How did you become involved with telemedicine?

I became involved in telemedicine very early in my career, although we didn't use the term telemedicine at the time. During my cardiology fellowship as part of research with the space program in the 1970's, I worked with engineers from Grumman to develop software programs for real-time monitoring of various cardiovascular functions during space missions. This mainly involved blood pressure, electrocardiogram, and vector cardiogram and ultrasound signals analyzed by an old PDP-11 computer. 

Then, in an unusual chain of events, I appeared as a guest on the "Tonight Show" discussing this research, and demonstrating some of the tests on Johnny Carson. That's when it struck me that the power of television should be harnessed and applied to health care. I have been involved with medical telecommunications ever since, including teaching and research in television and multimedia at the University of Notre Dame. 

When and why did you join University Texas Medical Branch in Galveston?

The UTMB Executive Director position came along last year. When I looked at this program, I was astounded not only by the size and scope of telemedicine activity here, but also by how completely it has been integrated into UTMB's daily operations. I believe a visit here is, literally, to see how a large part of tomorrow's medicine will be practiced. 

So when UTMB offered me this opportunity, it was the easiest decision I ever made, and here I am. 

When did telemedicine originate at UTMB, and how has it evolved?

In 1994 UTMB started telemedicine as part of its responsibility for the care of inmates in prisons run by the Texas Department of Criminal Justice. For many reasons, this has steadily grown, and the experience has been applied to many other areas, especially rural medicine, where UTMB has a long history. 

As I mentioned, telemedicine has become a very routine part of medical practice and education around the UTMB campus. Today we have telemedicine facilities in our 24/7 level I trauma center, correctional medicine center, 8 on-campus studios for distance education, 2 mobile systems, and 19 telemedicine centers for clinical care in all the major departments. Our radiology department is 100% digital. At the other end, we are connected to numerous community health facilities and prisons throughout Texas, cruise ships, and other countries. We also have 5 fully equipped mobile units with satellite connections for emergency deployment anywhere in the world by air and one mobile van, presently for demonstration purposes. 

Please describe the telemedicine training program at UTMB.

We have been conducting accredited telemedicine programs in our studio-classrooms for the past 9 years. The courses are designed for physicians, nurses, allied health personnel and anyone else interested in telemedicine. In the next few months we are going to begin Internet -based curricula, both text-based and with video streaming. We are also collaborating with a medical school in New York to rotate informatics postgraduate trainees through the Center for Telehealth for the telemedicine portion of their education. 

In addition to training, what are other areas the UTMB Center for Telehealth is involved in?

The Center is also responsible for telemedicine research, technology assessment, and support services for patient care conducted by our faculty throughout the campus. 

What are your research objectives?

Foremost is to put some real scientific rigor into determining what works, what doesn't work, and how we can make things work better in telemedicine. The literature is replete with plenty of anecdotes nicely hinting about the potential value of telemedicine. However, we desperately need to take this to the next level of published data in the mainstream peer-review literature, with the focus on outcomes. The burden is on telemedicine to prove itself to the rest of the world with good research; until then, issues like reimbursement and sufficient funding for education and infrastructure will remain problematical. 

So what are we doing in research? We have taken two large very large steps. 

First, UTMB has obtained federal funding for a Telehealth Resource Center. We are making this a collaborative endeavor involving all the academic health science centers in Texas as well as many community-based centers across the state. The purpose of the Resource Center is to study past and ongoing telemedicine activities, and make this information available to institutions desiring to develop telemedicine programs. Our first project is pooling the data and then analyzing the experience of grant allocations from the Telecommunications Infrastructure Fund, a 5 year, 1.5 billion dollar expenditure by the state of Texas. We believe that a lot of valuable information will be derived from this study, helping health care facilities make intelligent decisions about telemedicine, not just in Texas, but across the United States as well. 

Second, we have just recently received a very generous grant from a major communications corporation to establish a Telehealth Research Center. We have a very exciting plan on the drawing board about this, and will release more information as soon as it is final. 

You mentioned technology assessment was one of the Center's functions. Tell us more about that.

We have an exceptional technology team, the same group that builds the mobile units. They have become highly adept at evaluating products aimed at telemedicine applications. I suspect that there is a lot of technology being built in workshops and garages all over the world, as well as major manufacturers, that only need some testing and refinement to become valuable telemedicine tools. With our technology expertise and volume of activity out in the field, we are in a good position to help. 

What are the busiest clinical programs aimed at the underserved in Texas right now?

As you know, Texas is a very big place, with huge rural and urban populations, many of whom are desperately underserved because of money, distances, and the lack of proximate specialty care. So we really need telemedicine. The University of Texas health science centers, of which UTMB's program is the largest, and several other academic health science centers are leading this effort. Some of UTMB's own telemedicine programs are aimed at special needs children, high-risk pregnancy, geriatrics, asthma, mental health, oral health, diabetes, and epilepsy. The focus of UTMB's telemedicine programs is primarily on underserved populations with these disorders. 

