allotted? JG: Well, it looks as though if you just examine Tele-Medicine at the present time it excludes alternative medicine entirely, and part of that is because the impetus for a lot of these programs has come from academic medical centers where traditional, mainstream, allopathic medicine is practiced. Also, concerns about liability, concerns about reimbursement and so on, have made the field kind of tentative initially. One of the things about Tele-Medicine, though, that people should keep in mind, is that really what we're talking about is a medium for delivery of services. It's not like a CAT scan or MRI which is used for a specific kind of diagnosis. Instead it's sort of a way of extending a physician's or a provider's office so that, in itself, Tele-Medicine doesn't exclude alternative practitioners, instead it provides a medium through which they could potentially provide services at distance. Host: Alright, our number here again is 1-800-848-2298 ---- 1-800-848-2298. If you want to join our discussion of Tele-Medicine. It seems that from what I've read about Tele-Medicine that they're really not paying enough attention to alternative forms of therapy, however, in the world of cyberspace, if you will, for those people who are savvy about computers and bulletin boards and networks, there seem to be a lot of holistic therapy bulletin boards, discussion groups, groups that talk about acupuncture.... And there is one particularly in San Francisco/Bay Area in which people are sharing information about Attention Deficit Disorder (ADD) and there are different system operators that sponsor these discussion groups, these chat lines on-line and talk about all kinds of issues. There's almost a Lorenzo's Oil type story everyday of people who had some rare disease and are able to go on-line and research that disease. So I know that that exists, but there is also a real problem with it in terms of, well two things, let me bounce off of both of you. One is the difficulty of use, you have got to definitely be computer savvy to do Internet searches. And then second the question whether there might be a circulation of misinformation amongst these people. Do either of you have an opinion about that? JR: This is an example where technology links people to share information, just as some of the examples you gave. I think there is always a chance of misinformation when you have people sharing in an unedited type environment. People still have to make their own decisions about where they get the information. In terms of the Internet and the accessibility of it, there are also things that are available in terms of linking people right now just through telephones and support groups, as you just mentioned. So I do want to stress that there are different levels of linking people, and that's important to understand so that it doesn't turn out to be the "haves" and the "have nots" which is certainly a concern. Host: Another caller joins us now. David from Oakland, welcome to the program David.... We lost David. We'll come back to our callers in a second. The number here is 1-800-848-2298. Ah, we have Lorna from Long Beach. Hello Lorna. Caller #2: Hello. I heard the gentleman talk about the alternative use of alternative treatment, and the problems therewith. The other thing I'd like to know about is such things as chiropractic, naturopractic and so forth. Is the government going to put a clamp on it such as they do now with anything that is alternative and not the traditional, such as in Cancer treatment, AIDS treatment and so forth. There are many of these things that are known to the general public, but you can't get it on any sort of public media. Host: Thank you for your call Lorna. Will the government put a clamp, it could be rephrased to question whether the government will include, ever, alternative therapies being covered by Medicare or being paid for. Certainly their not being paid by insurance companies or by the government is a form of putting a clamp on it. Do we have an opinion from either of our guests? JG: Well, my guess is that things will probably continue as they are. That alternative therapies may be available by Tele-Medicine, or at least diagnostic procedures that might be used for alternative therapies. But I think the question of whether or not they would be reimbursed by Medicare really goes beyond whether Tele-Medicine would be reimbursed. Kind of a separate issue, that has more to do with the acceptance of homeopathy naturopathic approaches and that sort of thing. Host: Which we're still a long ways from that sort of consciousness in America, I think. In terms of reimbursement, Jim, so far there's only one state in which the local Medicare Administration is actually reimbursing for Tele-Medicine, is that true? JG: With kind of an exception, yes that's true. In fact, Tele-Radiology is probably being reimbursed right now. But nobody knows how much or to what extent, primarily because there's no separate way of coding that. But it's not officially being reimbursed. Otherwise only Georgia has approved Medicare reimbursement for Tele-Medicine. Host: The state of Georgia just, by the way, ordered a $4.5 million contract to a New York based company to build a state-wide Tele-Medicine network. I wonder if that has anything to do with their optimism about its use in that state, because they're reimbursing doctors, perhaps doctors would be more willing to jump on the Tele-Medicine band wagon. Our number here is 1-800-848-2298 1-800-848-2298. Concerning Tele-Radiology, there have been radiographs sent through phone lines in the traditional way, for almost 10 years, but now they're actually compressing and digitizing the images so that the whole process is speeded up. Isn't it true that the detection of certain kinds of fractures, fractures that don't have obvious fragments sticking out somewhere, they're harder to detect using