Telesurgery
Most recently, telesurgery has been used to perform complex operations on soldiers near the regions of heavy combat. If the on-site physician is unfamiliar with a certain type of malady, he can actually receive a live consultation from U.S. military medical centers, which has saved many patients’ lives.

The technology involved requires a high-resolution video feed that shows the operating table to an off-site medical advisor. With this particular set-up, the remote physician can also draw on the video feed’s screen, and his marks are shown to the operating surgeon. By using this capability, the remote physician can directly point out specific areas on the patient and the operating table.

The technology hasn’t been employed across the Army at this point, but it’s been used in several specific situations. The aim is to make this operating capability a universal part of medical combat support.

Burn victims will be especially aided by this technology. Many soldiers are severely burned by improvised explosive devices, and the on-site medics often need to consult with burn specialists at medical centers in the U.S.

Consumer Devices and Other Mobile Technology
Another exciting innovation coming from military telemedicine is the effort to leverage existing technology, and sometimes even consumer devices like Droid phones and iPhones, to replace the specialized devices currently being used by military personnel.

Oftentimes the latest consumer devices have been specially designed not only to be very lightweight, but these devices are also the beneficiaries of a thriving market that pushes software development and other progress. The US military is considering ways that it can adopt these platforms as a standard issue soldier’s gear, but add its own capabilities to whichever device they choose.

For example, squad leaders currently have a radio and microphone, but the military is considering ways to leverage this existing technology using noise-cancelling and text-to-speech software. The combat medics are already trained to speak out everything they’re doing to treat a patient as they actually do it, so there could be information that translates their speech to text and automatically makes it a part of each soldier’s electronic health record (EHR).

The military certainly has many others they can use telemedicine to benefit soldiers in the theater of war, but these two possibilities are good examples of the many innovations to come.

Elderly and Rural Patients
This combination of telemedicine and mental health support has been very important for the rural areas of the United States, where psychiatric services are needed even more urgently than in urban areas. Increasing the need even further are the elderly patients in rural areas, who sometimes cannot even leave their houses, but frequently are the most in-need when it comes to mental health services. Alzheimer’s and dementia affect older patients almost exclusively, and even depression is more common in the elderly population.

Because of most rural areas’ isolation, it is diffcult to attract and retain healthcare providers, especially specialists like psychiatric care providers. While many health clinics and doctor’s offices might have the necessary nurses and technical staff, many of them also cannot afford to do more than that and hire a full-time psychiatric doctor. However, with telemedicine involved, many companies are setting up a psychiatric telemedicine hub, and leasing out their services to more than one hospital or rural area clinic at a time.

Sarah Gibson is an excellent example of how this method can work so well. For 10 years, she has been the only psychiatrist offering her services in Apache County, Arizona. The residents of Apache depend on her abilities, and they also appreciate the fact that they don’t have to drive 45 minutes and wait 30 minutes to be at her office for a 15 minute appointment. But Sarah has only visited Apache County twice in the 10 years since she’s been offering her services there.

How Support is Achieved
The government supports mental healthcare initiatives in rural areas with more frequency than many other telemedicine projects.

Not only are federal grants available in fairly large numbers that help individuals and organizations set up a telemedicine mental health operation, but Medicare provides a large amount of third-party reimbursement for psychotherapy conducted through telemedicine.

The other factor that has motivated government to step in is that rural telecommunication services, especially high-speed connections, are much more expensive than in other areas. Sometimes they cost over 10 times as much as they would otherwise. However, federal rebates are offered to companies to compensate for their telecommunication lines.

But it has become on the decade’s major developments in healthcare delivery, and as people have gained trust in its reliability and security, the entire nation has picked up on the idea of at-home online healthcare.

Prescription Fulfillment
One of the major challenges of online healthcare’s growth has been the development of legislative policy concerning online prescriptions.

Before telemedicine was becoming more standardized and widespread, the disreputable and illegal online “pill mills” were churning out medications to people, but often with unintended consequences. The entire business was both illegal and dangerous.

But as legitimate healthcare companies saw potential in the industry, we began to get more guidelines for how telemedicine should operate. Some of the questions that state and national legislatures had to tackle were:

• Who can prescribe medications?
• Can healthcare providers issue a prescription for residents of other states?
• What can not be prescribed?
• What sort of examination is required for a prescription?
• Are face-to-face consultations required, or can other methods be used?

Suffice it to say that these details were hammered out, and we finally arrived at the state we are in today, where medications can be delivered across state borders, and face-to-face appointments are not always required.

It was also decided that all Schedule 1 controlled substances, as identified by the Drug Enforcement Agency, were not to be filled with online prescriptions.

Monitoring Prescription Drugs
Relatedly, another challenge of prescribing through the Internet has been monitoring the use of prescription drugs by those who order them.

