The University of Texas Medical Branch at Galveston (UTMB) has pioneered a state-wide video network to provide remote diagnosis and medical treatment and education via videoconferencing technology to a vast under-served constituency. The program combines the innovative use of an integrated services digital network (ISDN) over special leased telephone circuits, called T1 lines, with dedicated healthcare and information technology professionals and an ongoing telemedicine education program.

The initial phase of the UTMB telemedicine project began in the early 1990s with a pilot project conducted with the Texas Department of Criminal Justice (TDCJ) that utilized interactive video technology to curb the rising cost of health care for more than 100,000 prison inmates. Over the years, the project has grown six-fold. During the first year, UTMB saw 1,700 patients via telemedicine and now the weekly number has risen to over 150 for a total of more than 10,000 patients seen. UTMB at Galveston continues to provide much needed medical services and technical innovations to the TDCJ population.

In 1995, UTMB began to build upon its video network to create a multi-site, statewide consortium for telemedicine and healthcare distance learning to serve the greater Texas community. We define the term "telemedicine" as the real-time, interactive delivery of health care and the sharing of medical information using the advanced technology of two-way audio, and video. UTMB's telemedicine program now includes small clinics, the state's prison system, health care and higher education institutions. Today, the network serves more patients via telemedicine than any other program in the nation.

Much of the impetus for continuing to expand the UTMB telemedicine program has been driven by the size and geographic makeup of the state of Texas. The video network has been designed to meet the needs of the state's vast, under-served rural areas. From our 100-acre campus-hub south of Houston on the Gulf of Mexico, the UTMB video network stretches north to the Texas/Oklahoma border, east to Beaumont, west to San Antonio and south to Edinburgh, on the U.S./Mexico border.

The network employs an "ISDN over T-1" backbone using a central ISDN switch for routing calls to deliver videoconference communications between UTMB and remote clinics as easily as dialing a phone. This 'video network' provides much more than the conventional videoconferencing used extensively within the corporate environment. Healthcare providers nationwide are using the network daily to diagnose and treat patients.

Critical applications such as telemedicine require reliable network services. One technical challenge has been to design our video network architecture not only to deliver reliable, quality service, but to keep network operating costs to a minimum. Each remote site has been equipped with an array of specialized equipment, such as the following: a computer system replete with customized software; cameras capable of providing zoom-in detail; a stethoscope and a suite of medical peripherals; a facsimile (fax) machine; and dedicated phone lines that allow instantaneous two-way communication between Galveston-based doctors and the distant clinics' exam rooms. To date, more than two dozen services are provided via telemedicine over the network, including: general medicine; cardiology; pediatrics; ophthalmology; psychiatry; urology; orthopedics; neurology; and dermatology. Since the network's inception, more than 10,000 patients have been seen via video communications.

UTMB has implemented a comprehensive program to support this telemedicine initiative. The video network has been created to provide reliable, operator-friendly service for the healthcare professionals who are not typically technically-oriented.

Clinics have been specifically adapted with specialized medical and technical equipment. Specialized patient care personnel are being added to assure that the patients' emotional needs remain a priority upon their visits to our remote clinics.

Among the most valuable aspects of the program is an ongoing training program that ensures healthcare providers can maintain a continued standard of quality care while utilizing new technology. The "Open Gates Teletraining Institute," which is open to healthcare providers nationwide, provides courses on the techniques and technology of telemedicine and distance learning. The theories, skills, and methods in the practice of telemedicine are taught by a faculty of more than 60 physicians, physician assistants, nurses, educators, administrators, legal experts, technicians and information service personnel. The UTMB video network is used extensively by Open Gates as a hands-on educational tool.

We view our work in pediatric telemedicine for special-needs children as one of our most important efforts. This outreach networks UTMB to two remote sites hundreds of miles away, Lamar University's School of Nursing in Beaumont and Stephen F. Austin State University in Nacogdoches, Texas. Together with the UTMB School of Nursing we are utilizing nursing programs within the state's colleges and universities to house specially equipped "clinics" for special needs children. In 1998, the pediatric telemedicine network was expanded to include six additional sites within six public schools in Galveston, Beaumont and Nacogdoches, and four additional universities.

