Telemedicine Coming of Age
By Nancy Brown, September 28, 1996
* Updated on January 13,
2005
Telemedicine has been defined as the use of telecommunications to
provide medical information and services (Perednia and Allen 1995). It may be as simple as two health professionals
discussing a case over the telephone, or as sophisticated as using
satellite technology to broadcast a consultation between providers at
facilities in two countries, using videoconferencing equipment or
robotic technology. The first is used daily by most health
professionals, and the latter is used by the military and some large
medical centers. It is the practice of telemedicine somewhere in
between those two that will be described in this article.
Types of Technology
Two different kinds of technology make up most of the telemedicine
applications in use today. The first, called store and forward, is
used for transferring digital images from one location to another. A
digital image is taken using a digital camera, ('stored') and then
sent ('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 - 48 hours 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 of
telemedicine in use today. There are hundreds of medical centers,
clinics, and individual physicians who use some form of
teleradiology. Many radiologists are installing appropriate computer
technology in their homes, so they can have images sent directly to
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 slides may be sent from one location to another for
diagnostic consultation. Dermatology is also a natural for store and
forward technology (although practitioners are increasingly using
interactive technology for dermatological exams). Digital images may
be taken of skin 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 of the
three), are at the originating site. The specialist is at the
referral site, most often at an urban medical center.
Videoconferencing equipment at both locations allow a 'real-time'
consultation to take place. The technology has decreased in price and
complexity over the past five years, and many programs now use
desktop videoconferencing systems. There are many configurations of
an interactive consultation, but most typically it is from an
urban-to-rural location. It means that the patient does not have to
travel to an urban area to see a specialist, and in many cases,
provides access to specialty care when none has been available
previously. Almost all specialties of medicine have been found to be
conducive to this kind of consultation, including psychiatry,
internal medicine, rehabilitation, cardiology, pediatrics, obstetrics
and gynecology and neurology. There are also many peripheral devices
which can be attached to computers which can aid in an interactive
examination. For instance, an otoscope allows a physician to 'see'
inside a patient's ear; a stethoscope allows the consulting physician
to hear the patient's heartbeat.
Many health care professionals involved in telemedicine are
becoming increasingly creative 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 and
applications. Use of the Web to transfer clinical information and
data is also becoming more prevalent. Wireless technology is being
used for instance, in ambulances providing mobile telemedicine
services.
Programs and Applications
There are many programs world-wide using a variety of technologies
to provide healthcare. At the University
of Kansas Telemedicine Program, telemedicine technology has been
used for several years for oncology, mental health care to patients
in rural jails, hospice care, and most recently, to augment school
health services by allowing school nurses to consult with physicians.
Several telemedicine programs are being initiated in correctional
facilities, where the costs and danger of transporting prisoners to
health facilities can be avoided. The University of Texas Medical
Branch at Galveston Center
for Telehealth and Distance Education was one of the original
programs to begin providing services to inmates, and sees hundreds of
patients per month.
Home health care
is another booming area of telemedicine, including Japan, the UK and
the US. The Veterans
Affairs Administration has initiated home telehealth as part of
its telehealth program. Telemedicine does not have to be a high-cost
proposition. Many projects are providing valuable services to those
with no access to health care using low-end technology. The Memorial
University of Newfoundland telemedicine project has been using
low-cost store and forward technology to provide quality care to
rural areas in under-developed countries for many years.
The military and some university research centers are involved in
developing robotics equipment for telesurgery
applications. A surgeon in one location can remotely control a
robotics arm for surgery in another location. The military has
developed this technology particularly for battlefield use, and some
U.S. academic medical centers and research organizations are also
testing and using the technology.