Prescription drugs are not available over-the-counter because they just aren’t the same as OTC drugs. Many of them are dangerous at higher doses, or if used improperly. Overdoses and deaths involving prescription drugs are a daily subject in news headlines.

However, with strict guidelines on “best practices” and a strong effort to make sure the consumer knows how to use the medication properly, these risks can be alleviated to a satisfactory degree.

Security and Encryption
Online shopping was becoming popular just before online telemedicine took off, and some technological headway had been made in the field of security and encryption.

But the demands for high-security online databases and information transfer protocols were increased significantly with the advent of online healthcare delivery. When people’s medical information and loads of prescription drugs were involved, the stakes definitely got raised even higher. Insurance information was another big factor in improving security technology

But in today’s online marketplace, all of the reputable online prescription facilitators have dealt with security issues, and the best of them operate entirely on right side of the law.

The challenges of delivering reliable, safe surgery over a long-distance medium are numerous, but as technology improves, we’re able to do more and more with this branch of telemedicine.

An Introduction to Telesurgery
Traditionally, telemedicine is often said to refer to teleconsultation. A doctor reviews documents such as photos, x-rays, slides, or ECGs, and interacts with the patient to get a detailed feel of the situation. The doctor is then able to provide a diagnosis. Specialists will often use similar methods to provide their expert input on a course of treatment.

However, the main addition required to allow telesurgery is technology that allows for the “live” manipulation of the patient and his surroundings from a distance. Technology designed to achieve this possibility is said to provide “telemanipulation” capability.

The surgeon that wants to use telemanipulation technology must also have a detailed and realistic sensory input that makes him feel as if they are physically present at the remote site. The specialized technology that provides is deemed “telepresence” technology.

These are the key terms of telemedicine related to surgical operations, and now we will discuss the various methods that have been employed to achieve success in telesurgical operations.

Methods for Achieving Telesurgery
When surgical operation must be performed with the help of a long-distance care provider, several methods are available to the remote healthcare staff.

• Telepresence surgery is the most advanced, and this term refers to a system that transmits the surgeon’s actions while he sits at a remote surgical workstation. In addition to transmitting his movements, the system also provide haptic input (also called force feedback), which transmits the tactile information of the remote patient’s tissue back to the operating surgeon.

• Telerobotics transmits the surgeon’s movements, but doesn’t incorporate force feedback technology. This method is suitable for many operations.

• Telementoring requires the least advanced technology, but it can still be a tremendous help in emergency situations. In this case, an experienced surgeon will act as a guide for a less experienced surgeon who must perform a difficult or unusual procedure.

Benefits of Telesurgery
As this technology grows, it could be widely beneficial by reducing travel costs.

It could also allow specialists with highly valued skills to work internationally, bringing life-saving surgical procedures to patients all across the world. The benefits of telesurgery could even be used at extremely isolated locations, such as spacecraft and arctic research centers.

Hopefully we will continue to see the branch of telemedicine grow, as we continue into the 21st century of technology.

Naturally, a project to assess the challenges of bringing telemedicine to this area, termed Micronesia, has been undertaken. As the name suggests, this ethnogeographic region in the south Pacific is characterized by thousands of tiny islands, only some of which are populated.

The Micronesian Landscape
The nations focused on in this telemedicine project have been the Republic of Belau (Palau), the Republic of the Marshall Islands, and the Federated States of Micronesia.

The geographic landscape of these islands is fantastically different from what we’re used to on mainland continents. Among these three nations, there are over 2,000 separate islands, atolls, and islets, even though only 97 are inhabited. The population of these islands is exceedingly small, 160,000 total. And the total land mass is a mere 529 square miles, less than half that of Rhode Island. There a few densely populated villages, but roughly half the population also lives in very isolated areas.

Significantly, about 45% of the islander population is under the age of 15.

The Healthcare Situation
The call for telemedicine to help the people receive care in these islands is enormous.

These Micronesian nations are in an unusual and precarious position. They find themselves struggling with a strange dynamic between diseases of the developing world, and the healthcare challenges of the developed world. Malnutrition is a common problem in Micronesia, as well as communicable diseases such as cholera, typhoid, and tuberculosis.

However, these nations also experience high rates of chronic diseases like diabetes, hypertension, and cancer, which are usually diseases of the developed world. Unfortunately, these chronic disease also often go undiagnosed until they’ve become quite severe.

The Barriers to Providing Adequate, Affordable Healthcare
Because of limited national budgets and a high costs for off-island referrals, which naturally require air travel and are time consuming, the challenges are numerous.

But the telemedicine report mentioned above has narrowed down specific barriers, and done intensive research into how telemedicine can help resolve each of these problems.