Today, through telemedicine, children living in rural areas of Texas can more conveniently have their special health care needs attended to. No longer is it necessary for these children -- often discharged from the hospital with supplemental oxygen, feeding pumps or various monitors -- to travel over painfully long and tiring distances to receive appropriate tertiary care. The range of pediatric care provided is varied. Youngsters with such difficult conditions as spina bifida, cerebral palsy, traumatic brain injuries, metabolic disorders, and chronic problems caused by premature birth have been assessed and treated via telemedicine utilizing the UTMB video network.

Clearly the program continues to have a significant impact for the citizens of Texas in terms of providing technologically advanced healthcare services. But we can also evaluate the program in terms of cost-benefit. Patient and physician travel costs are often minimized or eliminated. Parents who would normally be required to take the day off from work can visit satellite clinics close to their homes, eliminating lost wages and reducing family stress. Physician specialists at a single location can diagnose and treat numerous cases throughout the state and around the world. The efficiency and simplicity of the network's architecture provide a clear path for expansion to ensure we can continue to meet the growing needs of the citizens and healthcare professionals of Texas. Lastly, the program serves as a national and international model of the blending of expert, patient-centered care and advanced communications technology.

Telemedicine utilizing the UTMB video network has revolutionized healthcare in the state of Texas. But understanding the social and geographic context in which our telemedicine program operates is important.

The state of Texas boasts some of the largest and most sophisticated metropolitan areas in the United States. We also have some of the largest sparsely populated counties in the country. Many of these areas do not have access to physicians or healthcare facilities. In fact, in at least 80 of the 254 counties in Texas, there are no physicians. Experienced care givers for special needs children are virtually non-existent. People in these areas, many of whom have incomes which rank below the poverty line, face significant obstacles when seeking medical treatment. Distance and poverty combine to create a large under-served community. UTMB's objective in building its video network has been to reach this population through telemedicine.

Imagine the difficulty of the parent of a special-needs child. Daily life is sometimes overwhelming. A clinic providing telemedicine services in a neighboring community can make all the difference not only in terms of a parent's ability to afford treatment, but in increasing the odds for success in managing a family crisis.

In late 1997, Glenda Honea's daughter became one of the first patients to be introduced to a UTMB telemedicine clinic. Today, she routinely utilizes the video facilities right in her home town, at Stephen F. Austin State University in Nacogdoches. Honea admits that at first, the assortment of TV monitors, cameras and other telemedicine tools looked daunting. But now, she and her daughter, three-and-a-half year old Melony, find the experience both fascinating and a critical time-saver. Having access to so many doctors via telemedicine is ideal, Honea says. "I see them all at once, instead of one at a time. It's like I am in Galveston. If I have to change Melony's formula, or change feeding times, they just write it all down and fax it to me right there. It sure saves a lot of time," she concludes.

A major factor in our success involved building a scaleable integrated services digital network (ISDN) operating over leased T-1 lines. Although ISDN is not new technology; it does, however, deliver the bandwidth, reliability and quality of service needed for video applications, such as telemedicine. Our network extensively employs a Madge Networks Wide Area Network ISDN AccessSwitches: Model 200, at the central hub on campus to switch calls out over leased, dedicated T-1 lines that terminate at far end sites to many Madge Model 20's. Bandwidth is available for up to 23 channels for a total of 1,472 kilobits per second for each call. The AccessSwitch dial plan capabilities allow users at any site to videoconference to any other site as if making an ordinary phone call. UTMB's connection to two major telecommunications carriers permits us public network access to national and international video sites in nearly any part of the world.

Due to our network's switched network design, ISDN can now be delivered to rural areas in Texas where it once was unavailable. Because each T1 line terminates to a smaller ISDN switch many miles away, the network can grow exponentially as new remote users are added. The scaleable architecture of the UTMB network allows us to easily add new sites as new applications emerge. The AccessSwitch also allows all users to share access to a multipoint control unit (MCU) for multi-site telemedicine consultation.

The UTMB video network infrastructure has been designed to allow us to manage and control usage and operating costs. Normally, video calls would be placed over the public telephone network and billed on a call-by-call basis. Telemedicine usage is such that the cost of our leased T1 lines is far less than if we sent our calls over the public network.

