Virtual’ patient record ready for TB controllers
TeleMed may go on-line soon in New Mexico
TeleMed, a way to create an instant patient record from disparate sources by using the Internet, is about to take off on its first test flight across the wide-open spaces of ew Mexico. There, the state’s TB control department is chomping at the bit to plug into the new technology, whose makers say it combines tight security with the ability to pull together data from different locations at mouse-click speed.
Developed by scientists at the Department of Energy’s National Laboratory in Los Alamos in collaboration with National Jewish Medical Center in Denver, TeleMed promises not to be just a distance-shrinker, but a groundbreaking new piece of data-crunching technology, says state TB controller Gary Simpson, MD, MPH.
"You absolutely cannot see this stuff and fail to be totally awed by it," says Simpson, who hopes to roll out TeleMed across his state’s far-flung network of rural health clinics.
Contrary to its name which calls to mind talking-head-style video conferencing what TeleMed actually does is grab data from multiple sources, in almost any shape or form imaginable (from digitized radiologic data to CAT scans to drug records) and flash-feed the data, packaged in easily readable document form, onto the computer screen.
By clicking across a menu of icons, clinicians can attach virtual Post-It notes or add taped or written comments. Or, using TeleMed’s data-mining capabilities, they can search thousands of radiographic images for statistical similarities and compare the resulting thumbnail-sketch series in an array inserted alongside the X-ray onscreen.
New Mexico’s doing fine on its own
Even without such wizardry, Simpson concedes, TB control in New Mexico has been running along just fine, thanks to the state’s single-jurisdiction infrastructure, its relatively small number of patients, and the collegial working relationships that exist among staff. Still, TeleMed could swiftly eliminate some of life’s daily hassles, says Simpson.
For example, when he’s called in to consult on a case, Simpson typically must wait up to a week for a patient’s X-rays to reach his office via the mail; then, once he’s done with the images, back into the mail they go. Invariably, there are also the requisite three to four hours spent on the telephone, as Simpson tries to make sure every member of the health care team is on the same page and is in possession of the same information.
Imagine the TeleMed version of the same scenario, he says.
This time, Simpson is seated in his Santa Fe office, a patient’s chest X-rays hundreds of miles away. He clicks on an icon, and the information already digitized and fed into one of five main points throughout the state where radiologic data will be scanned into the system pops up on screen. Another mouse click or two, and Simpson compares the chest X-ray he’s looking at with others taken over the past year at various hospitals or clinics across the state.
On-line correspondance
Since the patient has a cavity he’s been following for the past year, Simpson pulls up a section from a series of CAT scans that corresponds to the cavity. Finally, he sticks a virtual note onto the X-ray: What does Michael Iseman, MD, clinical scholar in the division of infectious diseases at National Jewish Medical Center in Denver, think about the worrisome cavity? Iseman, who just happens to be on-line himself, since his facility is currently also trying out TeleMed on a limited basis, responds on the spot.
As good as it sounds, some say TeleMed’s biggest problem is that it has underestimated the reluctance of the private sector to sign off on proprietary, confidential information.1
"There’s tremendous inertia in the medical community and for good reason," says Sandra Zink, PhD, program manager of the biosciences program at Los Alamos. "You don’t lightly give up whatever system you’ve had in place for the past 28 years; you do this very cautiously."
From the standpoint of logistics, it’s also tough to say exactly how difficult it will be to graft TeleMed onto those pre-existing systems, adds David Forslund, PhD, deputy director of the computer center at Los Alamos. "First, I’d have to know the software specifications," he says. "If the data’s on paper in a filing cabinet somewhere, obviously someone’s going to worry about it. But if it’s, say, in a Word document, there’s an electronic process whereby you can paste right into TeleMed with a few mouse clicks."
As for security issues, TeleMed developers say the system they’ve incorporated should please everyone, from HMO bean-counters to patients to providers. The technology is contained within an encryption device called an iButton, manufactured by Dallas Semiconductor Corporation in Dallas. The iButton is a dime-sized steel button that users keep with them, like a set of car keys or an ATM card, and which contains a tiny computer microprocessor.
Once a user touches the iButton to a receptor and then enters a personal ID number, he or she is authenticated and gains entry into the system. Providers at different levels can be coded for entry only into those portions of the database they are authorized to access.
When two HMOs need to share information
Having a way to share information on an as-needed basis stands to benefit everyone concerned, Simpson adds. Suppose a patient who’s a member of one HMO shows up in the middle of the night suffering from an adverse reaction to medication at an emergency room run by a second HMO. "The two HMOs really need to be able to share information," Simpson says. "They just don’t want to open themselves to a situation where someone could mine their files for addresses." TeleMed provides that narrowly focused capability, he adds, and restricts it to the hands of clinicians who need it.
Los Alamos scientists have spent $3 mil- lion and three years creating the system. Its precursor project, known as Sunrise, had been designed to help Net users navigate big, complex data sets without taking up equally huge amounts of memory or bandwidth. Originally, the Department of Defense was interested in developing such a tool because of its desire to monitor the health of employees moving from one job environment to another, to see how each place affected their health.
At National Jewish, TeleMed is already deployed on a small scale, with about a dozen clinicians using the system each week for case conferences. James Cook, MD, chief of the division of infectious diseases at the medical center, praises the results of the pilot project. "We’ve been able to share data to build a consensus on how to treat a patient’s particular problem," says Cook. "To reach this kind of decision, you want everyone to have the same information. And this is where TeleMed works wonders."
At National Jewish, radiology images are shipped on disk to Los Alamos, where they are loaded into the system. In New Mexico, Simpson hopes to go a step further by acquiring digital scanners and placing them at the four hospitals where the majority of the state’s TB cases are initially diagnosed.
TeleMed will greatly improve the ability of members of a health care team to function effectively together, Simpson says. He thinks it will also improve patient compliance. "Every time one of us sees the patient, since we all have access to the same information about him, we’ll all give him the same message," he says.
Good for the big city as well
Will the technology work as well in a big city as in a rural, sparsely populated state or a tertiary health care center like National Jewish? Simpson thinks so. "Paradoxically, this may be even more applicable in an urban setting, where the number of cases may be in the hundreds but where people are separated by layers of bureaucracy," he says. "Down here, we get by because we know each other. It’s easy for me to call someone hundreds of miles away and get through quickly. But in an urban setting, you might not even know the TB controller who works 10 miles away."
The technology is "scalable," say developers. In other words, since the data never actually leave their original repository, the system performs equally well with a dozen patients or a million.
For access, users need only a 486 computer, Windows 95, and access to the Internet. TeleMed is written in Java, a special language supported by Netscape’s Navigator browser (which means, developers concede, that it won’t work as well with the Microsoft browser, Explorer). Still, at its recent trade show in Chicago, the Radiological Society of North America pinned a blue ribbon on TeleMed for "best new technology devoted to information management."
(Editor’s note: Readers can visit the TeleMed Web site at www.acl.lanl.gov/telemed.)
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