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Monday, Aug. 18, 2008 | When military doctors aboard the USS Abraham Lincoln in the mid-1990s needed to perform abdominal surgery while the ship was deployed to the Persian Gulf, far from a well-staffed operating room, they needed some help. In a pioneering trial, Dr. Mark Talamini, a renowned surgeon, led the operation from his office in Maryland.

This month, when stroke patients showed up in a remote emergency room in rural El Centro, Dr. Brett Meyer, a stroke specialist in San Diego, made critical treatment decisions with a laptop and internet connection.

The trials were separated by more than a decade, but today, both Meyer and Talamini, now the chairman of surgery at UCSD, are local advocates of telemedicine: healthcare via technology. They said the field could become the equalizer of healthcare because of its potential to decrease medical costs while expanding patients’ access to expertise, regardless of where they’re being treated. Eventually, patients in remote areas and even developing countries could be treated by top-notch doctors, wherever they practice, without having to travel.

For example, a research breakthrough this month with Stroke Doc, a stroke treatment that allowed Meyer to make diagnoses via mobile cameras and a laptop, has telemedicine proponents hoping San Diego, already a medical and hi-tech hub, can take the lead in the field.

“I could be stuck in traffic and be able to pull over and take care of a patient immediately,” said Meyer, co-director of the University of California, San Diego Stroke Center.

For now, however, telemedicine is seldom used for anything other than teaching and research. Legal issues and licensing protocols present “all sorts of roadblocks and obstacles” that will have to be overcome before it can become common practice, Talamini said. Physicians are usually only licensed to practice in a couple of states, at most, and even within states, many hospital policies require doctors to be credentialed for specific facilities.

Telemedicine began to emerge in the early 1990s, with experiments like the surgery aboard the ship, but technology hadn’t advanced enough to make the practice wholly effective. Recently, however, the field’s been gaining a renewed momentum because of rapid advances in technology, namely wireless devices and cutting-edge software, which make it possible for doctors to transfer X-rays and monitor patients’ vital signs remotely, among other things.

In the early days of telemedicine, while the Navy doctor was cutting into the patient’s abdomen aboard the ship, a computer in the ship’s operating room sent images to Talamini from a tiny camera attached to an instrument inside the patient’s abdominal cavity. The two doctors talked to each other over the telephone while Talamini instructed his less experienced colleague.

“I pointed out anatomy and made suggestions,” Talamini said. “Why don’t you put the stitch here instead of there?”

Talamini said that in a hospital setting, surgery is a team sport, and the collaboration with the Navy doctor provided a similar collaboration. But erratic technology was a hindrance. Several times during the two-hour operation the surgeons lost either their computer or their telephone connections. Also, image transmission, which was carried over satellite feed from Maryland to the Persian Gulf, took at least 10 seconds for the ship and the office to send images back and forth, making the technology too unreliable in life and death situations.

Fast forward to 2008; Meyer is part of a team that developed Stroke Doc, a technology-based program that allows a doctor to see a patient through a full-screen mobile camera at the patient’s bedside. The camera transmits real-time audio and high-resolution video images, allowing Meyer to make quick and informed decisions when evaluating stroke patients from distant locations via internet.

“I feel like I’m immersed in an actual emergency room,” Meyer said. “I can zip in from a thousand miles away, zoom in on the pupils and see them contract.”

Long-term clinical trials are usually only halted when early findings aren’t promising enough for researchers to move ahead, but Stroke Doc proved so successful that this month a four-year, 400-patient study of it was stopped just over half-way through.

The program improved the diagnostic accuracy of stroke patients from 82 percent by telephone, the traditional long-distance consultation method, to greater than 98 percent via internet, according to the study published Aug. 2 in the online issue of the journal The Lancet Neurology.

The program is an example of how telemedicine is beginning to merge the life science and wireless communications fields, two of the region’s leading industries, making telemedicine likely to emerge as a lucrative local industry, said Ramesh Rao, director of UCSD’s California Institute for Telecommunications and Information Technology. Carmel Valley-based BF Technologies made the program’s audio/visual equipment, and San Diego-based Qualcomm developed the broadband wireless technology used to transmit information through a laptop when there’s no wired connection.

With strokes, time is of the essence, and the quality of the technology Meyer used is imperative. Most strokes are caused by blood clots in the brain that can be broken up by a clot-busting drug called tPA. But, he said, tPA is dangerous in some instances, and if wrongly given can cause brain hemorrhage or death. Relatively few doctors have the experience to make the correct decision, but Stroke Doc gives a distant stroke expert the detailed information needed to decide whether tPA should be given, Meyer said.

“It’s very exciting that immediately we can have a specialist and more power to take care of the patient,” said Dr. Rick Obler, an emergency room doctor at El Centro Regional Medical Center whose patients participated in the Stroke Doc trial. “I mean it really is at-the-bedside care.”

Researchers worldwide are studying ways to use telemedicine to improve treatment of a myriad of illnesses, such as diabetes, eye diseases and wound care.

Programs like Stroke Doc can also lower health care costs because patients don’t have to travel or be transferred to medical hubs, such as San Diego, for treatment. It’s not uncommon for patients to travel long distances to be treated by resident specialists at leading facilities.

Meyer said he’s trying to get funding for another study to evaluate the long-term outcomes for patients treated with telemedicine, but even if trials continue, it’s still unlikely that the technology will be extensively used anytime soon, he said. Licensing rules that were established to protect patients from untrained doctors are hindering the widespread use of telemedicine applications.

“It’s one of the hottest topics in medicine,” Meyer said. “How can providers get credentialed and licensed to practice out of state?”

Right now, doctors using telemedicine to treat patients are going out on a limb because there are no streamlined standards. A physician in one state, using a video link to examine a patient in another state, may be subject to licensing laws in both states, and the fear of potential liability and regulatory uncertainty is hampering the use of telemedicine, experts said.

As a result, advances in the field are largely being used to teach less experienced practitioners in so-called “virtual universities,” Talamini said. WebSurg.com, for example, is a free virtual surgical university that allows viewers to watch surgeons performing surgery.

Technology used in telemedicine will also need to be standardized and regulated, Meyer said, to ensure patient care isn’t compromised by shoddy equipment.

“A lot of patients end up doing better in the long run with specialized care, and remote exams can give us the same findings as at the bedside,” he said. “But [technology] has to be good enough that we know we’re seeing what we think we’re seeing and can trust [technology] like we do our own eyes.”

Please contact Darryn Bennett directly at darryn.bennett@voiceofsandiego.org with your thoughts, ideas, personal stories or tips. Or set the tone of the debate with a letter to the editor.

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