Do you have any international projects?

UTMB has a special interest in international telemedicine because the Houston-Galveston area has so many global connections through the deep-water seaports and the huge presence of the energy industry in Southeast Texas. Since its inception in the late 1800!s, UTMB has had a long relationship with these enterprises. We also work closely with several of the supporting aerospace and technology companies for NASA, which is nearby; they too are very international and have strong interests in telemedicine, for obvious reasons. 

Two years ago UTMB performed two tests designed to study the technical feasibility of international telemedicine. One involved a telemedicine unit on an offshore petroleum platform. The other test connected our center with a telemedicine unit in Perm, Russia. Find Perm on a map and you will agree it is as far and extreme as you can go. Both tests showed us that remote locations could be well served by telemedicine. 

Today we have many international initiatives. One of the most interesting is telemedicine services for cruise ships, which we have in place on several different ships operated by three major cruise lines. These operate all over the world, and many more ships are likely in coming months. Fractures are a special problem on ships, so we are busy with store and forward radiology interpretations and orthopedic consultations. Acute myocardial infarction is also a great concern for them, given their older populations, especially when they are cruising in remote areas. Of course, they encounter every other problem you might see on land, as well. 

We also have a contract with the government of Egypt for telemedicine service, with our present focus on teleradiology and telepathology. And we are in the planning stages for projects in Africa and Latin America. 

Our primary long-term international interest is in developing programs with emerging nations, which have enormous underserved populations, with staggering health problems. I believe these can be greatly alleviated with telemedicine. 

I read that UTMB has a large prison program. What are you doing in this area?

UTMB presently cares for about 150,000 prison inmates, with telemedicine for primary care, cardiology, orthopedics, mental health, urology, dermatology, and several other specialties. Before this program began, a prisoner would have to be shackled and accompanied by 4 prison guards for up to a 4-day round trip - I mentioned Texas was big - to Galveston to have atopic dermatitis diagnosed. Telemedicine saves the state a lot of transportation money and delivers much better and more convenient care for the inmates. 

I would add that the correctional care program is shared with Texas Tech University, which points up to fundamental philosophy: we believe collaboration among medical centers involved in telemedicine should be encouraged whenever possible. 

In addition to Texas state prisons, we also provide telemedicine for federal prisons, a state prison in New York, and are in active discussions with other states as well. 

What areas would you like to develop and expand on?

Almost everything, but you can grow only so fast. Our main focus is on serious health problems among the underserved - both rural and inner-city populations have so many unmet medical needs. Our priorities include chronic congestive heart failure, diabetes, mental health, neurology, asthma, children with disabilities, and AIDS. And the list goes on. The bottom line is for us to take some of these incredible telecommunication technologies and start applying them where they are really needed. There are folks suffering and dying out there, and telemedicine can greatly help do plenty to help them. 

WWhat excites you most about these projects? Do you have a favorite?

Anything telemedicine can do that really helps people - and that's a lot - excites me. However, I personally find technology itself much less interesting. 

I will mention a couple of my favorites at UTMB. One is a weekly telemedicine clinic for patients with epilepsy, who by law are cannot drive a car within 6 months of their last seizure. The second is our telemedicine clinic for special needs children, handicapped due to conditions such as cerebral palsy. Both of these illustrate what I mean by serving real needs. 

What are you doing in the area of demonstration projects?

We have several, and I will mention a couple. 

One involves a model rural health project in which we are working with physicians in the farm community of Weimar, Texas, located about 3 hours from Galveston. They have excellent primary care physicians there, so we are looking at ways we can provide specialty teleconsultations to help support their practices. We are also conducting patient education classes in Weimar, such as diabetes nutrition. 

Another project involves the employees of an insurance company located in an office building just 10 blocks from the UTMB campus. About a year ago a telemedicine center was installed in their facility, and connected to physicians at UTMB. Over 90 percent of their employees now prefer to see their physicians through telemedicine rather than traveling to the campus. The employer likes the program because the time away from work is drastically reduced, even with such a short driving time for a face-to-face visit. Based on what I have seen in this program, I suspect that within a few years telemedicine centers in large office complexes will be commonplace. 

A lot of our readers are psychologists and counselors. What are you doing in this area, and what do you see developing?

One project, which is funded by a combination of federal and state grants, is designed to deliver psychiatric consultations for abused women and children in underserved areas of East Texas. This is a joint project between UTMB and Stephen F. Austin University. 

