At a time when funding for telemedicine programs in the United States is hitting an all-time low, hampered by the federal budget squeeze and national cost-cutting measures in healthcare, foreign governments and industries are developing advanced telecommunications networks to support healthcare and other core services for their citizens at home.

International telemedicine can be as simple as interpreting a radiology image sent by fax or over broadband networks, and sending an analysis by email in return. Yet it also can involve sophisticated remote monitoring and surgical equipment, allowing physicians to conduct examinations and procedures on patients in clinics thousands of miles away.

In the Pacific Rim, telemedicine application development is rapidly occurring, and in Europe, demand for telemedicine videoconferencing equipment is at levels similar to those in the U.S., according to Feedback Research Services, Jacksonville, Ore., in its 1997 report, "The World Market for Telemedicine Products and Services." In particular, those countries with robust, growing economies--such as Japan, Australia, Malaysia, Singapore, Chilé, Argentina and Brazil--are becoming hot markets for information technology suppliers.

A telemedicine project linking Thailand's Ministry of Public Health and 20 hospitals for distance learning, clinical consultations, health information access and administrative meetings will go live this fall in Bangkok; and Russia has installed satellite-based videoconferencing for use by universities and medical facilities, according to news briefs posted on the Telemedicine Information Exchange Web site sponsored by the Telemedicine Research Center, Portland, Ore.

Increasingly, the U.S. academic medical community is playing a hand in promoting telemedicine abroad. Many of the world's leading tertiary care centers--the Mayo Clinic, Stanford University Medical Center, the Cleveland Clinic and others--have established links overseas to provide medical services and education. Currently there are 13 U.S. medical centers involved in some form of international telemedicine, according to a survey of telemedicine programs conducted by the Association of Telemedicine Service Providers, Portland, Ore. and Telemedicine Today magazine. While most of these programs are still in experimental stages, they could signal the beginnings of a financially viable telemedicine movement.

Why should the average medical center or delivery system care about international collaborations led by this country's top echelon of healthcare providers? For one, the research and experiments under way at these institutions may provide clues to how telemedicine can effectively and economically function over extremely long distances and in communities with minimal infrastructure and technological sophistication. Second, tertiary care centers are increasingly facing the same budget pressures as are non teaching facilities; their concepts could be applied throughout the industry as a means to generate new revenue streams abroad, or make domestic programs more practical.

UCLA's telemedicine department has been conducting studies on the economic feasibility of telemedicine. "The main initiative we are involved in right now is to evolve telemedicine from a value-added or ancillary service into an integral part of the overall health plan," says John Dionisio, PhD, director of technology for UCLA's telemedicine division. UCLA's fledgling teleradiology consulting program with Chilé has already produced profits for the institution. Other providers are also seeing a business case develop for their international efforts, in the form of direct payment for consultations, or from inpatient referrals.

With the glut of medical specialists in this country, telemedicine as a means to export U.S. medical expertise could be a remarkable new market. For example, foreign patients who come to U.S. medical centers for care sorely need an affordable follow-up visit when they return home, according to international healthcare informatics specialist Marion Ball, vice president of First Consulting, Baltimore. "This could be a major economic boon for this country."

In the big picture, international telemedicine initiatives could be the catalyst for a futuristic healthcare model: the international integrated delivery system--one that spans oceans, continents and cultures, not just cities and state lines. Dionisio boils it down to this: "The whole point is to connect practitioners so that it doesn't matter that you cross international borders."

The King wanted to provide his citizens access to the world's best medical care, without sending critically ill patients all the way to Rochester. Mayo is now coming to Jordan, through an ongoing, satellite-based, live and interactive continuing medical education (CME) program. Since the program began 18 months ago, Jordanian physicians have chosen the topics for Mayo to develop into CME sessions.

A full-motion, interactive video satellite system was also installed, but because they are so expensive, just a few clinical consultations have occurred, according to Marvin Mitchell, head of video communications and visual services and administrator of Mayo's telehealthcare center. Since Jordan's government pays for the country's healthcare, it must pay for the equipment, transmission costs and Mayo's clinical fee--a heavy burden for a country poor in comparison to its oil-rich neighbors.

Mayo is now developing less expensive store-and-forward technology that will be prototyped at a hospital in the United Arab Emirates in 1998. Mayo plans on an evolving program of clinical consultations there, made financially possible by the new technology which will transmit voice, data and radiology images to Mayo in one file over ISDN lines, at a high resolution but using low bandwidth. Mayo is trying to limit face-to-face consultations to keep costs down. "In many cases, a phone call will suffice, versus a fully interactive videoconference," Mitchell says.

