Published: October 8, 2012
NANTUCKET, Mass. — When Sarah Cohen’s acne drove her to visit a dermatologist in July, that’s what she figured she’d be doing — visiting a dermatologist. But at the hospital on Nantucket, where her family spends summers, Ms. Cohen, 19, was perplexed.
In this special issue of Science Times, we look at some of the many ways that technology is changing the world of medicine.
“I thought I was going to see a regular doctor,” she said, but instead she saw “this giant screen.”
Suddenly, two doctors appeared on the video screen: dermatologists in Boston. A nurse in the room with Ms. Cohen held a magnifying camera to her face, and suggested she close her eyes.
Why? she wondered — then understood. The camera transmitted images of her face on screen, so the doctors could eyeball every bump and crater. “Oh my God, I thought I was going to cry,” Ms. Cohen recalled. “Even if you’ve never seen that pimple before, it’s there.”
That, she realized, was the point. Technology, like these cameras and screens, is making it affordable and effective for doctors to examine patients without actually being there.
More hospitals and medical practices are adopting these techniques, finding they save money and for some patients work as well as flesh-and-blood visits.
“There has been a shift in the belief that telemedicine can only be used for rural areas to a belief that it can be used anywhere,” said Dr. Peter Yellowlees, director of the health informatics program at the University of California, Davis, and a board member of the American Telemedicine Association. “Before, you had to make do with poor quality, or buy a very expensive system. Now, you can buy a $100 webcam and do high-quality videoconferencing.”
The technology is especially being embraced in professions like ophthalmology, psychiatry and dermatology, which face shortages of physicians. At Kaiser Permanente, dermatologists “sit in a suite in San Francisco” and tele-treat patients throughout Northern California, Dr. Yellowlees said. “It’s much more efficient than having 20 hospitals, each with a dermatologist.”
On Nantucket, an island 30 miles from the nearest spit of mainland, “telemedicine just makes a lot of sense,” said Dr. Margot Hartmann, chief executive officer of Nantucket Cottage Hospital. “It allows us to meet the mission of the hospital better because we’re offering more locally,” and saves patients the cost and time of flying or ferrying off-island, then driving to Cape Cod or Boston hospitals.
The island may be small, but it has strikingly diverse medical needs. Its year-round population of about 10,000 balloons to 50,000 in the summer. And while it is famous for wealthy visitors, its year-rounders are much less affluent. They include immigrants from many countries, and range from businesspeople to scallopers.
Nantucket has all the ailments one would find anywhere, plus some exacerbated by island life: skin cancer, tick diseases, water accidents.
“Most people are within an hour of some major hospital,” said Joanne Bushong, the hospital’s outpatient clinical coordinator. Not Nantucket. “We’re not practicing rural medicine; we’re practicing island medicine.”
Nantucket’s hospital has a handful of year-round doctors. While mainland specialists do visit, fog or storms can keep them from getting there. And specialists cost money. The hospital, millions in the red in recent years and now needing $60 million to replace its outmoded 1957 building, must pay for the specialists’ travel and lodging.
Telemedicine, done by doctors at Massachusetts General Hospital, saves some of those costs, and generates revenue because it means more tests are done on Nantucket. “If someone was going off-island to see a dermatologist, they would probably have their labs and X-rays done where that dermatologist was,” Dr. Hartmann said.
Instead, tele-dermatology saves nearly $29,000 a year because two dermatologists now visit only four times a year, but appear on screen six times a month and see 1,100 patients a year. Previously, dermatologists visited monthly, and always had “100 people on the waiting list,” Ms. Bushong said.
Nantucket also uses tele-radiology, having Boston radiologists, some specializing in certain body areas, read X-rays and scans. It has used tele-pediatrics twice, for a child in a car accident and one in diabetic crisis. Tele-stroke uses video neurologists to quickly determine if a patient’s stroke type warrants a clot-busting drug, tPA, or if tPA could harm the patient.
Tele-endocrinology, for thyroid problems and diabetes, is starting. And Nantucket hopes to have video sessions for autistic children “so parents would not have to take kids with autism off-island, since it’s hard to travel with them and it upsets them,” Ms. Bushong said.
