Doctors are getting 'wired' in novel ways to benefit patients.

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. 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 which 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') 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. It is usually between the patient, their provider and a specialist, but may be any combination of the three. 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 rehabilitation. 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.

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 over 400 patients per month.

Home health care is another booming area of telemedicine. A program in Japan has home bound patients communicating daily with a physician, nurse or physical therapist. 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 Health Care Financing Administration (HCFA) will reimburse for teleradiology and telepathology, but not specialty consultations for Medicare patients; many private insurers also will not reimburse. 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.

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 do not have cable wiring or other kinds of telecommunications access required for more sophisticated uses, so those who could most benefit from telemedicine may not have access to it. Congress passed the Telecommunications Reform Act in 1996 which, among other things, allows rural education and health care networks to get connectivity rates similar to those charged in urban areas through the Universal Services Act. As of early 2000, the program had just begun to provide monies to rural areas for telecommunications improvements. See the Telemedicine Information Exchange's Legal section for more information on these and other legal issues.

Many of the current telemedicine projects side-step these and other problems by obtaining federal funds. However, as federal funding has become less available for telemedicine, many private corporations and telecommunications companies are stepping in to fill the void. Pressure on the appropriate government and legislative agencies will surely increase as more people realize the benefits of telemedicine.

Technology manufacturers and telecommunications companies are already 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.

Once the current barriers are resolved, the practice of telemedicine will likely undergo a radical change and transition from its current state of grant-funded projects, military demonstration projects and a few self-funded programs, to become a major industry within the health care field.

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)

Ten years or fifteen 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 2000, the ramifications of E-Health (a general term encompassing health care delivery, administration and information dissemination) and it's relationship to telemedicine are being analyzed. 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 early 2000, the potential of telemedicine and E-health is still left to our imaginations.

About the author
Nancy Brown, MLS
Project Manager
Telemedicine Research Center
brown@telemed.org

For more information
For comprehensive information on telemedicine, visit the Telemedicine Information Exchange (TIE). The TIE, which is funded by the National Library of Medicine, offers a database of over 7000 citations on telemedicine, many with abstracts; articles from the major telemedicine publications indexed and abstracted; a history of telemedicine; a 'What's New' section; a list of meetings for the next year; legal, business, and home health information, and much more. The TIE also provides several links to other sites offering useful information on telemedicine.

References
Perednia, D.A. and Allen A. 1995. Telemedicine technology and clinical applications. JAMA, v. 273(6): 483-488.

Kurtz, G.L. 1994. The future of telecommunications in rural health care. Healthcare Information Management, v. 8(3):5-9.

Merrell, R.C. 1995. Telemedicine in the 90's: beyond the future. Journal of Medical Systems, v. 19(1):15-18.