A Faster, Multimedia Internet?
CONVERGENCE IS ON the horizon. Where voice, data and images have previously traveled down different transportation channels it is now becoming possible to send all types of information across a single communications medium at a lower cost. CIOs are talking about multimedia email where physicians could dictate clinical notes or attach video clips of a patient’s X-ray and send them on to a referring physician. Voice over IP and video over IP technologies are raising the possibility of interactive Web-based videoconferencing from home. In the not-too-distant future a patient cruising her HMO’s Web site for disease advice could click on an icon establishing a phone connection with an advice nurse and ask questions through a PC microphone.
For rural doctors, making long distance phone calls to a referring hospital over the Internet could cut phone bills by more than half; Internet telephony is now being offered by major telecom firms across the country for dirt cheap rates of seven cents a minute. Networking companies are investing millions into the development of technologies that will support a multimedia world, and cable and telecom carriers are introducing high-speed Internet access in test markets across the country. This is encouraging for healthcare in its quest to create a multimedia patient record that providers can access in real time, from virtually any location.
Examples of how telehealth and Internet technologies could merge are beginning to unfold in small ways across the country. Cisco Systems and Acuson Corp. have been staging high-profile demonstrations of an application for viewing ultrasound images remotely over the Internet. Using a Web browser, Acuson’s WebPro package allows users to pull an entire exam over the Internet or an intranet from Acuson’s ultrasound imaging system at the lab.
Telemedicine eyes the Internet
The DoD has several Internet-enabled telemedicine studies and projects under way. An Internet-based teledermatology system at the Walter Reed Army Medical Center in Washington, D.C., is in the process of rolling out to 11 hospitals and 41 clinics in the Army’s 21-state North Atlantic region. Using an inhouse-developed system, primary care providers will be able to send encrypted patient histories and digital photos over the Internet to a database on the Walter Reed server. Walter Reed dermatologists can then log on to a password-protected Web site and review cases, zooming in on images for more detail.
The main advantages of using the Internet, says Lt. Col. Ronald Poropatich, telemedicine director at Walter Reed, are broader distribution capabilities and cost savings from sending text data and images in the same electronic file: previously, patient histories were faxed separately. Poropatich says there have been no major performance issues yet with using the Internet.
Strategic Monitoring Services, Inc. (SMS) is a New York City-based disease management firm that recently won a DoD contract to provide Internet-based medical records, outcomes and patient education for chronically-ill lung disease patients. SMS uses a combination of telemedicine, home care and the Internet to manage its patients. Clinicians dial into an intranet to retrieve daily assignments and multimedia patient records, and to file reports at the day’s end, while patients are using Web TV to review disease and treatment information. "Truly interactive, data rich disease management is not yet there for the DoD or anyone else, but it is inching closer," says Gregory Muth, CEO of SMS.
Stanford Medical Center has been providing ISDN-based educational videoconferences to physicians at hospitals in Singapore and Manilla for several years and is now looking to pilot a Web-based program of prerecorded lectures and grand rounds to its Asia partners. Stanford has developed software for video streaming over the Internet to physicians through a secure Web site, according to James Bair, director of international medical services at Stanford. "They’ll be able to get very current medical information whenever they want."
Full speed ahead
The ticket to making telemedicine and telehealth viable over the Internet is finding more bandwidth. A heavily-promoted telecommunications service coming of age now is digital subscriber line, (commonly called DSL or xDSL) a broadband technology that uses the existing copper wire infrastructure to deliver transmission speeds of up to 8 Mbps downstream--much faster than ISDN at 128Kbps or a T-1 line at 1.5 Mbps and cheaper too. Cost estimates for DSL are ranging from $100 to $250 a month.
Unlike the circuit-switched technology ISDN lines use, DSL uses a dedicated, packet-switched connection found in frame relay, ATM or IP networks, according to Kieran Taylor, DSL product marketing manager at Bay Networks, Santa Clara, Calif.
"What makes DSL possible is it uses the same phone wiring of the network today but at a higher spectrum," Taylor explains. "It goes above the four kilohertz used for voice… and that’s what enables the multi-megabit speeds." Bay Networks offers DSL products that can deliver symmetrical or asymmetrical configuration--such as 7 Mbps down to the user and 1 Mbps up to the network, or 2 Mbps in both directions. Cisco Systems and 3Com also offer DSL products, as well as a growing contingent of smaller companies.
