Telemedicine: an historical perspective

Telemedicine: an historical perspective

Chris Higgins, Earl Dunn and David Conrath

The use of telecommunications technologies to help deliver medical services has increased over the past few decades and is now well accepted. Called telemediclne, it involves medical diagnosis and management with the participants (doctors, nurses and patients) in different places. The practice

is not new and follows closely behind technological developments. This pap er traces its use from the beginning of the twentieth century to the present day. Topics covered include the major telemedicine projects, their Impact and the lessons learned from them. A summary of the characteristics of the various technologies Is included. Keywords: Telecommunications; medicine; Health care

Teie-

Chris Higgins is Assistant Professor in the School of Business Administration, University of Western Ontario, Canada. David Conrath is Professor at the Department of Management Sciences, Faculty of Engineering at the University of Waterloo, Canada. Earl Dunn is Professor at the Department of Family and Community Medicine, University of Toronto, Canada. ‘D. W. Conrath, E. V. Dunn and C. Higgins, Evaluating Telecommunication Technologies in Medicine, Artech House, Dedham, MA, USA, 1963. *D. R. Foote, E. Parker and H. Hudson, ‘Telemedicine in Alaska. The ATS-6 satellite biomedical demonstration’, Lister Hill National Centre for Biomedical Communication, Department of Communication Research, Stanford University, 1976. 3M L. Rockoff, ‘Technology in rural health care’. Commitment. Vol 2. No 4. 1977, PP 24-29. 4T. Ft. Willemain and R. G. Mark, ‘Models of health care systems’, Biomedical Science Instrument, vol 6, 1971, pp 9-l 7. 5B. Park, An introduction to Telemedicine: interactive Television for Delivery of Health Services, The Alternate Media Centre, wntinued on page 308

0306-5961/64/040307-7$3.00

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Providing health care to residents in rural and remote areas is a major problem faced by governments and the medical profession alike. At the root of the problem is the reluctance of physicians to live in remote or isolated areas. Other contributory factors include poor transport facilities, unreliable communication systems, unstable economic conditions and adverse environmental factors. Despite many attempts to alleviate the situation, such as physician-incentive plans, specialized transport facilities and the use of non-physician providers, more needs to be done. In the past decade, a field of research has developed which focuses on the feasibility, practicality and acceptability of using various telecommunication technologies to distribute medical services to underserviced areas. Called telemedicine, it is concerned with situations in which the physician and the patient or consultant are physically separated but are connected via telecommunications systems. It has been argued, and in fact demonstrated, that scarce medical resources can be distributed to underserviced areas with the aid of telemedicine systems,‘-3 thus alleviating the problems faced by rural or remote residents in obtaining medical services. This paper aims to provide a basic understanding of the development of telemedicine. Such a review is useful for several reasons: first, it teaches a better understanding of the present situation and how it was reached; second, and probably most important, it should help to prevent a repetition of past mistakes and unfruitful endeavours; third, it provides a solid basis on which to plan future developments.

Definitions

of telemedicine

Telemedicine, defined literally, means medicine at a distance. However, few researchers in the field accept this definition at face value since it would include correspondence, intermediaries carrying messages, and other modes of communication. One notable exception is provided by Willemain and Mark4 who defined it as ‘any system of medical care in which the doctor and his patient are at different locations.’ Nevertheless, most authors go at least one step further and insist that the definition should include a reference to telecommunication technologies. For example, Park’ defined telemedicine as ‘the use of two-way or interactive television to conduct transactions in the field of health care.’ Bird6 similarly defined telemedicine as ‘the practice of medicine without

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Telemedicine:

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the usual physician-patient physical confrontation, via an interactive audio-video communications system.’ Both of these authors felt that the key element was the communications technology (in this case interactive television). Other definitions are not as restrictive as this. Shinn’ defined telemedicine as ‘situations in which health care professionals use telecommunications channels to communicate with each other or with their patients, with the goal of improving in some way the delivery of health care services.’ Dissatisfied with existing definitions, Bennett et al,* coined the term ‘telehealth’, which they stated implied a broader range of health-related activities than telemedicine, including patient and provider education and administration. The review presented in this paper is selective. Our focus is on the major experiments, field trials or operating systems which contributed to the provision of health care through the use of telecommunications technology. The review is presented chronologically as far as possible. A comprehensive bibliography can be found in Conrath et al.’

