Each day at 10 a.m., you "knock" on Joe's door using your special phone, ready to complete your assessment of his COPD. He answers, as always, looking forward to your visit. Thirty seconds later, you see each other on computer monitors-your screen is 30 miles away, his is in his living room.

This scenario is becoming more common for some home care nurses, but remains merely intriguing for many others. Telemedicine practice has proved its cost-effectiveness in some target populations and geographical areas, but so far it's not for everyone.

For example, Debra Blomquist, RN, vice president of clinical services for Kansas Care Inc., reports that about 5 percent of her agency's patients (or between 30 and 40 patients per week) receive telemedicine visits. Because Kansas allows Medicaid reimbursement for telemedicine visits, Kansas Care has been using this technology for about six years.

These visits, which use an interactive audio-video system to monitor vital signs and other clinical data for home-based patients, eliminate about one-third of the cost of regular in-person visits that would require travel time and expense, Blomquist said. Kansas Care's most successful group of telemedicine patients is monitored for CHF maintenance.

"We're doing everything we can to expand telemedicine use by marketing to physicians and doing demonstration projects," Blomquist said. "However, because of the cost of the equipment, very few agencies in Kansas are like us. The cost of the equipment scares them."

Systemwide telemedicine programs have become abundant-about 150 in the United States today--but many have been changing as grants expire.

For example, initial grants that supported the Midwest Rural Telemedicine Consortium have ended. The consortium linked more than 38 hospitals, clinics and nursing homes in more than 30 communities across north and south central Iowa.

Some of the consortium's operations have transitioned to other facilities such as Mercy Medical Center in Des Moines, Iowa. For now, the consortium is focused on education and small demonstration projects.

Studies that show significant cost-benefit to telemedicine, however, remain scarce. They either report the results from focus-limited demonstration projects or have small sample sizes.

"Many reviews have been conflicting," said L. Chris Baker, MSN, RN, administrator of the virtual pediatric intensive care unit at Childrens Hospital Los Angeles. "I am finding that pricing is sometimes apples and oranges and with variables quickly changing."

The unit provides real-time assessment, consultation, Web site data collection and communication among providers caring for critically ill and injured children. Better studies should emerge from the wider availability of high-speed fiber-optic LAN lines and satellite up- and downlink services.

Guillermo Gutierrez, Ph.D., MD, professor of medicine at George Washington University, said that recent telemedicine improvements have drastically reduced the cost of providing telemedicine services: expanded broadband (DSL, cable modems, etc.) that allows high-quality sound; images and video transmission; dramatic cost decreases in personal computers and scanners, sound cards and video cameras; and better browser software that provides secure and stable platforms for medical communication.

So far, the most common and successful subset of telemedicine is teleradiology, which allows radiograph viewing from a distance--especially beneficial to link rural health facilities with urban trauma centers.

According to Telemedicine Today, the number of teleradiology films viewed last year soared to 250,000. Still, practitioners find kinks in using the technology-among them the learning curve for practitioners to properly use the equipment.

In September, the first major trans-Atlantic surgery was announced. Doctors from the European Institute of TeleSurgery in Strasbourg, France, and surgeons in New York used a surgical robotic arm to perform a gallbladder procedure via video and high-speed fiber-optic lines.

The surgeons said the technology allowed acceptable lag time of the transmitted video during the procedure. The 68-year-old patient has recovered with no complications.

Also earlier this year, successful laparoscopy procedures were performed between teams from Rome's Policlinico Casilino University and Johns Hopkins University in Baltimore.

Reimbursement policies
A major obstacle in widespread telemedicine adoption is adequate reimbursement, especially through Medicare. A 2001 report to Congress reported that as of 2000, almost two years after establishing telemedicine reimbursement policies, Medicare had reimbursed a total of $20,000 for 301 teleconsultation claims.

Although still a major barrier, Medicare reimbursement should slightly improve with policy changes that went into effect Oct. 1. Before, reimbursement for telemedicine services was allowed only in specific rural areas, using split-fee rates, or using specific telemedicine technologies (i.e., live video transmissions but not store-and-forward consultations that send recorded images to specialists).

The new reimbursement policies are reported to eliminate fee-sharing requirements, expand eligible locations and expand the number of CPT codes that are eligible for Medicare reimbursement.

Another telemedicine obstacle is the restriction on licensing among health care providers who treat patients using telemedicine practices.

Physicians have made little progress with this issue; efforts to address the problem have targeted national licensure, special telemedicine licensure standards, exemptions, endorsements and state registration or limited licensure.

Nurses fare somewhat better with more states adopting or basing their legislation on the Interstate Nurse Licensure Compact, a 1998 licensure model established by the National Council of State Boards of Nursing Inc. The compact, which champions coordination of multistate licensure, guides states as they define practices of registered and practical/vocational nurses across state borders.