Telemedicine Mixes Health Care, Technology

Feb. 15, 2002 -- In 10 years, a doctor could be automatically alerted if something goes wrong with a chronic health condition — and may use a robot to perform surgery, from across the room or miles away.

That is, if insurance companies agree to pay for these advances in telemedicine, the science of delivering health care from afar.

Doctors have been cooperating across distances for years. Jerri Nielsen, a doctor at the South Pole was diagnosed with cancer via a jury-rigged, Web-connected camera attached to a microscope. And medical personnel in rural areas and prisons have used video links to tap the expertise of city hospitals.

But new technologies promise to bring telemedicine beyond the tried-and-true videophone.

One example: Pacemakers from German firm Biotronik get in touch with the doctor, silently and wirelessly.

Other body-linked devices are paving the way for a new era of "tele-homecare."

"There are manufacturers that make implantable drug pumps … neurostimulators to ease pain in your back and your muscles," said Biotronik project manager Mark Johnson.

Diabetics and others with chronic health conditions will eventually be able to pick up "home telemedicine instrumentation packs" at drug stores which will take blood pressure, blood sugar and other readings at home and zap them to a doctor through the Internet, according to Jonathan D. Linkous, executive director of the American Telemedicine Association.

VivoMetrics' LifeShirt, meanwhile, is a wearable, washable T-shirt-like device that monitors life signs. Eventually, it may be worn by firefighters so medical personnel can monitor their health in burning buildings, and by patients with congestive heart failure so doctors can know the moment something goes dramatically wrong. Patients with sleeping problems could be monitored via LifeShirt at home rather than undergo an uncomfortable, multi-day sleep study at a lab.

VR in the ER

Telemedicine is also bringing surgeons' skilled fingers into tiny spaces, and spaces thousands of miles away. Doctors already use virtual-reality interfaces and robots to perform abdominal surgery through tiny incisions.

In January, Columbia University's Dr. Michael Argenziano did the first robotic coronary artery bypass operation — a relatively common procedure that normally requires a 10-inch incision in a patient's chest and weeks of recovery. With his robotic tools, Argenziano was able to perform the surgery through three pencil-sized holes in his patient's chest.

The Da Vinci robot system used by Argenziano is the subtlest of the available systems, he said. For one thing, it offers true virtual-reality, binocular vision — two cameras in a goggle-like setup give the doctor a more immersive experience than other robotic systems which rely on the surgeon watching an image on a flat screen.

"If I dropped a needle with the instrument, I'd actually jump back and look between my knees to see if I had dropped the needle," he said.

"It's only a matter of time before experience and comfort with these new techniques drives them to dominate," Argenziano said. "There's no incision, less pain, and a faster recovery" - as little as eight days rather than the 6-12 weeks for traditional surgery.

Dr. Michel Gagner at New York's Mount Sinai Hospital took robot surgery up a notch last September when he operated on a patient in Strasbourg, France via robot while sitting more than 3,000 miles away. A dedicated high-speed computer link connected Gagner with his operating room in France.

Gagner said remote robot surgery will still require a live surgeon to stand by in case something goes wrong.

"It will be sort of a co-pilot type of expertise," he said.

Don't expect to see Gagner's type of remote robot surgery in your hospital any time soon. The first applications will come in very remote locations, probably military outposts, Gagner said. In years, third world countries might be able to tap the expertise of Western surgeons — if their Internet networks and budgets can afford the high-speed links and million-dollar robots.

The Cash Crunch

There's one huge barrier standing between patients and these advanced procedures: money. Insurers are the gatekeepers of the U.S. medical system, according to health care analyst Mark Bard of Fulcrum Analytics, and insurers are unconvinced they'll be able to save money with these therapies.

While Argenziano's robotic bypasses may save insurers big bucks by allowing patients to leave hospitals sooner than with traditional procedures, Bard said remote robotic surgery will be the provenance of the super-wealthy who would currently travel to see top surgeons.

"People in … the Middle East, today they'd travel to Duke University to do surgery … that will play to the same segment of society. It's not going to expand beyond that, because the economics just aren't there," he said.

Tele-homecare may save money by reducing emergency room and doctor's office visits, but no insurer wants to spend the money to study and install new technologies that may not have immediate payoffs, Bard said. This won't stop tele-homecare, he said — but it will delay its acceptance, as it's anticipated the federal Medicare and Medicaid bureaucracy will explore the technology, albeit slowly.

And tele-homecare may have another surprising opponent: doctors. By reducing office visits, pacemakers like Biotronik's also reduce doctors' incomes, Bard said.

"If telemedicine replaces an office visit, the doctors want that money," he said.

A spokesman for the American Medical Association said the doctors' organization doesn't yet have a stand on tele-homecare.