FEATURES | Two African American ophthalmologists from the Los Angeles King-Drew Medical Center have created a telemedicine program that uses computers, videoconferencing, internet networks and office software to evaluate patients in a remote neighborhood clinic.



Telemedicine in the 'Hood: Treating Patients From a Remote Location With Aid of High-Technology Communications.
Black Issues in Higher Education. Aug. 20, 1998

By Jordan Elgrably

Sean Morris's eyes worry him; they hurt sometimes and he wonders what to do about it. A friend's report of a six-month wait for exams at the county hospital had discouraged him from seeking help. But recently, the twenty-four-year-old discovered the Carmelitos Teleopthalmology Center only a short walk from his home.

Morris calls to make an appointment and, to his surprise, is scheduled for the next day. After filling out the necessary paperwork on the day of his visit, medical assistant Denise Kelly leads him into the examination room and introduces him to a young ophthalmology resident from Drew University, Dr. Michelle Banks. Banks first takes several pictures of Morris's eyes from varying angles using a computerized retinal camera.

This digital camera is connected by a cable to a computer, and Morris is amazed to see his eyeballs floating instantaneously onto the computer screen. Thanks to this innovation, testing him for glaucoma won't require the traditional dilation with numbing eye drops.

Also viewing the digitized images of Morris's eyes is Dr. Yadavinder Dang -- an ophthalmologist sitting at his computer five miles away at the King-Drew Medical Center. Banks and Dang discuss Morris's eyes; Morris can see and hear Dr. Dang on the screen, and the doctor is able to study this patient thoroughly without even being in the room.

While a high percentage of new patients arrive at Carmelitos with serious eye problems, Morris gets a clean bill of health. His condition is diagnosed as "dry eye" -- nothing a little vial of artificial tears can't remedy.

Big-city public hospitals can be antiseptic, anonymous, and anything but userfriendly -- particularly if you are an uninsured patient without easy access to preventive treatment. Recognizing that the Black and Latino population in their county service area of 1.4 million Angelenos is already woefully underserved by existing facilities, two African American ophthalmologists have almost single-handedly launched the nation's first urban telemedicine program.

Using leading-edge technology that includes videoconferencing, online computers, and advanced software, thirty-four-year-old Dr. Charles J. Flowers Jr. and forty-five-year-old Dr. Richard S. Baker co-direct a new telemedicine program at the Carmelitos Housing Development, the largest housing development in Los Angeles. However, thanks to the new advances in information technology, they can do their directing from a distance.

Flowers and Baker work from their base at the King-Drew Medical Center and Charles R. Drew University of Medicine and Science, located in the Watts/Willowbrook area of Los Angeles. They communicate in real time with an on-site physician and two medical assistants, who examine Carmelitos residents like Shawn.

"Sixty percent of the population coming in already have disease," says Baker. "Forty percent need serious treatment, and 7 percent are already blind in one eye."

The Carmelitos clinic, situated in the housing project's community center, is the first of five such locations scheduled to go online within the next few months. One test site already operational is the Grace Four Transitional Home, a private care facility located on a quiet lowers residential street, where developmentally disabled residents can videoconference with clinical psychologist Dr. Joan Cooper, over at King-Drew. Since the program's inception in October 1996, five doctors have been trained at the center.

While telemedical technology may strike some as intimidating, the learning curve for physicians is minimal.

"Doctors with only basic computing skills can be trained in a couple of hours," says the program's information specialist, Ian Denchesy -- who points out that it took Dr. Joan Cooper, a clinical psychologist, only about forty-five minutes before she was functional.

"I am totally unwashed," says Cooper. "This program is really a testament to the human spirit, that you can do anything when the technology is good and you have good people to work with."

According to Denchesy, who is the Management Information Systems (MIS) director for Drew's Research Centers in Minority Institutions (RCMI), a program funded by the National Institutes of Health, "Once completed, King-Drew will have the world's most comprehensive telemedicine network, serving an estimated 4,000 to 5,000 patients throughout Los Angeles County in 1999."

And Baker points out, "In the first year we were up and running, we saw more patients than 70 to 80 percent of all other telemedicine programs that had gone before us."

