Telecommunications helps patients, health-care professionals

By Jim Barrett

"Hello, McAllen."

"Good morning, doctor."

"Shall we get started?"

Ray W. Mackey, MD, a clinical professor of pediatrics, was at the Health Science Center, 250 miles from a 5-year-old patient and her mother. But everyone could see one another. And everyone could hear and talk to each other.

New technology is able to put patients and doctors together over vast distances, and the Health Science Center is about to adopt this "telemedicine" to better serve South Texas. The region is rural, underserved by medical standards and it covers 53,000 square miles, an area larger than the state of Arkansas.

"Within two years, we should start seeing a number of two-way audio-video instrumentations that tie the Health Science Center to several health facilities in South Texas where our students and residents are being trained," said Ciro V. Sumaya, MD, head of a campus committee that has evaluated how to use new telecommunications technology. Dr. Sumaya said there are 10 to 15 facilities in San Antonio and South Texas that could make good use of such hookups.

Telemedicine is the latest dimension in audio-visual technology. Using high-quality imaging, the physician can consult with and examine a patient as well as view or exchange X-rays, sonograms, CT/PET scans, MRIs and microscope slides. It also is suited for instructional uses.

Pioneering efforts in telecommunications have brought telemedicine where it is today. The Health Science Center already operates the award-winning Teleconference Network of Texas (TNT), which offers specialized courses nationwide via interactive audio hookups. TNT began in 1971 and is one of the country's oldest and most successful learning networks. The university's telecommunications services department added satellite reception capability for "telelearning" to the campus in 1992.

In 1978, the Health Science Center opened its first telelearning classroom. This added the dimension of interactive two-way television images. It immediately allowed pharmacy students in San Antonio to take courses from UT Austin as well as pharmacy and pathology faculty on the Health Sciences Center campus to teach pharmacy students at the UT Austin campus. Telelearning has grown to include hookups with UT Brownsville and Texas Tech University in Lubbock for nursing programs.

"We want to expand our long-distance learning and bring in new types of capabilities. We are looking at a spectrum of equipment to meet whatever educational or consultation technique we might need," said Dr. Sumaya, the School of Medicine's associate dean for affiliated programs and continuing medical education.

Last fall, the university conducted demonstrations of some of the most sophisticated telemedicine equipment.

"I was impressed. I felt I was able to interact with the patient even though the system lacks the hands-on aspect where you examine the patient directly," said Dr. Mackey, one of dozens of faculty members who tried out the equipment.

"A patient and the primary physician could interact with a consultant at the same moment in time with all the available medical information on that patient available and at hand," he said. "The effect could be very close to waving a wand and having a consultant come into your office while you, the primary physician or resident in training, are actually seeing a patient with a difficult diagnosis."

Dr. Mackey, who travels to McAllen once a month for a pediatric epilepsy clinic, said telemedicine technology would allow doctors to see more patients at remote sites than ever before.

The price of telemedicine systems varies widely, but the basic components are about the same: a camera, microphone, speaker, and two television screens that show the people at each end.

Dr. Mackey used a highly sophisticated unit that has two 33- inch high-resolution color monitors. It is contained in a cabinet about as wide as a car, and costs about $100,000 at each site. The unit has a camera mounted about 5 feet off the ground. It shoots live images, and has a remote-control zoom for close examinations. Microphones transmit conversation in real time. A personal computer in the set allows the doctor to store images, and reference pertinent information.

Less expensive units have smaller monitors, and deliver lower resolution images. They are more portable than the larger units and provide a picture closer to that of a home TV set. These units cost as little as $20,000 at each site, and are suited for smaller classes of five to 10 students.

The largest units have connections for electronic stethoscopes and video from otoscopes so the physician can hear a patient's heartbeat and conduct routine physical exams.

Microscopes also can be hooked up to the units, allowing transmission of pathology slides for interpretation at both ends. Separate computerized systems also can transmit X-ray images to distant sites.

Faculty members say the uses for telemedicine seem almost unlimited, and they have immediate ways of making the technology pay off. For example:

+ Wichard A.J. van Heuven, MD, professor and chairman of the ophthalmology department, has plans to use a telemedicine system that would make it possible to do eye screenings on diabetic patients along the Texas-Mexico border. Health care workers could send back digitized images from a fundus camera/ophthalmic imaging system, which takes pictures of the back of the eye and stores them in a computer. Specialists using a modem and personal computer could immediately view the image and refer the patient to an ophthalmologist if they detect a problem.

