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A quick guide into the world telemedicine.

Introduction

Rapid advancement of telecommunications and information technology has created the

potential for high-quality expert healthcare to be delivered when and where it is needed.This report will explain the development of the telemedicine industry and defines itscurrent scope and reveals the potential regarding to its future. It also addresses thestrategic, technical and operational issues faced by clinicians and healthcare managersconsidering the introduction of telemedicine services offering solutions for a variety ofsituations.

What is telemedicine?

An umbrella term that encompasses various technologies as part of a coherent healthservice information resource management program.Telemedicine is the capture, display, storage and retrieval of medical images and data

towards the creation of a computerized patient record and managed care. Advantagesinclude: move information, not patients or providers; enter data one in a health carenetwork; network quality specialty health care to isolated locations; and build fromhands-on experience. The departments frequently using this technology are pathology,radiology, and patient consultation from the distance.Telemedicine is the use of telecommunications for medical diagnosis and patient care. Itinvolves the use of telecommunications technology as a medium for the provision ofmedical services to sites that are at a distance from the provider. The conceptencompasses everything from the use of standard telephone service through highspeed, wide bandwidth transmission of digitized signals in conjunction with computers,fiber optics, satellites, and other sophisticated peripheral equipment and software.

This picture shows the technological diversity of thetelemedicine.

Telemedicine can be divided into three areas: aids to decision-making, remotesensing, and collaborative arrangements for the real-time management of patientsat a distance. As an aid to decision-making, telemedicine includes areas such asremote expert systems that contribute to patient diagnosis or the use of onlinedatabases in the actual practice of medicine. This aspect of telemedicine is the oldest inconcept. Remote sensing consists of the transmittal of patient information, such aselectrocardiographic signals, x-rays, or patient records, from a remote site to acollaborator in a distant site. It can also include transmittal of grand rounds for medical

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education purposes or teleconferences for continuing education. Collaborativearrangements consist of using technology to actually allow one practitioner to observeand discuss symptoms with another practitioner whose patients are far away. Thisraises important issues of referral and payment arrangements, staff credentialing,liability, and licensure potentially crossing state lines. Two-way workstations, whichprovide smooth digital motion pictures, have been integral to the long distance, real-time

treatment of patients. As new technology is found, collaborative arrangements are thefuture of telemedicine.The concept of telemedicine is not new. Articles on telemedicine projects can be foundin the literature over the past twenty-five to thirty years. To gain an historical perspective,this report covers aspects of telemedicine described above going back to the beginningof medical records, this was a first step towards the todays telemedicine when doctorswere exchanging opinions via telephone, fax regarding the accuracy of a examination ora treatment. In the information moved from the fix to more mobile/flexible networks,since the bust of Internet we have seen an increase in data-exchange regarding moreaccurate imaging and patient records. It includes human as well as veterinary medicine,also the technical aspects as well as the clinical concerns. Areas of patient recordstorage or shared hospital and computer resources are todays driving force behind the

telemedicine and e-health.Now with the more increasing need for information a common solution is needed.Several related issues such as the Unified Medical Language System, IntegratedAdvanced Information Management Systems and communications technologyinfrastructures, are addressed but only as they relate to telemedicine.The picture below describes a typical system developed in the recent years.

Two different kinds of technology make up most of the telemedicine applications in usetoday. The first, called store and forward, is used for transferring digital images from one

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location to another. A digital image is taken using a digital camera, ('stored') and thensent ('forwarded') by computer to another location. This is typically used for non-emergent situations, when a diagnosis or consultation may be made in the next 24 - 48hours and sent back.The image may be transferred within a building, between two buildings in the same city,or from one location to another anywhere in the world. Teleradiology, the sending of x-

rays, CT scans, or MRIs (store-and-forward images) is the most common application oftelemedicine in use today. There are hundreds of medical centers, clinics, and individualphysicians who use some form of teleradiology. Many radiologists are installingappropriate computer technology in their homes, so they can have images sent directlyto them for diagnosis, instead of making an off-hours trip to a hospital or clinic.Telepathology is another common use of this technology. Images of pathology slidesmay be sent from one location to another for diagnostic consultation. Dermatology isalso a natural for store and forward technology (although practitioners are increasinglyusing interactive technology for dermatological exams). Digital images may be taken ofskin conditions, and sent to a dermatologist for diagnosis.The other widely used technology, two-way interactive television (IATV), is used when a'face-to-face' consultation is necessary. The patient and sometimes their provider, or

more commonly a nurse practitioner or telemedicine coordinator (or any combination ofthe three), are at the originating site. The specialist is at the referral site, most often at anurban medical center. Videoconferencing equipment at both locations allow a 'real-time'consultation to take place. The technology has decreased in price and complexity overthe past five years, and many programs now use desktop videoconferencing systems.There are many configurations of an interactive consultation, but most typically it is froman urban-to-rural location. It means that the patient does not have to travel to an urbanarea to see a specialist, and in many cases, provides access to specialty care whennone has been available previously. Almost all specialties of medicine have been foundto be conducive to this kind of consultation, including psychiatry, internal medicine,rehabilitation, cardiology, pediatrics, obstetrics and gynecology and neurology. There arealso many peripheral devices which can be attached to computers that can aid in an

interactive examination. For instance, an otoscope allows a physician to 'see' inside apatient's ear; a stethoscope allows the consulting physician to hear the patient'sheartbeat.Many health care professionals involved in telemedicine are becoming increasinglycreative with available technology. For instance, it's not unusual to use store-and-forward, interactive, audio, and video still images in a variety of combinations andapplications. Use of the Web to transfer clinical information and data is also becomingmore prevalent. Wireless technology is being used for instance, in ambulances providingmobile telemedicine services.