Space-Age Technology

Telemedicine, the ability to work on a patient while being physically removed from that patient through high-tech virtual treatment, has been around since the early 1960s. The National Aeronautic and Space Administration first developed the concept so that doctors could consult astronauts thousands of miles away in space. Currently, it is used almost exclusively in rural areas and prisons as a way to minimize healthcare costs.

Additionally, foreign doctors sometimes tap into U.S. expertise through telemedicine links. The U.S. Army has a $30-million system in place in Bosnia, according to The New York Times, which links "medical staff there to physicians at military bases around the world."

Determined to innovate, Flowers and Baker did what any pioneering team must to prove just how serious they are about an untested program. The doctors used their own credit cards, when necessary, to jump-start urban telemedicine back in the fall of 1996. A year earlier, Flowers, who is an avid reader of PC Magazine, realized that the technology already existed.

Flowers and Baker completed initial developmental research and took frequent trips together around the country to examine compatible hardware and software. Baker drew on modest funds from his budget as director of Drew's RCMI to cover some communications expenses in the early stages, including the purchase of two computers.

Today, each telemedicine site -- including the Martin Luther King Eye Clinic, the Carmelitos Clinic, and Grace Four Transitional Home -- is outfitted with a standard Pentium personal computer (PC), a Vtel SmartStation videoconferencing system, a Second Opinion Software patient record system, Internet Explorer 4, Netmeeting, and Microsoft Office Professional.

As part of their big-picture strategy, Flowers and Baker also head Drew's new urban informatics test bed -- a laboratory in which new information technology and medical examination processes are integrated.

"What we do," Baker says, "is take technology and try different approaches to see what works and what doesn't to actually provide the most bang for the buck in terms of economic feasibility."

Physicians at urban hospitals around the country can testify to the frequent bottlenecks that occur in waiting rooms which service treatment facilities for uninsured and Medicaid/Medicare patients.

"In our setting, we just don't have enough board-certified physicians available to meet the heavy demand," Baker says. "With telemedicine coming in at a third of the cost, we can staff these clinics and we can optimize the allocation of our primary resource, which is manpower."

One of the innovations arising from Drew's urban informatics test bed will be a new "telemedicine technician," who will already have the basic training of an allied health professional or medical assistant. The technician will then get cross-trained in a variety of fields.

"So an ophthalmologist making six figures will be converted into several technicians at a lower cost, creating more jobs," Baker says.

But if such programs churn out telemedicine technicians and their multiple deployment, might that not affect a specialist's earning potential?

"No," Baker insists, "you're optimizing resources and delivery. The technicians with the right training and protocols can provide that first tier of care. And your [boutique] ophthalmologist can expand his market share by having a telemedical system in place. It's a way for doctors to go into areas where they hadn't ventured before. And it's a way to lock in a referral source."

Getting off the Ground

While the early stages of the urban telemedicine program may have struck the Drew bean counters as a lose-lose situation, it has become apparent to many in the medical establishment that lucrative possibilities abound. The field already has its own advocacy group, the American Telemedical Association (ATA) in Washington, D.C. Additionally, the Telemedicine Research Center (TRC) in Portland, Oregon, has set up a Web site called the "Telemedicine Information Exchange," which now averages approximately 50,000 hits a month.

"The Drew urban telemedicine program is the only such program in the nation right now that is serving a specific inner-city network," says Glenn Wachter, research associate at TRC. "That makes them very unique indeed."

Telemedicine, however, has yet to receive across-the-board approval from private and public insurers. Currently, teleradiology is one of the few telemedicine specializations reimbursed by Medicare. As a high-profile industry, it may be a few more years before telemedicine sweeps the country.
"Telemedicine is developing slowly, and that's as it should be," says the ATA's John Linkous.

Actually, it wasn't until November 1997 that Flowers and Baker published the first peer-review report on their ground-breaking project, in Telemedicine Journal.

"Quite often," notes Flowers with a bemused smile, "doctors in the system have no idea what we're doing. A lot of them find out about these projects by reading [journalism] articles."

