Switch on for a real medical drama

Some years ago, when video cameras were a new technological marvel, there was a vogue in ultra-liberal households for videoing childbirth. It is a trend that may soon be reappearing, but rather than the proud father peering through the eyepiece it will be the midwife, and instead of adding to the family archive, she will be filming only when complications arise. The pictures will then be fed to her car parked outside, which will contain a special transmitter to beam the pictures up to a satellite, and so to a consultant at a maternity unit.

This vision of the not-so-distant future, known as telemedicine, is being propounded by Mark Denne of Siemens Nixdorf, who is trying to sell a revolution in primary health care. Besides the childbirth application, he believes it could transform other elements, such as GPs' home visits. "About 40 per cent of them are unnecessary," he says. "A nurse or other paramedic could do them using the camera for back-up if necessary."

The Siemens Nixdorf system involves tiny cameras, 2in x 3in x 3in, weighing only 250g, linked by radio (rather than wires) to a transmitter only 30 per cent bigger than a car radio. It irons out problems encountered with earlier, bulkier systems. Mr Denne is not saying how much individual units cost, but the company is looking for bulk leasing deals with back-up services built in.

Telemedicine was born in the early Sixties with the advent of the space race. Data about the astronauts' hearts and other physical functions were continually sent back to mission control to give maximum information should any of them fall ill. The hi-tech Nasa approach culminated earlier this year with a surgeon, sitting at a bank of equipment in Belgium, controlling a scalpel-wielding robot as it performed a hernia operation on a man in an operating theatre 144 miles away in the Netherlands.

It was an impressive technical feat, but how useful is it?

"This is a very specialised application," says Dr Wendy Hasted, research manager for the healthcare firm RGIT, which concentrates on telemedicine. "It gets a lot of attention and might be life-saving on a space trip, but so far we have found that low-tech schemes are actually more useful."

The basic idea of telemedicine is simple and makes a lot of sense. It is a way of linking doctors and patients using modern communications technology. Much of medicine has to be organised on a belt-and-braces principle - specialist knowledge is usually not needed, but someone has to be on hand just in case. Telemedicine holds out the possibility of saving both patient and specialist time, and consequently money, by making that expertise instantly available, whatever the distance.

However, as is often the case with pioneering technologies, the reality is not quite as effortless as the vision. Just what it is up against can be seen from the problems with a prototype remote camera system known as CAMnet. This had its first medical try-out several years ago, on an offshore oil platform that had no qualified medical personnel on board.

"It was useful on one occasion in deciding what to do with a man with a stomach ache," says Dr Hasted. "Should he be flown off the rig as a possible appendicitis case - the safe but expensive option; or left on the rig - cheap but life-threatening if wrong. Via the camera mounted on a rigger's helmet, a doctor on land was able to conduct an examination." The decision was that the man did not have appendicitis and could remain on the rig. The decision proved to be correct.

CAMnet next turned up last year at a Norwich hospital, where the accident and emergency consultant Alan Jones was keen on kitting out his ambulance staff with it. "In serious accident cases, the patient's chances of recovery increase greatly if they can get proper treatment within an hour," he says. "With CAMnet I could instruct an ambulance man on the scene to do something like reflating a punctured lung on the spot."

In the event, however, CAMnet only had a single outing, with a fake patient from the Casualty Union. Technical glitches caused, for example, voice lag and lighting problems and the cost was about pounds 50,000 plus servicing.

CAMnet surfaced at several other projects, where it never quite proved as useful as expected, and has now come to rest in the Antarctic with the British Expedition, but has not yet been needed. As usual, the possibility is always there for life-saving interventions - appendix, or perhaps thoracic surgery - but on past form it seems unlikely.

Mark Denne, however, is confident that the Siemens Nixdorf system avoids some of the CAMnet's technical problems. It is much smaller and lighter and does not need any cable connections; and by offering leasing deals to hospitals and others, Denne can overcome the problems with capped budgets for capital investment.

Telemedicine is not just sexy technology looking for an application. Within the past 18 months a number of trial projects have been started in the UK to discover whether they could live up to the hype. For example, Professor Richard Wootton of Belfast University, who favours a low-tech approach, has recently set up a link between a new walk-in accident clinic near the Houses of Parliament - the South Westminster Centre for Health - and the Royal Victoria Hospital in Belfast.

Casualty units near the Houses of Parliament did not want to get involved with the project because of potential medical legal problems. There were worries about who would be responsible for anything that might go wrong during patient treatment made this way.

Professor Wootton, who worked at the Westminster Hospital before it closed, was not worried. So the link was made with his new hospital.

The clinic is staffed by three nurses who see about 30 people a day. Nurse practitioner Lynda Sibson says: "We can handle 98 per cent of the cases but every now and then we get something that is out of our experience, such as a tricky wound or an unusual skin rash, and we need to ask an expert."

But instead of sending those patients for a long wait at an accident department, they can be taken into what is effectively a video-conferencing room where a consultant in Belfast can examine the patient on camera.

Do the consultants lose anything by not being in physical contact? "No, it seems to work very well," says Sibson. "They can see anything they want to, the picture quality is quite good, and we can carry out a physical examination." Do the patients find it strange describing their symptoms to a TV screen? "No, by and large they feel reassured. They like the feeling that expert help is at hand."

In fact, clinics with a telemedicine link-up are much more likely to send over questionable X-rays for a second opinion. That is what has been happening at another pilot study running between a community hospital in Peterhead and the Royal Hospital in Aberdeen. "Sending the X-rays down a line often saves the patient an 80-mile round trip to the hospital," says manager Allison Leslie. "They did have that wandering CAMnet helmet camera briefly, but now there's only the wee camera on top of the video phone. It's OK for looking at a limb, but the patient has to be able to stand."

Similar American projects do not have to put up with such privations. About 30 per cent of American rural hospitals now have some telemed connections. An example is the award-winning project at Kirby, the smallest hospital in Monticello, Illinois. Eighteen months ago, it linked up to the accident and emergency department of a large hospital some miles away and installed the works - dedicated phone line for high quality pictures, an interactive video camera, an audio unit with a stethoscope, an Elmo overhead camera for radiographs, electrocardiograms etc, and a high-intensity, low-magnification dermascope.

"Results at this time have been excellent," declared a recent assessment. "Patients report extremely high levels of satisfaction in the areas of patient privacy, effective diagnosis, decreased waiting and travel time, and interpersonal communication." Most significantly it concluded: "There has been a 14 per cent increase in patient volume and revenues as well as a $100,000 reduction in cost by staffing with physician assistants instead of physicians."

Ultimately that is what telemedicine is all about. It may well save some lives and cut down on patients' petrol bills, but its fate will be decided by financial considerations. Just who pays for it in the new NHS internal market has yet to be worked out, and there are those who fear it may lead to a deskilling of those at the sharp end. Its supporters vigorously deny this - but then they would, wouldn't they?