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The development of telecommunications and computer technology since the 1960's Space Age has implications for the improvement of the quality of health care for those who live in remote or isolated areas where access to quality health care has traditionally been a problem (Samuelson, 1986; Zundel, 1996).
Telemedicine, the use of two-way telecommunications technology, multimedia, and computer networks to deliver or enhance health care, is a growing trend internationally, with the United States, Canada, the United Kingdom, and Scandinavia among the leaders in developing this field (Basher et al., 1975; Foote, 1976; Basher and Lovett, 1977; Picot, 1985; Cronin, 1995).
Telemedicine is defined by the Telemedicine Information Exchange (1997) as the "use of electronic signals to transfer medical data (photographs, x-ray images, audio, patient records, videoconferences, etc.) from one site to another via the Internet, Intranets, PCs, satellites, or videoconferencing telephone equipment in order to improve access to health care." Reid (1996) defines telemedicine as "the use of advanced telecommunications technologies to exchange health information and provide health care services across geographic, time, social, and cultural barriers."
According to the Telemedicine Report to Congress (1997), "telemedicine can mean access to health care where little had been available before. In emergency cases, this access can mean the difference between life and death. In particular, in those cases where fast medical response time and specialty care are needed, telemedicine availability can be critical. For example, a specialist at a North Carolina University Hospital was able to diagnose a rural patient's hairline spinal fracture at a distance, using telemedicine video imaging. The patient's life was saved because treatment was done on-site without physically transporting the patient to the specialist who was located a great distance away."
In addition, the 1997 report states that "Telemedicine also has the potential to improve the delivery of health care in America by bringing a wider range of services such as radiology, mental health services, and dermatology to underserved communities and individuals in both urban and rural areas."
The practice of medicine through telecommunications, or telemedicine, began in the early 1960’s when the National Aeronautics and Space Administration (NASA) first put men in space. Physiological measurements of the astronauts were telemetered from both the spacecraft and the space suits during NASA space flights. These early efforts were enhanced by the development of satellite technology which fo stered the development of telemedicine.
NASA funded telemedicine research projects in the late 1960’s and early 1970’s. According to Basher, Armstrong, and Youssef (1975), there were fifteen telemedicine projects active in 1975.
One pioneer telemedicine project, STARPAHC, or Space Technology Applied to Rural Papago Advanced Health Care, was developed by NASA to deliver health care to the Papago Indian Reservation in Arizona. The project, which ran from 1972-1975, was implemented and evaluated by the Papago people, the Indian Health Service, and the Department of Health, Education, and Welfare. The goal was to provide health care to the isolated Papago Reservation. A van, which carried a variety of medical instruments including electrocardiograph and x-ray machine, was staffed by two Indian paramedics. The van was linked to specialists at the Public Health Service Hospital by a two-way microwave transmission (Telemedicine Research Center, 1997).
In 1974, NASA conducted a study with SCI Systems of Houston to determine the minimal television system requirements for accurate telediagnosis. A high-quality videotape was made of an actual medical exam conducted by a nurse but supervised by a physician watching on closed-circuit television. These videotapes were systematically electronically degraded to less than broadcast quality. The original and degraded videos were then shown to randomly selected groups of physicians who attempted to reach a correct diagnosis (Telemedicine Research Center, 1997).
The results, reported in "Final Report: Video Requirements for Remote Medical Diagnosis" (SCI Systems, Inc., 1974), included: 1) statistical significance between the means of the standard monochrome system and the lesser quality systems did not occur until the resolution was reduced below 200 lines or until the frame rate was below10 frames a second; 2) there was no significant difference in the overall diagnostic results as the pictorial information was altered; 3) there was no significant difference in remote treatment designations of TV system type that would cause detriment to patients; and 4) the supplementary study of transmissions of 25 cases using televised radiographic film showed no diagnostic differences between the televised evaluations and direct evaluations if the televised evaluations were above 200 lines and special optical lenses and scanning techniques were utilized (Telemedicine Research Center, 1997).
In 1989, NASA conducted the first international telemedicine project, Space Bridge to Armenia/Ufa, after a powerful earthquake struck the Soviet Republic of Armenia in December 1988. An offer of medical consultation was extended to the Soviet Union by several medical centers in the United States. Telemedicine consultations were conducted under the guidance of the US/USSR Joint Working Group on Space Biology using video, audio, and facsimile between a medical center in Yerevan, Armenia and four medical centers in the United States. This project was extended to Ufa, Russia to aid burn victims there after a fiery railway accident (Telemedicine Research Center, 1997).
Telemedicine technology has increased and the cost of equipment has decreased in the past ten years, resulting in an increase in the number of telemedicine research projects and increase in the scope of those projects. The Telemedicine Information Exchange (1997) lists over 130 telemedicine research sites. The "4th Annual Telemedicine Program Review" (Grigsby and Allen, 1997) lists 80 active telemedicine programs in 1996, in 38 states and Washington, D.C., 8 of which use only store and forward technology and 72 of which use two-way interactive audio-visual technology. There are 1,032 total telemedicine sites (hubs and spokes) which performed 21,274 consultations, 91% (19,380) of which were interactive audio-visual and 9% (1,894) of which were store and forward.
Since 1993, when there were only twelve active programs in the US, the number of programs has doubled yearly, while program activity (number of consultations) has tripled since 1995. The top five types of consults in 1996 were: mental health (21%), trauma care (16%), cardiology (12%), dermatology (11%), and surgery (8%). Emergency or trauma telemedicine emerged in 1996 as one of the fastest growing applications of this technology (Ibid. 1997).
Early projects using telemedicine in rural health care proved to have great beneficial effects on patient survival and recovery, but the equipment was expensive and rather cumbersome (Park 1974; Grundy et al. 1977; Grundy, Jones and Lovitt, 1982). As the cost and size of the equipment has come down, and the technical quality has gone up, telemedicine has become much more feasible to use in rural health care (Dakins 1995).
