Telemedicine Applications and Challenges

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Category: Medical Technologies

Telemedicine Applications and Challenges Lakshmi S. Iyer The University of North Carolina at Greensboro, USA

INTRODUCTION Telemedicine is a function of information and communication technologies (ICT) that facilitates exchange of medical data to assist the health care industry in providing services to the society more competently. Its applications range from diagnosis, treatment, and prevention of disease, to continuing education of medical professionals, research and evaluation. Telemedicine is not a process aimed to replace traditional practices of medicine. It simply acts as a partner of the industry to reduce inadequacies in time and resources. ICT should not be viewed only as a competitive advantage of health care organizations, but rather a fundamental commodity intrinsic to the delivery of global health care (Iyer & Dey, 2005; Nash & Gremmillion, 2004). Pedigo (1997) illustrates the essence of telemedicine with the follow example: In April 1995, a student at Peking University sent an e-mail requesting medical assistance for a fellow student, Zhu Ling. Zhu Ling was experiencing rapid hair loss and paralysis. An extensive online network of physicians, toxicologists and other experts collaborated with Ling’s physician in Beijing to respond to the SOS email. With the assistance and suggestions from over 2,000 responses, the Beijing physician was able to treat Ling in the best possible way and prevent death. The Zhu Ling case was the first recorded use of the Internet to seek diagnosis and patient care from a distance. Telemedicine has the potential to help bridge the time and distance gaps that can mean life or death for some patients. It can provide live video conferencing between local, rural doctors and clinics to the necessary specialists at a major hospital or research center. These conferences can provide quick and accurate diagnosis and save both the patient and the doctor time and money. This article presents a background on telemedicine including components, applications and benefits of telemedicine, challenges and trends in telemedicine, and conclusion with some direction for future research in telemedicine.

BACKGROUND Telemedicine removes geographic barriers and is anticipated to save money by treating patients on-site rather than in an expensive hospital setting, improve patient care by giving health care providers access to teaching medicine resources,

and target services to populations that have been hard to reach (remote rural areas), expensive to serve (prisons, mental institutions), and historically neglected (urban poor). The most important benefit of telemedicine is its ability to access patient data from any remote location (Demiris, 2004). It is impossible to have specialists in all areas available at all times to any given hospital or emergency care service. There are people worldwide that live in rural and remote areas who are not able to receive the type of care they need due to their distance from the nearest facility that specializes in their illness. Moreover, in most developing countries, there is a severe scarcity of medical specialists. Lack of capital, facilities, and systems are some of the common problems faced by developing countries. Telemedicine coupled with telecommunications can provide a solution to some of the above problems. The U.S. Department of Defense has been using telemedicine technologies to support their operations in Saudi Arabia, Kuwait, Somalia, Haiti, Cuba, Panama, Croatia, and Macedonia (Garshnek, Logan, & Hassell, 1997). The telemedicine project in the Persian Gulf in 1993 had computerized tomography (CT) scanners installed in transportable modular military hospital units and deployed in the Saudi desert just south of the Iraqi and Kuwaiti borders. During Operation Restore Hope, physicians in Somalia were able to communication and share medical data with specialists in Washington DC. Telemedicine has always played an important role in astro medicine as well. From the 1960s, astronauts have been monitored by groups of medical specialists through telemetry during the space operations. Currently, NASA is making efforts to hold conferences in the micro-gravity environment between astronauts on the orbiting space-crafts and the medical specialists on earth (Garshnek et al., 1997). These one-way video and two-way audio conferences would make a phenomenal difference in the safety and security of the astronauts on board. Treatment of inmates in the prison (Cooper, 1997) is another application of telemedicine. It helps to maintain a secure prison system by minimizing movement of the prisoners in case of a medical problem. The state of Iowa has implemented a telemedicine project via which medical staff of the prison can consult with doctors at the University of Iowa through a two-way video conference. This system transmits captured images letting physicians located at a remote place view a patient’s ears, throat, or skin. It also

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Telemedicine Applications and Challenges

enables sharing of x-rays and other information to help with diagnosis and follow-up care. Telemedicine and telehealth also eliminates travel cost as well as travel delay (Jossi, 2005). Moreover, immediate real-time access to patient data gets rid of time lag and accelerates early detection of diseases that can improve overall performance of the health care industry (Jossi, 2005). Medical information shared over a network can support research collaboration by allowing researchers to exchange findings over the networks at no additional cost. Informational networks online also provide a means to establish official and unofficial educational programs over a wide area across the globe.

