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Medecine without frontiers

Even in the Antarctic, your doctor is just a phone call away.
Britain's first tele-dentists are poised to begin work. Four consultants at the University Dental Hospital, Cardiff, will examine the teeth of patients in clinics up to 60 miles away and make treatment decisions based on what they see on a screen in front of them.

Patients will have their dental problem filmed with a camcorder, the doctors will view the live images as they are transmitted down telephone lines and recommend what treatment should be carried out by local practitioners. The project, due to get off the ground later this year, will be the 18th telemedicine scheme in Britain with dermatologists, psychiatrists, ophthalmologists, obstetricians, and casualty doctors already involved in similar schemes.

Oil rig workers off the Scottish coast, scientists in remote Antarctica, dermatology patients in rural Wales, expectant mothers on the Isle of Wight, and people with eye problems in a Greek village are already benefiting from telemedicine projects based in Britain.

For some doctors, telemedicine is the brave new frontier in the delivery of health care, where specialist services can be more widely shared and more swiftly available, and where emergency medical help can be given to patients hundreds of miles from a doctor.

For others, the cost effectiveness of the technology has yet to be proven, and there are those who still have lurking doubts over safety and fear that the technology linking the patient and the doctor may go disastrously wrong. There are a few, too, who are yet to be persuaded that telemedicine is little more than a high-tech toy that has been over-promoted by a handful of enthusiasts.

Telemedicine has been slowly evolving since the late 1960s, but was given a big push in the 1970s when research backed by the US National Aeronautical and Space Administration (Nasa) found that the quality of care provided at a telemedicine centre staffed by paramedics with cameras was no worse than that provided in a conventional clinic staffed by doctors.

Since then telemedicine has developed apace, especially in the US, where intense competition between large telecommunication companies has stimulated a rapid spread of projects, ranging from the remote medical examination of prisoners in a North Carolina high security jail, to a DIY obstetrics care system in Brooklyn where patients take home a computer-based kit linked to the hospital.

The main aims of telemedicine, regarded by enthusiasts as one of the most innovative areas in the delivery of health care, is to use interactive telecommunications for the diagnosis and, in some cases, treatment of patients.

At the technical level it is a marriage of fibre optics, fast computers, high resolution monitors and advanced telephone lines. At the patient end it usually involves he or she being filmed with a camcorder by a nurse or a GP and having a consultant many miles away look at the problem and talk to the patient and their doctor at the same time.

It can, however, also be a fast-track way of processing data. Some big hospitals, such as the Hammersmith in London, have been looking at processing X-rays, for instance, and shipping them back to GPs in rural areas over telephones lines, giving a much faster return than at present.

For most professionals, the principle attraction of telemedicine is that it makes better use of scarce resources, and in most cases this is the expertise of a consultant. By using video links a consultant can see many more patients.

According to a review of telemedicine by Dr Bill Maton-Howarth of the Department of Health, there are 17 active projects in the UK, with many more in the pipeline. Ten centres are working on various ideas, he says, but warns that there have been few attempts at examining the cost effectiveness of telemedicine.

Dr Richard Wootton, Britain's only professor of telemedicine, based at Queens University, Belfast, has costed one of the longest running projects, which links the city's Royal Victoria Hospital with a health centre in Westminster.

Professor Wootton says the annual cost of the project was pounds 7,250 a year, compared to the alternative costs of having medical staff on site at the centre, which would have been pounds 50,000 a year - a net saving of pounds 42,000.

"The Westminster centre, which is staffed by nurse practitioners, faced one of the classic paradoxes in staffing healthcare facilities: it was adequately staffed to treat 98 per cent of the cases presented to it, yet needed to consider employing more highly skilled staff to cope with only two per cent of the case load," he says.

As well as saving money, as in Westminster, telemedicine widens access to expertise. In Wales, the dental hospital is a regional unit and some patients with problems that cannot be dealt with locally currently have to travel to Cardiff to be examined. Once the project begins, they can be examined locally.

Professor Malcolm Jones, who is setting up the teledentistry project, says: "Essentially, the dental hospital will be the hub of the service, and various clinics will be the spokes. We will provide consultant diagnosis and treatment support services along the spokes.

"As a first step we will be providing services to community clinics in the South Wales Valleys and from there we plan to expand into rural Wales to other clinics and eventually to practices. Initially, we will be looking at orthodontics and then move into paediatrics."

He adds: "As consultants we are very thinly spread and this is a way of providing a consultant service to rural Wales without anyone having to travel."

The removal of the need to travel may be one of the main attractions for patients, but ironically, it is not taken into account in costings, as Professor Wootton points out: "Some of the main savings are in the intangibles like patients not having to spend time getting from, say, the isle of Wight to a London hospital."

He is convinced that the secret to further expansion of telemedicine in the UK is providing proof that it saves money. "It is my belief that until you have studies which show that telemedicine in a specific circumstance is economic to the health service it simply won't happen on any scale. We might not like it but unless you can show a new technique is cost effective on the NHS, it is not going to get introduced. It is crucial to find evidence of cost effectiveness."

Dr Bill Maton-Howarth at the Department of Health says there needs to be further research too, into issues like the confidentiality of patient information, patient consent, and the duty of care that doctors and the health service have.

Both in the UK and the US telemedicine has already spread across international boundaries with specialists in New York performing diagnostic work on a patient in Saudi Arabia, and Bristol-based eye specialist Dr Demetrios Papakostopoulos providing a diagnostic service for the population of a poor Greek village.

Telemedicine has found a role in the more glamorous side of health care too - accidents and emergencies - by giving camcorders with telemedicine links to paramedics in remote situations like oil rigs and Antarctic expeditions.

An EC-funded telemedicine project - Mermaid - is poised to take the technology one step further and revolutionise health services to merchant ships. It's hoped that by equipping ships with cameras and data links to a multi- lingual, 24-hour medical centre, all sick seamen will get instant access to medical treatment.

And similar work is also under way to find ways of providing remote health care to future space explorers, the vision that Nasa researchers had nearly 30 years ago which gave the original impetus for telemedicine and which is now finally much closer to becoming reality.