Early experiences

continued from page 307 New York University, New York, 1974. 6K. T. Bird, ‘Telemedicine: concept and practice’, in R. L. Bashshur, P. A. Armstrong and Z. I. Youssef (eds), Telemeditine: Explorations in the Use of Telecommunications in Health Care, Charles C. Thomas, Springfield, Illinois, 1975. ‘A. M. Shinn, ‘The state of the art in telemedicine and the need for research’, in Bashshur et al, op tit, Ref 6. ‘A. M. Bennett, W. H. Rappaport and F. L. Skinner, Telehealth Handbook, US Dept of Health, Education and Welfare, 1978, PHS 79-3210. w. Einthoven, ‘Het Telecardiogram’, Nederl Tijdschr v Geneesk, Amsterdam, 1906, pp 1517-1547. “0. B. Learning and A. G. Smith, ‘The flying surgeon service of Queensland’, Medical J Australia, Vol 1, No 8, 1970, pp 387-90. “J. Gershon-Cohen and A. G. Cooley, ‘Telognosis’, Radiology, Vol 55, 1950, pp 582-587.

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One of the first uses of modern communications technology in medicine occurred in the early 1900s. Einthoven, the developer of the electrocardiogram, transmitted heart tracings via telephone lines from the local hospital to the laboratory where his string galvanometer was located. In 1906, in a paper entitled ‘Het Telecardiogram’, Einthoven described his system and indicated he could anticipate events before the attending physician. ‘Thus we are able, to the great surprise of Professor Nolan, to warn him telephonically an instant before he was to observe a dropped beat.” For both technical and political reasons, one of the earliest uses of the radio was for emergencies on ships at sea. By 1912 regulations required all ships with more than 50 passengers and/or crew to have a radio and two trained operators for medical and other emergencies. Similarly, the Australian Flying Doctor Service’” used radio telecommunications to assist in supplying outreach medical services. Gershon-Cohen and Cooley” were involved in the 1940s in transmitting roentgenographs over telephone lines. This process, which they labelled ‘telognoses’, transmitted facsimiles of X-rays using a modified wire-photo transmitter. The experiment was considered a success. The authors stated that in two years of operation the radiologist never made an error because of an impaired image. Furthermore, they concluded almost prophetically that: we have had sufficient experience with this first experimental

model during the past two years to venture the prediction that if and when this service can be supplied at low enough cost it will become a useful tool for the small rural hospital in obtaining full-time expert radiologic services for its staff.

These and other sporadic instances of experimentation occurred throughout the first half of this century but it was not until the late 1950s and the early 1960s that a concerted effort was made to use technology in the delivery of health services.

Modern developments Table 1 summarizes

the major telemedicine

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Table 1. Modern pro/ects.

j2R A. Benschoter, C. L. Wittson and C. G. Ingham, ‘Teaching and consultation by television’, Mental Hospitals Magazine, Vol 16, 3 March 1965, pp 99-100. I%. L. Wittson, D. C. Afflect, D. Craig et al, ‘Two-way television in group therapy’, Mental Hospitals Magazine, Nov 1961, pp 21-23. 14C. L. Wit&on and R. Benschoter, ‘Twoway television: helping the Medical Centre reach out’, Amer J Psychiatry, Voll29, NO 5, Nov 1972, pp 136-l 39. 15K T. Bird, ‘Cardiopulmonary frontiers: quaiity health care via interactive television’, Chest, Vol 61, No 3, March 1972, pp 204-05. ‘%. L. H. Murphy, D. Barber, A. Broadhurst and K. T. Bird, ‘Microwave transmission of chest roentgenograms’, Amer Review Resp Disease, Vol 102, No 5, Nov 1970, pp 771-77. “R. L. H. Murphy, T. B. Fitzpatrick, H. A. Haynes, A. Harley, K. T. Bird and T. B. Sheraton, ‘Accuracy of dermatologic diaanosis bv television’, Archives Dermatol$y, Vol l-05, No 6, 1972, pp 833-35. R. L. H. Murohv. P. Block. K. T. Bird and P. Yurchak, ‘A&&racy of cardiac auscultation by microwave’, Chest, Vol 63, 1973, pp 578-81. 19R. L. H. Murphy and K. T. Bird, ‘Telediagnosis: A new community health resource’, Amer J Public Health, Vol 64, No 2, Feb 1974, pp 113-19. 20D. J. Seibert, ‘INTERACT: A decade of experience using two-way closed circuit television for medical care and education’, Final report submitted to Lister Hill Centre for Biomedical Communications, Washington, DC, USA, 1977. “D J. Seibert, ‘The provision of speech therapy and dermatology consultations via closed circuit television’, Report HSM-11 O72-387, Bureau of Health- Services Research. US Public Health Service. Deot of Health ‘Education and Welfare, 1977. ’ “C. Solow, R. J. Weiss, B. J. Bergen, C. J. Sanborn and R. J. Chapman, ‘24-hour psychiatric consultation via TV’, Amer J Psychiatry, Vol 127, June 1971, pp 120123. 23R. L. Vinikoos and J. Persault, ‘Alcohol

