Small Animal/Exotics
EMERGING TECHNOLOGY
Telemedicine—Creating the
Virtual Veterinary Hospital
T. Arch Robertson, DVM
VETMED Consultants
Phoenix, Arizona
H
ave you ever wanted a reli-
able second opinion on chest
radiographs of a coughing pa-
tient to assist your evaluation before
prescribing therapy or referring the
patient to a specialist? Have you peered
through a microscope at a cytologic
sample confident of the diagnosis
but not 100% sure? Would it not be
ideal to have the slide of that sample
reviewed by a board-certified cy-
topathologist to confirm your diag-
nosis? How could such consultations
change the quality of medicine in
your practice?
Telemedicine can help veterinari-
ans tackle these daily dilemmas and
practice veterinary medicine at a high-
er level than previously possible. Ac-
cessing veterinary specialists for case
consultations is possible through
telephone line transmission or email.
More and more specialists are be-
coming involved with telemedicine
(Table One) as an effective method
of assisting general practitioners.
What Is Telemedicine?
Veterinary telemedicine is the use
of electronic information and com-
munication technologies to assist
practitioners in providing clinical
care when separated by distance.
Telemedicine provides practitioners
with decision support via meaningful
communication with other veterinar-
20TH ANNIVERSARY
V
ians or specialists, thereby providing
better health care in a cost-effective
way. Communication is accom-
plished by digitizing and compress-
ing medical data (e.g., radiographs,
ultrasonograms, photographs, and
cytologic images) into the hard drive
of a computer for archival (store) or
transmission (forward) purposes. The
images are stored within computer
files so they can be subsequently
viewed by or shared with colleagues
or specialists. Applications are as
simple as telephone consultations or
as elaborate as interactive consulta-
tions.
The Early Days
Veterinary telemedicine essentially
started in 1980 when Dr. Larry
Tilley presented the idea of using a
transtelephonic electrocardiogram
(ECG) transmitter to connect veteri-
narians nationwide to The Animal
Medical Center in New York; the
idea eventually evolved into Car-
diopet. By connecting a simple de-
vice to a patient, an ECG could be
transmitted over ordinary telephone
lines and displayed on a monitor
thousands of miles away. A board-
certified cardiologist or internist then
reviewed the ECG along with the ac-
companying case history and sent a
report with a probable diagnosis,
prognosis, and therapeutic recom-
mendations.
Today, even in its infancy, tele-
medicine allows a more complete data-
base to be distributed electronically
to other veterinarians and special-
ists. Through telemedicine, practi-
Compendium February 1999
tioners can now transmit ECGs, ra-
diographs, echocardiograms, labora-
tory data, and video images for evalu-
ation. Because all of this medical
information is being bundled togeth-
er, specialists can deliver a more
accurate prognosis, diagnosis, and
therapeutic plan. The end result is
enhanced access to quality care.
Usefulness
The veterinary profession, especial-
ly in rural areas, has historically ig-
nored professional and physical isola-
tion of general practitioners from
colleagues and specialists. Most veteri-
nary hospitals are one- to two-doctor
practices, which can lead to inade-
quate access to veterinary informa-
tion or knowledge of up-to-date prac-
tices and can be a barrier to optimum
care as well as professional satisfac-
tion. Two information networks (Vet-
erinary Information Network [VIN]
and Network of Animal Health
[NOAH]) help in the education pro-
cess but do not yet have the ability to
accommodate interactive monitoring
of patient evaluations while they are
in progress.
Despite their dedication, most
practitioners realistically cannot have
expertise in all areas of veterinary
medicine. Telemedicine can bridge
the gap between general practitioners
and veterinary specialists, thereby al-
lowing practitioners access to current
diagnostic and therapeutic informa-
tion.
The financial benefits should also
be considered before deciding to use
telemedicine. When they refer pa-
Compendium February 1999 20TH ANNIVERSARY Small Animal/Exotics

