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— Masys sees telemedicine improving emergency response beyond what is now considered cutting edge. "Currently, there's not a video component, with the doctor interacting with the patient. But imagine if we had high-speed wireless communications capabilities in our environment, where the ambulance would almost become a TV studio -- you would roll in to the back of the ambulance, and there you're seeing the providers as if you were already in the emergency room.

"The experience of telemedicine when well done actually removes from the participants the focus on technology. The patient interacts with the doctor on the television as if they were right there. The doctor, similarly, tends to look through the technology and focus on the patient. You look through the medium to see the problem at hand."

His ongoing investigation of telemedicine has led Masys all over the country to observe more advanced applications. Particularly impressive was East Carolina University. "They have little offices set up with soundproofing. There are six of them in a row, and they schedule their practitioners to be there. The doctors have an electronic stethoscope, and they can listen in real time. The nurse-practitioner puts the stethoscope on the chest, and the doctor listens over the link. It's quite a natural communication. Like most communications technologies, when they work really well they appear not to be there. It's bringing people together with the kind of interaction they would get face-to-face."

Telemedicine's beginnings -- the first time it involved more than a doctor returning a phone call -- can be traced to the mid-'60s. "Those were the first programs that developed things like remote EKG telemetry, which was quite a fancy thing in those days. They'd take a telephone and put it in an acoustic coupler. They had very slow radio speeds. It was all high-tech in those days, although very ordinary by today's standards. So there's a history that goes back at least 25 years. But in spite of the increasing amounts of bandwidth and the ubiquity of the Internet, telemedicine really hasn't taken off.

"Outside of having a grant that pays the cost of the technology, when you mix all the technology in and the fact that Medicare, until recently, and most health-care insurers would not pay for telemedicine, there was no incentive whatsoever to do it. Also, the costs saved tend to be the cost of travel. Families don't have to dislocate themselves and drive 100 miles to see the doctor then drive home, but the doctor never paid those costs anyway. The family may save some money, but the health-care institution doesn't realize a benefit. The Health Care Financing Administration, which creates the rules for Medicare reimbursement, has had a number of demonstration projects for telemedicine over the last ten years. Those were projects that would pay both parties, but under a very adverse set of rules. For instance, in most of the financing administration's demonstration projects, they required that there be a doctor on both ends of the line, and they would reimburse 80 percent of the face-to-face rate for the same service and the doctors had to split it! That's not a very strong incentive for anybody to give these demonstration projects.

"Another problem is the issue in the era of the Internet of medical licensure. State medical boards have held that the doctor is transported to the patient by telemedicine. That's a little backwards, because in most face-to-face health care, the patient transports themselves to the doctor. For purposes of licensure, they've said, 'Well, the doctor is transporting himself to the patient, so the doctor has to have a license for any state where the patient might have the need.' That's a real disincentive. Let's say you were the world's specialist in some rare medical condition and you knew more about it than anybody, so you said, 'Okay, why don't I use the Internet to try to make my services available to whoever needs them, because they're scattered all over the planet.' Well, currently, in the United States that means you would have to get 50 medical licenses for every state in the union and pay all the costs and go through all the difficulties, because every state does it differently. That's an insurmountable problem. Then there's malpractice. If something goes wrong, in whose jurisdiction did this event happen? Was it the state where the practitioner is or the state where the patient is?"

If the potential benefits seem distant, there is some movement to get there. "The state of California has passed a telemedicine act that for the first time reimburses any care provided by a California provider to a California patient. There's no face-to-face requirement for, say, MediCal reimbursement. So that's very progressive. At the end of the 2000 session, Congress passed a bill that expands telemedicine services nationwide, reimbursed by Medicare -- and the president hasn't undone it yet! That will, I think, increase some scenarios where it will be feasible to do it. There will be improvement, but how fast, I don't know."

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