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— Most San Diegans have medical help available, even the uninsured. Many residents are minutes away from an emergency room; even rural San Diegans can be life-flighted to a trauma center. But what do you do when there is no hospital in proximity when you are injured or gravely ill? The answer is telemedicine.

Dr. Daniel R. Masys is a cancer-and-blood specialist and the director of bioethical information for UCSD Medical School in La Jolla. He is also one of a few San Diego experts in this field of medicine. "It's the use of information technology to serve health-care purposes when distance separates the participants. They are not face-to-face but in separate places. That includes not only high-end applications like two-way audio and video, but things as ordinary as the use of a telephone or e-mail."

The need to deal with medical emergencies in distant locales brings the military to mind. "They've put the largest amount of resources and operational testing in telemedicine because they are exactly in that situation. They have corpsman trying to take care of people on submerged submarines where they can't break radio silence or they'll risk their mission. They've put a lot of attention and resources into it. The action in Bosnia was the first war where there was a major commitment to telemedicine, where they used satellite-based communications. CTMR scans [a combination of CAT scans with MRIs] from the front were interpreted from Walter Reed and other places. They didn't save any money doing that, but they didn't intend to. They did find out, however, that it was effective, especially for specialty services. They can't be having neuroradiologists flying into harm's way."

UCSD has explored the possibility of an on-campus telemedicine institute. "We did have a research contract, for which I'm the principal investigator, which started in 1996. That gave patients for the first time access to their medical data in the UCSD system through a highly secure specialized Internet connection through their Web browser. So anything your doctor could see in the hospital computer, you could also see. If you went in for a lab test or you had an x-ray, you could get the results yourself. It required a lot more than a password and a code. You needed a user ID and password to even begin the session to download what's called a 'cryptographically signed job applet' that then challenged you for additional evidence for a string of characters that you sent back with a password that was never used a second time. It was a high-assurance system, much higher than using your credit card on the Internet. It was a successful test. We completed the first phase in 2000, and we had about 210 physicians and 56 patients signed up. The patients were uniformly positive about the idea that they could get their medical information as easily as their doctors could. They thought it was wonderful, though there were complaints that they needed help understanding the information because it was technical. We expected that and had a support desk. But doctors, who are used to having easy-to-use systems with less security, didn't like it at all. It took about a minute and a half to go through the high-security log-in, and for most doctors, that was unacceptable.

"There have been a number of federally funded research programs and demonstration projects in telemedicine. The closest one with the University of California is based in Davis, where they have a telemedicine center and have had for almost a decade. They have built upon other demonstration projects, like the one in the state of Georgia that created a statewide telemedicine network. In North Carolina, East Carolina University has had a very vigorous telemedicine program, and there are some in Texas too. The ones that seem to be sustainable -- that is, not just doing it as a grant or research project, then dropping when the money goes away -- have been prison telemedicine."

Prison telemedicine has grown rapidly because of two incentives: cost and the undesirability of practicing medicine on convicts. "From the point of view of the prison, it's very high-risk to have their inmates going outside the institution to visit doctors in the community. It's also very costly to have two guards going along. The most successful telemedicine programs to date have tended to be prison telemedicine, where the money that was being spent on guards and vans could be put into technology instead. The consultant can be on the other end of the wire in a television interview with a nurse-practitioner presenting the case or a doctor inside the walls getting a consult on something not commonly seen. This way you can bring a specialty to people who could otherwise not get it cost-effectively...or at all."

Dr. Masys's favorite example of telemedicine involves a female physician in Antarctica. "She was flown to Antarctica and was providing care there. For six months out of the year, it's completely inaccessible, and shortly after she arrived she discovered a lump on her breast. Very quickly, lumps were developing under her arm. Communicating over the Internet with cancer specialists in Indiana and other doctors who were providing advice, she was able to train the people around her, none of whom had medical training, to do biopsies, interpret slides, and send pictures of what the slides looked like. They airdropped from the C130 Hercules the chemotherapy drugs that she administered to herself until they got a brief period where they could land. It was only minus 30 degrees instead of minus 60 degrees, and they had 90 seconds to get the airplane off when they got her back to the States. That was clearly a life-threatening situation where she had a very rapidly developing form of cancer. If they had waited for the sun to come back to Antarctica, she would have been dead. That's got a lot of play in the press."

Telemedicine is practiced most frequently in San Diego through the 911 system. "When an ambulance rolls up to your house, those units use EKG telemetry so that they connect to the emergency department at one of our major hospitals in San Diego and the doctor sees your EKG tracings while the emergency medical team technician is presenting the vital signs and other information. Hands-on care at the scene is supplemented by telecommunications technologies that are bringing another pair of eyes, another mind to bear on the decision-making. Emergency-room doctors are listening to the case being presented along with the emergency technicians, and they make the decisions: Is this an emergency? Do we have to get to the closest place as quickly as possible? Can this person be stabilized? Those kinds of things."

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