Telemedicine, the application of telecommunications technology to health care, requires the integration of technology, tools and training with medical care practices and problems. Although it is not necessary to be an expert in all these components to effectively use a telemedicine system, only through cooperation among health professionals, computer system developers, telecommunication providers, and educators can telemedicine achieve its potential to improve the delivery of health care, particularly in rural or remote areas.

The purpose of this course is to introduce students in the health sciences (including nursing, medical technology, and medicine) to the fundamental concepts of telemedicine, including:

• Basic principles of telecommunications and internetworking of computer systems;
• Use of communications software, including electronic mail and browsers for the World-Wide Web;
• Forms of telecommunications, including videoconferencing, remote data monitoring, and file transfer, applicable to medical care in remote or rural environments.

These concepts will be demonstrated through lecture and by examples of existing telemedicine systems developed by local, regional, national, and international organizations. Among the systems that will be discussed and demonstrated are:

Other projects will be discussed and reviewed as time permits.

Imagine this: a nationally known neurologist is conducting rounds at the hospital in Thermopolis , Wyoming, as she does every two weeks. After pulling up the latest X-rays and lab results on her computer for a particular patient who has come in for a consult, the doctor asks a physician's assistant to describe the patient's worsening tremor. The doctor then asks the patient to walk across the room, touch her nose, and write her name. After watching the patient, the doctor and the PA make a firm diagnosis, discuss a plan for treatment, and arrange a follow-up visit. Her rounds complete, the doctor looks out her office window in Cheyenne, thinking about her rounds in Sundance tomorrow, while the patient drives back to her ranch outside of town.

Telemedicine literally means medicine at a distance. It is more narrowly defined as the integration of telecommunications, information, human-machine interface, and medical-care technologies for the purpose of enhancing the delivery of health-care. It can include the transfer of basic patient information over computer networks (medical informatics), the exchange of images such as radiographs or pathologies among geographically separated specialists, remote patient interviews and examination through videoconferencing and remote monitoring, and educational activities. With the rapid growth in telecommunications and computer technology over the last few years, telemedicine has become an important part of medical development, with the potential to greatly improve the quality of future health care.

People living in remote or rural environments have limited access to basic health care. Geographic isolation, the scarcity of physicians and clinics, and the difficulty of travel to larger cities where such care is available are among the factors limiting this access. Efforts to encourage physicians and other health professionals to establish practices in underserved areas have only been partly successful.

Telemedicine is one way in which more and better health care can be delivered to such remote areas, both in the United States and throughout the world. The technology exists allowing health professionals to examine patients through video links to remote clinics, to view medical images and patient records electronically transmitted from one location to another almost instantaneously, even to review from afar the results of biopsies or vital signs from a patient during an operation.

Telemedicine can also be used for educating health professionals in rural or remote communities, and to give them access to up-to-date or specialized information that might otherwise be difficult to obtain in a timely manner. It can be used in public health programs and to assist local organizations in health-related campaigns such as accident prevention, pre-natal care, etc. It may even be useful in developing more cost-effective methods of providing health care in private clinics or managed-care organizations, which present difficult computer integration and communication challenges due to their size and geographic distribution.

There are studies on the specific benefits of telemedicine to the health care industry and on plans for its use:

• A recent report by Arthur D. Little, Inc. revealed that telecommunication technologies could reduce healthcare cost in the United States by $36 billion each year through the deployment of selected telecommunications applications nationwide.
• The Health Care Financing Administration's study at Georgia indicate that physician referrals may be reduced as much as 80% by connecting primary care physicians with specialists.
• Preliminary results for cases in which communication between physicians was used in a Texas prison system suggest that 70% to 80% of patients do not require additional referral.
• According to the 1995 HIMSS/Hewlett-Packard Leadership Survey, more than 80 percent of the respondents are either using or planning to use multimedia technology in their organizations. The most significant uses cited for multimedia technology in health care are education (42 percent) and remote diagnostics (32 percent).
• The HIMSS survey also revealed there is significant interest in telemedicine technologies among respondents. Nearly two thirds say they've invested already, or it's a priority.

Like telemedicine, the word "telecommunications" is based on the Greek root tele (at/over a distance); generally, telecommunications means the electronic transmission of information over a distance. There are several forms of telecommunications that most of us take for granted today, including telephones, radio, and television. With the advent of computers, satellite communications, and computer networks, however, many new forms are becoming more commonplace: electronic mail, videoconferencing, file sharing, even remote control over tremendous distances (such as the Sojourner robot that is part of the Mars Pathfinder mission).

