Currently, computer technology is helping medical personnel in delivering more efficient health care in lesser amounts of time and consequently at lesser expenses. Existing technology is helping in faster and better diagnosis and management of a patient even if the concerned specialist is physically located several thousand kilometres away.

Distance is no barrier to better diagnosis and management of a patient with this technology. It is envisaged that the consulting doctor would be physically located at great distances away from the patient and still be able to not only see, speak, diagnose and treat but also operate on the patient through telerobotics. In fact telepresence surgery, as detailed above, is already a reality. One could sit in the comfort in one's home and yet actively participate in the training process of any emerging medical technique being carried out at a place which is half-way round the globe. You will be able to ask questions and the surgeons at the other end can answer right back to you. So, it is a technology that would allow better trained doctors to be present anywhere on a continued process.

Telemedicine or "healing by wire" (Time Magazine)] is the term given to the u se of modern telecommunications and information technologies for the provision of clinical care to individuals located at a distance and to the transmission of information to provide that care. In other terms, it is remote telematic health care.

Though some refer to this application of information technology as being 'futuristic' or 'experimental', telemedicine with all the technological gadgetry, as we have come to recognize it today, actually enjoys a history that dates back to the 1950s, starting with pioneering projects at universities, hospitals, and a Red Indian reservation. Telemedicine systems today, of equivalent competency and relevancy, operate in many countries besides USA. Since the early part of 1990s, this technology is fast becoming a much favoured tool in enriching the ever widening repertoire of the medical specialist.

Telemedicine is not one specific technology but a means for providing health services at a distance using telecommunications technology, medical expertise and computer science. It spans every echelon of health care, from the first responder (e.g., GP) or emergency medical systems to tertiary (Third level - usually refers to the hospital, i.e. institutions, in medical sciences) medical specialty consultations to performing invasive and/or surgical procedures to delivering home care.

A large-body of people world-wide residing in remote and rural areas are still struggling to gain access to timely and specialty medical care. This is perhaps one of the largest failures of the international community, and a human tragedy of epic proportions. When man could be placed on the moon in early 1970s, it is iniquitous that even in late 1990s we are as yet unable to provide quality medical care to a considerable population of the world. Although WHO has made it its goal to deliver "health for all by the year 2000", that dream still remains as elusive today as it was when it was first thought of unless something radical and proactive is not initiated without delay.

Telemedicine seeks to reduce the burdens on valuable resources (particularly in those areas where they are sparse) by improving availability to medical care for those sections of the population who have sub-standard access to quality health care, no matter where they are physically located. In areas where quality health care is available, this technology would make it possible to allow access to even higher standards of health care.

The technology uses electronic signals to transfer medical data in real time from one from one site to another overcoming all geographical barriers. The medical data so transmitted may be in the forms of high resolution photographs, picto-micrographs, radiological images and scans, sounds, 'real-time' video pictures, patient records (in textual and audio-visual form), video conferencing, etc. This transfer of medical data may use the Internet, intranets, extranets, PCs (desktops, laptops, etc.), satellite and microwave link-ups, videoconferencing equipments, telephones, mobile, data/voice/fax modems, ISDN lines and ordinary or fibre-optic cables. In near future, ADSL {Asymmetric Digital Subscriber Line, which converts twisted-pair phone lines into digital "pipes" that allow up to 6.1 MBPS downstream to the client (90 times faster than ISDN), and up to 640 KBPS upstream from the client. This operates through a separate data network at the phone company's central office, and requires special modems which was about $4,000/pair in 1997, with prices dropping dramatically. Price should be competitive with ISDN. Pac Bell and GTE have recently begun ADSL trials} technology is expected to revolutionise this process further.

Already telemedicine is being increasingly utilised by health care providers by a growing number of medical specialties like dermatology (study of the diseases of the skin), oncology (study of cancerous diseases), radiology, surgery, cardiology, psychiatry and home health care. A trend in USA is the use of telemedicine in correctional facilities in which time and money for inmate transportation are reduced while safety for health care personnel and the public at large is concomitantly increased.

The technology is also expected to fine tune the overall management of health care and resource allocation for remote health care emergency programs by transmitting images to medical centres for long distance evaluation by the appropriate medical personnel. It will permit medical professionals conducting clinical research to be linked together despite geographical separation, sharing patient records and diagnostic images while exchanging information online on a video/tele-conferencing basis. Improvement of medical education in the form of continuing medical education is also made possible by linking several community hospitals together with the sponsoring medical institution.

