Not long ago, the role telehealth would play in the overall healthcare system was still uncertain. Not anymore.

If you had asked Yadin David in 2001 for his take on telemedicine—was it for real, for instance, or just a bunch of hype—he would have pointed out that more than 150 telemedicine programs were already in operation. David was perhaps the best person in the nation to ask the question: He was then president of the Center for Telehealth and e-Health Law and director of biomedical engineering at Texas Children’s Hospital in Houston. In his answer, he would have used words like “promise,” “opportunity,” and “possibility.” Then he most likely would have opined that for telemedicine to succeed—“to become a staple of medical practice”—colossal changes would first have to take place in everything from the telecommunications infrastructure to clinical practice itself. Sure, he’d have said (as he did in his 2001 Journal of Clinical Engineering article, “Telemedicine: I Can See the Highway, But Where is the Ramp?”), telemedicine is ready to roll. It just needs a better roadmap to achieve widespread adoption.

But that was 13 years ago. Today, says David, who is now a consultant, no one doubts how telemedicine might work, and “almost everyone is convinced that it’s a solution.” Telemedicine has “turned the corner,” he says, and that ramp—the one he referred to in his article—is in place, well-marked, and open to traffic. “In fact, I’d argue today [that] telemedicine, if it’s not on Main Street, is only a block away.”

A 2013 report by the market research firm IHS supports David’s assessment. Telehealth, IHS claims, is “set to expand tenfold by 2018.” (Telehealth is broader than telemedicine in that it includes remote healthcare services that aren’t necessarily clinical in nature.)  The number of patients using telehealth services is expected to hit 7 million annually by that year. The report points out that telehealth offers solutions to many of the biggest problems associated with conventional healthcare delivery, from escalating costs to how to handle an aging population in need of more and higher-quality care. Telehealth, IHS notes, has “yet to reach its tipping point,” but it is nonetheless “becoming an integral part of healthcare.”

Challenges and Opportunities

As that tipping point approaches, then, are biomeds prepared? Will the job of the HTM professional change as telehealth becomes more common?

David, who recently developed a telemedicine system for a hospital neurology department that wanted to make its concussion service available to remote sites, considers the growth of telehealth to be a “tremendous opportunity for biomedical and clinical engineering professionals, and especially for those who do their homework.” Currently, he notes, telehealth systems are mostly managed by telecommunications and IT people. Biomeds, for their part, are typically responsible for the same components they’ve always looked after—the medical devices that connect to the system.

This division of labor is fine, he says, but as telemedicine grows, those HTM professionals with the broadest range of skills will stand to gain the most. “If you think you can just keep doing what you’re doing and become a telemedicine maven, you’re in for a big surprise.” Biomeds who develop competencies in areas like telecommunications and telemedicine-specific clinical protocols, regulatory standards, and work processes, he says, will be in the best position to advance their careers as telemedicine evolves.

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Wayne Hibbs, principal at the design firm BSA LifeStructures, where he focuses on technology and equipment planning for healthcare facilities, agrees. Hibbs says he’s followed the development of telemedicine closely since it first came into use in the 1990s, and has watched it “reinvent itself” several times since.

Now, he notes, smartphones and high-resolution webcams are increasingly allowing patients to take vital signs and other health readings themselves from home, and to then send that information electronically to their doctors, wherever they may be. This vein of telemedicine is still in the “beta-testing” phase, he says, but “it’s beginning to happen, and it’s on the horizon for everybody.”

When that day comes, adds Hibbs, “the biomeds of the world [will] get involved by making sure that the patients at home not only have access to the right equipment, but that it works correctly and they know how to use it.” He imagines “a whole new category of biomed people who are like computer geeks on call.” They’ll either form their own consulting companies or work for the insurance industry, making home visits when individuals sign up for policies “and the insurance company wants to make sure they actually have the right health apps and know how to use their new Apple iPhone 6.” This “new frontier of telemedicine,” as Hibbs calls it, will require biomeds and clinical engineers to be the quality-control experts—the boots on the ground ensuring “that the picture the physician is viewing is color correct” or “the sound of the electronic stethoscope is clear.”

Of course, even as telehealth gains ground in the home, the biggest demand for its use most likely will come from medical facilities themselves. Inova Health System’s enVision eICU in Falls Church, Virginia, provides an example. There, nurses and physicians work in a room with eight workstations and six computer screens to provide around-the-clock remote support to patients and clinicians in the critical care units of affiliate hospitals elsewhere in the state. Inova’s clinical engineering team, working closely with IT, supports and manages all of the technology involved, from the audio and video equipment to the carts, batteries, inverters, and other components of the telemedicine system. And they do it on both ends—not only in the eICU, but also in the hospitals themselves.

Inova’s administrative director of telemedicine operations, Steven Dean, calls the clinical engineering team “a critical asset,” and describes their role as “broader” than that of the typical HTM pro. “They’re not just working on medical devices,” he notes. In telemedicine, “that line between where networks and infrastructure meet, it starts to get blurry.” At Inova, adds Dean, the clinical engineers have learned to “handle that component where those two worlds overlap.”