References

Project

Location

Date begun

Wiltson

Nebraska

Logan Airport

Boston

1961 1966

12-14 6, 15-19

INTERACT Willemain, Mark Dade County Prisons WaterloolToronto

New Hampshire Boston Florida Toronto

1966 1972 1973 1974

Alaska Project

Alaska

1974

20-23 53. 54 25 1,26-30 32-35 2.36-39

STARPAHC University of Western Ontario Memorial University Universite de Montreal

Arizona Ontario

1976 1976

40.41 42

Newfoundland Montreal

1977 1978

4345 46-48

The modern era of telemedicine development can probably be traced to Wittson’2-‘4 at the University of Nebraska in the late 1950s. Using a black and white television system, with transmissions via a microwave network, his group demonstrated the feasibility of conducting individual and group psychotherapy over a distance. They were able to show that remote therapy was no less effective than if the therapist was physically present. They also evaluated psychodiagnoses, psychological testing, speech therapy consultations and the area of mental retardation. Wittson’s pioneering work was followed in the late 1960s by the Logan Airport Telemedicine Project in Boston under the direction of Bird.6,‘S-‘9 Using black and white television and a microwave link to the Massachusetts General Hospital, patients at the Logan airport could be assessed and treated by a remote physician. As part of a research project the first 200 patients seen were also examined in person by a physician at the remote site. In 96 per cent of cases the doctor on site concluded that the remote physician had made a correct judgement. The telediagnosis physician tended to be a harsher judge of his own ability. In only 64.5 per cent of the cases did he feel that a satisfactory diagnosis was made. It appears that, while these doctors could make accurate diagnoses via a telecommunications link, their level of confidence was lower than if they had been physically present. This is not surprising in light of their lack of experience with this method.

decades.

US Department

of Health,

Education

and Welfare

projects

The INTERACT System in New Hampshire/Vermont, USA,2&23 is one of the earliest and most successful telemedicine systems. INTERACT is a two-way microwave television and telemetry communications system established in 1968 to link seven northern New England institutions (five of which were medical facilities). Starting in 1972 three of the locations were used in research projects funded by the US Department of Health, Education and Welfare (DHEW). The Burlington to Claremont link was used to provide speech therapy for 25 children via two-way interactive television. The therapist did not feel that television impeded her rapport with the students, nor did it require an unacceptable commitment of additional time. There was also a high degree of satisfaction with the system.24 Dermatology consultations were provided from the Dartmouth-Hitchcock Medical Center to the Claremont Hospital. A total of 131 patients were treated remotely continued on page 310 during the trial phase of the project. In all cases the dermatologist felt

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continued from page 309 follow-up counselling via interactive television’, in L. A. Parker and C. H. Olgren (eds), Teleconferencing and interactive Media, University of Wisconsin-Extension, Madison, 1980. 24J. J. O’Neill, J. T. Nocerino and P. Walcoff, ‘Benefits and problems of seven exploratory telemedicine projects’, Technical report MTR-8788, The Mitre Corporation, McLean, VA, USA, 1975. 25J. H. Sanders. L. Sasmor and T. A. Natiello, An Evaluation of the impact of Communications Technology and Improved Medical Protocol on Health Care Delivery in Penal Institutions, The University of Miami, Coral Gables, Florida, USA, 1974.