Because DSL uses ordinary phone lines, it may be a viable option for rural telemedicine sites where ISDN or T1 is unavailable or unaffordable. But its future is tied closely with the phone companies, which are still deciding when and how to offer it, pending standardization issues between differing versions of the product and market demand. In the meantime, Taylor says that a DSL system can be installed within a medical campus to facilitate speedy links for sending radiology images or other large files between departments and facilities.
DSL is also hampered by its distance limitation: a "last-mile" transport, it only covers the distance between the customer and the local phone office, after which the connection can continue over the Internet or a private leased line. Isolated sites that are 20 to 30 miles from the nearest phone office will be out of luck.
Dr. William Goodall, director of telemedicine at Allina Health System in Minneapolis, says DSL could provide the bandwidth to make interactive video more viable, but he is skeptical for now because of the distance limitations. Allina has a largely rural telemedicine network connecting 28 sites in Minnesota and Wisconsin, using dedicated T1 lines and VTEL equipment. In the near term, Goodall believes a new frame relay T1 service offered by US West will allow the network to conduct high quality, uninterrupted video consultations.
Bill Montgomery, CIO at Fletcher Allen Health Care in Burlington, Vt., says DSL could be a boon for his organization’s statewide telemedicine network, "as soon as it’s stable and reliable and the cost is reasonable." He says costs need to be closer to common Internet access charges of $20 to $30 month. Much of the problem, he says, is that the ISPs and the telecommunications firms do not have the market demand yet to support newer technologies. "Internet providers are struggling just to provide Web browsers and email."
Another high speed networking technology available in a few markets is two-way cable modem, which purports to connect users to the Internet at speeds of up to 10 Mbps through the existing cable infrastructure. It is largely being delivered to an estimated 100,000 homes for around $30 to $40 a month, but according to Taylor, the technology could also be used in healthcare.
On the application side, real-time Internet-based video is becoming a reality. Fletcher Allen and the University of Vermont’s College of Medicine soon will begin to deploy PC video workstations to physician offices in Vermont and rural upper state New York, connected over an intranet to servers at Fletcher Allen Medical Center. The vendors under consideration are Intel, Zydacron and PictureTel. Montgomery’s goal is to equip 600 offices with the technology to support videoconferencing, distance learning and other consultations. "The communications links with the doctors in our communities is the best way to help manage quality and outcomes," he says.
The technology that will allow Fletcher Allen to do this is called IP multicasting, a networking protocol that broadcasts one video file through a network and allows multiple subscribers to tune in using the same bandwidth. Multicasting saves bandwidth by replicating video packets to each subscriber only at the last minute, according to Kevin Dickson, marketing manager for Cisco’s IOS networking software. Also important, he says, is the ability to assign priority to packets during the transmission so that the video does not break up--a feature in Cisco’s products.
Montgomery envisions multicasting will allow clinicians to tune in to live interactive education with video in one window of the screen, course materials in another, and a microphone and camera for asking questions during the session. Running such a course over ISDN lines would be cost-prohibitive for more than two or three people, he says. "That technology (ISDN) is going to be a good standard for quite a long time but it’s not the way most people will be moving in the next five years."
Still, Montgomery admits that most Internet video applications are nothing more than toys, and the industry is still working on standards for sending video over an IP network. "We need the performance to be like getting 30 complex Web pages per second," he says. Using an ATM backbone from Cisco that guarantees bandwidth availability, he is hoping to achieve 21 to 25 frames per second on video transmission.
As Fletcher Allen moves to a capitated payment system that will make telehealth more economically viable, Montgomery sees an opportunity to solve the twin problem of overuse of resources by doctors and patients who don’t have enough knowledge, and underuse, if a patient can’t or won’t travel for treatment. "We expect to gain market share and reduce our utilization." If Internet technology can be used, it will be more cost-effective and ubiquitous too.
According to Taylor, the latest predictions point to mid-1999 for widespread availability of an infrastructure that could effectively support Internet-based telemedicine. Security concerns will likely bar adoption of this model until much later, however. Goodall does not see the integration of telemedicine and the Internet in Allina in the foreseeable future, even with the increasing availability of industrial-strength encryption and other security tools. "The more secure you make it, the more difficult it is to access," he observes. While Montgomery also adopts a cautious approach to untested developments like DSL, he’s optimistic about the potential impact of the Internet on healthcare: "It’s no different than the telephone at the turn of the century."
Polly Schneider is senior editor at Healthcare Informatics.