Components of Telemedicine The success of telemedicine depends on how effectively the capabilities of technology have been exploited to benefit the health care industry. Health care industry requirements should be analyzed carefully before considering technology as a solution. Telemedicine systems may be developed using two key dimensions: internal and external integrations (Raghupathi & Tany, 2002). Internal integration refers to technologies that are applied to integrate systems with one another within an organization. External integration refers to systems and technologies interfacing with outside organizations and agency computer systems. The fundamental telemedicine integration should be planned to allow a scope for future expansion if necessary. Scalability should be used as a valuable measuring rod for every telemedicine project. The basic components of a telemedicine project infrastructure are discussed in the following sections.

Telecommunication The first step is to ensure a network connecting all remote facilities in order to communicate with each as desired. This could vary from a basic telephone service to broadband Internet. Considering complex operations requiring huge amounts of data being interchanged across the globe in seconds between systems, telemedicine networks often require a high bandwidth. Asynchronous transfer mode (ATM) coupled with resilient synchronous optical network (SONET) has been one of the most popular configurations from the early 2000s. It offers high-quality and low-delay conditions. These systems are supported by fiber optic cables that allow data to be transferred up to 40 gigabytes per second. Mobile communication systems are also critical to telemedicine industry. This includes cordless, cellular, satellite, paging, and private mobile radio systems (Ackerman, et al., 2002). Wireless technology is the next big step for telemedicine. Wireless end users within a physician’s office, hospital building, or even medical campus can be connected with a wireless local area network (WLAN).

Interoperable Systems Interoperability adds value to the system by ensuring flexibility and cost-effectiveness (Ackerman et al., 2002). The system design should allow stations developed by independent vendors to interact with each other. Medical devices and other peripherals connected to one vendor’s station should be able to interact with that of another station created by another vendor. Systems should be further designed to allow creation of individual stations in a plug-and-play

Table 1. Telemedicine interactions and technical requirements (Adapted from Garshnek et al., 1997) Applications

Interaction Processes

Data Transferred

Min. Bandwidth Reqd.

* Telepsychiatry * Remote Surgery * Interactive Exams

Real time, one-way or twoway interactive motion video

Voice, sound, motion video, images, text

Moderate to High

* Dermatology * Cardiology * Otolaryngology * Orthopedics

Still images or video clips with real-time telephone voice interaction, ‘store and forward’ with data acquired and sent for later review

Voice, sound, still video images, text

Low to Moderate

* Distance Education * Training

One-way or two-way real-time or delayed video

Voice, sound, motion video, images, text

Full Spectrum: Low to High

* Health Info. Networks * Medical Records

Transfer of electronic text, image, or other data

Text, images, documents, related data

Low to High

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fashion from components developed by multiple vendors. Middleware is a possible solution to ensure interoperability with systems.

the patient remains at their home or any other remote location.

Computing Processes

APPLICATIONS OF TELEMEDICINE

Store-and-Forward: It is usually used for sending digital data between hosts in a telemedicine network. Images taken on digital cameras or still videos are sent as simple e-mail attachments. Depending on the data range, computing power and speed requirements may vary from two desktops connected to the Internet to a whole grid-enabled network. Real-Time Video Linking: Typically higher bandwidth communication channels (ISDN lines) are required to enable real-time processing (Biomedical Informatics Ltd., 2003). It is the basis for “face-to-face” consultation between patients and specialists located at two different parts of the world. Specialized video conferencing equipments at both locations are used to facilitate “real-time” consultation. Computing power and speed are determined based on the combination of processes involved in the particular telemedicine application. Table 1 illustrates the differences in the technical requirements of telemedicine in respect to its application.

Telemedicine enables health care providers to deliver efficient and cost effective quality care to persons at some distance from the provider. Organizations such as the European Space Agency (ESA) are providing funding for projects to support the provision of health care services in rural and remote areas (see Figure 1). The most common applications of telemedicine are telecardiology, teledentistry, teledermatology, telepathology, telepsychiatry, and telesurgery.