tients for specialty consultations,

TABLE ONE general practitioners naturally lose
Veterinary Telemedicine Specialists income. In today’s economy, savvy
practitioners are adding services to
Company/Individual Disciplines maintain a healthy bottom line. Tele-
medicine allows practitioners to com-
Cardiopet Cardiology, dermatology, plete more thorough workups on both
48 Notch Road exotics, internal medicine, routine patients and patients that
Little Falls, NJ 07424 nephrology, oncology, would have previously been referred.
800-726-1212 ophthalmology, radiology, Therefore, in addition to increasing
Fax: 973-890-5617 surgery profit (see Profit Projections for a
Fictitious Clinic), practitioners can
DocuTech Services, Inc. Internal medicine enjoy professional stimulation.
Johnny Hoskins, DVM
PO Box 82433 The Technology
Baton Rouge, LA 70844 With telemedicine, information is
Phone/fax: 225-751-9272
digitized and compressed via comput-
Email: hoskirk@msn.com
er hardware (video capture card) and
Foster Hospital Dermatology telemedicine software into the hard
for Small Animals drive of a computer. After images
Gene Nesbitt, DVM have been archived, most telemedi-
Tufts Veterinary School cine software programs allow users
200 Westboro Road (i.e., practitioners or specialists) to
North Grafton, MA 01535 enhance the images through manipu-
508-839-5395 lation. Changing contrast, brightness,
hue, and saturation is common to all
Veterinary Diagnostic Radiology, cytopathology software. Zooming in and out and
Imaging & Cytopathology rotating images are also possible.
2892 SE Vista Way Archived images and patient records
Gresham, OR 97080 are then transmitted to specialists for
503-492-9978 evaluation via telephone or email.
Fax: 503-661-0504 Specialists then use a reader’s software
Email: marcp@transport.com program to review transmitted rec-
ords and images and generate a report
Veterinary Telerad Radiology that can be faxed or sent by email to
100 Circle Road referring practitioners.
San Rafael, CA 94903 The turnaround time depends on
415-491-0654
two unrelated variables: the specialist
800-762-0125 or
and the telemedicine software pro-
Email:jowensdvm@aol.com
vider (see Caveats of Veterinary Tele-
VETMED Internal medicine, medicine). If specialists do not give
Larry P. Tilley, DVM & Associates cardiology telemedicine cases high priority, the
22 Descanso Road turnaround time could take longer
Santa Fe, NM 87505-9125 than desired by practitioners. In ad-
800-214-9760 dition, if the contract of the tele-
Fax: 800-820-6815 medicine software provider forces in-
Email: TILLEY@compuserve.com formation to be sent through its
service first and then forwarded to
Marsha Whitely, DVM Radiology the specialists, the turnaround time
9324 Lake Valley Drive could be delayed. The future of
Cincinnati, OH 45247 telemedicine will be fueled by rapid
513-923-4851 turnaround time and the quality of
the final report. If the turnaround
Small Animal/Exotics 20TH ANNIVERSARY Compendium February 1999

time is 24 hours, the value of tele-

Profit Projections for a Fictitious Clinic medicine to many practitioners is
probably lost.
Specialist fee for internal medicine cases: $350/case Learning to use software programs
Average number of cases referred: 3/month is fairly straightforward. Familiarity
Revenue: $1050/month
with Windows 95 or 98 is essentially
Specialist fee for oncology cases: $650/case all users need to have. Practitioners
Average number of cases referred: 2/month unfamiliar with Windows 95 or 98
Revenue: $1300/month may initially have difficulty; howev-
Specialist fee for cardiology cases: $450/case er, the programs are user-friendly and
Average number of cases referred: 3/month easy to master.
Revenue: $1350/month
Cost Considerations
Specialist fee for dermatology cases: $250/case
Average number of cases referred: 2/month The cost of telemedicine opera-
Revenue: $500/month tions depends on practitioner needs.
To transmit patient records and sim-
Projection of increased revenue with telemedicine $4200/month ple images (e.g., skin lesions), practi-
tioners need a digital camera, an Intel
Profits generated (total increased revenue) $50,400/year Pentium® computer, access to the In-
with telemedicine ternet or standard telephone lines,
and telemedicine software (Table
Two). This camera/software/hard-
ware package would cost between
Caveats of Veterinary Telemedicine $5000 and $10,000. Including a top-
of-the-line mounted digital camera
As with all technologies, veterinary telemedicine has some weaknesses
that need to be resolved, including the following well-known caveats: (Table Three) and viewbox for cap-
turing radiographs will add about
$3000. A radiograph scanner will
■ Initial quality of radiographs—If a radiograph is poorly exposed from
cost between $10,000 and $25,000,
the initial flat film, the image quality can only be computer-enhanced
depending on the manufacturer and
by about 5% when changing contrast and brightness.
■ Digital cameras and scanners—The images captured by digital features. New ultrasound equipment
cameras are inferior in quality to those of scanners. Image quality can purchased at the same time will cost
also be affected when the zoom, aperture, and focus functions on digital from $14,000 to $35,000 or more.
cameras are not properly used. At present, scanners are the preferred Telemedicine consultation fees
method of capturing quality images. range from $25 to $75 per case. Car-
■ Digital radiography—Eventually, digital radiography will make diology and internal medicine con-
scanners obsolete because it eliminates the need for radiographic film sultations may be more expensive
and screens. With digital radiography, images can be created and stored because the information to be inter-
similar to how a digital camera stores a picture to be downloaded preted is more complex than that for
to a hard drive. Digital radiography also will eliminate the need for interpreting radiographs or cytologic
radiography processors. Once this technology is available on the samples. Practitioners generally add
veterinary market, however, the equipment will be very expensive. 50% to 100% of these fees when
■ Image capture card—Less expensive cards create poorly defined
charging clients. However, clients
images; practitioners should invest in good-quality cards.
could actually spend more on office
■ Turnaround time—The effectiveness of telemedicine depends on the
response time of the specialist and the telemedicine software provider. visits to specialists because travel-re-
■ DICOM (digital imaging and communications for medicine) lated costs must be added to referral
compatibility—Most current telemedicine software is not DICOM fees.
compatible. DICOM, a standard protocol used in human medicine, Telemedicine software will contin-
manages medical images by allowing one software system to ue to improve, but the ongoing costs
automatically read another without relying on conversion software. to practitioners will not become pro-
At present, telemedicine software is proprietary, which prohibits the hibitive. Today, computer hardware
ability to read other software programs. lasts approximately 5 years, and prac-
titioners always have the option of
Small Animal/Exotics 20TH ANNIVERSARY Compendium February 1999

