Telemedicine/Telehealth

Telemedicine is a growing field made possible by improved, more widely available, and affordable telecommunications services. Once narrowly defined as direct provision of medical services using telecommunications technology, the term telemedicine is now being supplanted by "Telehealth", and covers "use of electronic information and communications technologies to provide and support health care when distance separates the participants" (US Veterans Administration) or "use of electronic information and telecommunications technologies to support long-distance clinical health care, patient and professional health-related education, public health and health administration" (Office for the Advancement of Telehealth, US Health Resources and Services Administration.)

These definitions include activities providing direct and indirect clinical services such as teledermatology, but also include educational and administrative uses of these technologies to support health care, such as for continuing education or administrative videoconferencing. As convergence of video, voice and data networks occurs in the marketplace, it is not surprising that services previously offered on multiple media are now migrating to converged Internet, providing opportunities for convergence of a number of health care activities occurring at a distance.

• Brief history of Telemedicine/Telehealth

  The earliest recorded use of telemedicine was a 1950's Nebraska demonstration project using closed circuit television to provide mental health services from a university medical center to a state hospital 100 miles away. Forty years ago the NASA space flight telemedicine program began so that medical personnel on the ground could monitor astronauts' biomedical responses to space flight and to provide any necessary medical care. NASA's "Telemedicine Space Bridge to Armenia" Project provided medical assistance in response to a severe earthquake in Armenia in 1988. Using a live, two-way satellite link medical personnel at hospitals in Salt Lake City, Houston Texas, and Maryland conducted many sessions with Armenia physicians for a variety of medical consultations. Due to the enormous expense of these pioneering efforts it is only within the last ten years that the practice of telemedicine has begun to move from pilots to public availability.
  

• Current Practice of Telemedicine

  Remote clinical diagnosis via videoconferencing is currently used in some rural areas. A rural doctor or nurse practitioner consults with a physician based at a metropolitan or university hospital. Using videoconferencing technology and specially adapted medical tools, the remote doctor can see the patient, talk with the local health care practitioner, hear a heartbeat through a remote stethoscope, see images from ear/nose/throat exams, or examine skin conditions. This application has typically required leased T-1 telephone or ISDN lines, which can be quite expensive. Due to a number of issues (cost effectiveness, patient/physician acceptance of the technology, licensing and payment issues), the most common use of such facilities has been to provide health care to prisoner populations. Prisoners have a legal right to receive needed medical treatment, but the cost of transporting a prisoner to a medical facility is extremely high since at least two guards and possibly and ambulance are required for transport during trips requiring an entire day. This high transport expense has provided cost-justification for telemedicine in states such as Virginia and Texas.

  A notable pioneer in broader acceptance of telemedicine can be found at the East Carolina University's Telemedicine Center [1]. Their telemedicine program employs an array of interactive video and audio technologies to deliver clinical care and education to the rural population of eastern North Carolina. Since 1992, the Center has supported over 7,500 telemedicine consultations in over 35 different medical specialties, and over 10,000 distance learning and continuing medical education activities. ECU's Telemedicine Center includes an operational communications hub providing connections between points of need and global medical resources utilizing POTS, ISDN, T-1, Microwave, Satellite, and IP technologies.

  The US Veterans' Administration (VA) [2] has had a number of clinical telemedicine programs, including teleradiology/filmless digital imaging, telepathology, telenuclear medicine (MRI), home telephone monitoring of cardiac pacemakers, telephone liaison care programs, and more.

  NORTH Network in Ontario Canada [3] runs an extensive H.323-based telehealth service for remote hospitals and clinics in the northern parts of the province. They use a private IP network (dedicated to health care applications) to link over 60 sites in the north to large urban teaching hospitals. They currently facilitate hundreds of videoconference enabled consultations per week as well as running an extensive educational"broadcasts"using the same technologies. They've avoided the typical billing problems for remote consultations by getting a special government grant that allows them to directly pay consulting physicians.

  Tandberg [4] is a vendor offering systems specifically designed for the healthcare industry. The HealthCare System III is a turnkey solution that combines an H.323 videoconferencing station with medical examination tools that can be read at a distance, thus allowing the doctor to see both the patient and an auxiliary transmission, including sonograms, store and forwards, telescopic images, or a computer or graphic image. The Intern II is a compact system; it has a built-in MCU, provides HIPAA compliant data encryption and meets UL, CSA and FCC regulations so that it can be rolled right up to a patient's bedside.

  NASA is designing a highly portable Telemedicine Instrumentation Pack (TIP) to collect medical audio, video and data from the patient in space.