she had control of the situation and stated that all lesions were discernible. Patient satisfaction was also high. INTERACT continued to operate after funding was terminated, indicating its usefulness and economic viability to the seven institutions involved. In addition to the research conducted using the INTERACT system, DHEW funded six other exploratory telemedicine projects3 involving a variety of health care delivery settings and medical applications (see Table 2). O’Neill, 24 in a report prepared by the Mitre Corporation, summarized the benefits and problems associated with these field trials. One benefit was that consultation services became available where they had not been before. It was also noted that there was no appreciable patient dissatisfaction with care given via a telemedicine system. O’Neill concluded that these projects clearly demonstrated the feasibility and usefulness of telemedicine. On the negative side, there were many legal and technical problems and dissatisfaction was expressed by some of the providers. In particular, many of the systems were too complex for the physicians to operate. Other complaints were made about the resolution, quality of the colour, location of the equipment and the interruption of the provider’s schedule to handle telemedicine sessions. In all cases it was found that the systems were used less than had been expected. Another major telemedicine project was conducted in Florida’s Dade County jails. Sanders and Sasmor*s compared the relative effectiveness of three video communications systems (black and white television, colour television, and slow-scan black and white television) to provide consultation services to inmates in Dade county jails. Each of the three detention centres was linked by one of the video systems to the Jackson Memorial Hospital. In terms of project needs, the percentage of successful consultations was 63 per cent for slow scan, 78 per cent for colour television, and 81 per cent for black and white television. The results for slow scan were due, in part, to a number of ‘technical difficulties. Overall, the systems were well received by the physicians but disliked by the nurse practitioners who felt it increased their work load. Table2. DHEW telemedicine project SUmmarY. Title