adding random-access memory

TABLE TWO (RAM), which is inexpensive. In ad-
Hardware and Software Needs dition, if the hard drive reaches its
capacity, the images can be down-
Minimum Need Cost loaded onto a disk for storage and re-
trieval. Finally, because digital scan-
Computer (Intel Pentium® 200 with $2000–$3000 ners and cameras will not be obsolete
16-MB, 17-inch Super VGA Color in 5 years, replacement costs should
Monitor, 2.5-GB hard drive) not be a concern. Therefore, the pri-
mary ongoing expenditure will be
software upgrades, which the pro-
Telemedicine software $500–$2500
vider typically does twice a year.
Dedicated telephone line $100–$200 installation Practitioners are urged to verify
Internet service provider $35–$45/month that the software company is reliable
Digital camera $700–$1500 and has users willing to endorse it
Radiograph scanner $10,000–$25,000 (i.e., a referral list), can accommo-
date multiple direct methods of trans-
mission, has user-friendly software,
and is in sound financial condition
(see Prepurchase Considerations). If
TABLE THREE veterinary telemedicine is similar to
Comparison of Imaging Equipment human telemedicine, numerous soft-
ware companies may emerge and dis-
Equipment Pros Cons appear before a remaining few battle
for the market share. Currently,
Digital camera Inexpensive (less than Less dynamic range three software companies are primar-
$2000); smaller file size; (causes moderate image ily involved in veterinary telemedi-
captures image faster (10– loss); unacceptable cine (see Companies Currently Offer-
15 sec); quicker transmit image quality ing Telemedicine Software).
time (file size relatively
small); easy to operate Space Considerations
The amount of space devoted to
Scanner Enhanced image quality Expensive; larger file telemedicine equipment depends on
size; captures image the practitioner’s goals. For example,
slower (>1–2 min); an area measuring about 4 × 4 feet
longer transmit time would be needed to accommodate
(larger file size); digital the computer, equipment cart, ultra-
telephone line required sound machine, and scanner or digi-
tal camera needed to transmit image
radiographs or ultrasonograms; where-
as for cytologic or dermatologic re-
Prepurchase Considerations ferrals, practitioners would only need
enough space for a computer and
1. How many users does the provider currently have? digital camera.
2. How long has the company been in business?
3. How often does the company provide software updates? Continuing Education
4. Can information be transmitted directly to specialists without going One of the greatest benefits of
through the provider’s lines? telemedicine is the continuing edu-
5. Will the company furnish a list of at least 10 to 15 referrals? cation (CE) that results from interac-
6. How many different ways can information be transmitted (e.g., tion between practitioners and
telephone lines, email, file transfer protocol [FTP])? board-certified specialists in an at-
7. Is the provider’s software DICOM 3.0 compatible? mosphere that is also entertaining;
hence, I refer to veterinary telemedi-
Compendium February 1999 20TH ANNIVERSARY Small Animal/Exotics

cine as a form of “edutainment.” The same specialists who

Companies Currently Offering speak about a specific disease process at veterinary confer-
Telemedicine Software ences can personally help practitioners evaluate patients in
their practices. Practitioners therefore have an opportunity
DVM Communications to immediately apply what they have learned rather than
3645 Warrensville Center Road laboriously taking notes at a conference or relying on
Suite 212 memory to evaluate cases. Additional CE opportunities
Cleveland, OH 44122 will be gained when VIN and NOAH offer online
800-417-9707 telemedicine services. At present, VIN and NOAH discuss
Email: DVMcom.com cases based on records without images; having live images
to share with users will improve the CE process. As impor-
Remote Veterinary Consultants tant as the CE benefit is to have fun while solving difficult
100 Chastain Center Road cases. Telemedicine can provide an incredible amount of
Suite 100 edutainment for practitioners, specialists, and their entire
Kennesaw, GA 30114 staffs.
800-553-3265
Email: bcampbell@remotevet.com
Bibliography
Sound Technologies Brown EA: Consult doctors online. Vet Econ: September 1998.
5256 South Mission Road Norsworthy G: Practices without boundaries. Vet Prod News: July 1996.
Bldg 804
Bonsall, CA 92003
800-268-5354
Email: soundvetco@aol.com