Dr. Marcin Pediatric intensivist James Marcin is conducting a telemedicine consult with a Northern California hospital patient and health-care provider.

In November 2006, California voters approved Proposition 1D, a $10.4 billion education infrastructure bond designed in part to help the University of California accommodate enrollment growth by adding new buildings and repairing older ones. Included in the measure was $200 million specifically to provide the necessary infrastructure to support growth in the university's medical schools and enhance its telemedicine programs throughout the state. At the same time, the state approved an expansion of the UC Davis School of Medicine class size to include students who are committed to practicing medicine in rural areas.

Thomas Nesbitt, a professor in family and community medicine, has been at the forefront of telemedicine and rural health care for more than 20 years. He is also founder of UC Davis' Telemedicine Program and executive associate dean for Clinical and Administrative Affairs at UC Davis Health System. We recently sat down with him to find out what changes we can look forward to now that the state has more money for its medical schools and telemedicine efforts.

UC Davis: Since Proposition 1D was an education infrastructure bond, how do you see it actually helping rural doctors take better care of their patients?

Dr. Nesbitt: Two events occurred at about the same time that I believe will result in real change for rural communities that historically have been medically underserved:

  • The education infrastructure bond that was approved by voters last year is providing the facilities and technology to accommodate an expansion at UC Davis School of Medicine, as well as the other UC medical schools.

  • UC Davis also received state approval and funding, separate from Prop. 1D, which is allowing us to actually expand our class size for the first time in more than a generation.

The synergy of the two decisions is enabling UC Davis to train a more technology-savvy generation of doctors, some of whom will definitely be going into clinical rural practice. As a result, I believe residents in the state's rural communities will experience enhanced levels of health care in the coming years.

UC Davis: The bond act specifically mentions funding for telemedicine. What role will UC Davis have in this important program?

Dr. Nesbitt: Proposition1D provides $200 million for facilities and equipment needed to advance the use of telemedicine technology in California to help connect the state's medically underserved populations with the same health-care expertise as urban communities.

UC Davis has been designated as the hub for the UC system's effort and has received $35 million to build the new California Telemedicine Resource Center, slated for completion in 2010. The new center will house the UC Davis Center for Health and Technology, the Telemedicine Learning Center, a virtual hospital for training and education, and technology-smart classrooms.

Together, these facilities will be used to train the next generation of physicians in applying advanced information and telecommunications technologies to their practices and to provide opportunities for today's physicians to stay abreast of the latest advances in medical science.

But most of all, the new resource center will allow the UC system to link its five academic health systems together in a new way that will better serve California's health-care and health-education needs.

UC Davis: What evidence is there that telemedicine is an effective and safe way to improve the care of rural residents?

Dr. Nesbitt: There is increasingly positive literature on the efficacy of telemedicine with some very sophisticated studies comparing telemedicine with face-to-face care. We also have evaluated our experiences with the literally thousands of consults that we have done. We have completed some formal studies on the subject, including one published in 2005 in Telemedicine & eHealth. In that study, we reported that specialty telemedicine consultations were found to result in changes in diagnoses in 48 percent of the cases, changes in treatment therapy in 81.6 percent of the cases, and clinical improvement in 60.1 percent of the cases. These cases involved dermatology, endocrinology and psychiatry specialty consultations with primary care physicians.

In another study, published in 2004 in the Journal of Pediatrics, we demonstrated that a regional pediatric ICU-based telemedicine program, providing live interactive consultations to a rural adult ICU, can provide quality, supportive care for select critically ill children, thus meeting a significant need in a geographically underserved area. Moreover, we found that both rural providers and parents or guardians were very satisfied with the program's ability to provide quality care while allowing the patients to remain in their local community.

UC Davis: UC Davis pioneered the use of telemedicine. How have you seen it evolve over the years?