For Mayo, one of the world's most renowned medical institutions, international telemedicine is a natural spin-off of its already thriving global business. Mayo specialists see 10,000 to 12,000 patients every year from the Middle East, Europe and South America, out of a total of 400,000 that come to Rochester. Foreign patients are financially significant for Mayo, accounting for 10 to 12 percent of its patient revenue, according to Mitchell.

Nevertheless, Mitchell insists that the international telemedicine and teleconferencing programs are not considered a revenue stream. "We are an educational institution, and one of our missions is to promote medical education," he says. And clinically, he adds, "By providing them (the foreign hospital) a means to triage cases before the transport, we can perhaps save them some money."

Without a doubt, these transoceanic links will cultivate Mayo's distinguished international reputation and steady flow of overseas patients. "Our hope is that this will provide additional referrals to Mayo sometime in the future," Mitchell concedes.

Baylor made headlines when its world famous heart surgeon Michael DeBakey served as a consultant to the medical team that performed heart surgery on Russian President Boris Yeltsin in 1996. DeBakey, a proponent of telemedicine since the 1960s, also was involved in a telemedicine demonstration that year using the Internet to link Moscow State University with Baylor for an educational program on heart disease. But Baylor has now set its sights on the "Health Channel," a new digital satellite-delivered continuing medical and nursing education service the institution will market worldwide.

"Baylor is interested in reversing the traditional flow of services that an academic medical center provides internationally," Fitzpatrick says. "Traditionally we've been patient importers. We want to turn now to be knowledge exporters."

The satellite service initially will be delivered through an 18-inch satellite dish to homes in Canada, the U.S. and Mexico. For $99 a month, including hardware and installation, users will receive 40 hours of programming a month--which Fitzpatrick says will later increase to 12 hours a day. While it won't be interactive, it is filling a need for medical education without the expense of traveling, according to Fitzpatrick. The new digital service, provided by EchoStar Communications Corp., Englewood, Colo., has made such international broadcasts more affordable.

"It suddenly allows me to get distance education to a very wide group of individuals for what it used to cost to do one hour of ISDN connection to a single site in central Europe," Fitzpatrick explains. While such a service could be surpassed by much cheaper Internet-based programs in the future, Fitzpatrick says the service is still needed in rural areas that may not have Internet access yet: "I don't see this as competitive with the Internet but complementary."

The spread of digital satellite technology in the next few years will play a big role in driving down the costs of bandwidth for phone and fax lines, and eventually video, according to David Balch, director of telemedicine at the East Carolina University Medical Center, Greenville, N.C. Predicts Balch: "This will change the nature of the global telecommunications infrastructure." Desktop telemedicine stations are also maturing and are poised to dramatically lower costs from the larger workstations that require a separate room.

Using the Internet to transmit images and data, or to conduct teleconferences or consultations, is another less-expensive alternative. East Carolina has tested store-and-forward technology over the Internet in Asia and Australia--with good results, Balch relates. "The Web is really maturing," he says. "That will be a big factor in making this affordable."

UCLA is also exploring the Internet for international links, yet Dionisio acknowledges that speed and security issues remain prohibitive. "One of the assumptions here is that the Internet will become a safe and secure enough transport for medical information," he says.

Mayo's Mitchell is even more wary of the Internet because of the transmission delays that will occur with large image files, and because of the high security risk of some of its international patients: "Mayo deals with a lot of heads of state. There is a good strategic advantage for people to find that data."

Instead, Mayo is focusing on continuing its in-house development. In conjunction with The Method Factory, a Boston-based systems integrator, Mayo's programmers are now building a technology that will prevent the image loss that typically comes with compression technology. This "loss-less" technology is something physicians have specifically requested.

For example, East Carolina University Medical Center plans to help developing nations design and install telemedicine networks through Telemedicine Technologies Company (TTC), a recently formed local consulting company in which the university has a majority interest. TTC is one of the partners helping to develop a "multimedia super corridor" in Malaysia, a $2 billion project that will install the infrastructure to support a 20-mile long office park designed to attract foreign high-tech firms. TTC is also pursuing contracts for telemedicine networks in China, according to Balch. In Asia, says Balch, the appeal for U.S. expertise is primarily for technology rather than clinical knowledge. "They don't care so much about Western medicine."

