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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:
1. using telemedicine in correctional
facilities and home health care
settings, can significantly reduce the
time and costs of patient
transportation;
2. 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;
3. permitting physicians doing clinical
research to be linked together despite
geographical separation, sharing
patient records and diagnostic images.
4. 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.
(House and Roberts, 1977).
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. (Watson,
1989).
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.
This page was last updated on Wednesday,
July 07, 1999
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