Programs and Applications

There are many programs world-wide using a variety of technologies to providehealthcare. Telemedicine technology has been used for several years for oncology,mental health care to patients in rural jails, hospice care, and most recently, also toaugment school health services by allowing school nurses to consult with physicians.

Telemedicine Applications

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Named ProjectsMilitary ProjectsHome Health CareGeneral Applications

Telemedicine in Education

Medical EducationAllied Health EducationContinuing EducationOther Educational Applications

Several telemedicine programs are being initiated in correctional facilities, where thecosts and danger of transporting prisoners to health facilities can be avoided.Home health care is another booming area of telemedicine, including Japan, the E.U.and the US.Telemedicine does not have to be a high-cost proposition. Many projects are providingvaluable services to those with no access to health care using low-end technology.

The military and some university research centers are involved in developing roboticsequipment for telesurgery applications. A surgeon in one location can remotely control arobotics arm for surgery in another location. The military has developed this technologyparticularly for battlefield use, and some U.S. academic medical centers and researchorganizations are also testing and using the technology.The picture below shows the different media types for different applications and need intelemedicine.

Advantages of Telemedicine

Providing healthcare services via telemedicine offers many advantages. It can makespecialty care more accessible to underserved rural and urban populations. Video

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consultations from a rural clinic to a specialist can alleviate prohibitive travel andassociated costs for patients. Videoconferencing also opens up new possibilities forcontinuing education or training for isolated or rural health practitioners, who may not beable to leave a rural practice to take part in professional meetings or educationalopportunities. While studies have yet to confirm this, it appears that the use oftelemedicine can also cut costs of medical care for those in rural areas.

Barriers to Telemedicine

There are still several barriers to the practice of telemedicine. Many private insurers alsowill not reimburse, although some states, have legislated that they must reimburse thesame as for face-to-face consultations. Other programs have negotiated with payers fortelemedicine reimbursement. Fear of malpractice suits is another consideration forphysicians, as is acceptance of the technology and lack of 'hands-on' interaction withpatients, although most patient satisfaction studies to date find patients on the wholesatisfied with long distance care.Many potential telemedicine projects have been hampered by the lack of appropriatetelecommunications technology. Regular telephone lines do not supply adequate

bandwidth for most telemedical applications. Many rural areas still do not have cablewiring or other kinds of high bandwidth telecommunications access required for moresophisticated uses, so those who could most benefit from telemedicine may not haveaccess to it.Many current telemedicine projects side-step these and other problems by obtainingfederal funds. However, in the past three to four years, federal funding has become lessavailable for telemedicine. In 2005 the chalange will be to grant appropriation fundingand make it available for future development. Some private corporations andtelecommunications companies are stepping in to fill the void, however, pressure on theappropriate government and legislative agencies is needed before more funding willbecome available.Technology manufacturers and telecommunications companies are vying with each

other to produce the low-cost equipment and bandwidth needed. Many states arecreating networks which link education, government, business and healthcare. Distanceeducation is commonplace and most educational institutions and many companies allaytravel costs for meetings by using video.

Conclusion

It's not too much of a stretch of the imagination to realize that telemedicine will soon bejust another way to see a health professional, just as seeing friends and family whiletalking to them on the phone is becoming commonplace. Farther down the road, it hasbeen theorized that we each could have a 'Personal Diagnosis System' as part of ourhome entertainment centers. This system would monitor our daily health status and

automatically notify a health professional if we become ill.Fifteen or twenty years ago we had no idea we would rely heavily on faxes, answeringmachines and e-mail, tools which are now low-tech and taken for granted. In early 2005,telemedicine still has not reached its potential. However, information about telemedicinecontinually increases, there are many programs in operation since 1994, andtelemedicine technology is usually included in hospital remodels or new hospitals. In themid-90's Ronald C. Merrell, from Yale University School of Medicine said, "Theinnovations we will encounter as we step beyond feasibility are dazzling in their

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potential." In 2005, the potential of telemedicine, telehealth and e-health is still left to ourimaginations.

References

http://www.americantelemed.org/

http://www.telemedtoday.com/http://telehealth.net/

http://www.telemedicine.lu/

http://mdc.cinenet.net/flagship/medicine/index.html

NASA Telemedicine Technology Gateway : http://www.nttc.edu/telemed.htmlhttp://www.pulsar.org

http://www.federaltelemedicine.com/links.htm

http://tie.telemed.org/

Journal of Medical Systems, 1995, 19/1

25.05.2005 Constantin Gherici Turku.

http://www.americantelemed.org/http://www.telemedtoday.com/http://telehealth.net/http://www.telemedicine.lu/http://www.nttc.edu/telemed.htmlhttp://www.pulsar.org/http://www.federaltelemedicine.com/links.htmhttp://tie.telemed.org/http://www.americantelemed.org/http://www.telemedtoday.com/http://telehealth.net/http://www.telemedicine.lu/http://www.nttc.edu/telemed.htmlhttp://www.pulsar.org/http://www.federaltelemedicine.com/links.htmhttp://tie.telemed.org/