digital images than the conventional radiographs, Jim Grigsby, do you know? JG: Well, that's true. The most recent research shows that certain what they call non-displaced fractures, so they're subtle fractures, the detection of them is quite a bit lower than with conventional X-ray film. There are also certain things that physicians look for on chest X-rays that don't show up as well on digitized images as they do on conventional film. It's not exactly clear whether this reflects in part lack of experience with the radiologists in reading digitized images, but the fact is that there is a definite difference in quality. Host: So we might be trading off quality of health care for speed and access, particularly for rural inhabitants, is that true? JG: Well, it's a possibility. I think, though, the prevailing feeling is that, the practitioners know that a particular application of Tele-Medicine is not as accurate or not as effective as conventional medical care that they will avoid it. Host: Let's bring another listener into the discussion. Roger from Richmond, you're on the air. Hello Roger. Caller #3: Hi. I actually have a sort of a specific question. I have a young friend, who I live with, who has been diagnosed as schizophrenic and he is in trouble with the law for petty theft. And we have been trying to get medical help for him, but have also been trying to get legal help through the Internet. And I have been having some success through the Internet with like a --- that's devoted to schizophrenia, but I was just wondering if you had any Internet hospital resource to go to about the legal end of it. Host: On the legal end I'm not personally familiar, do either of my guests have any idea where, on the Internet, where a good source is? It sounds, Roger, like you're pretty Internet savvy already. Caller #3: Yeah, I am, and this is coincidental, because right at the moment I've been trying to work on this and knew you were on the air talking about it, so I thought I'd dial in. Host: Well great, thank you very much for joining us. Jim do you have any ideas? JG: No, I'm afraid I don't. Host: You might just check, Roger, with what discussions there are. They usually have a listing of all of the discussions on the Internet and you can just take a search. I'm sure you know how to do that better than we do. JG: About all I could recommend would be the news groups or using one of the "Gophers". Host: Yeah. The question of patient empowerment this is a good one that... it's good that Roger has the knowledge of how to search through the Internet for answers to his questions, but you really have to be pretty savvy, don't you, to be able to work your way through this stuff. And you're talking about telephone touchpad interaction, Janice, is that something that the rest of us who aren't so computer savvy could be participants in? JR: Well, I think, first of all, information is out there and is as easily accessible as your telephone. You have to, certainly be part of your health care system that offers that kind of information and most people do know how to use the telephone. The medical community has been putting out educational information in a variety of forms, I don't know... way back in the '70s they started by having people call numbers and cassette tapes were put in and messages were played. So this really is just the next step in the evolution and I know there are many of the health maintenance organizations that are using this to educate and so I would encourage people to ask their own health care providers how to access educational kinds of information, and of course, the Internet is still there as well. Host: For those of you who are on the Internet and would like to join our simulataneous chat channel, just go to the name "trp5" on IRC, which stands for Internet Relay Chat, to share your ideas about today's topic of Tele-Medicine. Let's bring in another caller. Mark from Lawrence, Kansas. Welcome to the program Mark. Caller #4: Hello, how are you? Host: I'm doing fine, Mark, how are you today? Caller #4: Good. My question involves the idea of getting back to the quality issue. We've been using the Tele-Net service in the area and I've been involved in different ways, but I do see a quality difference in the fact that certain groups are able to purchase certain qualities of equipment. We're using everything from a wireless stethoscope to Doppler radar on chest X-rays and I've been seeing a big difference between one group's responses to what equipment they're using and the results are a higher quality than others. Are we going to start seeing some standards as well? Host: Excellent question, Mark. Thank you for your call. Jim Grigsby, do you anticipate some standards being set by HCFA, for instance regarding these technologies? JG: Well, I think HCFA will be involved to a certain extent in setting standards for the use of Tele-Medicine. A lot of the professional organizations are quite involved. The American College of Radiology, for example, is currently trying to establish standards for the use of Tele-Radiology. I think what we see right now is that the field is very immature, the various technologies are somewhat incompatible with one another, although some uniformity is developing. There isn't really adequate research at this point to say exactly what specifications a system should have, but I think that as more programs come on line, more research is done over the next few years, and as the professional organizations become increasingly involved, we'll see kind of a natural evolution of standards. Host: Our number is 1-800-848-2298, if you want to join our discussion. The question of the standards being set so that these technologies are compatible with each other is one aspect, but the caller also raised the question of cost. Now, I would suspect that that's going to be a major factor in terms of who gets to have access