In summary, telemedicine is a high-tech solution to the universal problem of access to health care. Due to this technology, geographical isolation need no longer be the insurmountable obstacle that was present to catering to the basic needs of timely and quality medical care.

By the term telemedicine network, one refers to a set of functional relationships among telemedicine facilities, which in turn refers to locations where telemedicine services are provided and/or received.. A telemedicine network usually contains a hub and at least one spoke, but may contain multiple hubs and spokes. A network can contain several different projects with distinctly separate funding sources. As a sum of all these parts, the network provides and obtains telemedicine services such as consultations. [Top]

History

While the explosion of interest in telemedicine since late 1980s makes it appear that it is a relatively new use of telecommunications technology, the truth is that telemedicine, within its wide definition of 'distance healing', has been in use in some form or other for more than sixty years.

Telemedicine, in its crudest possible forms were practiced when ship-to-shore communiqué's took place for quarantined ships and ships having ill sailors/passengers on them who needed medical assistance but were not enough close enough to shore to allow the ship to seek that assistance from a medic in person. Most of these communications were carried out through the wireless via Morse code. Then came the age of the radio which allowed voices to be transmitted back and forth. This technology was put to excellent use by the flying doctors of the Australian outback. With the advent of telephone things certainly became easier and simpler.

But nothing perhaps has contributed as immensely as has been the quest of man to go gallivanting around in outer space. When manned space missions were launched, the mission controllers on ground had to know all that was going on aboard the space craft, particularly how the various life processes behaved in the weightless environment. Thus the R&D people at the space agencies had to devise ways and means to 'see-listen-hear' in such a fashion that would make it appear that the mission controllers are not actually several hundreds and thousands of kilometres away but as if they were sitting inside the space craft along with with the astronauts. Thus came all the innovations, inventions and discoveries that has made telemedicine and telematics in health care a reality today.

The efforts of the various space administrations in telemedicine began in real earnest the late 1950s. These early efforts and subsequent enhancements in communications satellites fostered the development of telemedicine and many of the other medical devices in the delivery of health care as are available today. NASA provided much of the technology and funding in the USA for early telemedicine demonstrations. There were however several other pioneering efforts not only in the US, but all over the world.

A few of these are ut infra:

1. Space Technology Applied to Rural Papago Advanced Health Care (STARPAHC)} programme, where a van staffed by two paramedics carried a variety of medical instruments including electrocardiograph and x-ray. The van was linked to the Public Health Service hospital and another hospital with specialist by a two-way microwave telemedicine and audio transmission;
2. Nebraska Medical Centre at the Nebraska Psychiatric Institute was one of the first facilities in the USA to have closed-circuit television in 1955. In 1964 a two-way link between the psychiatric institute and Norfolk State Hospital were set up, almost 180 kilometres apart. The psychiatric institute also experimented with group therapy. The link was used for education, and for consultations between specialists and general practitioners. In 1971 the Nebraska Medical Centre was linked with the Omaha Veterans Administration Hospital and VA facilities in two other towns;
3. Massachusetts General Hospital/Logan International Airport Medical Station which was established in 1967 to provide occupational health services to airport employees and to deliver emergency care and medical attention to travellers. Physicians at MGH provided medical care to patients at the airport using a two-way audio-visual microwave circuit. The medical station was staffed by nurses 24 hours/day, supplemented by in-person physician attendance during four hours of peak passenger use. Evaluation of diagnosis and treatment of the nurse-selected patients was made by participating personnel and independent physician observers. Analysis was also made of the accuracy of microwave transmission. Inspection, auscultation, and interpretation of x-rays and microscopic images were also performed quite satisfactorily. Necessary hands-on procedures were however performed by the nurse-clinicians;
4. Alaska ATS-6 Satellite Biomedical Demonstration that took place in 1971, the primary purpose of which was to investigate the use of satellite video consultation to improve the quality of rural health care in Alaska. Satellite ground stations permitting transmission and reception of black and white television were installed at four locations, and a receive-only television capability was installed at the Alaska Native Medical Centre in Anchorage. All five sites had two-way audio. Two of the locations had no resident physician. Simultaneous two-way video capability was not available, although the one-way video could be switched for transmission from any site except Anchorage. The project established that the satellite system was workable, could be used effectively by health aides at the various locations, and could be used for practically any medical problems except emergency care (emergencies could not wait for scheduled transmission times). It was also determined that the "unique capabilities of the video transmission may play a critical role in 5-10% of the cases selected for video presentation. Otherwise, there was little measurable difference between the effect of video and audio consultation";
5. In a further study conducted by NASA in 1974 to determine the minimal television system requirements for telediagnosis established the fact that there was no significant difference in remote treatment designations as a function of TV system type that would cause detriment to patients;
6. The Memorial University of Newfoundland (MUN) was an early participant in the Canadian Space Program. Since 1977, The Telemedicine Centre at MUN has worked toward developing interactive audio networks for educational programs and the transmission of medical data. Among the guidelines followed were: use the simplest and least expensive technology; be flexible; involve the users from the beginning of the project; seek administrative support in hospitals, clinics and other agencies; and include evaluation. The MUN project has been an effective demonstrative model for the judicious and low-cost use of telemedicine technology. They have proven that many times there is no need for the higher-end, higher-cost video-conferencing equipment;
7. The North-West Telemedicine Project set up in 1984 in Australia to pilot test a government satellite communications network (the Q-Network). The project goals were to provide health care to people in five remote towns south of the Gulf of Carpentaria. Two-thirds of these people were Aborigines or Torres Strait Islanders. The Q-Network consisted of 20 two-way earth-stations and 20 one-way (television-receivers only) earth stations. The hub of the network was the Mount Isa Base Hospital. All sites were supplied with a conference telephone, fax, and freeze-frame transceivers. Evaluation for the project showed that the technology did improve the health care of these remote residents. While it was impossible to calculate the operating costs of the telemedicine network separate from the other functions of the network, some health care costs were reduced. Fewer patients flew to and from these remote areas for routine consultations, and fewer patients were evacuated for emergency reasons. [Top]

