House calls

Marilyn Parker’s new pacemaker is so smart, it calls the doctor for her. Each night, while the 58-year-old Spokane woman sleeps, the device “talks” to a monitor by her bedside and reports any troubles to her cardiologist.

“It takes care of everything automatically,” says Parker, who received the pacemaker last month.

Parker is one of a handful of heart patients to get the Biotronik home-monitoring pacemaker in Spokane in recent weeks.

The device is part of a growing category of health-care delivery known as telemedicine, which uses telecommunications technology to improve patient care.

Telemedicine itself is nothing new. It’s been used for years by doctors who communicate with each other across the globe by videophone. Or by rural patients who see a faraway specialist via a video linkup in their hometown.

In North Idaho, surgeons in Sandpoint can beam a tissue sample onto a monitor for pathologists in Coeur d’Alene to diagnose.

Increasingly, though, telemedicine is moving out of the hospital and into our homes, such as with the Biotronik pacemaker and defibrillator.

“When I’m driving down the road in my car, I have several dials and warning buttons that will tell me if I’m low on oil, if it’s overheating,” says Jonathan Linkhous, executive director of the Washington, D.C.-based American Telemedicine Association. “We’re just trying to use the same technology for our own selves, for our own bodies.”

The technology can be used to test, monitor and treat a variety of conditions.

There’s a pulmonary monitor so people can keep track of their lung conditions at home. There’s an at-home fetal monitor that can keep some women with difficult pregnancies out of the hospital. There are blood-pressure cuffs that transmit readings directly to the doctor’s office.

St. Luke’s Rehabilitation Institute in Spokane often sends telemedicine kits home with patients recovering from brain and spinal cord injuries or strokes. Patients receive a rolling backpack with a telephone, a converter and a small television, says Sharon Hall, a St. Luke’s physical therapist.

Once everything is hooked up, the patient and therapist can watch each other even if they are hundreds of miles away.

A patient typically has another therapist or family member present, one who might not be well-trained in spinal cord injuries, while someone with more experience demonstrates movements on the screen.

Tyrell Pulkrabek, 23, used the telehealth monitor for two years while in rehabilitation after he broke his neck in a car accident.

Pulkrabek, who now lives in North Dakota, was living in Grand Coulee during his rehabilitation. The technology saved him from having to make regular drives to Spokane for therapy, he says.

“It was pretty cool, actually,” Pulkrabek says. “They would show me stuff through the TV, and then I could show them what I could do.”

For example, therapists helped him learn how to move from his bed to his wheelchair, he says. They showed him how to put his socks and shoes on.

And if he developed a sore, he didn’t have to travel 85 miles to get it checked out. He could show it to the therapists on the monitor, and they told him if it was serious enough to merit attention, he says.

The help he got via video, he says, “is pretty much what turned me around.”

“When I first came back there, I thought my life was over,” Pulkrabek says. “(Now) I can get dressed, undressed and stuff like that. I’m driving now, looking for my own house.”

There may come a day when even a healthy person can go to the drugstore and buy a “telemedicine instrumentation kit” that will keep track of various vital signs and send the information to a medical center, Linkhous says.

“There’s a whole range of remote-monitoring equipment that’s available that essentially gives the patient or the consumer or the physician the ability to use only what’s specifically necessary,” he says.

“It’ll make them more independent, for people who have chronic diseases. It will keep healthy people healthier; there’s no issue about it.”

But the growing use of this technology raises some pressing questions. First, of course, who will pay for it? There’s not only the cost of the devices and monitors themselves but also the price tag on the experts who must take the time to interpret the information.

Dr. Michael Kwasman, a Spokane cardiologist and electrophysiologist who has implanted several Biotronik pacemakers in recent weeks, says he’s been told he can bill for the time he’s spending following up on reports from the Biotronik pacemakers, but he hasn’t done so yet.

But Hall says she doesn’t get reimbursed for long-distance physical therapy.

“That’s a very problematic situation because all of the treatments I’m doing that way are free,” she says. “And how long can you do that?”

And then there’s the important issue of who’s to blame if something goes wrong.

“No one wants to take on more liability,” says Kwasman.

Kwasman gets e-mail reports about his patients’ pacemakers. But, he wonders, what if he overlooks an important detail.

A patient could later say, “Why didn’t you look at it, doctor? It was there, doctor,” Kwasman says.

The Biotronik pacemakers are a good choice for patients with frequent irregular heart rhythms, Kwasman says. With many traditional pacemakers, patients can hold the telephone up to their chests and transmit information to their doctor.

But the home-monitoring devices allow doctors to be notified of cardiac events that go unnoticed even by patients.

“Things can happen that are subclinical but still important,” Kwasman says.

But will home-monitoring pacemakers really improve the care patients receive? Kwasman isn’t sure.

“Time will tell,” he says.

“I’ve been one of these people who feel like some of this technology is being driven by industry and not necessarily by health-care needs and patients’ and physicians’ needs.”