The first major seed money for the project -- a $49,000 grant -- came from the Los Angeles County Community Development Commission (CDC). After nearly a year of successful patient treatment at Carmelitos, CDC official Carlos Jackson decided Flowers and Baker could use some help from Capitol Hill. Jackson engaged a lobbyist who drummed up the support of Millendar-McDonald, one of the project's most ambitious fundraisers and the driving force behind bill H.R. 4274, which is currently up for approval before the House Appropriations Subcommittee on Labor, Health, Human Services, and Education. The bill, which seems likely to pass, includes a $1 million grant for Drew's urban telemedicine program.

"We are looking into other major health areas which telemedicine can address -including hypertension, diabetes, lupus, and leukemia," says Millendar-McDonald. "The bill has been sent to the Senate side and [Health Resources Services Administration Deputy Director] Tom Wolford has promised to fund this project."

Drew University, unfortunately, doesn't have the deep pockets of a UCLA or a Cornell, Flowers's alma mater.

"Our physicians have to go through a lot of challenges to prove themselves, and we do our best to support them," says Drew Vice President for Advancement Robert I. Woods Jr.

Despite Drew's $62 million annual budget, discretionary funds are modest, and most of the university's programs must be funded by outside sources. Woods noted that a new strategic plan is in the works, however.

"I would expect that Dr. Flowers's and Dr. Baker's work will be very much highlighted in the plan as a way to go," Woods says. "The president [Dr. Charles K. Francis] always speaks of it as one of the highlights of the institution."

Created partially in response to the 1965 Watts Rebellion, Drew University is a postgraduate medical school that was founded in 1966 and named in honor of the brilliant Black physician, Dr. Charles R. Drew (1904-1950). Drew became famous for his pioneering work in blood preservation during World War II. Ironically, he bled to death from injuries sustained in an auto accident when he was only forty-six years old.

Often, notes Baker, people assume that proximity to a hospital equates with easy access. But that is not necessarily so. As a county official recently told Baker, a gunshot victim from one public housing project, situated only two blocks away from the nearest medical facility, barely made it in alive. That two-block radius happens to be divvied up by three different gangs.

"Don't ask me how," Baker says, "but obviously if you go to that health center, you have to have a life-and-death situation."

Culture Specific

Dr. Flowers is excited about where the urban telemedicine program may go, in part, because it can be tailored to a precise cultural population.

"Not only are you looking at a paradigm shift with respect to how healthcare is being delivered," he says, "but you're looking at a change in the culture. One of the things we saw as we went around the country was that many of these sort of high-falutin' telemedicine systems were gathering dust because people weren't using them. Not only does telemedicine have to be doctor-friendly, it has to appeal to the patient as well."

Urban telemedicine can be "culture specific" because, adds Dr. Baker, "you can deliver healthcare within the community of the participant, rather than taking the person out of that community and putting them in a foreign environment. If you have a largely Latino environment, for instance, your site can be linguistically and culturally Latino because some of the practices include both alternative and traditional allopathic approaches.

Cooper, the clinical psychologist, appreciates this pioneering program because the equipment "is not only going to allow me to have direct service contact with some of these clients at the place where they need intervention, but this will also enable mental healthcare professionals to expand their knowledge and abilities to do a better diagnostic on site and come up with a better treatment plan for people with psychiatric disorders.

"I have been delivering mental health services to this special population for nearly twenty years, and with the Department of Health Services and then the L.A. County Health Services major crash back in '95, we had a major gap. So this is really exciting now," he adds.

Soon, Dr. Flowers says, federal, state, and private funding for urban telemedicine will permit his team to expand into cardiology, dermatology, and ENT (ear-nosethroat). And in addition to serving a disadvantaged population, the program provides for leading-edge education of young doctors.

"Our clinic at King is so backlogged, we work appointments four months in advance," says Banks, who commutes between King-Drew and Carmelitos. "Here, I can do the examination while they observe me and we can actually incorporate the patient into our dialogue. The program has all the advantages of being at a university, right here in the community."

Jordan Elgrably is a freelance reporter who has written on culture and society for such publications as the Los Angeles Times and The Washington Post.

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