Online Medicine - The Doctor is IN

Technology has changed our lives drastically over the past 20 years. Just about everything can be done online these days from shopping, dating and working to even consulting a doctor thousands of miles away.

One of the fastest growing online medical Internet platforms is Myca which allows doctor-patient consultation remotely, by phone, email, instant messaging or even videoconferencing. It also enables patients to schedule doctor's appointments online. Myca is barely two years old but has gained quite a following. In the US, the Myca Platform goes under the Hello Health trademark. Welcome to today's e-practice. The doctors call themselves "your friendly 21st doctors in the neighbourhood".

Telemedicine / virtual medicine encompasses any digital form (e-mail, fax, telephone, videoconferencing, etc.) of bringing together patients and physicians. However, with the arrival of less expensive broad-band internet access and digital imaging, telemedicine currently refers to interactive, full motion, two-way video and audio over high-speed data networks. Patients and physicians are connected through secure web camera video that also allows rapid assessment of the patient.

What makes e-practices appealing?

(1) Cost-efficiency. E-practices need fewer personnel to run and operate, need less space to rent, thus have less overhead. This translates into cheaper bills for patients. E-practices normally charge less than the traditional doctor's practice.

(2) Convenience. E-practices are efficient and convenient. Patients can set appointments online, and can choose the media they prefer. There are less hassles, no long waiting time in waiting rooms, no long drives or commutes to see a specialist. Refilling of prescriptions goes faster. Medical information is all stored electronically, easily available for future use.

(3) Privacy. For one reason or another, patients may prefer a more discrete way of consulting a doctor rather than just simply walking into a doctor's practice. E-practices offer the anonymity that many patients may wish for. For the Internet generation, online medicine is hip and cool. The Facebook-like platform of Hello Health appeals to this age group.

Skeptics, however, assert that virtual practices can't truly replace traditional face-to-face medical practice. Here are their arguments:

(1) Lack of empathy. Many people feel that medicine is becoming dehumanized by technological advancement. Bedside manners are important aspects of medicine wherein e-practices are rather lacking. A picture on the video screen or a voice over the phone is no substitute for a flesh-and-blood doctor.

(2) Data protection and privacy. E-practices have to rely on electronic health records. Due to well-publicized cases of data stealing and hacking, concerns over data protection are still a major hurdle to overcome.

(3) Regulation and accreditation. Virtual practices now exist all over the world, from Europe to India. Anybody can pretend to be health practitioner online. Scams over the Internet abound. Think about online pharmacies that offer all types of medications that may turn out to be counterfeit, much worse dangerous. Many health advocates are concerned about similar scams that can put the susceptible patient at risk. Currently, there are no real regulations governing e-practices.

Telemedicine doesn't simply stop at consultation but extends to follow-up care of the chronically ill. How about having somebody to remind you of checking your blood pressure, taking your medicine, and refilling your prescription? Canadian researchers investigated the effect of computer-automated phone calls in the management of hypertension. Their results show that such a system helps patients manage their hypertension effectively.

A policy statement from the American Heart Association recommends "the implementation of telemedicine within stroke systems of care." These recommendations especially apply in remote rural areas where there are no specialized stroke centers and very few neurologists to cover emergencies. Telestroke patients provide their medical history online and are examined by doctors remotely. Pictures from neuroimaging are displayed on the doctor's local computer and quickly interpreted. If needed, treatment including thrombolysis (clot-busting) is ordered and can be monitored. In addition, with the use of the so-called crowdsourcing diagnostic data, neurologists are now able to diagnose more accurately ischemic stroke.

Cost-efficiency and acheiving a better and more accurate diagnosis utilizing crowdsourcing is the major argument in favor of telemedicine. The Canadian study on automated blood pressure monitoring system had to conduct an additional investigation on cost effectiveness. Without this additional benefit, the healthcare system wouldn't accept it. Crowdsourcing diagnostics is a tool which can be used by doctors in an online or face-to-face practice. Using computer software, doctors enter the symptoms and test results of a patient, and the software give the most likely diagnoses and the probability for each.