Only three things are necessary to achieve communication: a sender, a receiver, and a medium that transmits information from the first to the second. This is true even in human, face-to-face conversation! (What is the medium here? If you are speaking, it is the air that carries sound waves from you to your listener; if you are gesturing or using sign language, it is light, which carries the image of your movements.) However, to support long-distance communications (i.e., farther than your voice or vision will allow you to hear or see someone), technology is necessary. Electronic devices like telephones, TV cameras, or computers allow you to create information that is then transmitted through media such as cables, satellite systems, or computer networks.

Most of these systems interpose switches or routers in the medium that relay information from one intermediate point to another, deciding along the way how to get an electronic message to its intended destination in the best manner. These decisions are made with the help of communications protocols, which are simply standards for information transfer that all senders, receivers, and routers involved in a transmission agree to use. (These protocols are the reason that you can talk to someone using a different long-distance telephone service than you do, or why you can send E-mail to a friend, even if you're using a Macintosh and he/she is using a PC.)

Much of the interest in telecommunications recently has come about because of the phenomenal growth of the Internet, which is a term for the tens of thousands of interconnected networks from academic, military, government, and commercial entities worldwide. The agreement by all users on specified protocols for communication on the Internet allows any computer with an Internet connection to communicate with any other connected computer, no matter where each of them are. The Internet encompasses millions of computers and several different media, ranging from telephone lines to fiber-optic links to microwaves to satellite transmissions.

It should be noted that "Internet" with a capital "I" refers to a specific world-wide collection of networks that is managed by a private consortium of universities and commercial companies. (Development has started on "Internet 2," a new internet to be managed by the U.S. government, among others, that will focus on research and science. Other internets can exist; if these interconnected networks are completely internal to an organization or company, they are sometimes called "intranets" to distinguish them from "the Internet.") The Internet itself originated in 1969 as an experimental network of 4 computers at UCLA by the Advanced Research Projects Agency (ARPA) of the U.S. Department of Defense. The goal of the project was to develop a communications system that could withstand a nuclear attack. The idea was to use computers to send messages from anywhere to anywhere, eliminating the need for a central command post and creating a communications system that could operate even if large portions of the "network" were destroyed.

Access to the Internet requires very little -- a computer, a modem or networking hardware, a network link (direct: university, employer, commercial link or on-line service: AOL, Prodigy, CompuServe, MS Network), and driver software. This collection of technology allows a computer in one place to access files on another computer; requests and responses are sent through gateways to remote sites. The software that controls the network finds the various sites by name and domain (.gov, .mil, .edu., .com) and sets up a connection between the requesting computer and the responding one.

The Internet (and most other internets) support telecommunications in a number of ways. The ability to compose, send, and receive electronic mail between users has been around since the early days of ARPANET. Newsgroups are specialized forums in which users with a common interest can exchange messages on technical and nontechnical topics. (Chat rooms are real-time, interactive versions of newsgroups, where people can send messages back and forth to those who are connected to the "room" at that time.) Using programs such as "telnet" or "rlogin," users on the Internet can perform a remote login on any other connected computer, as long as they have authorization and an account for that computer. A user can also make copies of files from other computers onto their own, using programs for file transfer such as FTP.

Even with all these features, most of which have been available for several years, usage of the Internet was pretty much the province of research groups, universities, and a few big companies until 1989, when a group of high-energy physics researchers at a University in Switzerland developed a technology for distributing results over the Internet. This technology evolved into the World-Wide Web, which many people today think is synonymous with the Internet itself. Certainly, Web technology has driven the transition of the Internet from an academic research tool to a household word.

Soon after the Web's introduction, organizations with Internet access began providing Web sites as a means of presenting information to "surfers" both local and global. With the privatization of the American Internet, providing commercial space on the Web became a very important part of maintaining it. Today, many big and small companies are using the Web for marketing and other commercial applications. In addition, there are incredible amounts of information available through the Web and other Internet sites (examples: art, science, personal data, resumes, forms, ...). Web "pages" now support not only text, but images, sound, video, even interactive (live) communication.

• 23% are using the Internet.
• 17% are on the WWW.
• 73% of WWW users search for information about products and services.
• 5.6 Million people or 15% have purchased online!

By health care, I mean the diagnosis and treatment of illness. (It should be noted that the author is NOT a health-care professional, and so this description is by necessity a very coarse one.) The diagnosis of illness involves two basic tasks: the collecting of information about the patient (both current and previous conditions) and the analysis of that information to arrive at a conclusion about the causes of the illness. Once the illness is diagnosed, then treatment consists of determining the best course of action to ameliorate or improve the patient's condition.