Speciality

Locations

Duration

References

Illinois Dept of Mental Health Picturephone

Mental health

Illinois 5 sites

30June 197215 July 1974

24

Lakeview Clinic Bi-directional Television

Rural group practice

Minnesota 2 sites

29 June 197229 March 1974

23, 24

Mount Sinai Wagner Cable Link

Pediatrics Orthopedics Psychiatry

New York

27June197229June 1973

24, 55

INTERACT

Speech therapy Dermatology

Vermont/ New Hampshire 3 sites

29 June 197212 October 1973

20-24. 56

BethanyIGarfield Community Care Network

Medical Laboratory Pharmacy Administration

Illinois 5 sites

29June197215 February 1974

24

Cambridge Television/ Telephone

Primary health care

Massachusetts 4 sites

27June197231 March 1974

24, 31

Ohio 2 sites

27June 1972 15 November 1973

24, 57-59

Case Western

310

2 sites

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Telemedicine: an historicalperspective University of TorontolUniversity of Waterloo telemedicine research =D. Conrath, E. V. Dunn, J. N. Swanson and P. Buckingham, ‘A preliminary evaluaBeginning in 1974 a University of Toronto/University of Waterloo team tion of alternative telecommunication sysconducted several experiments comparing alternative technologies for tems for the delivery of primary health care to remote areas’ IEEE Transactions on telemedicine,‘.2G30 as very little such research had been undertaken (for Communications, Vol 23, Ott 1975, pp two exceptions see Moore3’ and Sanders et al,“’ neither of which were 1119-1126. 27D. W. Conrath, P. Buckingham, E. V. conducted under experimental conditions). Up to that point virtually all Dunn and J. N. Swanson, ‘An exresearchers had assumed that two-way colour television was the best perimental evaluation of alternative comand most appropriate technology. Yet, given the costs involved, munication systems as used for medical diagnosis’, Bt3havioral Sciences, Vol 20, research was needed to determine whether this was true. The results No 5. Seot 1975. OD 29%30!% were somewhat surprising. When hands-free telephone, slow-scan **D. W. Conrath; El V. Dunn, W. G. Bloor video, black and white television and colour television were compared and B. Tranquada, ‘A clinical evaluation of four alternative telemedicine systems’, Bethere were no significant differences in the effectiveness of the physician havioural Sciences, Vol 22, Jan 1977, pp in the diagnosis and management of patient problems. 12-21. Based on these results a study, using a relatively inexpensive video =E. V. Dunn, D. W. Conrath, W. G. Bloor and B. Tranquada, ‘An evaluation of four system (slow scan), was begun in 1977.‘.32-3” The project linked six sites telecommunication systems for the delivin the Sioux Lookout Zone in northwestern Ontario to two hospitals in ery of primary health care’, Health SerToronto. The research included evaluations of medical consultations vices Research, Vol 12, No 1, Spring 1977, pp 19-29. (including radiology, cardiology, orthopedics, dermatology and other 30E. V. Dunn, D. W. Conrath, C. Higgins, areas), education and the social uses of the system. A cost-effectiveness H. Acton and H. Bain, ‘An operational slow study was also undertaken. This project demonstrated no direct cost scan system in a remote area’, in Barber et al (eds), Lecture Notes in MedicalInforma- savings of the system, although there were some changes in the way tion, Springer-Verlag, Berlin and New medicine was practised.’ York, 1979. One of the first evaluations of a field trial in a remote location was 31G. T. Moore, T. R. Willemain, Ft. Bonanno, W. D. Clark, A. R. Martin and R. P. undertaken by Foote et a1.2*3G39This project, which ran for nine months Mogielnicki, ‘Comparison of television and beginning in 1974, used the experimental AT!%6 satellite. Television telephone for remote medical consultaconsultations were available to some of the remote communities in tion’, New Engl J Med. Vol 292, 3 April 1975, pp 729-32. Alaska for three one-hour sessions each week. Technical problems with 32E. V. Dunn. H. Acton. D. W. Conrath. C. the equipment and the fact that the experiment interfered with their Higgins and ‘H. Bain, ‘Telemedicine links normal practice were cited by the physicians as sources of patients in Sioux Lookout with doctors in Toronto’, Canadian Med Assn J, Vol 122, dissatisfaction.36 Patient attitudes were generally favourable. Although No 4, Feb 1980, pp 484-486. the complete costs and benefits were not given, the authors concluded 33E. V. Dunn, H. Acton, D. W. Conrath, C. that the costs for live video were too high for the Indian Health services Higgins and H. Bain, ‘The use of slow scan television for continuing medical education to consider. The authors suggested that more experiments be done with in a remote area’, J of Med Educ, Vol 55, narrowband equipment (which is less expensive) to determine how June 1980, pp 483-495. effectively the needs of a remote setting could be met. %C. Higgins, E. V. Dunn and D W. Conrath, ‘Health professional attitudes toOne of the more extensive trials for remote health care delivery wards the introduction of a new technology involved mobile clinics with telecommunication links to a local hospital. into a health care system’, Canadian Med This project, known as STARPAHC (Space Technology Applied to Assn J, 29 July 1982. 35C. Higgins, D. W. Conrath and E. V. Rural Papago Advanced Health Care), provided care to an Indian Dunn, ‘Provider acceptance of telemedipopulation in rural Arizona.40.4’ One of the prime criteria was that tine in remote areas of Ontario’, J Fam health care services should be provided at a reasonable cost compared Prac, Vol 18, No 2, Feb 1984, pp 28589. 36D. R. Foote, ‘Satellite communications with alternative methods of achieving the same level and quality of for rural health care in Alaska’, J Comservice. The mobile clinic, which was equipped with sophisticated munication, Vol 27, No 4, 1977, pp 173telemedicine equipment including broadband video, was compared to a 82. 37R. Fortuine, ‘Medicine by satellite telehealth centre (with the same telemedicine technologies) and to the phone - a new breakthrough’, Alaska out-patient department at the regional hospital. The per visit costs for Medicine, Vol 18, No 5, Sept 1976, pp the mobile clinic were 34 per cent higher than for the health centre, and 72-73. %H. E. Hudson and E. B. Parker, ‘Medical 100 per cent higher than for the out-patient department. When the per communications in Alaska by satellite’, visit costs were recalculated for a less sophisticated telemedicine system New Eng J Med, Vol 289, No 25, Dee (X-ray transmission, voice and data only) the costs of the mobile clinic 1973, pp 1351-6. 3%. B. Hurlbert, ‘Health care programs for and health centre were nearly indentical, although still 45 per cent scattered populations’, Public Health Rehigher than the out-patient department. view, Nos 3 and 4. July and Dee 1975. The major problems cited by providerswith the STARPAHC project ““P. Decker and T. W. Justice, ‘Telemedicontinued