• Limited primary care and specialty care
• High cost of patient transfer off island
• Limited diagnostic (laboratory, radiology, and pathology) facilities
• Limited opportunities for continuing medical education
• Stress of professional isolation
• High cost of telecommunications
• Too few indigenous practitioners and directors

As mentioned in the report, distance and isolation is often cited as a reason that medical care is difficult to provide. But perhaps nowhere else in the world does this reason have such a profound effect on care as in Micronesia.

Children at school are often supervised in their diabetes care by a school nurse, who is usually given a letter from the doctor containing instructions on each child’s diabetes care. Because of how much time children spend in school, it’s crucial for the school nurse to be informed on the child’s routine care practices, but unfortunately it’s common for best practices to be difficult to adhere to. Each school nurse has many patients to watch after, and the children aren’t always well-informed on their own care needs.

Unfortunately, the routine care of type I diabetes is crucial to maintaining optimal health, energy levels, concentration, and weight. Any deficiency in the routine care of a chronic disease like diabetes can serious consequences. And, being the most common chronic disease for school-age children, it’s incredibly important that we keep our standards as high as possible concerning treatment and routine care.

Fortunately, evidence suggests that telemedicine can help improve patient blood glucose monitoring, and balance the overall health of the individual who is tackling the challenges of diabetes.

The Study of Telemedicine
Dr. Roberto Izquierdo and a team from SUNY Medical University studied children from the ages of 5 to 14, and found that the children who attended video conferences monthly through a telemedicine program, which put them in contact with a telemedicine diabetes center, had improved blood sugar control at the end of a six-month period. These children also experienced fewer visits to the emergency room and fewer hospitalizations due to their diabetes. Compared to the children who received standard care from school nurses, they were much better off in their fight against type I diabetes.

Comfort level with the telemedicine program was high as well as self-reported satisfaction. Over 90% of the participants said they would use the program again. Children also reported that they felt better about their disease in general, as if they understood their diabetes better and also felt more assured that it was properly being taken care of.

Conclusion
As we’ve seen the in the past, telemedicine has several applications, from inter-specialist medical networking, to teaching, to emergency care for isolated areas. But chronic disease management is clearly one of the most suitable applications for telemedicine, and this country is fortunate to have so many opportunities to apply telemedicine.

The telemedicine system, known simply as the Center for Telehealth, coordinates and maintains many different programs, ranging from the Children’s Medical Services project to a project focused on patient data management systems.

Today we’re going to look at the center’s programs and their essential details, and try to provide readers an overview of how this important center is providing much-needed service to the rest of the state.

Important Programs
The GHSU Center for Telehealth has over a half-dozen studies and programs in place right now.

One of them, which we’ve already mentioned, is the Children’s Medical Services Project. The program was established in the mid-90’s, and ever since it has been helping children receive specialist pediatric care while maintaining continuous care from their local primary care physician.

So far, the program has been so effective that it actually factored into Medicare’s decision to expand reimbursement policies, and has heightened the level of pediatric care being delivered via telemedicine all across Georgia.

The Electronic House Call and Cybercare Project is another example of a successful project from the GHSU. This project is a proof-of-concept approach to building a system that can deliver healthcare to patients’ homes, which means that so far it’s been implemented on a small scale, with telemedicine units installed in 25 homes.

While it may seem like a small-scale operation, each unit is equipped with state-of-the-art interactive audio/video conferencing, as well as remarkable array of medical tools. The in-home units are capable of assessing heart rate, blood pressure,  temperature, blood oxygenation, weight, a stethoscope, blood glucose, electrocardiograms, spirometry, fetal heart rate, and uterine activity.

The Telemedicine Morning Report program is another care-delivery mechanism that’s pushing the limits of what people typically do with telemedicine. The program is designed to help multiple doctors who are treating the same patients conference with each other on a monthly basis, and also to help doctors get patient status updates once they leave the care facility. These updates have proved crucial for ensuring continuity of care, as many patients have at-home problems that put them back in the hospital just days after being discharged.

These programs from GHSU Center, and over twice as many other programs, are examples of what state-wide organizations can accomplish with coordination and resources, and we’re looking forward to bringing you more articles on programs related to your state!

The problem is that we don’t see the true numbers that represent the drastic difference in care between the Americas and other areas like Africa. Recently the World Health Organization released a World Health Report that can help us develop a clearer image of what’s really going on in these other countries.

Take, for instance, the fact that the Americas deals with only 10% of the global burden of disease, yet we have 37% of the world’s health workers engaged in our care, and these workers spend more than 50% of the world’s health financing. A look at these same numbers for Africa can show us the drastically biased allocation of the world’s resources. The African region has 24% of the disease burden, but is being assisted by only 3% of the world’s healthcare workers, and these workers have access to less than 1% of the world’s healthcare resources.

The difference is enormous, and numbers can only begin to paint a clear picture of the tragic situation. Clearly, however, telemedicine has a huge role to play as a way for skilled healthcare professionals to step in from a distance and address the needs of this global health crisis.