The Changing Face of Telemedicine

Telemedicine is a technology that permits medical data to be stored, retrieved, exchanged and analysed with ease anytime anywhere. With all the tools, both hardware and software, already in place and continuously arriving in the market by the day if not b y the hour, telemedicine is not destined to remain merely the high value offering to the patricians by the elitist providers as it currently is. It's proper destiny is to be the value added offering to the plebeians by the GP sitting in the center of the marketplace.

Telemedicine's destiny is to be a communications device dedicated towards providing the best of available health care to anyone anytime anywhere. It's back-end is a RDBMS with a suitable front-end that is user-friendly, if anything, and is based on client-server technology. The various clients/servers are connected to the scanning machines, microscopes, analysing instruments, video cameras, scopes capable of recording even the faintest of sounds, and other equipments (e.g., ECG machines, pulse oximeters, etc.). This would allow all of the functions that telemedicine promises to be carried out and some more.

However, in order to achieve all that is possible, the different developers of the system must ensure that the various front-ends from where data is being manipulated is compatible with each other. This is the most important one, even more than other important concerns like security.

For instance, consider an electronic bill sent to a purchaser of care services as a claim for care provided to a patient. For the purposes of ensuring that the message is delivered and acknowledged, the message must contain such data items as:

• the patient identification
• the items for which payment is claimed
• the date(s) when and place(s) where these services were rendered
• the amount of payment claimed
• the identity of the account to which payment is to be made

In order to make it possible to process such claims quickly and efficiently, the various contents need to be laid out in a standard format, so that the receiving system can automatically scrutinise the message, detect errors and improbabilities, verify details (such as that the patient is insured by that purchaser, and the current reimbursement rates for those services), and dispatch funds to the correct account. In short, process the information with the greatest possible accuracy within the shortest interval of time.

It is even necessary for the structure of the data within each of those defined data elements to conform to a certain pattern. E.g., the date might be required in the 'ccyymmdd' form (e.g., 19980601 for 1^st June 1998), and the professional services rendered might be required as alphanumeric data.

Alternatively, the message from the laboratory providing the results of a request for a full blood count. This would also require a predetermined data set, laid out in a standard form, such as the Read Codes. In addition to dates., the numeric values for the various types of blood cell, together with a text report would have to be included in the message. Say the haematocrit of the patient is 45%; the figure '45' has therefore got to be incorporated into the message. It is vital that recipient should recognise this as a haematocrit value, and should not be able to mistake it for the platelet count (x 10,000) or the patient age, or indeed any other element at all. Any material that is not essential to the transmission is omitted, and the remaining content is reduced wherever possible to compact and concise the codes. In case of a full blood count message, the names of the attributes (e.g., Total White Cell Count per millilitre, or Haemoglobin in grams per decilitre) are predefined and therefore known to both sender and receiver: they are therefore not required to be transmitted. What is required is the value of that attribute in the full blood count.

