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Small Animal/Exotics

Small Animal/Exotics

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Published by: taner_soysuren on Dec 07, 2009
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ave you ever wanted a reli-able second opinion on chestradiographs of a coughing pa-tientto assist your evaluation beforeprescribing therapy or referring thepatient to a specialist? Have you peeredthrough a microscope at a cytologicsample confident of the diagnosisbut not 100% sure? Would it not beideal to have the slide of that samplereviewed by a board-certified cy-topathologist to confirm your diag-nosis? How could such consultationschange the quality of medicine inyour practice?Telemedicine can help veterinari-ans tackle these daily dilemmas andpractice veterinary medicine at a high-er level than previously possible. Ac-cessing veterinary specialists for caseconsultations is possible throughtelephone line transmission or email.More and more specialists are be-coming involved with telemedicine(Table One) as an effective methodof assisting general practitioners.
 What Is Telemedicine?
Veterinary telemedicine is the useof electronic information and com-munication technologies to assistpractitioners in providing clinicalcare when separated by distance.Telemedicine provides practitioners with decision support via meaningfulcommunication with other veterinar-ians or specialists, thereby providingbetter health care in a cost-effective way. Communication is accom-plished by digitizing and compress-ing medical data (e.g., radiographs,ultrasonograms, photographs, andcytologic images) into the hard driveof a computer for archival (store) ortransmission (forward) purposes. Theimages are stored within computerfiles so they can be subsequently viewed by or shared with colleaguesor specialists. Applications are assimple as telephone consultations oras elaborate as interactive consulta-tions.
The Early Days
Veterinary telemedicine essentially started in 1980 when Dr. Larry Tilley presented the idea of using atranstelephonic electrocardiogram(ECG) transmitter to connect veteri-narians nationwide to The AnimalMedical Center in New York; theidea eventually evolved into Car-diopet. By connecting a simple de-vice to a patient, an ECG could betransmitted over ordinary telephonelines and displayed on a monitorthousands of miles away. A board-certified cardiologist or internist thenreviewed the ECG along with the ac-companying case history and sent areport 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-
Small Animal/Exotics20TH ANNIVERSARY
February 1999
tioners can now transmit ECGs, ra-diographs, echocardiograms, labora-tory data, and video images for evalu-ation. Because all of this medicalinformation is being bundled togeth-er, specialists can deliver a moreaccurate prognosis, diagnosis, andtherapeutic plan. The end result isenhanced access to quality care.
The veterinary profession, especial-ly in rural areas, has historically ig-nored professional and physical isola-tion of general practitioners fromcolleagues and specialists. Most veteri-nary hospitals are one- to two-doctorpractices, 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 optimumcare 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 toaccommodate interactive monitoringof patient evaluations while they arein progress.Despite their dedication, mostpractitioners realistically cannot haveexpertise in all areas of veterinary medicine. Telemedicine can bridgethe gap between general practitionersand veterinary specialists, thereby al-lowing practitioners access to currentdiagnostic and therapeutic informa-tion.The financial benefits should alsobe considered before deciding to usetelemedicine. When they refer pa-
Telemedicine—Creating theVirtual Veterinary Hospital
T. Arch Robertson, DVMVETMED ConsultantsPhoenix, Arizona
February 199920TH ANNIVERSARYSmall Animal/Exotics
tients for specialty consultations,general practitioners naturally loseincome. In today 
s economy, savvy practitioners are adding services tomaintain a healthy bottom line. Tele-medicine allows practitioners to com-plete more thorough workups on bothroutine patients and patients that would have previously been referred.Therefore, in addition to increasingprofit (see Profit Projections for aFictitious Clinic), practitioners canenjoy professional stimulation.
The Technology 
 With telemedicine, information isdigitized and compressed via comput-er hardware (video capture card) andtelemedicine software into the harddrive of a computer. After imageshave been archived, most telemedi-cine software programs allow users(i.e., practitioners or specialists) toenhance the images through manipu-lation. Changing contrast, brightness,hue, and saturation is common to allsoftware. Zooming in and out androtating images are also possible. Archived images and patient recordsare then transmitted to specialists forevaluation via telephone or email.Specialists then use a reader
s softwareprogram to review transmitted rec-ords and images and generate a reportthat can be faxed or sent by email toreferring practitioners.The turnaround time depends ontwo unrelated variables: the specialistand the telemedicine software pro-vider (see Caveats of Veterinary Tele-medicine). If specialists do not givetelemedicine cases high priority, theturnaround time could take longerthan desired by practitioners. In ad-dition, if the contract of the tele-medicine software provider forces in-formation to be sent through itsservice first and then forwarded tothe specialists, the turnaround timecould be delayed. The future of telemedicine will be fueled by rapidturnaround time and the quality of the final report. If the turnaround