Mental health is an enormous problem in the United States, and places outside metropolitan areas may be hundreds of miles removed from the nearest psychiatrist. We have found, as have others, that certain forms of psychiatry and psychology management by telemedicine appears to be very effective. As a matter of fact, telepsychiatry for our prison population works so well that we recently hired a dedicated psychiatrist for this service. 

You are a cardiologist by training. What would you do in cardiology?

Distance monitoring of cardiovascular function carries huge potential. That is mostly related to the fact that a lot of cardiology is centered on physiologic parameters like heart rate and rhythm, blood pressure, and intracardiac pressures. Imaging techniques, particularly ultrasound, are important, too. Cardiac rehabilitation is also well suited for telemedicine. 

At the moment, pacemaker assessment and distance monitoring of the standard ECG are by far the largest applications. 

My general view, however, is that a lot more needs to be done in cardiology. Cardiovascular diseases are, by far, our number one health problem in the United States, so I believe we need to be much more aggressive in establishing telemedicine's role in this area. 

After the earthquakes in India someone emailed an item about a Japanese medical team using a portable satellite dish and digital camera to take and send a picture of an injury from the site. This is along the lines of KISS. I am convinced that one of the most exciting areas in telemedicine is the potential role it may have in international health and disaster responses. Tell me about what you and UTMB are doing in this area.

Our technology team builds portable units using off-the-shelf products configured to meet specific medical tasks. These "fly-away" telemedicine systems are designed for rapid deployment, easy set-up and use, and connectivity nearly anywhere in the world. The systems can be operated by minimally trained medics, and contain the tools necessary for rapid triage and diagnosis of patients in the field. These units range from suitcase size up to our 34" cube unit called BOB, the Big Orange Box. 

Texas is so big, how are you managing in your state or in Mexico?

Fortunately, as I mentioned before, our state legislature has been very progressive in funding a huge telecommunications infrastructure. We also have a statewide telemedicine plan nearing completion that will be submitted for legislative consideration by the end of this year. When these are implemented, in just a few more years, all communities in Texas, from the deep woods of East Texas to the deserts of far West Texas, will be connected for whatever telemedicine support they need. 

With regard to Mexico, Texas has a special relationship with our friends to the south of our border, so as a state institution we are committed to collaborative projects there. For example, we are having discussions with a medical school there to see how we can work together in telehealth. 

Looking ahead 1, 5, and 10 years from now, where and what do you see in telemedicine, here in the United States and internationally?

I believe the speed with which telemedicine matures will depend greatly on our ability to prove its efficacy. Then, as critical masses of usage are reached, technology costs will fall rapidly. When this is coupled with professional reimbursement for services, which is inevitable, it will become a routine part of health care. 

As telemedicine matures in the United States and other modern nations, my great hope is that, in parallel, we will extend our ability to emerging nations around the world. Third world countries have health problems bordering on the catastrophic and while telemedicine isn't the whole solution, I believe it can make a serious impact, if used properly. 

What do you want to do, and in what direction would you like to see your program go?

UTMB already has a large, varied telemedicine presence, and that is soon to greatly expand as a number of additional projects go online. 

Volume isn't everything, of course. The quality must be there as well, and we have an entire campus of experts in medicine, nursing, and allied health already plugged in; they will continue to ensure the highest level of quality. After all, because telemedicine is basically a connection between patients and professionals, its quality is a direct function of each institution's established standards of care, whether the encounters are face-to-face or at a distance. 

I have to add, unfortunately, that the flip side is also true. Armed with telemedicine, bad doctors will make things only worse, as they will reach more patients. You can count on every charlatan in the land rushing in to use telemedicine once reimbursement is in place. Some of the stuff you see on the Internet today is an early warning sign of that. 

That is one reason why it is critically important for academic health institutions, like UTMB, to continue to lead the way as telemedicine becomes integral to our health care systems. 

The ATA annual conference is one way to keep up with the world of telemedicine, yet I am convinced we need to use the medium of email and the Internet more to keep our peers up to date, such as what Hutchinson does in Georgia. What do you want to say or add to your colleagues out there? And what word of advice can you offer?

As I mentioned before, education is my first love, and the Internet is a fabulous medium for professional education. This will be particularly true when we have sufficient broadband to deliver quality video. I genuinely believe that the Internet is going to fundamentally change all levels of education. 

Thanks,
Bob Pyke Jr.,RN,CPNP
Assistant Editor & Roving Reporter TelehealthNet News

Vincent E. Friedewald, MD, FACC, FACP
Clinical Professor of Medicine &
Executive Director, Center for Telehealth
University of Texas Medical Branch at Galveston

Articles |  Books | Interviews |  Chat Room
Privacy | Telehealth Conferences, Meeting Schedules and Organizations
Service Agreement | Telehealth and E-health Glossary |  Home