  Another approach is to build your own telemedicine system. By combining a videoconferencing device, a PC, and medical devices that can interface into a computer, one can build a videoconferencing system that best meets the needs of the end users. Georgia Tech's Biomedical Interactive Technology Center [5] has developed such a system for use in Sarov, Russia, a former Nuclear City. The system combines off the shelf PC's with a PictureTel codec, digital cameras, medical instruments interfaced to the computer, scanners, printers, and a video microscope. A system like this can be customized to meet the exact needs of the users, but it lacks the polished, integrated interface one can expect in a commercial system. As the new field of telemedicine grows and evolves, homegrown systems such as these will help refine the needs of systems, and will influence the product design of future commercial telemedicine products.

  In an effort to push the field of telemedicine forward significantly, the National Library of Medicine [6] in 1996 awarded 19 multi-year telemedicine projects intended to serve as models for evaluating the impact of telemedicine, assessing various approaches to confidentiality in telemedicine, and testing emerging health data standards. A symposium summarizing activities in and results from this program was held in March 2001, and proceedings are available on-line [7].

  An emerging application in telemedicine is home health care delivery using videoconferencing. Patients being monitored for a number of conditions might be sent home with a PC-based telemedicine appliance that can be used to connect them back to a hospital or doctor's office via ISDN, DSL or cable modem connections. Such systems often combine medical diagnostic devices such as stethoscope, ECG, otoscope, etc. American TeleCare [8] is a pioneer in this field. Other vendors include AMD Telemedicine [9], AeroTel Medical Systems [10], Medtronic [11], and March Networks [12].

• Current Issues associated with Telemedicine/Telehealth applications

  There are many unresolved questions in the field of telemedicine:

  Acceptance: The Veterans Administration states that more specific evidence of efficacy/therapeutic and diagnostic impact/cost analysis are needed in many areas of telemedicine; in other words, telemedicine is not widely accepted as an approved medical practice by doctors or patients.

  Security:Security of telemedicine sessions and related information is a crucial issue. The Health Information Portability and Accountability Act of 1996 (HIPAA) guarantees privacy of patient medical records by federal law, and with individual as well as institutional accountability for violators. HIPAA compliance becomes mandatory in Spring 2003. (http://cms.hhs.gov/hipaa/)

  For videoconferencing systems used in telemedicine, an implication is that reliable session encryption will be mandatory. An excellent white paper describing the state of H.323 encryption is available from UKERNA [13] (United Kingdom Research and Education Networking Association). The report describes the H.235 security recommendations that are part of the H.323 standard, but finds little implementation of this standard within H.323 clients. Some vendors such as VCON have built proprietary encryption schemes into their products; these proprietary solutions may solve an immediate problem but prohibit interoperability. The authors conclude that encryption at the H.323 application level is in its infancy so encryption can presently only be offered widely via network layer encryption, for example by use of VPN or IPSec.

  Regulation and Reimbursement:In the United States, until the late 1990's, private and public third-party payers generally did not have explicit policies to pay for telehealth services. The Office for the Advancement of Telehealth [14] in the US Department of Health and Human Services' Health Resources and Services Administration is an excellent source for information on regulatory and reimbursement issues. The Balanced Budget Act of 1997 was a significant step forward for telemedicine because it allowed Medicare payments for patients in rural communities having no health care services at all; this prohibited payment to medical specialists such as cardiologists or radiologists whose expertise might be valuable to a general practice physician. The types of services covered were required to be "interactive" and thus did not apply to "Store and Forward" technologies such as when X-rays or laboratory tests might be forwarded to a specialist for diagnosis. The rules were expanded by the Benefits Improvement Act of 2000 to allow coverage to include any type of medicine to any rural area and to any entity that had participated in a Federal telemedicine demonstration project (for example, Veterans Administration Hospitals, even in urban areas). The practice of medicine across state lines is severely restricted by current laws.

  Note: This particular description is US-Centric. We welcome comment on these issues from residents of other countries to post for comparison.

• Standards and Guidelines for Telemedicine/Telehealth Videoconferencing Systems

  The Office for the Advancement of Telehealth maintains guidelines [15] for evaluating telemedicine/telehealth systems. These guidelines are based on goals of interoperability, compatibility, scalability, accessibility, and reliability. Guidelines are also provided by area of medical specialization, such as dermatology or psychiatry.
  

• Additional Resources:
  • The Telemedicine Information Exchange [16] was created and is maintained by the Telemedicine Research Center with major support from the National Library of Medicine [6].
  • The American Telemedicine Association seeks to bring together diverse groups from traditional medicine, academic medical centers, technology and telecommunications companies, e-health, medical societies, government and others to overcome barriers to the advancement of telemedicine through the professional, ethical and equitable improvement in health care delivery. ATA was established in 1993 as a non-profit organization and is headquartered in Washington. Links to telemedicine organizations in other countries can be found on the ATA web site [17].