Veterinary Telemedicine Specialists
Cardiology, dermatology,48 Notch Roadexotics, internal medicine,Little Falls, NJ 07424nephrology, oncology,800-726-1212ophthalmology, radiology,Fax: 973-890-5617surger
DocuTech Services, Inc.
Internal medicine Johnny Hoskins, DVMPO Box 82433Baton Rouge, LA 70844Phone/fax: 225-751-9272Email: hoskirk@msn.com
Foster Hospital
for Small Animals
Gene Nesbitt, DVMTufts Veterinary School200 Westboro RoadNorth Grafton, MA 01535508-839-5395
 Veterinary Diagnostic
Radiology, cytopathology 
Imaging & Cytopathology 
2892 SE Vista Way Gresham, OR 97080503-492-9978Fax: 503-661-0504Email: marcp@transport.com
 Veterinary Telerad 
Radiology 100 Circle RoadSan Rafael, CA 94903415-491-0654800-762-0125 orEmail:jowensdvm@aol.com
Internal medicine,Larry P. Tilley, DVM & Associatescardiolog22 Descanso RoadSanta Fe, NM 87505-9125800-214-9760Fax: 800-820-6815Email: TILLEY@compuserve.com
Marsha Whitely, DVM
Radiology 9324 Lake Valley DriveCincinnati, OH 45247513-923-4851
Small Animal/Exotics20TH ANNIVERSARY
February 1999
time is 24 hours, the value of tele-medicine to many practitioners isprobably lost.Learning to use software programsis fairly straightforward. Familiarity  with Windows 95 or 98 is essentially all users need to have. Practitionersunfamiliar with Windows 95 or 98may initially have difficulty; howev-er, the programs are user-friendly andeasy to master.
Cost Considerations
The cost of telemedicine opera-tions depends on practitioner needs.To transmit patient records and sim-ple images (e.g., skin lesions), practi-tioners need a digital camera, an IntelPentium
computer, access to the In-ternet or standard telephone lines,and telemedicine software (TableTwo). This camera/software/hard- ware package would cost between$5000 and $10,000. Including a top-of-the-line mounted digital camera(Table Three) and viewbox for cap-turing radiographs will add about$3000. A radiograph scanner willcost between $10,000 and $25,000,depending on the manufacturer andfeatures. New ultrasound equipmentpurchased at the same time will costfrom $14,000 to $35,000 or more.Telemedicine consultation feesrange from $25 to $75 per case. Car-diology and internal medicine con-sultations may be more expensivebecause the information to be inter-preted is more complex than that forinterpreting radiographs or cytologicsamples. Practitioners generally add50% to 100% of these fees whencharging clients. However, clientscould actually spend more on officevisits to specialists because travel-re-lated costs must be added to referralfees.Telemedicine software will contin-ue to improve, but the ongoing coststo practitioners will not become pro-hibitive. Today, computer hardwarelasts approximately 5 years, and prac-titioners always have the option of 
Profit Projections for a Fictitious Clinic
Specialist fee for internal medicine cases:$350/case Average number of cases referred:3/monthRevenue:$1050/monthSpecialist fee for oncology cases:$650/case Average number of cases referred:2/monthRevenue:$1300/monthSpecialist fee for cardiology cases:$450/case Average number of cases referred:3/monthRevenue:$1350/monthSpecialist fee for dermatology cases:$250/case Average number of cases referred:2/monthRevenue:$500/month
Projection of increased revenue with telemedicine$4200/monthProfits generated (total increased revenue)$50,400/year with telemedicine
Caveats of Veterinary Telemedicine
 As with all technologies, veterinary telemedicine has some weaknessesthat need to be resolved, including the following well-known caveats:
Initial quality of radiographs—
If a radiograph is poorly exposed fromthe initial flat film, the image quality can only be computer-enhancedby about 5% when changing contrast and brightness.
Digital cameras and scanners
The images captured by digitalcameras are inferior in quality to those of scanners. Image quality canalso be affected when the zoom, aperture, and focus functions on digitalcameras are not properly used. At present, scanners are the preferredmethod of capturing quality images.
Digital radiography 
Eventually, digital radiography will makescanners obsolete because it eliminates the need for radiographic filmand screens. With digital radiography, images can be created and storedsimilar to how a digital camera stores a picture to be downloadedto a hard drive. Digital radiography also will eliminate the need forradiography processors. Once this technology is available on theveterinary market, however, the equipment will be very expensive.
Image capture card 
Less expensive cards create poorly definedimages; practitioners should invest in good-quality cards.
Turnaround time
The effectiveness of telemedicine depends on theresponse time of the specialist and the telemedicine software provider.
DICOM (digital imaging and communications for medicine)compatibility 
Most current telemedicine software is not DICOMcompatible. DICOM, a standard protocol used in human medicine,manages medical images by allowing one software system toautomatically read another without relying on conversion software. At present, telemedicine software is proprietary, which prohibits theability to read other software programs.

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