Telemedicine Equipment There are a huge range of devices that are used in telemedicine for acquisition, presentation, storage and delivery of medical data (Mirza 2004). In this article, a few typical equipments are discussed as follows: •

•

•

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Electric Phone Stethoscope is used to pass high quality auscultation sounds over low bit rate with switches at receiving units picking diaphragm frequency sounds. An e-steth produces phonocardiogram by digitalizing heart and lung sounds using a sound card. The relevant data is then attached to an email for transmission. Physicians opening the email attachments receive the pertinent diaphragm frequency with the phonocardiogram and sound playing in the background automatically. Telemedicine Video Imaging System assists diagnosis of patient data. Special cameras with specific features to power zoom, auto focus, frame capture, and electronic image polarization together are used for video imaging. Vital Signs Devices is typically used for homebound patients. It helps in the constant monitoring of heart rate, respiratory rate, blood pressure, and temperature of patients located in remote areas. Patient data can be transmitted to the hospital through this machine while

Telecardiology Telecardiology, along with ECG interpretation service, aids physicians by providing them with instant access to cardiac assessment. Besides direct telephone access to cardiologists, general practitioners are prepared with hand-held, automatic standard 12-lead electrocardiogram ECG transmitters. These 12- ECG transmitters allow for online cardiac consultations and ECG interpretation. A full medical report including ECG signals are sent out by the general practitioners to the cardiologists. In turn, the respective cardiologists respond to the report with their consultation to the general practitioners.

Teledentistry Teledentistry benefits patients in remote locations by allowing them to get specialized dental consultation over a network. Their dental information is electronically sent and reviewed

Figure 1. Visiting patients in their homes through telemedicine (Source: ESA, http://www.esa.int/esaCP/SEMMT0M26WD_index_0.html)


by dental specialists. Teledentistry encompasses real time and offline dental care which includes diagnosis, treatment planning, consulting and follow-up.

Teledermatology Teledermatology is the process of providing patients situated at remote locations with dermatology consultations using information technology mechanisms. Telemedicine is exceptionally valuable to teledermatology since it is visual in nature, and health practitioners other than dermatologists are poor at diagnosing skin diseases. Studies have shown that 20% of general practitioners are not able to diagnose twenty of the most common dermatological problems.

Telepathology Telepathology is the transmission of digitalized histological or macroscopic images between remote locations. It is used for diagnostic, prognostic, quality control, research, and educational purposes. An example of a typical telepathological structure would consist of a CCD or digital camera connected to a microscope with a computer having a good graphics card and software to control the images over a network. Telepathology is an important contribution to the health care industry as it allows for faster diagnosis and consultations by pathologists located at remote places.

Telepsychiatry Telepsychiatry provides specialized psychiatry care or support from remote settings. Patients, physicians, and specialists communicate with each other by phone, fax, e-mail, the Internet, still imaging, and live interactive two-way audiovideo conferences. Video conferencing is primarily used for clinical consultative sessions. Telepsychiatry services include assessments, diagnosis, treatment, psychological testing, medico legal assessment, case conferencing and management, education, supervision, support, administration, and research. However, patient’s privacy and confidentiality of communication are vital concerns in telepsychiatry. Telepsychiatry sessions are making sincere efforts to maintain the same standards as those followed by face-to-face consultations to protect patient information.

at Harvard are conducting further research to enhance this issue. Sensors enabled to send three-dimensional information to tiny pins on the surgeon’s fingertips are being designed to let the doctors feel changes in texture or the strength of his or her grip. This technology is being developed to be used as a medium to detect lung tumors or to insert needles into delicate tissues. Telecardiology, teledentistry, teledermatology, telepathology, telepsychiatry, and telesurgery are only a few of the extensive list of applications of telemedicine. However, there are several challenges of telemedicine that it needs to overcome before being utilized to its full potential.

