WHAT IS TELEMEDICINE
Worldwide, people living in rural and remote areas struggle to access
timely, quality specialty medical care. Residents of these areas often have substandard
access to specialty health care, primarily because specialist physicians are more likely
to be located in areas of concentrated population. Because of innovations in computing and
telecommunications technology, many elements of medical practice can be accomplished when
the patient and health care provider are geographically separated. This separation could
be as small as across town, across a state, or even across the world. Broadly defined,
telemedicine is the transfer of electronic medical data (i.e. high resolution images,
sounds, live video, and patient records) from one location to another. This transfer of
medical data may utilize a variety of telecommunications technology, including, but not
limited to: ordinary telephone lines, ISDN, fractional to full T-1’s, ATM, the
Internet, intranets, and satellites. Telemedicine is utilized by health providers in a
growing number of medical specialties, including, but not limited to: dermatology,
oncology, radiology, surgery, cardiology, psychiatry and home health care.
Trends observed nationally include:
using telemedicine in correctional facilities and home health care
settings, can significantly reduce the time and costs of patient transportation;
fine-tuning the management and allocation of rural health care
emergency services by transmitting images to key medical centers for long distance
evaluation/triage by appropriate medical specialists;
permitting physicians doing clinical research to be linked together
despite geographical separation, sharing patient records and diagnostic images.
improving medical education for rural health care professionals,
where rotations is made possible by linking several community hospitals together with the
sponsoring medical school.
In general, the numerous and ever expanding applications of telemedicine
allows its users to reduce the burdens inferior health care access through utilization of
technology. Because of telemedicine, geographical isolation need no longer be an
insurmountable obstacle to the basic needs of timely and quality medical care.
HISTORY OF TELEMEDICINE
While the explosion of interest in telemedicine over the past four or five
years makes it appear that it's a relatively new use of telecommunications technology, the
truth is that telemedicine has been in use in some form or other for over thirty years.
The National Aeronautics and Space Administration (NASA) played an important part in the
early development of telemedicine (Bashshur and Lovett, 1977) . NASA's efforts in
telemedicine began in the early 1960s when humans began flying in space. Physiological
parameters were telemetered from both the spacecraft and the space suits during missions.
These early efforts and the enhancement in communications satellites fostered the
development of telemedicine and many of the medical devices in the delivery of health care
today. NASA provided much of the technology and funding for early telemedicine
demonstrations, two of which are mentioned below. A book by Rashid L. Bashshur published
in 1975 (Bashshur R.L. et al. 1975) lists fifteen telemedicine projects active at the
time. There were several pioneering efforts not only in the US, but all over the world. A
few of these and some later projects are worth examining briefly. To find articles about
these programs, follow the links to the Bibliographic database, which will give you a
reference and abstract (if available), which describes these programs. Many of these
programs have other articles besides those listed which describe them. To find these, do a
word search in the Bibliographic database on the project of interest.
Space Technology Applied to Rural Papago Advanced Health Care
(STARPAHC):
One of the earliest endeavors in telemedicine, STARPAHC delivered medical care to the
Papago Indian Reservation in Arizona. It ran from 1972-1975 and was conceived by the
National Aeronautics and Space Administration (NASA), engineered by NASA and Lockheed, and
implemented and evaluated by the Papago people, the Indian Health Service and the
Department of Health, Education and Welfare. Its goals were to provide health care to
astronauts in space and to provide general medical care to the Papago Reservation. A van
staffed by two Indian paramedics carried a variety of medical instruments including
electrocardiograph and x-ray. The van was linked to the Public Health Service hospital and
another hospital with specialists by a two-way microwave telemedicine and audio
transmission. (Bashshur, 1980).
Nebraska Medical Center:
The Nebraska Psychiatric Institute was one of the first facilities in the country to have
closed-circuit television in 1955. In 1964 a $480,000 grant from the National Institute
for Mental Health allowed a two-way link between the psychiatric institute and Norfolk
State Hospital, 112 miles away. The link was used for education, and for consultations
between specialists and general practitioners. In 1971 the Nebraska Medical Center was
linked with the Omaha Veterans Administration Hospital and VA facilities in two other
towns. The psychiatric institute also experimented with group therapy. (Benschoter, R.A.
1971) .
Massachusetts General Hospital/Logan International Airport Medical
Station:
This station was established in 1967 to provide occupational health services to airport
employees and to deliver emergency care and medical attention to travelers. Physicians at
MGH provided medical care to patients at the airport using a two-way audiovisual microwave
circuit. The Medical Station was staffed by nurses 24 hours/day, supplemented by in-person
physician attendance during four hours of peak passenger use. Evaluation of diagnosis and
treatment of the nurse-selected patients was made by participating personnel and
independent physician observers. Analysis was also made of the accuracy of microwave
transmission. Inspection, auscultation, and interpretation of roentgenograms and
microscopic images were also performed. Necessary hands-on procedures were performed by
the nurse-clinicians. (Murphy, R.L. Jr. and Bird K.T.(1974) and (Murphy, R.L. Jr., et al
(1972) ).
Alaska ATS-6 Satellite Biomedical Demonstration:
In 1971, 26 sites in Alaska were chosen by the National Library of Medicine's Lister Hill
National Center for Biomedical Communication to see if reliable communication would
improve village health care. It used ATS-1, the first in NASA's series of Applied
Technology Satellites launched in 1966. This satellite was made available in 1971, and was
still in use in 1975. The primary purpose was to investigate the use of satellite video
consultation to improve the quality of rural health care in Alaska. Satellite ground
stations permitting transmission and reception of black and white television were
installed at four locations, and a receive-only television capability was installed at the
Alaska Native Medical Center in Anchorage. All five sites had two-way audio. Two of the
locations had no resident physician. Simultaneous two-way video capability was not
available, although the one-way video could be switched for transmission from any site
except Anchorage. This was an exploratory field trial, not a rigorous experiment.