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continued from page 311 tine in a rural health delivery system’, Advances in Biomedical Engineering, Vol 3, New York, Academic Press, 1979. 41M. Fuchs, ‘Provider altitudes toward STARPAHC: A telemedicine project on the Papago reservation’, Medical Care, Vol 17, 1979, p 7. 42L. S. Carey, E. S. Russell, E. E. Johnson and W. W. Wilkins, ‘Radiologic consultation to a remote Canadian hospital using Hermes spacecraft’, J Canadian Assn Radiologists, Vol 30, March 1979, pp 12-20. 43A. M. House and J. M. Roberts, ‘Telemedicine in Canada’, Can Med Assn J, Vol 117, No 4, 20 August 1977, pp 186-a. 44A. M. House, J. M. Roberts and E. M. ‘Telemedicine provides new Canning, dimensions in CME in Newfoundland and Labrador’, Can Med Assn J, Vol 124, 15 Mar 1981, pp 801-02. 45J. M. Roberts, A. M. House and E. M. Canning, ‘Comparison of slow scan television and direct viewing of radiographic!?, J Can Assn Radiologists, Vol32, No 2, June 1981, PP 14-17. 46G. Page, A. Gregoire, C. Garland, J. Svlvestre. J. Chahlaoui. P. Fauteux, R. D&.sault,. R. Sequin anb F. A. Roberge, northern Quebec’, ‘Teleradiology in Radiology, Vol 140, No 2, Aug 1981, pp 361-6. 47G Page, J. Sylvestre, F. Roberge and J. Chahlaoui, ‘Narrowband teleradiology’, J Can Assn Radiology, Vol 33, 1982, pp 221-26. 4eF. A. Roberge, G. Page, J. Sylvestre and J. Chahlaoui, ‘Telemedicine in northern Quebec’, Canadian Med Assn J, Vol 127, NO a, act 1982, pp 707-09. 4gB. W. Gayler, J. N. Gitlin, W. Rappaport, F. L. Skinner and J. Cerva, ‘Teleradiology: An evaluation of a microcomputer based system’, Radiology, Vol 140, No 2, Aug 1981, pp 355-360. ‘OW. Rappaport and F. Skinner, ‘A laboratory evaluation of teleradiology’, Technical Report MTR-8028, The Mitre Corporation, McLean, VA, USA, 1979.

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2.5 per cent of the time) and the interruption of their already full work-load to provide television consultations. Fifty per cent of the physicians felt that face to face consultations were much better, and many of the doctors felt the system was too costly for the benefits gained. However, some of the providers stated that the increase in access to health care for a population that previously had not received such care was a major benefit of the project. In addition, the non-physician providers considered the telemedicine system a major advance. Between 1976 and 1978 the Communications Technology Satellite (CTS) programme, coordinated by the Canadian Department of Communications, funded studies in education, health, community interaction and administration. Three of these projects were medically oriented. These were conducted at the University of Western Ontario in London, at Memorial University in Newfoundland and at I’Universite de Montreal in Montreal. The University of Western Ontario programme used the Hermes satellite.42 For five months in 1976-1977 this system linked Moose Factory Hospital in northern Ontario to the University Hospital in London via a video link. In addition, the hospital was connected via an audio link to a small remote community, Kashechewan. The 112.5 separate units of work transmitted on the network involved radiology (including fluoroscopy), anaesthesia, psychiatry, physiotherapy, orthopedics and other medical specialities. This project focused on consultations, although there were some experimental educational programmes. These medical consultations were successful. Physicians were able to remotely monitor and supervise health care delivery from hundreds of miles away. The Memorial University project’s major objective was to distribute the expertise of the university health centre to the remote areas of Newfoundland and Labrador.4Hs The focus was on the education of health professionals, although there were some studies of medical consultations. Using the Hermes satellite, five sites were interconnected: the university centre in St. John’s; two sites on Newfoundland island and two in Labrador. The technology involved a one-way video/two-way audio system. A further enhancement was the development of a four-wire audio conferencing system which linked seven communities, all on the island. This system was also used primarily for educational programmes. The educational programmes were successful and the system was effective in providing updates for remote practitioners. L’Universite de Montreal developed an extensive system to interlink several hospitals, centered at 1’Hopital Sacre Coeur in Montreal, for the transmission and interpretation of EKG’s via the telephone. In addition, in 1979, using the Anik-B satellite, this group linked one of the James Bay construction centres to three locations in Montreal.-* This system was used for studies in teleradiology as well as in tele-education and teleconsultation. These studies were continued for over six months and demonstrated that radiologists and other providers could function effectively at a distance. Mitre Corporation had been conducting experiments in the field. In the late 1970s they turned their attention to slow-scan video and its ability to provide remote radiological consultations.49’50 More recently the Mitre Corporatioq has evaluated, in detail, the use of a sophisticated

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Telemedicine: Table 3. Advantages and disadvantages

of tetamedicine

an historical perspective

Systems.