TELEMEDICINE CHALLENGES There are many issues involved with telemedicine that must be addressed before it can be utilized or applied to its full potential. Some of these issues include: licensure of those that provide the service over state/country lines, insurance payment issues, privacy and security, cost and accessibility, and industry-wide standards, especially relating to safety and liability (Kantor, 1997). Organizations such as the Sandia National Laboratories (www.sandia.gov) are developing secure online telemedicine techniques. Figure 2 shows Sandia’s Linda Gallagher checking her blood oxygenation and pressure with sensors connected to a state-of-the-art unit from TelAssist Corp. In general the challenges of telemedicine can be broadly categorized into the two following sections.

Figure 2. Use of online techniques at Sandia National Lab for checking blood oxygenation and pressure (Source: http:// www.sandia.gov/media/NewsRel/NR1999/telemed.htm)

Telesurgery Telesurgery is the most interesting application of telemedicine. Surgeons perform micro-surgery by manipulating the hands of a robot (Angood, 2001). Over 2,000 brain surgeries performed by telesurgery have been successful. Currently, the main problem is that the robotic tools do not let surgeons feel patients’ tissues. Researchers at the Biorobotics Laboratory 3731

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Telecommunications Challenges In rural and underdeveloped areas, where telemedicine is most needed, telecommunication technology is not up-todate. Standard telephone lines do not provide the bandwidth necessary for many telemedicine projects. In addition, setting up telecommunication channels is an expensive mission. Proponents of telemedicine are still not sure whether they can afford such a huge investment solely because cost of telemedicine projects is not yet accurately justified (Huston & Huston, 2000). Even though a large number of prison-based teleconsultations cases have been able to show cost savings, this data could not be used for reimbursement purposes considering its exclusive security and transportation expenses.

Socioeconomic Challenges Legal issues regarding physician licensing, liability, and patient confidentiality exist. As physicians are licensed by states, there is a legal problem when a physician consults across state lines. It is necessary for states to engage in interstate provisions of service in order to fully benefit from telemedicine. Currently, interstate agreements vary greatly. Several states maintain that physicians must be licensed in both the sending and receiving states. Other states have entered reciprocity agreements with neighbors. Liability is an obstacle in providing telemedicine. There is a debate related to which physician would be liable for a poor patient outcome: the primary care or the consulting physician. In the case of a poor outcome, it is not clear if the patient should file suit in the residing state or in the state the practitioner is located. Medicaid covers telemedicine consultation in only 10 states. Medicare will reimburse for telemedicine services provided in rural counties that are designated as health professional shortage areas. This Medicare provision, authored by North Dakota Senator Kent Conrad, was part of the Balanced Budget Act of 1997 (Moreno 1998). Most commercial payers do not cover routine telemedicine consultation. Physician reluctance and patient apprehension are also obstacles. Some rural physicians fear the loss of patients to urban facilities. The public and physicians worry about the impersonality of telemedicine as well. Differences in resources available, language, and literacy together with cultural differences in acceptability of telemedicine are other serious obstacles telemedicine needs to overcome.

imperatives which are dramatically changing health care delivery. Telemedicine will not only allow physicians and other health care workers to take better care of patients, but will provide patients with tools to allow them to take a much more active and effective role in taking care of themselves. There have been several measures taken to solve the issues discussed. In the United States, the Telecommunications Act of 1996 established supplements to the cost of providing the necessary structure to support the technology in some rural areas. In addition, telecommunication companies are working on projects to connect the government with education, health care and business (Brown, 2002). There are scientific advancements such as “intelligent clothing,” which monitors the condition of a patient’s health then relays that information to medical specialist. Nevertheless, these measures are still at their development stages. The full potential of telemedicine can only be understood when all or most of the barriers of telemedicine are eliminated.

CONCLUSION Developing a reliable delivery system has been slow, which contributed to the cautious pace of telemedicine in the early 90s. Reliability is an issue for some aspects partly due to a lack of industry standards. Although the technology appears as simple and as familiar as turning on a TV set, in fact multiple technical elements are involved, and users must be trained to operate the equipment. Telemedicine projects require broad-based planning, installation, and operational support. Legal and jurisdiction issues are also a concern for some types of telemedicine. If the diagnosis is incorrect, who is liable: the consulting doctors or the one that is present with the patient? Which state or country is responsible? Who gets paid by the insurance company and how much? These are questions that are still being considered for the future of telemedicine.

