History of Telemedicine

This unit of the History of Health Information Technology in the United States will cover the history of telemedicine. Telemedicine is a medical discipline based strongly upon information technology and is steadily gaining importance in the field of health informatics.

This presentation will review how telemedicine is defined.  We will also provide a basic history of telemedicine efforts in the United States and will provide a brief summary of the current status of telemedicine as it is today in 2010.

First, let us define telemedicine. You can pause the slides if you need time to read the definition.

Telemedicine definitions range from the technical to the strategic.  Perhaps the most detailed in regards to specification of technology is the definition used by the United States Center for Medicare and Medicaid Services, or C-M-S. This definition states, along with a basic concept of telemedicine, that at minimum, telemedicine as defined by CMS must function to provide two-way, real-time communication between the patient and provider.

A slightly different definition of telemedicine is the telehealth definition used by the United States Health Resources and Services Administration or HRSA (pronounced HERSA) Their definition is less specific regarding technical function, but includes a broader scope which includes clinical care, health education, public health and health administration.

Perhaps the most succinct, and most comprehensive, definition of telemedicine is that offered by Dr. Joseph Kvedar (pronounced KVAYDAR) of Harvard Medical School, a longtime telemedicine practitioner and advocate. His statement shares that telemedicine is the delivery of medical care independent of time and location. While the least technically specific, it provides what may be the most meaningful definition of telemedicine, as it emphasizes the value to the patient, who is the ultimate direct beneficiary of all medical services.

A frequent confusion exists between the terms telemedicine and telehealth.

Now for the history of telemedicine as both concept and application.

The integration of telecommunications into clinical medicine is the defining factor of telemedicine, and its roots carry back to the earliest days of diagnostic technology. Most individuals are surprised to learn the Willem (WILL-EM) Einthoven (pronounced like Einstein combined with Beethoven) the discoverer of the original electrocardiogram or EKG, also inadvertently created what is identified as the world’s first telemedicine link. After being denied the ability to see his patients directly in the hospital as he developed the EKG, he devised a method to transmit the early EKG over newly installed telephone lines. This connection between the hospital and his research clinic functioned perfectly. His apparatus and its performance were published in a notable article in 1906.

As telecommunications technology developed and radio use became commonplace, the populist press began to visualize new applications for the nascent technology of radio. In 1924, a radio enthusiast magazine titled  Radio News described and illustrated what it termed “The Radio Doctor” - a complete bedside unit that allowed a physician to remotely examine, diagnose, and treat a patient.

This whimsical system has surprising parallels to actual telemedicine units in use today - having two way sound and video, an electronic remote stethoscope, monitors for vital signs (NOTE: Do not emphasize the word vital.  It is like they are one word-vitalsigns), and a method for printing prescriptions.

No evidence survives that it was ever built, even though a complete circuit diagram was included in the magazine. The writer of this article and publisher of the magazine, Mr. Hugo Gernsback, went on to notoriety as a publisher of popular science fiction through the coming decades and after his death, the Hugo award for science fiction literature was named in his honor.

Telemedicine by radio persisted until the mid-20th century, most frequently applied by doctors providing advice to ships at sea using maritime radio. As television emerged nationally beginning in the 1950’s, telemedicine applications were attempted using TV. In 1955, a Nebraska psychiatric institute created and operated a successful closed-circuit television system to a hospital over 100 miles away. The video was black and white TV, the standard for the time.

Television projects became the mainstay of telemedicine through the mid-20th century. An additional notable project once again used black-and-white closed circuit TV to link the medical clinic at Boston’s Logan International airport to Massachusetts General Hospital just across the bay. Concerns over Logan Airport’s limited road and train access led to the project, and a paper published after doctors had seen 1,000 patients over the link was the first positive evaluation of the diagnostic equivalency of a telemedicine link versus in-person care.

Television remained the primary medium for telemedicine throughout the 1970s. Many pilot projects were undertaken across the United States, and most of these were funded by the United States government through agencies such as the Department of Health, Education, and Welfare or H-E-W, the Health Care Financing Administration known as HCFA (pronounced HICK-Fuh) or the Federal Communications Commission , the F-C-C..

During this time, interest in telemedicine waned as the high costs of the involved television systems limited development. As measured by MedLine citations ,a premier online source for medical research, there was a 44% decrease in research literature activity related to telemedicine when one compares the like periods 1975-1982 versus 1982-1990.

With the 1990’s came the advent and popularity of the personal computer. This spurred new interest and developments in many forms of telemedicine that were based upon personal computer software. These applications ranged widely in use across many medical specialties, but few found sustainable success.

Upon the millennium celebration in the year 2000, two factors began to drive a fast expansion and exploration of new telemedicine applications.

First of these was the development of low-cost solid state devices with high performance levels for both black-and-white and color imaging. Driven by the consumer video camera industry, the capabilities of what once were high cost imagers was now available widely. Ultimately this new generation of devices outperformed their predecessors in many ways, and at significantly lower cost.

Secondly, the widespread growth in the availability and popularity of the Internet offered new ways for computers to communicate and send digital files. With these two elements, a new generation of telemedicine systems and methods developed and began widespread application.

Federal grant support for telemedicine continued from the early television explorations of the 1970’s through multiple grants awarded through the 1990’s via many different US government agencies.

Their number and complexity grew so great that Congress requested a review of this activity by the US Department of Commerce. The outcome of the review led to the 1997 Telemedicine Report to Congress. While it was a comprehensive review of the federal projects, and worked to apply a standardized evaluation framework, it resulted in no clear conclusions and made no specific recommendations, further muddying the already unclear waters regarding the value of telemedicine to national health care.

Through the undaunted efforts of telemedicine advocates, the Telemedicine Report to Congress was updated in 2001 under a new governance that included many telemedicine organizations and practitioners. This resulted in a deeper analysis and focus on policy needs from a governmental level.

The 2001 report identified five key focus areas for policy development.  These were lack of reimbursement, legal issues, safety and related standards, patient privacy and confidentiality, and telecommunications infrastructure.

The 2001 report, unlike its predecessor, made concrete recommendations and developed action plans for specific governmental agencies for improving the policy issues. While many of these recommendations were implemented and are still ongoing, the results are mixed, but some areas have shown progress.

As we look at current major applications of telemedicine today in 2010, there are key areas which one should be aware of.

First, technologies to obtain and securely share biometric data reliably have led to applications in remote Intensive Care Unit bed management (referred to as Tele-I-C-U)  as well as home monitoring of chronic care conditions for post-discharge management and care improvement.

Second, advanced development of digital image processing has led to successful applications in radiology (referred to as Tele-radiology) as well as pathology and dermatology (referred to as Tele-pathology and Tele-dermatology, respectively). In each of these disciplines, patient images are obtained and transmitted to remotely located physicians for interpretation and diagnosis.

Lastly, advances in live two-way video has led to telemedicine applications in remote stroke patient management during emergency room presentations (referred to as Tele-Stroke) as well as many programs providing ambulatory care visits in both primary care and specialist care.

As we look to the future, telemedicine development is expected to continue.

Telemedicine’s flexibility and virtual encounter capabilities will assist us as continued pressure emerges on the United States health system for high levels of health outcomes, as well as rising patient expectations of access and convenience.

Additionally, continued progress in the development of microelectronics and telecommunications technologies will also further telemedicine’s future through lower technology costs, improved technical performance and technical range of applications, and through improved patient safety.

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