Thus the following statements can be made about a message:

• every type of message has a defined purpose
• each message type requires a predefined set of data elements to fulfil that purpose
• every element has a defined meaning (e.g. ICD or as in a national data dictionary or Read Code)
• the data elements must be in a predefined position in the message, indicating to what they relate
• each data element must be presented in a predefined way (i.e., a preferred format) coupled with predefined 'dimensions' (e.g. x10,000 cells per mm³, grams/Litre, etc.)

The messages are to be kept as short as possible for four reasons:

1. to minimise network traffic and therefore peak traffic capacity required
2. to minimise connection times and therefore user costs
3. to minimise the probability of an error arising in the transmission
4. to make it easier to find an error in a rejected message

Thus one can plainly see that there are enormous number of parameters that must be harmonised into one grand orchestra capable of playing not mere chamber music but a full symphony flawlessly every time without fail.

In order to achieve efficiency maximisation of telemedicine the following points needs to be kept in mind:

• Use the simplest and least expensive technology
• Be flexible
• Involve the users from the beginning of the project
• Seek active administrative support from all the professionals who would actually be the eventual end-users
• Include evaluation so that all niggling cobwebs and bugs that always have the rather irritating habit of rearing up at unexpected times. [Top]

Key IT requirements of Health Care Enterprise

• Transparent global access
• Interoperability
• Desktop usability
• Platform flexibility
• Fast and efficient application development
• Manageability
• Investment protection [Top]

Examples of Telemedical/Combined Informatics Applications

• Networking of large health care groups, multicampus linking of hospitals and research centers, linkages among rural health clinics and central hospital(s)
• Physician-to-hospital links for transfer of patient information, diagnostic consultations, patient scheduling, research literature searches, and video programme distribution for public education on health care issues
• Use of video and satellite relay to train health care professionals in widely distributed or remote clinical settings
• Transfer of diagnostic information such as ECG/X-rays/Scans/picto-micrographs / pictures of specimens, etc. through video-conferencing among members of health care teams
• Video links between patient and physician for diagnostic interview purposes
• Capturing "grand rounds" on video for use in remote consultation, training, and for transmitting the images world-wide
• Instant access to, and aided search techniques for, gathering information from databases and/or electronic library collections
• Data warehousing allowing extensive data mining and the creation of Medical Data Marts [Top]

Elements of Success in Telemedicine Projects

• Technology
• Equipment characteristics
• Patient confidentiality
• Purchasing the right equipment
• User friendliness
• Networks
• Efficient administration
• Planning
• Marketing : both internal as well as external
• Training of staff and end-users [Top]

Minimum Requirements for Telemedicine

The following gizmos are required at the end-user level to provide as well as receive telemedicine as it is today. The list is neither exhaustive nor exclusive. Down the way of development process, without any shadow of doubt, several of the named equipments would be found to be redundant and others vital for it.

• Desktop or Laptop PC, having multimedia capabilities, a suitable pointing device (i.e., mouse/trackball/joystick) and a colour inkjet printer, or an Information Kiosk which is touch screen enabled, and a video-camera attached (plus, for the person who puts in data, which may both be the patient or his doctor, a suitable camera and/or scanner);
• A modem of 28.8 KBPS speeds or higher;
• A telephone line, preferably with fibre-optic cabling or better still ISDN line (though coaxial cables will still make do), or a mobile phone connection;
• Internet connection with e-mailing (more preferably video e-mail) facility;
• Enough computer literacy to be able to use the equipments and softwares with reasonable ease and efficiency.

The computer is used not only for the front-end for input/output of information but also for connecting to the computer at the other end. The multimedia capabilities are necessary to help process audio, video and text based information in a reasonable span of time . Long time lags are a positive disincentive for telemedicine overall as the end-users would not only get frustrated due to endless waiting while the information is exchanged and processed but also due to the very definite possibility of loss in connection as a consequence of timing out as well as high connectivity charges. The video camera is used for capturing "live" video data and transmission in real time, the display of the same being done by the computer screen. Scanners are poor substitutes for capturing still pictures/images but one is certainly better with than without. The audio is captured with suitably placed microphones and the output by the speakers. Since the microphones and speakers are an integral part of all multimedia kits, I have not mentioned them separately. Colour inkjet printers of 600 dpi (dpi or Dots Per Inch - this number represents the number of dots the printer prints per inch to represent a character or picture or whatever; the higher this number is the greater is the resolution and consequently the finer is the quality of the print; 600 dpi or better is considered to be almost laser-like in quality) or better resolution are more than adequate, there is no overwhelming need to invest in expensive laser printers that print in colour, mere black and white printers are simply not good enough, laser or not. Most of the vendors are now offering such inkjet printers at most competitive prices. Remember though, you must shop around for hardware of all descriptions if you want a good deal. If you are patient enough, you will get a very attractive equipment at the most affordable prices.

