On-The-Move Telemedicine

A video camera in the speeding ambulance records paramedics telling a frightened patient to lift her right arm, then her left. Miles away at the emergency room, Dr. Marian LaMonte watches the woman's halting movements on a computer screen - getting a precious head start in diagnosing a stroke long before her patient arrives.

Welcome to the first on-the-move telemedicine, using wireless technology to link the desperately ill to a neurologist from the moment they're strapped into an ambulance. It's a pioneering experiment that University of Maryland doctors hope could one day help more of the nation's 600,000 stroke victims get treatment in time to save brain tissue.

It also may rejuvenate interest in telemedicine, until now hospital-based instead of in moving ambulances. Despite almost a decade of research showing telemedicine can help Americans who otherwise wouldn't have access to cutting-edge care, very few doctors use it.

"In theory, we could have every doctor hooked up," says Dr. Michael Ackerman of the National Library of Medicine, which called together frustrated experts last week to debate how to spread the technology. Ackerman said many patients who are routinely referred to specialists "could be handled by telemedicine and start treatment right away."

Telemedicine uses computer technology to let doctors virtually examine patients over long distances. Consider a University of Iowa program in which specialists hundreds of miles away examined and treated rural children with cerebral palsy and other disabilities using two-way video, saving families $125 in time and travel per session plus the struggle of repeated long-distance doctor visits.

Yet aside from radiology - X-rays and other scans routinely are evaluated by long-distance radiologists - there are only 200 telemedicine projects caring for patients, most federally funded. Many doctors complain that the technology is too difficult or time-consuming and worry about reimbursement – complaints proponents say are fixable.

But the pioneering Maryland ambulance could prove the best persuasion - if a new study shows on-the-move telemedicine truly salvages stroke victims' brains.

"If we can make this system work for a complex neurological exam, then it's cake to treat any other disease," says LaMonte, who heads the University of Maryland's stroke team.

Fewer than 3 percent of stroke victims get the brain-saving drug TPA because it must be given within three hours of the first symptoms. The telemedicine ambulance lets some of the complex exams, required to ensure TPA is the right choice, begin immediately. This is especially important for victims who live hours from a hospital that has stroke specialists.

Maryland neurologists and the technology firm TRW Inc. used four cell phones hooked to a modem to link in-the-ambulance monitors and a video camera with the university's Internet server. At the hospital, LaMonte analyzes the vital signs an talks paramedics through coordination and other neurologic tests, watching via four new diagnostic-quality video images beamed each 10 to 15 seconds.

In initial testing with 12 patients, LaMonte says the system yielded good exams. For example, one showed suspicious signs that a man with stroke-like facial weakness had encephalitis instead, leading to an emergency room test of his spinal fluid that otherwise might have been long delayed.

The technology had kinks. LaMonte sometimes was cut off when the ambulance drove faster than cell phone links could keep pace, for example. TRW made some changes, and LaMonte is about to begin testing whether the $25,000 telemedicine kit - stored in a backpack ready to carry to the nearest ambulance - saves crucial time in treating patients.

Until then, experts are struggling to spread conventional telemedicine. To counter doctors' complaints, they note that Medicare and some managed-care groups have begun paying for telemedicine consultations, and that operating computers isn't harder than operating medical equipment.

Ackerman foresees telemedicine as part of everyday practice: A primary care physician sees a suspicious mole, dials the on-call telemedicine dermatologist, sits the patient at the video-equipped office computer and voila, an instant consultation.

But today most telemedicine requires an appointment at a special studio. Nor are there standards for telemedicine care or to ensure that computer systems can "talk" to each other.

"This is a very key time," warns Dr. Douglas Perednia, a Portland, Ore., dermatologist with the Association of Telehealth System Providers. "We've got to do this right to realize the full benefit of this technology."

By Lauran Neergaard
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