About Telemedicine

Telemedicine is the use of medical information exchanged from one site to another via electronic communications to improve patients' health status. Closely associated with telemedicine is the term "telehealth," which is often used to encompass a broader definition of remote healthcare that does not always involve clinical services. Videoconferencing, transmission of still images, e-health including patient portals, remote monitoring of vital signs, continuing medical education and nursing call centers are all considered part of telemedicine and telehealth.

Defining Telemedicine

Telemedicine is not a separate medical specialty. Products and services related to telemedicine are often part of a larger investment by health care institutions in either information technology or the delivery of clinical care. Even in the reimbursement fee structure, there is usually no distinction made between services provided on site and those provided through telemedicine and often no separate coding required for billing of remote services.

Telemedicine encompasses different types of programs and services provided for the patient. Each component involves different providers and consumers.

Specialist referral services typically involves of a specialist assisting a general practitioner in rendering a diagnosis. This may involve a patient "seeing" a specialist over a live, remote consult or the transmission of diagnostic images and/or video along with patient data to a specialist for viewing later. Recent surveys have shown a rapid increase in the number of specialty and subspecialty areas that have successfully used telemedicine. Radiology continues to make the greatest use of telemedicine with thousands of images "read" by remote providers each year. Other major specialty areas include: dermatology, ophthalmology, mental health, cardiology and pathology. According to reports and studies, almost 50 different medical subspecialties have successfully used telemedicine.

Patient consultations such as using audio, video and medical data between a patient and a primary care or specialty physician for use in rendering a diagnosis and treatment plan. This might originate from a remote clinic to a physician's office using a direct transmission link or may include communicating to a physician over the Web.

Remote patient monitoring uses devices to remotely collect and send data to a monitoring station for interpretation. Such "home telehealth" applications might include a specific vital sign, such as blood glucose or heart ECG or a variety of indicators for homebound patients. Such services can be used to supplement the use of visiting nurses.

Medical education provides continuing medical education credits for health professionals and special medical education seminars for targeted groups in remote locations. Consumer medical and health information includes the use of the Internet for consumers to obtain specialized health information and on-line discussion groups to provide peer-to-peer support.

Delivery Mechanisms

Networked programs link tertiary care hospitals and clinics with outlying clinics and community health centers in rural or suburban areas. The links may use dedicated high-speed lines or the Internet for telecommunication links between sites. Point-to-point connections using private networks are used by hospitals and clinics that deliver services directly or contract out specialty services to independent medical service providers at ambulatory care sites. Radiology, mental health and even intensive care services are being provided under contract using telemedicine to delivery the services.

Primary or specialty care to the home connections involves connecting primary care providers, specialists and home health nurses with patients over single line phone-video systems for interactive clinical consultations.

Home to monitoring center links are used for cardiac, pulmonary or fetal monitoring, home care and related services that provide care to patients in the home. Often normal phone lines are used to communicate directly between the patient and the center although some systems use the Internet.

Web-based e-health patient service sites provide direct consumer outreach and services over the Internet. Under telemedicine, these include those sites that provide direct patient care.

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 and their provider in one location and a specialist in another location. 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.

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.

Barriers to Telemedicine

There are still several barriers to the practice of telemedicine. In USA Many states will not allow out-of-state physicians to practice unless licensed in their state. As of October 2002, the Centers for Medicare and Medicaid will reimburse for interactive consults, but not store and forward. Many private insurers still will not reimburse for telemedicine consults. 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 high bandwidth telecommunications access required for more sophisticated uses, so those who could most benefit from telemedicine may not have access to it.

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.