Dr. Hartmann envisions tele-rheumatology and tele-psychiatry, among other teles. Instead of screens in one exam room and the emergency room, “I would love to see every room telemedicine-capable,” she said.
But there are limitations, nationally and on Nantucket. Dr. Yellowlees said interstate telemedicine was hindered by rules requiring that doctors be licensed in the state where patients are treated.
Insurance coverage varies, with Medicare and some policies covering telemedicine services only in rural areas. “If you’re in a city, Medicare will only reimburse if you’re in the same room as the doctor,” Dr. Yellowlees said.
And some telemedicine is not cost-saving or accepted by doctors on the receiving end. Memorial Hermann Hospital-Texas Medical Center in Houston ended a tele-I.C.U. program in which intensive care specialists monitored and assisted intensive care units at five other hospitals. It was expensive and not demonstrably better, and some doctors and nurses disliked being watched from afar, said Dr. Eric J. Thomas, associate dean for health care quality at University of Texas Medical School at Houston.
On Nantucket, Dr. Timothy J. Lepore, 67, a surgeon and the hospital’s medical director, sees value in some long-distance doctoring, but has some concerns. He especially prefers having a radiologist on-site because he believes that conferring in person helps prevent mistaken readings and gets quicker results.
Dr. Lepore said that one tele-radiologist misread a chest X-ray, missing that the patient had pulmonary edema, fluid in the lungs. And when Dr. Lepore injured a hamstring while running, a tele-radiologist said an M.R.I. showed Dr. Lepore had pulmonary edema of the hip, which was bizarre and impossible. His actual diagnosis: a torn hamstring.
Occasionally, Dr. Lepore said, “it just goes completely off the trolley.”
Dr. Efren Flores, a radiologist who divides time between Boston and Nantucket, said he has learned to heed Dr. Lepore’s insistence on fast, accurate tele-radiology readings because on Nantucket it is important to determine if patients can be treated there or must be flown to Boston.
Many patients appreciate that telemedicine saves them trips off-island, but not everyone likes it.
“There are some people who just flatly refuse, and I see them in person,” said Dr. Peter Schalock, one of the two Mass General dermatologists who treat Nantucketers remotely. He said he has had to get used to diagnosing without feeling a patient’s skin, relying on the nurse, Ms. Bushong, for that. “Somebody with 100 strange-looking moles, I can probably do in 10 or 15 minutes myself, when it might take half an hour with the camera. Definitely people with more interesting moles, I like to see myself.”
Still, “we’re pretty good at picking up what looks funky, to use a technical term,” Dr. Schalock said. “I really feel like we’re providing essentially the same quality care.”
So, in August Dr. Schalock remotely diagnosed eczema in Aaron Balazs, 35, but saw him in person in September and increased his medication dosage and switched him from a cream to pills.
Mr. Balazs, stationed on Nantucket with the Coast Guard, was not expecting video doctoring, and said initially “it was sort of awkward.” But he concluded “it’s definitely beneficial for both parties.”
By the time Ms. Cohen had her second session in August, this time with Dr. Schalock, she said, “I feel like it’s the same thing” as an in-person visit. She had accepted the mega-magnifying camera by then.
“It kind of freaks out some people,” Dr. Schalock said. “They say, ‘Oh my God, I should have shaved my legs!’ I’m not looking at the hair. I’m looking at the mole.”
It doesn’t matter how you take off bandages — quickly or slowly, they hurt. And it’s not just a matter of a little discomfort. Taking tape off improperly can cause serious injury among patients with weak skin — including babies born prematurely who are hooked up to tubes and other monitors secured to their skin. Conventional tape is designed to break apart at the point where the tape adhesive meets the skin, the researchers say. But a preterm baby’s skin will often rip more easily than the tape, so the tape itself stays together while the skin tears apart. In some cases, skin damage from tape removal can cause lifelong scarring. “This is one of the biggest problems faced in the neonatal units, where the patients are helpless and repeatedly wrapped in medical tapes designed for adult skin,” says Bryan Laulicht, who worked on the new medical tape.