An example of such a software is SimulConsult, a sophisticated online crowd-sourcing tool for identifying neurological disorders that demonstrates the potential of the Web to transform the way all kinds of diseases are diagnosed. It is like having access to the knowledge and experience of hundreds of other doctors. The result is better and quicker diagnosis, avoidance of unnecessary tests and referrals to the wrong specialists, and lower health care costs.

However researchers have identified six major barriers to the effectiveness of telemedicine, not only in stroke care but in general medical care overall; defining medical specialties suitable for telemedicine, medical licensure and liability laws, securing the health information being shared, creating simple processes for requesting and performing the consultation, developing financial models for reimbursement of telestroke services and gaining acceptance of remote consultation from patients, physicians, and payers.

Online medicine is also involved in one of the most exciting and promising areas of surgery - robotic telesurgery as opposed to the more common procedure of robotic-assisted surgery.

The da Vinci Surgical System is the most well known robotic assisted surgery system and has been around for more than a decade. It has been used in different kinds of surgical interventions from laparoscopic surgery to radical prostatectomy to heart bypass. The da Vinci is intended to assist in the control of several endoscopic instruments, including rigid endoscopes, blunt and sharp dissectors, scissors, scalpels, and forceps. The system is cleared by the FDA to manipulate tissue by grasping, cutting, dissecting and suturing.

Another system is the ZEUS Robotic Surgical System which has been cleared by the FDA "to assist in the control of blunt dissectors, retractors, graspers, and stabilizers during laparoscopic and thoracoscopic surgeries". It, too, is used to assist surgeons and has one advantage over da Vinci - it responds to voice commands.

Unlike robotic-assisted surgery which requires the physical presence of the surgeon on location, telesurgery can be performed by the surgeon from remote- the so-called online surgeon. In telesurgery the surgeon sits in a console and guides "the movement of the robotic arms in a process known as telemanipulation". In the UK, kidney operations have been performed by a robot remotely operated by a surgeon thousands of miles away. In Italy, a robot performed a heart surgery controlled remotely by a surgeon in Boston. These are, strictly speaking, not "unmanned" or "unassisted" surgeries but these are pioneering examples of telesurgery which allows surgeons to operate wherever they are. It is not yet as advanced or as popular as manned robotic surgery.

Robotic or telesurgery has the advantage of precision miniaturization, minimally invasive, less risk of infection, less blood loss, faster healing and shorter hospital time. Because of these advantages robotic surgery has become the favorite method of performing prostatectomy on men with suspected prostate cancer. It supposedly helps keep urinary and sexual function after the procedure.

Currently, robotic surgery is still of limited use due to the following limitations:

(1) Cost. Only big hospitals with sufficient funds and high caseloads can afford to invest in surgical robots. A da Vinci System would cost between 1 to 1.7 million US. Currently, there are only about 1,100 of these machines in the world.

(2) Acceptance. Many patients may still have the problem of accepting the fact that a machine is cutting them up or that the surgeon is thousands of miles away. For others, it can even be scary to imagine that medicine can be performed via YouTube or that medical records are exchanged over Facebook. As patients become more technology savvy, the acceptance will also increase.

(3) Training. A robot is only as good as its operator. It is estimated that a surgeon has to work on 100 cases before he can confidently and efficiently perform cardiac surgery with a robot. According to Dr. Douglas Murphy, a cardiac surgeon at St. Joseph's Hospital in Atlanta, there's no immediate financial incentive to do that [train in robotic surgery] since the reimbursement is the same. That means few surgeons -- let alone other members of the surgical team -- can afford to travel and observe an expert in action. That is why Murphy and colleagues, set up the first "robotic surgery college." Using multimedia presentations, web chats, and live video feeds of interventions, experts in Atlanta are now training surgeons thousands of miles away in robotic surgery.

From consulting and diagnosing to performing telesurgery, online medicine is here to stay and continues to proliferate. Despite legitimate concerns, the Doctor is IN.