REFERENCES Ackerman, M., Craft, R., Ferrante, F., Kratz, M., Mandil, S., & Sapci, H. (2002). Chapter 6: Telemedicine technology. Telemedicine Journal and eHealth, 8(1), 71-78. Angood, P. (2001). Telemedicine, the Internet, and World Wide Web: Overview, current status, and relevance to surgeons. World Journal of Surgery, 25(11), 1449-1657.

TELEMEDICINE TRENDS

Biomedical Informatics Ltd. (2003, December). Telemedicine. Retrieved April 15, 2004, from http://www.biohealthmatics.com/healthinformatics/telemedicine/telemed.aspx

The full scope of telemedicine is currently being defined, but its future will be driven primarily by the new economic

Brown, N. (2002, May 03). About telemedicine: What is telemedicine? Telemedicine Research Center. Retrieved

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April 15, 2004, from http://trc.telemed.org/telemedicine/ primer.asp Cooper, R. M. D. (1997, Spring). The University of Iowa Launches Telemedicine Project with Department of Corrections. Health Connections, 4. Retrieved April 15, 2004, from http://telemed.medicine.uiowa.edu/TRCDocs/Pubs/ 4HC/4hc11.html Demiris, G. (2004). Electronic home health care: Concepts and challenges, International Journal of Electronic Healthcare, 1(1), 4-16. Garshnek, V., Logan, J. S., & Hassell, L. H. (1997). The telemedicine frontier: Going the extra mile. Space Policy, 3(1), 37-46. Huston, T. L., & Huston, J. L. (2000). Is Telemedicine a Practical Reality? Communications of the ACM, 43(6), 91-95. Iyer, L. S., & Dey, D. (2005). Global healthcare applications: Telemedicine. Fortune Journal of International Management, 1(1), 57-71. Jossi, F. (2005, February). Telehealth. Retrieved July 22, 2005, from http://www.healthcare-informatics.com/issues/2005/02_05/cover.htm#telehealth

Pedigo, T. L., & Sr, M. D. (1997, October). Musings on telemedicine. Retrieved February 22, 2004, from http://medicalcomputingtoday.com/0opmusetelemed.html Raghupathi, W., & Tan, J. (2002). Strategic IT applications in health care. Communications of the ACM, 45(12), 56-61.

KEY TERMS ICT (Information and Communication Technologies): Includes computers, software, peripherals, and connections that are intended to fulfill information processing and communications functions. Internet: A computer network consisting of a worldwide network of computer networks that use the network protocols to facilitate data transmission and exchange. ISDN (Integrated Services Digital Network): A system of digital phone connections that allows voice and data to be transmitted simultaneously across the world using endto-end digital connectivity. SONET (Synchronous Optical NETwork): The standard for synchronous data transmission on optical media.

Kantor, M. (1997, January 31). Telemedicine report to Congress. Retrieved April 15, 2005, from http://www.ntia.doc. gov/reports/telemed/index.htm

Telehealth: The use of ICTs to deliver health and health care services and information over large and small distances.

Mirza, K. (n.d.). LastByte – Health goes digital: Telemedicine. Bytes for All. A Voluntary Online Initiative from South Asia. Retrieved on April 15, 2004, from http://www.bytesforall. org/7th/lastbyte.htm

Telemedicine: Derived from the Greek ‘tele’ meaning “at a distance” and the present word “medicine” which itself derives from the Latin “mederi” meaning“healing”.

Moreno, D. (1998, April).What is Telemedicine? The UND Center for Rural Health: A collaboration between the North Dakota State Data Center and the Center for Rural Health. Retrieved April 25, 2005, from http://www.med.und.nodak. edu/depts/rural/pdf/whatistele.pdf Nash, M. G., & Gremmillion, C. (2004). Globalization impacts the healthcare organization of the 21st century, Demanding new ways to market product lines successfully. Nursing Administration Quarterly, 28(2), 86-91.

Teleradiology: A means of transmitting radiographic patient images and consultative text from one location to another with the use of ICTs. Telesurgery: The use of medical technology such as robotics, sensory devices and imaging video that allows a surgeon to operate long distance. This technology provides doctors the full sensory experience of hands-on surgery.

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