Dr. Nesbitt: UC Davis launched its program in 1992 by setting up a simple fetal-monitoring link for high-risk pregnancies between a Colusa County hospital and our medical center in Sacramento. While Colusa is only about 55 miles away, it still gives me great satisfaction that we were able to figure how soon-to-be moms could remain in their own community, close to their families, rather than being sent to a distant hospital that would be both inconvenient and, for some, more costly than they could afford. We then began using the technology of videoconferencing — which is now called telemedicine — for outpatient specialty care. While it's still the mainstay of our clinical program, new uses for video technology include:

  • Inpatient care in infectious disease for patients with surgical wound infections, complicated pulmonary infections and orthopaedic infections.

  • Pediatric critical care, pediatric intensive care oversight.

  • Tele-interpreting. We bring medical interpreting services to the patient via video. We are averaging about 100 video interpreting events each day at UC Davis Medical Center, in Spanish, Russian and several Asian languages. Using the multipoint bridge, we have multiple sites in California, as well as throughout the world, participating in interactive case conferences. This provides mutual learning opportunities for physicians and other health-care providers.

  • Distance education. This live, interactive video brings the latest in research and patient care to the provider, no matter where they are. In keeping up with the times, we are also streaming video to the desktop on demand, and enabling iPod and portable device downloads on hundreds of our courses.

UC Davis: Is this kind of technology too expensive and complicated for many rural clinics, hospitals and physicians to consider?

Dr. Nesbitt: The good news is that constant advances in technology now mean higher quality equipment at more affordable prices. When we first began the telemedicine program, a videoconferencing unit could easily cost $100,000. Now, we can purchase a unit that is more portable, reliable and with better image quality for less than a tenth of that price. Moreover, the cost of sufficient bandwidth to sustain a video call has decreased substantially for rural sites that make use of Universal Services Fund fees that supports broadband expansion. And, with the Governor's broadband initiative, access for rural and frontier sites will increase, prompting telecommunications costs to decrease further.

California is also leading the nation in legislative and financial support for telemedicine growth. Providers are entitled to receive reimbursement for telemedicine consults, thanks to the passage of Senate Bill 1665 in 1996. The state law specifies that all specialty care provided via live telemedicine can be billed and paid at normal rates. That includes payments for the primary-care provider and the specialist who can both bill for a patient encounter.

In addition, the governor recently signed into law a bill that allows reimbursement for Store and Forward telemedicine (a method to transfer digital images and patient information from one location to another) for ophthalmology and dermatology.

An added bonus is that by keeping patients in their local communities, rural hospitals that use telemedicine can see increased revenues for both direct and indirect health-care costs. In an analysis we did of the financial impact of 229 consultations over a two-year period at one hospital, we found it generated about $16,000 in gross clinic revenue and about $64,000 in gross procedure revenue, including ancillary services ordered by the local physicians prior or during the telemedicine consultation.

UC Davis: What do you see as the future for telemedicine and remote health care? What are some of opportunities rural physicians can expect?

Dr. Nesbitt: Telemedicine holds great promise for health care. Continuing with its base in emergency and specialty consultations, telemedicine will evolve into a tool for proactive disease management and disease prevention. Continued advances in equipment and telecommunications technology will allow telemedicine to become fully portable with wireless capability, not only throughout a rural facility, but also in the field. This will enhance a rural area's ability to respond to natural disasters, such as fire or earthquakes.

I also anticipate an increase in the use of telemedicine as reimbursement issues for home health care and workplace wellness programs are resolved. In addition, I see a merging of telemedicine outreach with electronic medical records technology.

Perhaps one of the most significant factors in the future of telemedicine lies in the next generation of physicians. These new, young physicians will have considerable expertise in the use of advanced information technology. As I mentioned, UC Davis School of Medicine recently welcomed12 additional students into its first-year class. They are in a new five-year combined M.D. and master's degree program that focuses on developing physicians to become leaders and advocates for improving health-care delivery in the state's smaller, rural communities. A key component of that program will be in the use of telemedicine and informatics as tools in providing quality health care to rural residents. No matter where you live or work, these are very exciting times to be in medicine. Yes, there are big challenges, especially in smaller towns and more remote areas of the state, but I'm confident that UC Davis' vision and leadership can help make a real difference for Californians and their community clinics and hospitals.