Experts discuss benefits, dangers of telemedicine

By James Brice

Telemedicine, telehealth and teleradiology are bringing patients and physicians together, but problems can arise when there are opportunities to cash on the services that make these broadband connections possible.

At a meeting of AHCJ’s San Francisco Bay Area chapter last month, three experts on the highly subsidized practice of telemedicine and telehealth painted a much different picture about the sustainability of programs directed mainly at poor and underserved patients than did teleradiologist Eric Trefelner, M.D., who described the Wild West vision of teleradiology.

Telemedicine is approaching an era of great expansion, according to Thomas S. Nesbitt, M.D., M.P.H., the executive director for telehealth services at the Center for Connected Health Policy, a Sacramento-based telemedicine advocacy group. Nesbitt and colleague Kathy J. Chorba, program director for the Specialty Care Safety Net Initiative, identified new programs that will soon drive expansion in California and other states.

Nesbitt noted that California has been a national leader in telemedicine because of its diversity population and sprawling geography. State government and academic healthcare planners were pioneers in interactive video communications could span the geographical gap between isolated patients who need subspecialty healthcare and university-based practitioners who could provide it. Telemedicine programs at the University of California, Davis, provide services covering 43 medical specialties with hospitals and clinics in California’s Central Valley, he said.

The program’s reach is expanding substantially this summer with the implementation of the California Telehealth Network. California is one of 42 states to receive grants to finance telehealth networks. California received $22.1 million from the FCC. Nonprofit groups in California contributed another $10 million.

In August, AT&T is scheduled to begin construction on a broadband telecommunications system that will tie the network together. Fifty hospitals and medical clinics will be initially connected to the network, Nesbitt said. Another 800 have been approved for participation, with long-term goals calling for more than 2,000 facilities in the network.

Chorba laid out plan for California’s Specialty Care Safety Net Initiative, a separate collaboration between specialty departments at University of California medical schools and designated “safety net” medical clinics. Their patients will gain access to subspecialty care in dermatology, endocrinology, hepatology, neurology, orthopedic medicine, and psychiatry.

The three-year initiative was implemented Feb. 1, with funding through individual grants of up to $1 million to participating hospitals and clinics. The subspecialty hubs include University of California teaching hospitals at Davis, Irvine, Los Angeles and San Francisco. University of California, San Diego, will be added soon.

Nineteen primary care clinics, mainly on California’s rural north coast or central valley, are participating in the first phase of the program. About 45 clinics will ultimately be involved.

A telepharmacy program, operated by the Center for Consumer Self Care at the University of California, San Francisco, reflects how pharmacists are becoming more involved in clinical management of the patients for whom they prescribe drugs, said its executive director, R. William Soller, Ph.D.

The center’s collaboration with the St. Anthony Free Medical Clinic has made connections between pharmacists at UCSF Medical Center on San Francisco’s Parnassus Heights and diabetic patients in the Tenderloin, the city’s poorest neighborhood.

Participating pharmacists dispense care and advice along with prescription drug management during video consultations.

“The advantage is that through the televideo, we are able to look at how often the glucose meter has been used by the patient,” Soller said. “We can offer suggestions to improve their testing technique. [And with the help of an on-site nurse practitioner], we can get lab values, patient weight, blood pressures, and dispense pharmaceuticals.”

Teleradiologist Trefelner, co-owner of NightShift Radiology, billed himself as an “anti-speaker” after generally positive reports from the rest of the panel. It is a fast-growing, remote site radiology imaging service that allows radiologists across the country to take the night off while he and his colleagues render preliminary diagnoses for imaging studies performed at their hospitals during off-hours.

It is a lucrative business, Trefelner said. The radiology group practices almost always pay cash for such preliminary readings. They can afford the services because insurers will pay them more money for their final interpretation in the morning than they pay out for a preliminary reading rendered the previous night.

Wall Street has loved the concept, according to Trefelner. Nighthawk founder Paul Berger , M.D., accumulated a personal fortune of $250 million after his company went public. Trefelner’s NightShift Radiology was one of six teleradiology firms when it was founded in 2000. More than 200 companies now offer the service, he said.

Success has pushed teleradiology to the dark side of shady business practices, according to Trefelner. Hospital credentialing and state licensing are intended to assure that only U.S.-trained, board-certified physicians are allowed to interpret medical imaging, but that hasn’t stopped some firms from siphoning business overseas via broadband connections where it is read for pennies-on-the dollar by poorly trained, foreign doctors.

Trefelner predicted that teleradiology technology will continue to improve.  Fiber optic networks will become ubiquitous. Faster Internet speeds will allow huge medical imaging files to move nearly instantaneous from place to place. Real-time consultations allowing comparisons between current and past medical images, access to the patient’s electronic medical record, and source materials from on-line resources, promise to greatly improve the accuracy of patient exams, he said.

But Trefelner sees a downside from the increased corporate influence.

“Physicians will lose control over their medical practices, and patients will lose a sense of personal service from their doctors. There will be abuse and profiteering,” he said.

---

James Brice is an independent journalist in the San Francisco Bay area.
Thanks to Colleen Paretty, chair of the SF Bay Area chapter, for organizing this event. To get involved with the SF Bay Area chapter, e-mail Bay.Area.AHCJ@gmail.com.