to all these glitzy gadgets. I know for example Sprint, US Sprint is planning to charge $75,000 a month for an ATM system to link hospitals and rural clinics, and ATM means Asynchronous Transfer Mode, that's the technology designed to handle a combination of two-way video, graphics, text, voice, etcetera. So, just to put one of these systems in is going to be expensive, and then the cost per month. Now is Pac Bell going to be charging that high a monthly cost, Janice Rylander, do you know? JR: Well I don't know, because every cost depends on every system. But I think what you're talking about here is health care providers making decisions that are based on two factors, and one is their bottom line and the cost effectiveness to their bottom line in the business and the quality that it still maintains for their patients. So there are structured costs that would be associated with technology, but in most cases I think what you're talking about is the efficiency. Being able to deliver those services to a wider group of people, to be able to have more efficient use of personnel, and I think cost is a factor, but cost will be considered and the push in the health care industry is to manage their costs, to keep them as low as they can. And so I think that that technology has to be proven cost effective or the health care providers will not utilize them because they will not be able to do that in a managed care environment which has a fixed cost. Host: From Merced, let's hear from Todd. Hello, you're on the air Todd.... Hello, Todd? Are you with us? Guess we lost Todd, we'll come back to it. This cost question, Jim Grigsby, let's let you throw your hat into the ring as well. There are great debates about whether Tele-Medicine technologies are going to, in the short run, cost us more, the health care system as a whole, and in the long run save us, or vice versa. We're going to see a reduction of staff for example, aren't we? What is your view? JG: Well, it's a complex answer. A lot of the people who are strong proponents of Tele-Medicine argue that in fact Tele-Medicine has already demonstrated itself as a very cost effective means of delivering care to people in remote or rural areas or otherwise underserved populations. But I think, the example I gave earlier, for example the program that has been functioning for a year and a half, two years and seen 16 patients at $100,000 a piece, demonstrates that there may be obstacles. One concern that a lot of people have is that in the rush to develop Tele-Medicine programs, a lot of facilities may spend a fair amount of money to get these established and not have, first of all the adequate base of patients necessary to support the program, and secondly may not be really considering that this is a slow developmental process. People aren't just going to flock into Tele-Medicine. It's unlikely that we will go, for example, from fewer than a thousand patients seen in all of 1993 to the tens or hundreds of thousands that might be necessary to support these programs. So while they have the potential to be very cost effective, and under certain circumstances, I think what we're just going to have to do is study the problem as Tele-Medicine develops and find out what sort of systems are cost effective and what others may not be. Host: Our number again is 1-800-848-2298 if you want to join our discussion on Tele-Medicine. Just on the question of personnel, you used the code phrase, Janice, more efficient use of personnel. Nurses are going to be laid off, isn't that the bottom line, personnel -- health care personnel are going to be laid off as we need fewer personnel to handle patient needs, is that true? JR: Well, I can't say what individual health care providers will do with the cost savings and how they will utilize personnel. They may redeploy personnel in another way and get the administrative and the repetitive types of processes that don't involve patient care onto the technological end of things. So I think that's a natural assumption, people want to go to lay-off. Technology does drive more efficiencies and I think we've seen that in other businesses, not just health care. Banking being an example, where you do have the replacement of individuals by machines. I don't think that replaces the human quality in health care. But I think there are ways you can save, for example, UCLA, in their yearly operating expenditures of supporting their radiology department, spends about 2.44 million dollars a year in storage of film and personnel that drives the trucks to do that and a variety of other sources where that type of money could be redeployed into other health care in a system where digital images are stored. So I think it frees up, and I'd rather look at it as a redeployment. Host: The optimistic view. Al from Berkeley joins us now. Welcome Al, you're on the Communications Revolution. Caller #5: Hello. I have two questions. The first is the person from Pacific Bell said that there are a lot that could be cost efficiencies, savings and so forth, but I've always heard that the one industry that resists any such efficiencies is the health industry, and the use of technology in health has actually been one of the reasons for the skyrocketing costs in health care, that we get more scanning equipment, MRI kind of equipment in the Bay Area than you've got in all of Canada, that kind of thing. Isn't this one more major addition on a technology boom that people pay for but they don't really get the basic services. Host: Thank you Al for your call. Janice Rylander. JR: I think what's happening in health care now, and the emphasis that's being put, both from Washington and just the emphasis on the industry, is to look at those spiralling costs, to be able to look at being more efficient in managing their costs. I think technology is one way to do that and has been proven, more in the administrative