With advances in technology, high-quality telemedicine is now more affordable and popular than ever. Here are tips for planning an exciting and effective event.

A team of surgeons is performing the latest advanced cardiac procedure on an elderly man when suddenly he goes into cardiac arrest. It's code blue in the O.R. and, while doctors work to revive him, someone yells, "Get those cameras out of here." With 250 cardiologists at Boston's Copley Plaza Hotel watching the surgery, beamed live from a local hospital, everyone, including event organizers, remain calm as television directors and engineers cut to another hospital's O.R. without missing a beat.

Held in May, the course, called "Combined Harvard-Hospitals Interventional Cardiology Course," spanned three days. Physicians observed heart surgeries beamed from three area hospitals: Beth Israel Deaconess Medical Center, Brigham and Women's Hospital, and Massachusetts General Hospital.

"Doctors love these kinds of telemedicine events. It's almost expected in CME programs," says Robert Lewis, of Medical Media Communications Inc., Chicago, and meeting planner for the event. "In fact, we find that doctors want to see more even after the procedure is complete. They want to see the clean up, the prep. They can't seem to get enough."

Which would explain why Lewis is seeing a spike in telemedicine events in just the past two years. Several years ago Medical Media Communications handled several telesurgery events; this year, so far, he counts six. Advances in technology are driving the trend, but Michael P. Caputo, a former NASA project scientist who now serves as director of Telehealth Operations at Fletcher Allen Health Care, Burlington, Vt., also puts it in a more historical perspective: "This is how doctors have always learned--in the old days, they would go to the operating room or watch from a gallery above, except there was room for only a few. Now we can bring the O.R. right into a conference center for hundreds."

Exciting as telemedicine is for attendees, it can be nerve-racking for planners, as the above example illustrates. Here are strategies for ensuring that your production runs smoothly.

Choosing the Right Method First, planners need to decide what type of technology will best meet their program's goals. In other words, says Michael Ricci, MD, clinical director of telemedicine, Fletcher Allen Health Care; and associate dean of CME, University of Vermont College of Medicine in Burlington, "a technically demanding demonstration, say a pediatric cardiac procedure, might need a very high bandwidth, like satellite, in order for attendees to see the details." Other situations, such as telepsychiatry, for instance, where fine detail is not critical, can be handled with lower bandwidth.

Basically, there are three methods to choose from, according to Caputo, who is also treasurer of the American Telemedicine Association in Washington, D.C. (Caputo and Ricci run an annual symposium, "How to build a Telemedicine Program.") Satellite broadcasts can cost hundreds, even thousands, of dollars per hour, not to mention the additional cost of renting the specialized equipment to receive the signal.

Another disadvantage is that you have to schedule and reserve satellite time, and your slot, especially if you are doing a multi-site broadcast, may not coordinate with the procedures you are filming. If you're running behind schedule in one location, it's not easy to reconfigure reserved satellite time. On the plus side, "you get very good bandwidth and it's the closest to TV broadcast quality," Caputo says.

The second option is to do use high-speed phone lines, such as ISDN or T1 lines. For quality image and sound, Caputo recommends three ISDN lines and a feed rate of 384 Kbps are needed (a regular telephone line provides 56 Kbps). Finding a suitable facility shouldn't be a problem, as these days, nearly all hotels and conference centers in most major cities have ISDN access, Caputo says.

"The downside is that the quality is not quite as good as satellite, but that also depends on how many ISDN lines you use," Caputo says. "The resolution is not as sharp as on a home television set and there may be some lag time, but the technology is improving."

On the up side, ISDN connections are more reasonably priced, with the cost for connecting at about $100 per hour. Case in point: The Boston cardiology event was broadcast from the three hospitals to the hotel using fiber-optic landlines, which have unlimited capacity and were already in place at all the sites, including the hotel. According to the vendor, Andrew Straub, president of Blueyed Productions, LLC, Bedford, N.H., producing the three-day event, with a crew of six at each of the four venues, cost about $150,000. If the program had been broadcast via satellite, Straub says the cost would have been at least double the amount.

This method is also interactive, allowing attendees and those doing the procedure to talk back and forth, Caputo says, while satellite broadcast requires separate setups for interaction.

The third option is videostreaming over the Internet. "The biggest benefit is that there is almost universal access," Caputo says, "and it's much cheaper than the other two. You can have a bigger audience, but the sacrifice is on quality." He predicts, however, that as Internet speed and quality improves with broadband access, the disadvantage gap will narrow.

Location, Location, Logistics The next step is to ascertain whether the meeting sites and other facilities you want to use have telemedicine capabilities, Caputo says, "because that's the kind of thing that can drive up the cost." Ask facility staff if the site has ISDN connections, how many, and what kind of transmitting equipment, such as modems or fiber-optic wiring, is available. And then check it out yourself.

Lewis and Straub's pre-meeting routine included a site inspection of the hotel and the three hospitals to determine exactly how the cameras and crew members would set up.

"The hospital is where it gets complicated," Lewis explains, "because you can't assume that it is prepared with the technology. The biggest mistake a planner can make is to trust an institution's staff when they say they have the right equipment with the right quality." If your event requires T1 lines, for instance, your best bet is to check in advance--and in person--to see if those lines are really there.

But you never know what might happen between the time of your site inspection and the program. Ricci recalls running a live demonstration of a heart surgery from the O.R. at Fletcher Allen to a West Coast technology show in a conference center.

"We had had the O.R. wired with ISDN lines," Ricci says, "but some remodeling had been done in the room. Someone cut the wires, and sheetrocked over the jacks." The problem was fixed and the demonstration, went on as planned. The moral of the story: A last-minute site check is always a good idea.

Give Me Some Backup Even if you do last-minute checks, you can run into unexpected problems during a live broadcast, so backup plans take on Goliath-sized importance. Caputo's first rule of backup is what he calls "complete redundancy. It's from my days at NASA, and it applies very much to videoconferencing. What it means is that you have two of everything--two sets of equipment at each location, two sets of lines, an A and B switch--so that if one fails, you have the other."

More advice from Caputo: Have on hand a narrated videotape of the same type of procedure. "It's not as slick," he says, "but at least the physicians don't feel like they're being cheated."

It's important to have a program moderator who can "change the batting order on the fly," Caputo says. Lewis agrees: "You may be showing a live case for an hour, and often there are complications (in the procedure) or it runs longer than it's supposed to. It wreaks havoc on a planned event. The answer is to have presenters waiting in the wings, ready to go up at a moment's notice--it can get pretty lively for a planner."

Broadcast Rules Because telemedicine can be so complex and unpredictable, it's crucial to pick a vendor who has experience with health care events, says Lewis. It also helps make your job easier if vendors are up to speed on CME regulations, adds Straub, especially the Accreditation Council for CME's Essentials and Standards for Commercial Support.

In addition to those rules, hospitals and institutions often have their own set of regulations and bylaws on confidentiality, privacy, and rebroadcast of videotaped procedures. Straub makes sure that all the people involved in a telemedicine event, including patients and surgeons, sign the appropriate releases and waivers.

Straub recalls a situation where the taped surgical procedure ended up on the Internet without a signed release, which was in violation of the hospital's bylaws. "Television production opens the door to a lot of young, aggressive people," Straub says, "who often don't have the experience or understanding of the big picture in the medical world."