Telemedicine as a Solution
Despite the current emergency situation, in which the WHO estimates that over a million new doctors would be necessary just to meet the minimal basic demands of the African population, we do have access to solutions that might help us along.

Stories such as that of Demissie Sahle are great examples of what a difference telemedicine could make, although unfortunately the World Health Organization seems to only have minimal understanding of the potential improvement.

Demissie is a 68-year-old farmer who has a son, and they both have families in Amhara, a town about 200km north of Addis Ababa. Addis Ababa is home to the Black Lion Teaching Hospital, one of the only treatment centers that patients are referred to in all of Ethiopia.

When Demissie was diagnosed with an illness, he was ill for six months while trying unsuccessfully to receive treatment at the nearest health outpost. He eventually raised the money to travel to the capital, but it required over 500 US dollars, which meant the family had to sell whatever they could, including their only oxen.

But telemedicine is capable of making Demissie’s journey a “thing of the past,” according to several reports on telemedicine’s potential to turn around healthcare in the African area.

Next week, we’ll have a report of how this is being made possible by various organized telemedicine efforts.

Current Hair-Loss Telemedicine Systems
The system just mentioned is being used by a doctor in Toronto, Canada to reach patients at a variety of locales. Pharmacies, traditional doctors’ offices, hair salons, and medical spas are all becoming places where a patient experiencing hair loss can receive expert evaluation and get advice on how to start their hair-loss remedy plan.

Some of the options commonly suggested by this telemedicine hair-loss doctor include medication, an appointment for surgical hair-loss restoration, low-level laser phototherapy, mesotherapy, hair systems, or whatever combination of these treatments is suitable to the individual patient.

The Importance of Hair-Loss Telemedicine
Experts in hair loss evaluation are relatively uncommon, and the field requires a certain level of expertise to achieve not just medical proficiency, but proficiency in the art of creating an aesthetically pleasing, authentic-looking result. After all, not every doctor that has all the necessary medical knowledge will also have an artistic eye for the aspects of hair-loss restoration therapy that result in a real-looking finished product.

As a result, it’s actually very useful for patients to be able to seek out the services of the most widely recognized experts in hair-loss restoration for advice and evaluation.

Cosmetic concerns like hair loss are also important to people, just like more life-threatening medical situations. It’s good to see that telemedicine is being incorporated into the more daily aspects of medical care, and still serving such a useful role. In fact, similar hair-loss telemedicine clinics are popping up throughout the United States and Canada, notably in the western side of the country, throughout California.

Other Services Commonly Offered By These Systems
Because of the setup that is common for hair-loss telemedicine equipment, the same systems can also be used for other services,such as preliminary evaluations and advice-giving in other medical areas. Common fields include plastic surgery, dentistry, and dermatology. What ties these fields together is that most inspect and diagnosis is conducted by visual inspection, which affords a much more convenient and flexible use of videoconferencing technology in a telemedicine context.

As is common with telemedicine systems, many medical personnel are also receiving training in the aesthetics of hair transplantation, which they wouldn’t have access to without the telemedicine system.

What many people don’t realize is that HIV affects people everywhere, and in communities with limited healthcare, the opportunity for the virus to ravage the population increases dramatically. People who contract the virus are more often left completely unaware that they have it, which allows for much greater chances of spreading the virus. This unfortunate fact also means that when, or if, they finally start getting treatment, the disease has usually had a much longer time to progress to more advanced stages.

Location and Project Details
Once again, this telemedicine network is helping serve the residents of southern California, an area that has more isolated segments of population than many people realize. The communities being served by the project are in the San Bernardino, Riverside, and Imperial counties.

One of the reasons that the telemedicine consultations being offered are so necessary is that modern HIV therapy regimens are complicated, which requires more in-depth and comprehensive support services, with an emphasis on neurology specialist care. HIV patients are also living longer than ever before, so other forms of medical care sometimes take the forefront of their needs.

The Organizations Involved
Besides the telemedicine venture we just described, the the Desert AIDS Project does great work in preventing HIV, fostering AIDS advocacy, spreading current information, and educating people on the latest aspects of holistic HIV care.

The center offers free testing for HIV and other disease, allowing people to know for themselves whether they need treatment. They also disseminate knowledge about how to stop the spread of HIV, which is important because one in five people with HIV doesn’t know he or she has it.

The Southern California Telemedicine Learning Center is also doing commendable work with their curriculum of training programs that help educate professionals on why they should use telemedicine, as well as how they can use it best. The Center, developed by UC San Diego’s school of medicine, also offers individual classes on various aspects of telemedicine treatment, such as wound care, legal issues, interactive home telemedicine, and many other various topics.

As we’ve shown this week, there are many organizations that can cooperatively make a difference in how people receive healthcare, and bringing attention to the good work of each of them is just one more thing we can do.