The network's ease of use and reliability have made our telemedicine program very attractive to users. For us, the reward has been a huge leap forward in our ability to provide medical services over, essentially, a private high-quality ISDN network.

During the telemedicine examinations, parties at each location can see and hear one another. A nurse practitioner in the exam room accesses special instruments connected to video cameras, thus giving the distant physicians an electronic eye to probe a patient's ears, eyes and throat, as well as listen to a heartbeat. All parties can review and modify the patient's electronic file. Prescriptions or other instructions can be sent immediately via fax.

Telemedicine sessions for children with special needs have been embraced by our young patients almost without exception. Interestingly, this is because the telemedicine monitor so closely resembles a frequently used household fixture-the television.

Nelda Gunter of Newton, Texas, takes her four-year old granddaughter, Sable, to the telemedicine unit in Beaumont, a nearly four-hour trek to Galveston has been reduced to a little over an hour driving time to the video site. "It has been a good deal. I'm not into computers, so it was really an experience for me, "Gunter says" Sable loves it. She sees herself and her doctors on television screens in the room," she adds.

An added benefit has been the fact that the local healthcare providers frequently accompany the patient to the telemedicine clinic. Consequently, the opportunity for communication and information sharing has improved among medical professionals who would not ordinarily work together were it not for telemedicine. Primary care physicians serving or treating their patients at remote sites often learn from UTMB specialists and are able to apply what they have learned toward other patients with similar conditions.

The very power of the network itself has prompted innovations for its use. Our belief is that we have barely begun to scratch the surface of a myriad of applications that are feasible using the UTMB video network.

It was important to create a video interface that would be easy for medical personnel to operate so they could spend their time treating patients, not manipulating video equipment. It was also important to create a system that even individuals with minimal training could operate. With this in mind, the structure of the video network was developed to give us bandwidth on demand.

In late 1992 and early 1993, we undertook a pilot project spurred by the Texas Department of Criminal Justice's interest in curbing the rising health care costs for more than 100,000 inmates. The project, which utilized interactive video technology to deliver medical care, demonstrated the value of hundreds of telemedicine consults held between one of the state's 16 regional medical facilities for prisoners and UTMB. In 1994, the Texas State legislature crafted a managed-care plan for delivering health care to the state's prison population. The plan called for a substantial reduction in operating costs at the existing UTMB facility. Determined not to let reduced funding effect quality of care, we cut costs by further developing and utilizing the video network more efficiently. The resulting video network between UTMB and specialty clinics for inmate patients showed significant cost-reduction.

With a successful telemedicine program in place, we began to identify other potential free-world applications. One such application links 12 remote sites to the UTMB hub to provide medical care for special needs children where medical technology and expertise are not otherwise available. As discussed, this application creates a virtual exam room that saves patients the time and expense of traveling to major medical centers in distant cities. Finally, the telemedicine program contains an ongoing training module that ensures healthcare providers can maintain a continued standard of quality care while utilizing new technology.

The University of Texas Medical Branch at Galveston is a major academic health center dedicated to health science education, patient care, research and community service. Our sprawling campus covers over 100 acres, with 13,000 employees, making UTMB the largest employer in the area. UTMB's system of more than 40 clinics and state-of-the-art telemedicine facilities make it possible to reach patients even in far-flung, rural areas.

When we set out to develop our telemedicine project, the goal was to continue to provide the same quality care we had been providing since 1892. UTMB could have simply connected to an existing state-developed television network, that later proved far too cumbersome and expensive for the rapid escalation of our telemedicine projects. Not only has the technical path we chose allowed us to meet our original goal; it has allowed us to expand our services to provide quality medical care to Texans at large.

A prime example of this outreach is the Pediatric Rehabilitation Telemedicine Project. UTMB caregivers now treat hundreds of youngsters in rural areas of East Texas, including such locales as Jasper, Port Arthur, Silsbee, Orange and Vidor. On average, 20 patients a month are seen through this telemedicine network. In-person exams are routinely supplemented with computerized communication between clinics and specialists. At these remote sites, this application utilizes distance learning equipment already in place.

