A quick guide into the world telemedicine.

Introduction
Rapid advancement of telecommunications and information technology has created the potential for high-quality expert healthcare to be delivered when and where it is needed. This report will explain the development of the telemedicine industry and defines its current scope and reveals the potential regarding to its future. It also addresses the strategic, technical and operational issues faced by clinicians and healthcare managers considering the introduction of telemedicine services offering solutions for a variety of situations.

What is telemedicine?
An umbrella term that encompasses various technologies as part of a coherent health service information resource management program. Telemedicine is the capture, display, storage and retrieval of medical images and data towards the creation of a computerized patient record and managed care. Advantages include: move information, not patients or providers; enter data one in a health care network; network quality specialty health care to isolated locations; and build from hands-on experience. The departments frequently using this technology are pathology, radiology, and patient consultation from the distance. Telemedicine is the use of telecommunications for medical diagnosis and patient care. It involves the use of telecommunications technology as a medium for the provision of medical services to sites that are at a distance from the provider. The concept encompasses everything from the use of standard telephone service through high speed, wide bandwidth transmission of digitized signals in conjunction with computers, fiber optics, satellites, and other sophisticated peripheral equipment and software.

This picture shows the technological diversity of the telemedicine. Telemedicine can be divided into three areas: aids to decision-making, remote sensing, and collaborative arrangements for the real-time management of patients at a distance. As an aid to decision-making, telemedicine includes areas such as remote expert systems that contribute to patient diagnosis or the use of online databases in the actual practice of medicine. This aspect of telemedicine is the oldest in concept. Remote sensing consists of the transmittal of patient information, such as electrocardiographic signals, x-rays, or patient records, from a remote site to a collaborator in a distant site. It can also include transmittal of grand rounds for medical

education purposes or teleconferences for continuing education. Collaborative arrangements consist of using technology to actually allow one practitioner to observe and discuss symptoms with another practitioner whose patients are far away. This raises important issues of referral and payment arrangements, staff credentialing, liability, and licensure potentially crossing state lines. Two-way workstations, which provide smooth digital motion pictures, have been integral to the long distance, real-time treatment of patients. As new technology is found, collaborative arrangements are the future of telemedicine. The concept of telemedicine is not new. Articles on telemedicine projects can be found in the literature over the past twenty-five to thirty years. To gain an historical perspective, this report covers aspects of telemedicine described above going back to the beginning of medical records, this was a first step towards the todays telemedicine when doctors were exchanging opinions via telephone, fax regarding the accuracy of a examination or a treatment. In the information moved from the fix to more mobile/flexible networks, since the bust of Internet we have seen an increase in data-exchange regarding more accurate imaging and patient records. It includes human as well as veterinary medicine, also the technical aspects as well as the clinical concerns. Areas of patient record storage or shared hospital and computer resources are todays driving force behind the telemedicine and e-health. Now with the more increasing need for information a common solution is needed. Several related issues such as the Unified Medical Language System, Integrated Advanced Information Management Systems and communications technology infrastructures, are addressed but only as they relate to telemedicine. The picture below describes a typical system developed in the recent years.

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') by computer to another location. This is typically used for nonemergent 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 xrays, 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. The patient and sometimes their provider, or more commonly a nurse practitioner or telemedicine coordinator (or any combination of the three), are at the originating site. The specialist is at the referral site, most often at an urban medical center. 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 that 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-andforward, 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. Wireless technology is being used for instance, in ambulances providing mobile telemedicine services.

Programs and Applications

There are many programs world-wide using a variety of technologies to provide healthcare. Telemedicine technology has been used for several years for oncology, mental health care to patients in rural jails, hospice care, and most recently, also to augment school health services by allowing school nurses to consult with physicians. Telemedicine Applications

Named Projects Military Projects Home Health Care General Applications Telemedicine in Education Medical Education Allied Health Education Continuing Education Other Educational Applications Several telemedicine programs are being initiated in correctional facilities, where the costs and danger of transporting prisoners to health facilities can be avoided. Home health care is another booming area of telemedicine, including Japan, the E.U. and the US. 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 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. The picture below shows the different media types for different applications and need in telemedicine.

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 private insurers also will not reimburse, although some states, have legislated that they must reimburse the same as for face-to-face consultations. Other programs have negotiated with payers for telemedicine reimbursement. 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 still 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. Many current telemedicine projects side-step these and other problems by obtaining federal funds. However, in the past three to four years, federal funding has become less available for telemedicine. In 2005 the chalange will be to grant appropriation funding and make it available for future development. Some private corporations and telecommunications companies are stepping in to fill the void, however, pressure on the appropriate government and legislative agencies is needed before more funding will become available. Technology manufacturers and telecommunications companies are 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.

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. Fifteen or twenty 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 2005, telemedicine still has not reached its potential. However, information about telemedicine continually increases, there are many programs in operation since 1994, and telemedicine technology is usually included in hospital remodels or new hospitals. 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." In 2005, the potential of telemedicine, telehealth and e-health is still left to our imaginations.

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25.05.2005 Constantin Gherici Turku.