side of health care. And I think what we're talking about now is whether that can extend into the clinical. But there is a push right now, in health care, in fact I think there was a report that in the last month or so that indicated that this was the first time that the growth in health care expenses was either flat or reduced. So I think things are changing, I think the industry is starting to discipline themselves and look for ways to cut those redundant expenses, and I think they have been resistant. I think that's changing and I think technology is one way that they will look to to help cut some costs. Host: So you see technology cutting costs rather than driving them up as this caller suggests. Jim Grigsby? JG: Well, Janice may be correct about administration and savings as a result of technology, I don't know a lot about that. I do have some concerns though over the fact that nearly every major technological innovation in medicine over the last, quite a number of years, has led to increased costs. For example, if you look at some of what was said about CT scans or MRI when they first came out, it was argued that they would contribute to more cost effective medical care, we were eliminating certain tests that were invasive and possibly unnecessary. And, in fact, costs have tended to rise with the introduction of new technologies. That is not necessarily all bad. One of the proposed advantages of Tele-Medicine is that it increases access to care, so that if people who now don't have access are able to receive medical services that they require, then perhaps that is a cost that the society feels it is willing to bear. But I am somewhat more cautious about whether or not we're really going to achieve great savings. Again, I think research needs to be done on that. JR: I would just add that, for example, we have something that is going to be a part of our trust fund that's been set up between a hospital in one city and a clinic in another to provide 24 hour neurological capability by using telecommunications to link ... to send CAT scans. And just my common sense approach would say that linking through a communications line would be more cost effective than having a neurologist on-site 24 hours a day to be able to provide that capability. so I do see that there is some sharing of resources too, very expensive resources. Host: Yes, I would be curious if that's true, if your link on-line with your major hospital is costing you $75,000 a month, as US Sprint wants to charge. It's an open point at this point in time. Let's bring Bob into the show. Welcome to the program, Bob? Caller #6: Hello. I've been involved in the health care industry for quite some time, from the technology point of view and I have some concerns about the costs that hospitals incur, for instance an MRI -- we did a study once that the average patient that comes into a hospital, the average number of patients, it costs $300 per patient just for the cost of the maintenance program that was required from the manufacturer. So we had to be in a situation where we had to run the unit 16 hours a day and you had to push patients through, and so there was a situation developing where, were the patients being put through the MRI because they needed to go through it, or are they being pushed into it because we had to justify the cost? And another problem that developed is quality assurance. In an MRI you are very dependent on software to determine the quality of what is being seen in the patient, so you have to depend on the manufacturer to provide that quality assurance, and there is really no one out there. The FDA regulates these devices under what they call a 510K. And so the industry is kind of required to regulate themselves, but there have been some serious problems in the past with regulations by the industry. You know, the Dow/Corning thing and, I'm just wondering, has the FDA been looking at this as a medical device and are they considering putting a 510K on it? Host: Excellent points Bob, I thank you very much for your call. Does anyone know if there's going to be any FDA regulation of the software that drives some of this technology. JG: I don't know specifically about the software, my understanding at this point though is that the FDA is not planning to treat Tele-Medicine or associated technology as a medical device. Host: I think those are two good warnings that Bob offers from his front line experience. And certainly to try to justify the technology by using it when it might not be necessary. Let's very quickly try to get one more caller in from Kansas City. Hello, Mel, you're on the air. Caller #7: Yes, how are you today? I'm serious. How does this plan that we've been talking about fit in with President Clinton's proposal that he has on the table right now? Host: That's a simple question. Thanks Mel for your call. Do either of you know where Tele-Medicine is in relation to the Health Care Security Act. Jim Grigsby, do you know? JG: I don't know the details of it. I do know that probably progress on the issue of reimbursing for Tele-Medicine services is tied up with the Health Security Act. My understanding is that the Health Care Financing Administration has sent some language to Capitol Hill that was included in the regional bill, I'm sure it's been marked up quite a bit since that point, but I would guess that it is going to ... the thing will be detetrmined in part by what happens with the Health Care Reform. Host: Yeah, I think that's right. I think the aspect to watch is an amendment to the Health Security Act added by Representative Mike Sinar, Democrat of Oklahoma. But that does wrap it up for today. We're going to have to leave it on the legislative point. My guests have been Jim Grigsby and Janice Rylander. I thank all of you who called into our program. Please join us again next time. I'm Jude Thilman for "The Communications Revolution." .