The Telemedicine Program of Fletcher Allen Health Care and the University of Vermont College of Medicine, meanwhile, leverages the Level I trauma center’s medical expertise primarily by connecting its clinicians to remote hospital emergency departments throughout the region, as needed. (The telemedicine program is also used for instructional purposes—broadcasting, for example, grand rounds from Fletcher Allen to its referral hospitals—and as a means for technical-services experts in Burlington to troubleshoot equipment problems at other sites.)

Each emergency department, explains Tobey Clark, UVM’s director of Instrumentation & Technical Services, has its own “telemedicine system set-up that is largely for face-to-face consultation. They’ll have attachments where you can do things like hook up a camera to an endoscope so a specialist here can see the patient.” UVM has a dedicated staff of telecommunications professionals that handles the networking aspect of the operation, while the HTM department manages the “front-end equipment, just like they would any other medical device,” as well as the audio and video components. (Microphones and audio technologies tend to run into more problems than the video components, notes Clark.)

Clark’s advice for biomeds? “Know the basics of your system really well,” and create a block diagram you can refer to when problems arise. “The only way you’ll be able to troubleshoot problems is if you know what’s out there to begin with.”

Breaking it Down

One person who does know exactly what’s out there is Tim Gee, principal at Medical Connectivity Consulting in Beaverton, Oregon. Gee describes himself as a “connectologist” who advises medical device manufacturers and healthcare facilities on workflow automation and the integration of devices and information systems. In every telemedicine system, says Gee, there are three classes of components: the medical devices themselves, like the blood-pressure cuffs and otoscopes and electronic stethoscopes; off-the-shelf parts supplied by the telemedicine vendor, like the video cameras and audio equipment to which the medical devices attach; and the telecommunications infrastructure of the facility or facilities hosting the system.

“Obviously,” notes Gee, “the component every biomed is familiar with is the medical device. But the other two, they may not be.” If your hospital has a dedicated IT or telecommunications team, like the one at UVM, that won’t be an issue. But even so, Gee says, “there may not be a biomed at the remote site,” which could be a prison, a school, an ambulance, or a patient’s home. “And there may not be an IT person at that site either. Or it may be that in the hospital you have both, while in the remote clinic you just have a biomed.” In other words, he says, “who does what can vary.” It depends on the facility’s resources, “and on which end of the telemedicine system you’re on.”

Complicating matters further, notes Gee, when a component in a telemedicine system breaks, swapping out parts “can be difficult.” While medical devices tend to be bought for the long haul, the telecommunications components they connect to and are integrated with have relatively short life cycles. Carts, TV cameras, routers, switches, software—“they’re constantly being changed and updated and replaced with new models.” Add to that the fact that FDA regulations may limit one’s ability to simply replace broken, stolen, or misplaced telemedicine parts, and you have a “new dynamic that people in biomedical and clinical engineering are typically not accustomed to,” says Gee.

He recommends that biomeds be involved in the planning stages of any new telemedicine system so that they can “talk to the manufacturers and ask the right questions before any purchases are made.” Ensuring a system’s components are relatively easy to replace or service “can have a big impact on the cost of ownership,” he notes.

A telemedicine supplier who agrees with Gee (and there are certainly others) is Steven Normandin, president of Massachusetts-based AMD Global Telemedicine. “The biomedical engineering guys—to them, what we’re bringing in is just another product, and they already have 95% of the skill set they need to do everything they’ll ever have to do with it.” Still, he says, training is an important part of the installation process (“how a product is different than the other devices they’re using, how to clean it, what to do if something breaks”), and the HTM department “always signs off on what we’re putting in.”

AMD’s best-selling device is a general-examination camera most often used by correctional facilities, elementary schools, and rural healthcare facilities where physicians are in short supply, says Normandin. “That real sexy stuff you read about? Like the remote-assisted surgery, things like that? The majority of telemedicine is primary care. It’s doing the same things that you’d do in any doctor’s office. You’re looking in the ears, in the eyes; you’re listening to the heart, to the lungs. You’re taking all the vital signs. That’s the equipment we’re working with.”

When AMD first opened for business almost 24 years ago, continues Normandin, there was very little competition. Their telemedicine products, he says, “involved taking something like an electronic stethoscope and hooking it up to an Adobe encoder. It was finding a bunch of miscellaneous and usually nonmedical parts, things like graphic equalizers from stereo systems, and putting everything together until it all worked.”

Back then, he remembers, “most of the biomed guys looked at this field with a little apprehension. A lot of it didn’t match their core competencies. There were some areas that they weren’t used to.” Today, though, that’s changed. And while biomeds are now expected to work more closely with their IT colleagues—or, increasingly, to handle the basics of networking and communications themselves—this shift has not been so sudden that there wasn’t time to prepare.

Hibbs describes it as “a merging, where the IT techs and the biomed techs are getting closer and closer together every 6 months, and sometimes it’s getting harder to tell them apart.” Normandin, for his part, sees the same thing—and from his perspective, as a telemedicine vendor, that’s been fine with him. “There’s very little push-back now,” he says. “For the most part, these guys are just doing the things that they’re trained to do.”

Chris Hayhurst is a contributing writer for 24×7. For more information, contact editorial director John Bethune at [email protected].