"To transmit the entire image would normally take 15 to 20 minutes, but with new compression programs we are able to send an image in less than two minutes. There is no film processing and the patient does not have to wait three to five days for the results," said Robert Hobson, South Texas project coordinator for the ophthalmology department.

Hobson said that the ideal scenario would include a mobile unit that could house the imaging equipment connected to a dish antenna, a vision tester and an eye pressure measuring device. This would help reach many rural parts of the border region, which is heavily Hispanic, an ethnic group with a high risk of diabetes.

+ Rajam S. Ramamurthy, MD, a professor of pediatrics, teaches neonatal resuscitation to hospital personnel who deliver babies in South Texas. Her course takes a day, requires visual demonstrations of procedures and personnel must take the course every two years to keep up their certification. She covers hospitals in small cities and along the Rio Grande Valley border area.

"Our mission involves all of South Texas and we must reach people in remote areas. It would be a wonderful way for updating and training people in the field," Dr. Ramamurthy said.

Telelearning would sharply reduce travel for both instructors and students, and enhance the quality of rural health care, she said. "People who ordinarily wouldn't take some of these classes probably would because of the convenience. It would be an excellent educational tool," she said.

Telemedicine's cousin, teleconferencing, started as a way to patch three or more calling parties together. It bloomed in the '80s, and became a leading medium for distance education in the United States.

TNT, the Health Science Center's teleconference network, has been an extraordinary success. Nationally acclaimed, TNT was named "Most Outstanding Distance Education Network" in 1992 by the U.S. Distance Learning Association. Its courses are in high demand.

Use of the system rose 49 percent between 1990 and 1993. There are 283 classes available, up 15 percent. And in one year, participants spent 49,994 hours -- the equivalent of 5 1/2 years -- in TNT programs.

The network carries continuing education for health care professionals, and is used for medical consultations. The system allows two-way audio interaction. Instructors often use a slide or video presentation that is shown during the teleconferencing session at each participating site.

TNT has telelearning sites in all 50 states, Canada, Puerto Rico and Bermuda.

Teleconferencing is particularly helpful to health professionals and students with specialized interests, said Renee Drabier, director of Health Science Center telecommunications services. Students can study specialty courses their particular university does not offer. And those who otherwise might not have access to education can be reached through distance learning programs.

The Health Science Center made its modest start in interactive television with a classroom hookup to UT Austin. "The classroom was patched together. There were cables on the floor, and a lot of second-hand equipment," said Cliff Littlefield, PharmD, assistant dean for pharmacy education.

The College of Pharmacy on the San Antonio campus needed links to its parent school at UT Austin, and thus produced the first graduates of the interactive TV generation.

"The classroom was a means of providing lectures by faculty experts who otherwise would be unavailable," said Dr. Littlefield.

This telelearning that started in the late '70s caught on by the late 1980s. The University of Texas System began to connect its campuses with large-capacity telephone lines. The Health Science Center linked up in 1989 and opened a specially designed interactive classroom in 1992 at the McDermott Clinical Science Building, about a mile from the main campus.

The new classroom holds 65 students, more than twice the old room, and it operates an average of eight hours per day. There are weekend and evening classes, too.

The School of Nursing is the largest single user of the interactive classroom, offering bachelor's and master's programs in the Rio Grande Valley and a doctoral program in partnership with Texas Tech University. The school is offering about 250 hours of class instruction per 15-week semester. Most of the classes are offered at night and on weekends.

Telelearning via UT Brownsville has produced 17 nursing graduates, 12 of whom received master's degrees.

"We became very comfortable with the telelearning classrooms, where we could raise our hands with questions and the technicians would zoom in on us with a video camera so that the faculty were aware we had a question," said Kathryn Dougherty of Harlingen, who received a master's degree in December 1993. She is on the UT Brownsville faculty.

The Health Science Center's School of Nursing is mid-way through a five-year contract to offer its bachelor's and master's programs at UT Brownsville.

"Telelearning is a new tool that helps the School of Nursing reach out to distant areas, allowing students to continue their education in nursing and ultimately improving the primary care delivered to patients at those sites," said Delight Tillotson, MSN, associate professor and director of special projects for the school.

She said telelearning is especially important because the Rio Grande Valley has a nursing shortage. Students who otherwise would have to go to Houston or San Antonio can now pursue their degrees without quitting their jobs and moving, she said.

"These students have families and full-time jobs. They are key people who will really make a difference in the Valley," said Tillotson. "One of the goals of this outreach effort was to help the area 'grow its own' master's-prepared teachers and advanced practitioners who would stay and practice in the Valley. That goal is being met!"