Type of system

Advantages

Disadvantages

Telephone

Inexpensive Pervasive No training needed Multisites Easy switching

No visual image

Visual narrowband systems

Relatively low cost Pervasive Easy operation Visuals Multisites

No motion Less pleasing More time needed Usually no colour

Broadband television

Full motion video Most pleasing Best acceptance High quality

Hardest to operate Limited interactive sites Least pervasive Most expensive

slow-scan system for radiological services for the US armed forces.51 The system was effective and able to be used for both routine readings and emergency radiological consultations.

Discussion

5’A D. Little, functional Evaluation of the Washington Area Teleradiobgy Demonstration Project, Acorn Park, Cambridge, MA, USA, 1982. 52L. A. Parker and C. H. Olgren, Tekonferencing Technology and Applications, Artech House, Dedham, MA, USA, 1983. %. G. Mark, ‘Telemedicine system: the missing link between homes and hospitals?‘, Modern Nursing Home, Vol32, No 2, Feb 1974, pp 39-42. “R. G. Mark and T. Willemain, ‘Preliminary evaluation of the nursing home telemedicine project’, Paper prepared for the Second Telemedicine Workshop, Tucson, Arizona, 1975. ?. Muller, M. Krasner, C. Marshall, N. Cunningham, E. Wallerstein and B. Thomstad, ‘Cost factors in urban telemedicine’, Med Care. Vol 15. No 3. March 1977. .DD . 251-9. 56B J Bergen, C. Solow, R. J. Weiss, C. J. Sanborn, Ft. J. Chapman and P. Brew, ‘24-hour psvchiatric consultation via television’, Project 1 -Rl 1-MH02805-01, National Institute of Mental Health, Dee 1971. “J. S. Gravenstein, L. Berzina-Moettus, A. Regan and Y. H. Pao, ‘Laser mediated telemedicine in anesthesia’, Anesthesia and Analgesia Current Research, Vol 53, No 4, 1974, pp 605-09. ‘*B. L. Grundy, P. Crawford, P. K. Jones, M. L. Kiley, A. Reisman, E. L. Wilkerson and J. S. Gravenstein, ‘Telemedicine in critical care: an experiment in health care delivery’, J Amer College Emergency

Physicians, Vol 6, No 10, 1977, pp 43% 444. “F J. Staub, ‘OR Consultation by telemedicine’, AORN J, Vol 25, No 6, May 1977, pp 1169-78.

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Telemedicine is now an accepted method for helping to deliver health care, especially to remote areas. Many of the early controversies have been resolved and, as technologies advance, most of the present issues will cease to be important. For example, the controversy of narrowband versus broadband systems is becoming less of an issue as costs drop for the broadband systems and the capabilities of the narrowband systems increase. However, it will be a very long time before broadband transmission from a remote site to a central site becomes as inexpensive as a narrowband system (especially outside North America). Once economics cease to be an issue the questions will become task oriented. The lessons of the past ten years have taught us not to assume that any single technology is best for the task at hand. The original assumption that full motion colour television was necessary for telemedicine proved to be false. It would be a mistake to make any such assumptions for the technologies of the future. In other words, the question should be what is the best and simplest technology for doing the job. Table 3 lists some of the advantages and disadvantages of the basic systems. A more complete review of these issues can be found in Parker and Olgren.52 Many problems remain. First, there is resistance from many doctors who feel threatened by alternative approaches to the practice of medicine. Second, the initial expense in setting up telemedicine systems is high and it is difficult to justify the costs. Finally, other issues such as physician reimbursement and legal implications need to be resolved. A look at the more successful telemedicine projects gives some indication of what is left to be done. Although the main purpose may be the provision of medical care, other functions should be supported, especially education. Almost all successful systems have a large or even predominant educational component. This serves to justify the system’s existence and also encourages its use, thereby reducing much of the initial resistance. Other applications may be social and administrative in nature. The most important lesson we have learnt is to offer a range of benefits of which medical services is one component. December 1984

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