Advantages of Telemedicine
Providing healthcare services via telemedicine offers many
advantages. It can make specialty care more accessible to underserved
rural and urban populations. Video consultations from a rural clinic
to a specialist can alleviate prohibitive travel and associated costs
for patients. Videoconferencing also opens up new possibilities for
continuing education or training for isolated or rural health
practitioners, who may not be able to leave a rural practice to take
part in professional meetings or educational opportunities. While
studies have yet to confirm this, it appears that the use of
telemedicine 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 states will not allow out-of-state physicians to practice unless
licensed in their state. The Centers
for Medicare and Medicaid (CMS) still has several restrictions
for Medicare telemedicine reimbursement. Many private insurers also
will not reimburse, although some states, such as California and
Kentucky, have legislated that they must reimburse the same as for
face-to-face consultations. Other programs, such as Eastern Montana
and Inland Health in Washington, have negotiated with payers for
telemedicine reimbursement. Fear of malpractice suits is another
consideration for physicians, as is acceptance of the technology and
lack of 'hands-on' interaction with patients, although most patient
satisfaction studies to date find patients on the whole satisfied
with long distance care. (Gustke
et al 2000)
Many potential telemedicine projects have been hampered by the
lack of appropriate telecommunications technology. Regular telephone
lines do not supply adequate bandwidth for most telemedical
applications. Many rural areas still do not have cable wiring or
other kinds of high bandwidth telecommunications access required for
more sophisticated uses, so those who could most benefit from
telemedicine may not have access to it.
Many current telemedicine projects side-step these and other
problems by obtaining federal funds. However, in the past three to
four years, federal funding has become less available for
telemedicine. In 2005, the Technology Opportunity Program (TOP) will
not receive funds for telemedicine/telehealth, and the Office
for the Advancement of Telehealth (OAT) will not be able to fund
any new programs. Some legislation and grant appropriations passed in
response to 9/11 include the use of telehealth, but no direct funding
has been made available. Some private corporations and
telecommunications companies are stepping in to fill the void,
however, pressure on the appropriate government and legislative
agencies is needed before more funding will become available.
Technology manufacturers and telecommunications companies are
vying with each other to produce the low-cost equipment and bandwidth
needed. Many states are creating networks which link education,
government, business and healthcare. Distance education is
commonplace and most educational institutions and many companies
allay travel costs for meetings by using video.
Telemedicine or Telehealth?
The term 'telehealth' was originally used to describe
administrative or educational functions related to telemedicine. Now
that physicians use email to communicate with patients, and drug
prescriptions and other health services are being offered on the Web,
'telehealth' is generally used as an umbrella term to describe all
the possible variations of healthcare services using
telecommunications. The term 'telemedicine' more appropriately
describes the direct provision of clinical care via
telecommunications--diagnosing, treating or following up with a
patient at a distance. However, stay tuned. The terminology used to
describe healthcare services at a distance will likely change as fast
as the technology used to perform it.
Conclusion
It's not too much of a stretch of the imagination to realize that
telemedicine will soon be just another way to see a health
professional, just as seeing friends and family while talking to them
on the phone is becoming commonplace. Farther down the road, it has
been theorized that we each could have a 'Personal Diagnosis System'
as part of our home entertainment centers. This system would monitor
our daily health status and automatically notify a health
professional if we become ill. (Kurtz
1994)
Fifteen or twenty years ago we had no idea we would rely heavily
on faxes, answering machines 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 telemedicine
continually increases, there are many programs in operation since
1994, and telemedicine technology is usually included in hospital
remodels or new hospitals. In the mid-90's Ronald C. Merrell, from
Yale University School of Medicine said, "The innovations we
will encounter as we step beyond feasibility are dazzling in their
potential." (Merrell
1995) In 2005, the potential of telemedicine, telehealth and
e-health is still left to our imaginations.
References
Gustke S S, Balch D C, West V L,
Rogers L O. Patient
satisfaction with telemedicine. Telemedicine Journal, Spring,
2000, 6(1): 5-13. (Link last checked on June 10, 2004).
Kurtz G L. The
future of telecommunications in rural health care. Healthcare
Information Management, Summer, 1994, 8(3): 5-9. (Link last checked
on June 10, 2004).
Merrell R C. Telemedicine
in the 90's: Beyond the future. Journal of Medical Systems,
1995, 19(1): 15-8. (Link last checked on June 10, 2004).
Perednia D A, Allen A. Telemedicine
technology and clinical applications. JAMA, Feb 8, 1995, 273(6):
483-8. (Link last checked on June 10, 2004).
Revisions
May 3, 2003: checked links (N.B.)
January 13, 2005: checked links; made edits (N.B.)