Balch sees international telemedicine as a means to boost the university's network here at home, rather than as an additional revenue-generator through medical education or consultation. East Carolina has one of the oldest telemedicine networks in the country, a 12-site network that spans 10,000 square miles and sustains education and clinical consultations in 32 medical specialties. The network got its start in 1987 in distance education, based on microwave technology that linked the medical center with other universities in the state. Now, the network operates in a hybrid environment of microwave, T1, ATM, ISDN and phone lines, and has supported more than 1,700 consultations. An important part of the network's mission is continuing research and development at its testing laboratory--research that is threatened by dwindling federal grant money, says Balch.

Both the profits from the international projects and the techniques will be invested back into the program in North Carolina, which faces similar challenges of bringing high quality medical care to isolated communities throughout the state.

Says Santa Monica, California-based international telemedicine consultant David Krasnow, MD: "International projects provide a fertile learning agar from which to test theories, adapt to cultural diversity and trouble-shoot technological challenges. We have as much to learn from international interactions as they from us."

For example, many European countries are years ahead of the U.S. in achieving standards--one of the greatest barriers to the practical use of telemedicine, according to First Consulting's Ball. (See "National and Global Barriers to Telemedicine," below.)

And, says Krasnow, other countries may be able to improve upon our failures. "(They) know that they must develop a financially sustainable network." For example, In Latin American countries, he says, the financial risk will likely be spread among several network partners representing a number of industries.

Such lessons may be of great value to those in this industry who are skeptical of the business application of telemedicine. "As a revenue stream, I think it will be a ways off, if ever," voices James Bair, Stanford University Medical Center's director of international medical services.

Even the Mayo Clinic, with an active domestic telemedicine program since 1986, is still struggling with how to integrate telemedicine into daily practice. "Mayo has never stepped up telemedicine as a business, and to be able to make it flourish, it has to do this," Mitchell observes. Still, he admits, telemedicine will never take precedence over traditional patient visits: "We certainly would not turn away a patient at the Mayo Clinic who comes here physically for someone who comes electronically."

What could result from this growing demand for international telemedicine is a greater urgency for the U.S. healthcare industry to resolve the legal, financial and cultural issues preventing its growth here--lest we get left behind on the information superbahn by our global neighbors. Feedback Research Services estimates that Europe and the Pacific Rim could spend $1.4 billion on telemedicine products and services by the year 2001. If the United States fails to make telemedicine workable, predicts Balch, we may find the tables turned as international providers begin to compete for American patients in rural or underserved areas. "I can envision a country setting up offshore sites for telemedicine to provide services to clinics in the U.S."

But competitive fears in the end may be overshadowed by increased collaboration between countries in solving common problems, resulting in the progression and even success of telemedicine in delivering healthcare worldwide. In small ways, this is already happening. Out of a need to make telemedicine services more affordable for its international clients, Mayo is working on a fee schedule to allow complex consultations involving multiple physicians, diagnoses and tests to be packaged in one up-front cost. Such fees will also be applied to its domestic program.

According to Mitchell, providing a means for physicians in any country to take care of their patients at home is where the future of telemedicine lies. This idea, so simple and so universal, is powerful enough to one day transcend not only the boundaries between caregivers and communities in this country, but also the physical and cultural boundaries that separate all of us around the world.

But there is progress: An amendment in the Balanced Budget Act of 1997 will allow Medicare reimbursement of telemedicine consultations for beneficiaries living in counties defined by the feds as medically underserved. California and Texas passed laws mandating reimbursement by private insurers and Medicaid, and provisions of the Telecommunications Act enacted by the FCC will provide better access to affordable telecom services in rural areas. Still, there is a long road ahead before telemedicine can be widely deployed in this country. "It's not growing at the rate we think it can overseas," says David Balch, director of telemedicine at the East Carolina University Medical Center, Greenville, N.C.

In much of the world, healthcare is government-provided, and physicians are often licensed nationally, rather than at a state or regional level. "A lot of these international relationships are easier to establish because there aren't as many regulations and legal issues to discuss," observes John Dionisio, PhD, director of technology for UCLA's telemedicine department.

Yet James Bair, director of international medical services at Stanford University Medical Center, Palo Alto, Calif., says working with foreign governments can still be a deterrent. "The regulatory environments in a lot of the Asian Pacific countries where we are active are not as stringent as our own, but government control over all forms of healthcare and telecommunications could present problems."