To see how telecommunications can benefit health care, consider first the gathering of information about the patient's health. This is done in three basic ways:

• A patient's previous medical history is available as part of his/her patient records.
• A patient's current condition is interpreted through examination or observation by a health-care professional, as part of a routine check-up, office visit for a specific problem, emergency assessment at the scene of an injury or event, etc.
• Laboratory tests, including blood work, EKGs, X-rays, etc., provide additional information about specific conditions that usually cannot be observed externally.

Obviously, videoconferencing can be used in other ways. Many health-care professionals take advantage of the knowledge of others in the diagnosis and treatment of difficult cases, either by individual consultation with specialists or through medical "boards" that meet regularly to discuss new findings or unusual conditions encountered. With the right supporting technology, such consults and meetings can take place in cyberspace; videoconferencing allows interactive meetings to be held without the participants being in the same room. When interactive discussion is not necessary, E-mail or video recording could be used for asynchronous discussions, where one person can "post" a query and others respond to it at some later time. Responses can be directed to the individual making the query or to the entire group (in essence, this is how a newsgroup functions).

Many computer and telecommunications technologies exist that can enhance health care. However, it is essential that health-care professionals take the time to learn about the possible applications of these technologies and their usefulness in the proper circumstances. It is also important that technologists and scientists in the computer and telecommunications fields learn to work with people in the health-care industry and educate them about these possibilities, while learning about the technology with which theirs will be integrated. By developing the appropriate technology and tools in cooperation with trained health-care personnel, it is clear that great improvements in the delivery of medical services to rural and remote areas can be made.

That is not to say that challenges do not exist, however! There are several barriers inherent in overcoming distance in delivering health care -- technological, political, and professional. Among them:

1. Infrastructure planning and development. It is unusual for health-care applications to be considered in planning and developing new telecommunications and information technology. Policy makers at the state and national level must consider needs and solutions for multiple agencies and activities, both for cost sharing and avaoiding redundancies.
2. Telecommunications regulation. Competition for telecommunications services, particularly in rural areas of the US, has resulted in arbitrary boundaries between service areas and high costs for transmission services of the power needed to support telemedicine. Small users lack sufficient market power to negotiate favorable rates and service.
3. Reimbursement for telemedicine services. There is no clear and consistent policy at the national level that allows the costs of telemedicine systems to be reliably covered, but public and private payers are reluctant to set reimbursement policy at a lower level until more viable applications for telemedicine are developed.
4. Licensing and credentials. Currently, health-care professionals must satisfy numerous requirements to obtain a license to practice in each state and credentials to practice at individual facilities. The costs and adminstrative burdens of interstate practice are hard to justify, given the existing frequency of telemedicine consultations and examinations.
5. Malpractice liability. There is great uncertainty about whether malpractice insurance covers telemedicine services, particularly when those services cross state lines. Choice of venue and law issues have significant financial implications for parties involved in such litigation.
6. Security and confidentiality. While the Internet is a marvelous medium for transmitting information between remote computers, it is notoriously susceptible to security problems. Since confidentiality of patient information is a foundation of medical care in this and most other countries, the problems of keeping information transferred between computers away from unauthorized access must be solved.
7. Reliability of research on the Internet. The Internet's ease of access makes the publication of new results much faster and easier than through the time-honored method of journal articles. However, there is, as yet, no way to assure that information published on the Internet is reliable, or even true. Anyone with an Internet connection can set up a WWW site and publish anything he/she wants to write up. Therefore, research "results" on the WWW or other Internet service should be scrutinized carefully before being used.
8. Speed of communication. The Internet carries millions of pieces of information every minute, and demand gets larger all the time. Some critics have predicted the eventual collapse of the Internet frome the traffic it is forced to carry; already, there have been hours- or days-long outages among some service providers, and a recent error by the organization that manages the WWW's domain name service made most Web sites inaccessible for over 24 hours. Even when operating at full speed, it is difficult for the Internet media to transmit large amounts of information (like that needed for videoconferencing) at sufficient rates to avoid delays and degradation of the images or sound. New networking media is capable of carrying more information at faster speeds, but it will be a long time before such speed is available to remote areas of the Internet's world.

While these challenges are difficult, they can be overcome with cooperation among health-care professionals, technology specialists, and federal and state governments. Such cooperation is the key to telemedicine's achieving its potential to improve health care, not only for residents of rural areas in the US, but people everywhere.