Digital Docs

Okay, you can beam me up now," the elderly patient commands surgeon Stephen Hochschuler. She is at a clinic in Midland, and Hochschuler is sitting at a desktop computer in his office at the Texas Back Institute (TBI) in Plano, several hundred miles away. The patient is enjoying her starring role in a space-age technology that will transmit her image, via the Internet, to her doctor's computer screen. She has been recuperating at her West Texas home after surgery at TBI to correct a spinal problem, and thanks to a telemedicine system developed by a small Austin company called VidiMedix, she won't have to travel back to the Metroplex for a checkup.

She faces a computer and looks into a small camera just above the screen that transmits her image to Hochschuler's computer at TBI. A camera at Hochschuler's end simultaneously transmits his image to a window on the computer screen in the treatment room. As Hochschuler's face appears on the screen, the patient smiles and waves.

Following Hochschuler's instructions, and with the guidance of a medical technician, the patient walks and stretches and bends for the benefit of the camera so that Hochschuler can assess her mobility. She doesn't wince, but had there been an "ouch" or a groan as she moved about, the computer's internal microphone would have registered it. Using a zoom command from his computer, Hochschuler can get a magnified, detailed view of the surgical incision on her lower back and record the image for her permanent record.

With the capacity to get up close and personal, at least digitally, this interactive video communication is a standard part of the system that the folks at VidiMedix like to call network medicine rather than telemedicine. It's a kind of modular add-on system that allows any number of traditional medical instruments, including a stethoscope and an ophthalmoscope, to be adapted to Internet transmissions. It also gives doctors access to medical records and other information that can be kept in a central database.

Typing a command on his keyboard, the surgeon calls up the x-ray of the patient's spine that was taken just before the exam. The image appears simultaneously on the screen in the clinic for the benefit of the patient, who watches as Hochschuler points out the area, now healing, where her lower vertebrae were fused during the operation.

Hochschuler is pleased with her progress. And he's also pleased, he says later, with the progress in technology that has allowed this virtual visit. By avoiding travel, the patient has saved money, and they have both saved time. "I can get out to the clinic in Midland in person only twice a month," he says. "They can beam me out there anytime."

While telemedicine might seem more suited to the crew of Star Trek than, say, elderly West Texans, many doctors and other health-care specialists say that the Internet can offer a lifeline to an ailing health-care system. At a time when health-care costs are rocketing, when hospitals and clinics in rural areas are closing in epidemic numbers, and when medical specialists who are willing to live in remote areas are as rare as house calls, the appeal of bringing patients and doctors together via the Internet is undeniable. "We think telemedicine is the last great hope for reforming health care," says Anthony Cagle. A former director of marketing and business development for Apple Computer's Advanced Technology Group, Cagle helped found VidiMedix four years ago with Austin physician Jack Moncrief. Moncrief is a kidney specialist who is probably best known in medical circles for developing an unorthodox treatment for patients with failing kidneys called continuous ambulatory peritoneal dialysis, or CAPD. While the traditional treatment for late-stage kidney disease requires patients to travel to a medical center, where they are hooked up to a dialysis machine for hours at a time, several days a week, the portable CAPD device allows some patients a greater measure of mobility.

Moncrief first got interested in telemedicine around ten years ago, when it was still primarily a technology for extreme cases. Much of the early research in adapting video to medical care had been conducted for NASA and for the Department of Defense to develop means of remote medical treatment for astronauts and soldiers in the field—for situations where doctors could not be physically present. The technology got another boost when Texas prison officials began looking for practical ways to enforce judicial decisions mandating equal medical treatment for prisoners, which in many cases meant access to specialists. That access has often been via telemedicine, with the responsibility for treating the prison population divided up geographically between the University of Texas Medical Branch at Galveston and the Texas Tech University Health Sciences Center in Lubbock, both of which have strong telemedicine programs. As Moncrief puts it, "There's no way three GPs in Huntsville can deliver the same quality of care as three hundred specialists in Galveston."

Many of Moncrief's patients were poor, had multiple medical problems, and lived in areas that made travel to his office difficult. Telemedicine appeared to be a way to monitor the ones he could not always see in person, particularly those who were receiving dialysis in distant areas. "It was obvious to me it was the wave of the future," he says. In 1990 Moncrief joined an experimental program called the Texas Telemedicine Project along with Austin child psychiatrist Jane Preston, who was interested in seeing that young people from rural areas who had psychiatric problems received long-term follow-up care near their home once they completed treatment in the city. Moncrief's and Preston's offices in Austin were connected to facilities they were affiliated with in Giddings: an emergency room, a dialysis unit, and the local juvenile-offender unit.

Each time Moncrief consulted by video with one of his patients in Giddings, he filled out a form indicating whether he had saved himself a trip there or had saved the patient a trip to the emergency room in Austin. "During the two-year period of the study, we found that the system we were using would have paid for itself in three years," he says. And the cost of that early, rather unwieldy system, he points out, was five times what the company's system costs now. Paradoxically, he says he was able to monitor his patients more attentively by video than in person, since he didn't have to travel from his office to their location each time he needed to check on their condition. Now, with the current system he has set up to connect his office to various locations, he says, "I can see patients three times a day or more often if I need to. I can be more aggressive in treatment because I can see right away whether it's being effective or not."