Glenda Honea, mentioned earlier, is the mother of one of the first patients to be introduced to a UTMB telemedicine clinic. Today she routinely utilizes the video facilities right in her home town, at the Stephen F. Austin State University in Nacogdoches.

"It has become a regular thing. I take Melony every three months. Having the clinic so close, it is just a 15 to 20 minute drive for us. It's nothing at all to get there. I don't have to rush," explains Honea. Now gone are the numerous, nearly four-hour long drives to Galveston required during Melony's first year of life. "She was born so little. I was told she wouldn't live to be three. I had a lot of hard times, driving back and forth. Melony would get so tired," she recounts.

Similarly, young Sable, a spina bifida patient, and her grandmother Nelda Gunter of Newton, Texas, live in the country, far away from expert advice on the child's condition. "The doctors up here are just not familiar with dealing with kids that have this severe of a problem," Gunter points out. "My hope is that telemedicine in the future becomes even more commonplace than what it is now. It just saves me a lot of time," she said.

Future applications of UTMB's telemedicine effort promise to be numerous and varied. Clearly, benefits exist in providing elder care through telemedicine. Linkages can be established between a "community health team" and older patients without requiring those patients to come to a tertiary care center. Telemedicine units have already been placed in some nursing homes throughout Galveston with positive results. Elder citizens who have difficulty obtaining outside help can now acquire primary and extended medical health care from inside their nursing homes.

We have also begun to explore commercial applications for telemedicine. In particular, discussions have been initiated with companies who operate offshore oil-rigs. Positioned many miles from land, these rigs are staffed with on-board medics who can not always handle every medical contingency. The introduction of telemedicine could add a significant method of medical treatment without the cost associated with transporting either patient or medical expert. The same holds true for remote geological survey camps around the globe. But why stop there? Early discussions between UTMB and NASA suggest that remote health care technology is required, not only for the now-in-construction International Space Station, but also for future human habitats that may dot the Moon or distant Mars. We contend that there are many exciting opportunities to extend the power of telemedicine over the years and decades to come.

There remain serious hurdles to overcome if telemedicine is to become mainstream on a worldwide basis. For centuries, the practice of medicine has been conducted practitioner to patient within the confines of a single examination room. Telemedicine presents a new paradigm for healthcare. Striking a balance between wider applications of telemedicine and the enduring value of human interaction will be crucial.

With this in mind, we conducted a patient "satisfaction survey" with parents of special needs children receiving telemedicine services over the UMTB network. Specifically, we compared telemedicine clinics to traditional follow-up clinics. We found patient satisfaction was higher within traditional clinics, specifically when respondents were asked about emotional issues such as feelings of fear, frustration and anger.

As a result, we have begun to counter what we believe are legitimate psychosocial issues associated with telemedicine. A licensed professional counselor now attends every telemedicine session. In addition, a devoted segment of the total patient-doctor interview time is set aside to deal only with psychosocial problems. We are currently evaluating the effectiveness of this approach.
UTMB’s expertise in telemedicine has not come easily. At the project's inception, university leadership was not convinced of the value a telemedicine program could have. Times have changed, and so has UTMB leadership. Today, after demonstrating the program's successes, our IT and medical team have the full faith and support of the university's leadership.

Implementing UTMB's telemedicine programs is a large team of educational and medical professionals. Our challenge has not only been to provide continuing education for our telemedicine practitioners, but to furnish a user-friendly environment in which they can learn and practice their new technical skills. We recognized this need early on and have developed what we believe is a living laboratory for continuing telemedicine education.

There were several technology challenges associated with establishing the UTMB network. The concept of a switched video network originally met with resistance. The equipment we needed to purchase in order to build such a network was expensive, and telemedicine, though theoretically of value, was a new concept.
Medical practitioner licensing can also be of concern. For example, when conducting telemedicine sessions across state boundaries, how are doctors reimbursed for services rendered if their license to practice medicine is only in one state? Which site has responsibility should a liability issue occur? Resolving these kinds of questions will likely require much debate and legislation.

Setting legal and technical issues aside, the future of telemedicine remains bright. The rapid march of technology, more powerful computer systems, highly specialized software, ever faster data speeds over increasing amounts of bandwidth, and the availability of satellite video networks suggest incredible opportunities for expanded use of telemedicine.