Other barriers, such as the lack of standards and the high cost of infrastructure, equipment and ongoing support are universal. "There are great inconsistencies from nation to nation in their telecommunications capacities, and there are great inconsistencies here in the U.S. from institution to institution," Bair explains.

Poor infrastructure and lack of technical sophistication is commonly cited as one of the biggest stumbling blocks of working in developing economies. Yet in some parts of the Third World, the telecommunications infrastructure is quickly becoming more advanced than it is in the U.S.: Previously unwired countries in Africa, Asia and Latin America are moving directly into fiber-optic and wireless networks.

Scores of standards organizations in the U.S. and Europe are working on the various standards necessary to make telemedicine fly--including interoperability and data exchange, privacy and security, protocols, and practice guidelines. Health On the Net Foundation, Geneva, Switzerland, an international non-profit organization promoting use of the Internet in healthcare, is working on a code of ethics for telemedicine.

Because telemedicine information technology is still evolving, even basic system functionality has not matured. Stanford has all but abandoned its domestic and international clinical telemedicine projects because of unresolved business and technical issues, including the security and functionality of a third-party store-and-forward system. "It was not economically viable, nor did we see that the software was really ready to accommodate clinical consultations," Bair says. Instead, the institution will focus on its growing educational teleconferences with countries in the Pacific Rim, where Stanford gets most of its international patients. Currently, Stanford conducts monthly teleconferences between Stanford faculty and specialists at hospitals in Manila and Singapore-- free of charge.

Finally, the importance of understanding the intricacies of cultural and language differences cannot be underestimated; culture greatly influences the practice of medicine. Even something as simple as encouraging feedback can be a challenge, Bair points out: "We coach our professors before they give the lecture to please ask the audience to interrupt them and give them questions. In Singapore, the audiences are very reluctant to raise any questions, to challenge the professor."

International telemedicine remains out of reach for most of the world's population-- for now

Until the costs of telemedicine and telecommunications technology come down, international projects may be confined to large, well-known, tertiary care centers. And since foreign hospitals typically have to foot the bill for both the technology and the connection time, beneficiaries are largely the wealthy and/or politically-connected.

"If you're looking for a full blown workstation that can handle all those functions, cardiology images and so forth, at the resolution we require, you're probably looking at $100,000 to $125,000 per workstation," says Marvin Mitchell, administrator of the telehealthcare center at the Mayo Clinic, Rochester, Minn. "A lot of countries just can't afford that."

Part of the problem is that some U.S. medical centers have goals of attracting wealthy foreign patients who can pay a

premium, according to David Krasnow, MD, a clinical and international telemedicine consultant and executive director of the California office of Volunteer Optometric Services to Humanity. "From a professional standpoint, I'm not comfortable with that," he says.

Yet some internationally inclined organizations like UCLA are directing research and development into the grass-roots application of telemedicine. UCLA is providing radiology interpretations to a hospital in Santiago, Chilé, based on in-house-developed and third-party technology UCLA installed there. The experience has forced UCLA's telemedicine department to adapt the technology to meet the comfort level of the users in Chilé, who had limited computer experience, according to John Dionisio, PhD, director of technology for UCLA's telemedicine department. UCLA also had to learn how to work within the confines of the existing technology at the hospital. "There are certain constraints which in the long run work out really well because they test your limits," he observes.

The Chilean project has fueled UCLA with ideas on how to bring similar technology to low-income neighborhoods in America through low-level PCs, or telemedicine mobiles that could travel to poor communities to deliver care.

In its tele-educational programs in Latin America, The Cleveland Clinic is also discovering that telemedicine can benefit a larger audience than the upper classes. A current program with the Dominican Republic provides free lectures to any physician on the island. Another program with Ecuador was two-way: Cleveland Clinic physicians had the opportunity to learn about tropical diseases from Ecuadoran physicians.

International nonprofit organizations like SatelLife, Paris, France, are helping to provide communications capabilities to many Third World countries that have none. Through low-earth-orbit satellite and telephone-based networks, SatelLife has so far reached 4,000 healthcare workers in 30 countries who are now able to communicate with each other through email, and retrieve healthcare information through the Internet.

There may be the possibility for smaller, nontertiary care centers in the U.S. to participate in global telemedicine through "sister organization" relationships with small hospitals and clinics abroad, according to international healthcare informatics specialist Marion Ball, vice president of First Consulting, Baltimore. She believes there is an altruistic vision in all of this for U.S. healthcare organizations to help improve the quality of global healthcare: "This will give us the opportunity to give something very valuable to the world."