To Moncrief, telemedicine seems an inevitable solution to the growing centralization of medical care, which has concentrated specialists in large urban medical centers. "No single doctor can treat serious medical problems these days," he says. "We've become so subspecialized it's impossible for a doctor to know all the current research. The teams at the big medical centers and teaching hospitals can keep up with the latest medical armamentarium. But the minute you step outside that sphere, there's a time and distance problem in delivering care. With telemedicine, you can always communicate with that mother ship."

Nevertheless, in 1996, when Moncrief recruited Anthony Cagle and a graduate student at the University of Texas at Austin to study the feasibility of setting up a business to develop telemedicine systems, they found formidable obstacles—financial, technological, and bureaucratic—to their plan. While the medical community had been proclaiming the potential of telemedicine for years, it didn't seem to be filtering down from military and space applications to common use. For one thing, there was the problem of compensation, since insurance companies were then not required to cover telemedical consultations. For another thing, transmission costs were prohibitive for many potential clients. Telemedicine depends on broad bandwidth Internet capability, and many locations simply weren't wired with the necessary cable connections. Nor was the technology advanced enough to provide the storage capacity needed for patient records, including x-rays and CT scans.

Still, Cagle and Moncrief believed that there was room for a commercial product that would simplify the often unwieldy experimental systems that hospitals and other medical facilities were using, most of which required doctors to leave their office and go to a centrally located room that was set up with video capability. Their idea was to develop a desktop system that would mimic the way doctors actually work, so they wouldn't have to leave their office to consult with a patient. Fortunately, the partners didn't have to start from scratch: They were able to acquire an Austin company called Secure Digital Communications, which had developed a basic videoconferencing system for delivering real-time multimedia over the Internet. Although the system had been developed primarily for training programs, it proved to be a useful base for building a network medical system. In 1997 the fledgling company got another boost when the Texas Legislature passed a bill mandating that insurance companies pay for telemedical consultations.

Although it was difficult for VidiMedix, as a start-up company, to gain entrée to major health-care institutions, it began to develop partnerships with other companies that had established toeholds in health care as well as strongholds in technology. Among its first partners was IBM, which is working to develop a worldwide health care consulting business along with a reliable hardware platform for running software for medical applications.

One of VidiMedix's first major clients was TBI, which prides itself, as Stephen Hochschuler says, on its use of cutting-edge technology. TBI even asked a consultant trained in linguistics, Sandra Pinkerton, to study patient-physician interactions using the VidiMedix system to see if the communication was effective, compared with traditional consultations, and how it might be improved. Pinkerton says that after minor tweakings of the system, the video interactions actually contained more sharing of information and more "mirroring"—acknowledgment of each other's communications, including such gestures as head-nodding—than occur in ordinary clinical situations. Physicians with a less than lively bedside manner, however, or a tendency to mumble or look down at their notes have had to improve their skills for the benefit of the camera. Hochschuler says that the system actually removes distractions: "My patients get my undivided attention. I'm with them eyeball to eyeball." If there's any actual poking or probing that has to be done, he says, the nurse's or medical technician's hands can stand in for his.

Last year Temple's Scott and White Hospital signed up for a VidiMedix system to connect its main facilities to several outlying rural clinics spread over Central Texas. These clinics will have access to a battery of Scott and White's specialists in several fields, including orthopedics, cardiology, pediatrics, emergency medicine, and mental health. "Texas has had a hard time trying to keep rural hospitals and clinics in business," says Gregory Hobbs, who heads the telehealth program at Scott and White, which is the teaching hospital for Texas A&M's medical school. According to the Center for Rural Health Initiatives, many Texans are farther away from health care than ever. The state's $1.5 billion Telecommunications Infrastructure Fund (TIF) was set up to help develop Internet connections for schools, libraries, and hospitals in rural and disadvantaged areas. But 27 counties remain without a single primary-care physician, according to the Texas Department of Health, and in 1999 the state lost 44 rural health clinics.

That lack of health care, says Jack Moncrief, is helping the small town to die and the megalopolis to grow. "After they retire, people want to leave the city and move to their dream town or even just stay in the small town where they grew up," he says. "They'd prefer to live in Bastrop, for example. But the husband gets a heart condition or the wife gets breast cancer, and they have to move to Austin because they need to be close to a big medical center."

And that's where telemedicine comes in, Hobbs believes. In five years, he says, "it will be a ubiquitous part of health practice."

In June VidiMedix announced that it was departing the realm of struggling start-ups to enter the world of techno-health conglomerates. The company was bought for an undisclosed sum by e-MedSoft.com, a fast-growing medical-systems developer based in Jacksonville Beach, Florida. E-MedSoft.com offers a subscription service for its systems, which link doctors and health facilities to insurance companies, HMOs, and government agencies as well as pharmaceutical suppliers. According to Anthony Cagle, as a wholly owned subsidiary, VidiMedix and its interactive services will be part of the package of services offered by e-MedSoft.com.