Evaluation of the project was done by the Institute for Communications Research at
Stanford University. It was determined that the satellite system was workable, could be
used effectively by health aides at the various locations, and could be used for
practically any medical problems except emergency care (emergencies could not wait for
scheduled transmission times). It was also determined that the "unique capabilities
of the video transmission may play a critical role in 5-10% of the cases selected for
video presentation. Otherwise, there was little measurable difference between the effect
of video and audio consultation." (Foote, D. et al. 1976) and (Foote, D. 1977).
Video Requirements for Remote Medical Diagnosis:
In 1974 NASA contracted with SCI Systems of Houston to conduct a study to determine the
minimal television system requirements for telediagnosis. The experiment was conducted
with a help of a simulated telemedicine system. First, a high-quality videotape was made
of actual medical exams conducted by a nurse under the direction of a physician watching
on closed-circuit television. This was the baseline for the study. Next, these videotapes
were electronically degraded to simulate television systems of less than broadcast
quality. Finally, the baseline and degraded video recordings were shown (via a
statistically randomized procedure) to a large number of physicians who attempted to reach
a correct medical diagnosis and visually recognize key physical signs for each patient.
Six television systems were investigated: two systems were compatible with transmission
over full bandwidth television channel, while the other four allowed more detailed
investigation of the frame rate and horizontal bandwidth required for each medical case.
The following four results were found: 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 reduced below 10
frames/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 as a function of TV system type that would cause detriment to
patients; 4) the supplementary study of radiographic film televised transmission (25
cases) showed that no diagnostic differences occurred between the TV evaluations and the
direct film evaluations for TV resolutions above 200 lines if special optical lenses and
scanning techniques were utilized. (SCI Systems, Inc. 1974).
Memorial University of Newfoundland (MUN):
MUN was an early participant in the Canadian Space Program. The joint Canadian/U.S. Hermes
satellite provided Canadians with an opportunity to use satellite technology in distance
education and medical care. Since 1977, The Telemedicine Centre at MUN has worked toward
developing interactive audio networks for educational programs and the transmission of
medical data. Among the guidelines followed were: use the simplest and least expensive
technology; be flexible; involve the users from the beginning of the project; seek
administrative support in hospitals, clinics and other agencies; and include evaluation.
The MUN Teleconferencing System, a province-wide network consisting of five dedicated
circuits, began programming in 1977. There are installations in all provincial hospitals,
community colleges, university campuses, high schools, town halls and education agencies.
MUN has been active in international teleconferencing, and played a significant role in
the School of Medicine at the Univ. of Nairobi, Kenya in the 1960-70s. In 1985 MUN became
involved in the International Satellite Organization (Intelsat), linking to Nairobi and
Kampala, which later was extended to six Caribbean countries. MUN has been a model for the
judicious and low-cost use of telemedicine technology . They have proven that many times
there is no need for the higher-end, higher-cost videoconferencing equipment. .
The North-West Telemedicine Project:
This project was set up in 1984 in Australia to pilot test a government satellite
communications network (the Q-Network). The project goals were to provide health care to
people in five remote towns south of the Gulf of Carpentaria. Two-thirds of these people
were Aborigines or Torres Strait Islanders. The Q-Network consisted of 20 two-way
earth-stations and 20 one-way (television-receivers only) earth stations. The hub of the
network was the Mount Isa Base Hospital. All sites were supplied with a conference
telephone, fax, and freeze-frame transceivers. Evaluation for the project showed that the
technology did improve the health care of these remote residents. While it was impossible
to calculate the operating costs of the telemedicine network separate from the other
functions of the network, some healthcare costs were reduced. Fewer patients and
specialists flew to and from these remote areas for routine consultations, and fewer
patients were evacuated for emergency reasons.
The NASA SpaceBridge to Armenia/Ufa
In 1989 NASA conducted the first international telemedicine program, Space Bridge to
Armenia/Ufa. In December of 1988 a massive earthquake hit the Soviet Republic of Armenia.
An offer was extended from the United States to the Soviet Union for medical consultation
from the site of the disaster in Armenia to several medical centers in the U.S. Under the
auspices of the U.S./U.S.S.R Joint Working Group on Space Biology, telemedicine
consultations were conducted using one-way video, voice, and facsimile between a medical
center in Yerevan, Armenia and four medical centers in the U.S. The program was extended
to Ufa, Russia to facilitate burn victims after a terrible railway accident. This project
demonstrated that medical consultation could be conducted over a satellite network
crossing political, cultural, social, and economic borders. (Pers. Commun. Chuck Doarn,
NASA, January 1996). The last ten years have seen a steady increase in the number of
telemedicine projects throughout the U.S. and internationally. As more government funding
became available in the early 90s, and as technology costs continue to decrease,
telemedicine is possible for a wider spectrum of users. An article in Telemedicine Today,
Spring 1995 (Allen and Allen, 1995) lists the top twenty interactive television
telemedicine sites in the U.S. by number of consultations for 1994. The Active
Telemedicine Projects in the TIE lists over 130 sites internationally.
Descriptions of these and other early projects may be found in various
publications or as more obscure government funding reports listed in the TIE Bibliography.
A search using the text word of the project you are interested in, or a search using
"telemedicine" as a keyword and "history" as a subcategory will bring
up these citations. Many will have abstracts, and the full citations will allow you to
obtain these documents from your local library. |
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