Modem, or modulator-demodulator, of an acceptable speed is necessary for connecting computers to each other via a valid telephone connection (land-based, satellite-based, and mobile). This gadget converts the signals into a suitable form which can be transmitted. The modulator part converts the signals into a form that can be transmitted, the demodulator part reconverts them back into a form that the computer can "understand". Speeds of less than 28.8 KBPS are not suitable f or transmission of 'live' video pictures and the overall transmission time is also compromised.

The description of the other equipments are self-explanatory. I have mentioned the Internet, even though I am sure that a lot of pundits will frown on this, since I feel that this network of networks can easily be used. Not only is it already in place, but also because I firmly believe that the various security concerns can be efficiently addressed without much ado.

The Information Kiosks will possibly not be able to allow any type conferencing other than solely text-based ones. Unless of course these kiosks are video and audio enabled. This would necessitate providing an acoustically secure environment. Sponsoring and/or participating organisations may however wish to significantly alter this situation by providing such machines (akin to cash/credit card points of various banks). An extra spin-off from this would be the establishment gaining a head start in strategic marketing terms.

A few might opine that a Web TV too has impressive possibilities in telemedicine. I doubt whether this technology will be good enough for all round use. In order to fully tap the complete capabilities of telemedicine, one needs to be able to interact in real time face-to-face and preferably one-on-one. Not merely to be deluged with a mountain of information, albeit with a certain degree of interactivity to some limited extent. The hardware must come armed with microphone and video cameras attached to it, a printer and a scanner helping matters further. Today, the best option is the computer-based equipment. I do concede that the TV of tomorrow would actually be a fully functioning computer in itself in all its aspects. Then Web TV or TV or computer whatever gizmo you have, they will all essentially be the same machine with the same functionalities.

Worried? Well, the prices of all the equipments are coming down dramatically with each passing quarter (i.e., three months), fibre-optic cabling and ISDN is becoming more of a rule rather than an exception for all newly laid telephone lines capable of allowing larger bandwidths for improved connectivity and speed of transmission, and the Internet usage growing exponentially. ISPs are already able to provide connections at higher than 28.8 KBPS speeds and thus multimedia applications/programmes/objects are downloadable and playable at acceptable speeds. As for computer literacy is concerned, if you are not may I take this opportunity to wish you the very best of luck. If you think you can survive the next millennium without this almost basic expertise in a world with or without telemedicine, you sadly are definitely in cloud cuckoo-land! [Top]

Telepresence Surgery, Telebridging and Telerobotics

Telepresence Surgery is a technique by which an operation may be conducted at one centre while the expert (or a panel of medical professionals) who is physically located at great distances away and yet is able to effectively guide, or hold a question-answer session with, the surgeons who are actually performing the operation.

This is achieved by telebridging, where chiefly satellite communications are used apart from other means of telecommunications, to provide audio and video link in real time between two earth points almost exclusively. Such links are mostly true and being less prone to disruptions are quite dependable. The results are quite spectacular and looks similar in appearance and impression of live television broadcast which are interactive to boot. Increasingly many medical symposiums these days are adopting this technology to make these meetings more meaningful, substantive and lively to the various participants.

Telerobotics is a step further. The main surgeon is physically located somewhere else but is able to operate on a patient using a telerobotic arm. Each and every one of his movements performed (down to finest detail) at his geographic location are captured with the help of various sensors and telemetered across a telebridge to be accurately duplicated by robotic arms located by the patient. Strategically placed video cameras shrewdly record and transmit in real time pictures of the operating area to the surgeon who views it all, including all that he is doing, on the television screen placed in front of him. It is akin to performing laparoscopic surgery long-distance.

This method of surgery is however not expected to be a winner. Just as pilot-less never became popular, one does not have much hope for pilot-less surgery either. Will you fly in a plane flown by a robot or be operated on by one? One wonders.

Robots (and not just robotic arms) that are capable of responding to verbal commands may be used too. Once can use the computer network (like the telemedicine network) to issue the commands to the robots. The downside is that it can carry out only pre-set commands which are repetitive. Hence, such machines may be excellent for providing basic nursing care, like administering oral medications (taking the right number of tablets or capsules and a glass of water to wash the medicines down one's throat), and other such actions that are essentially non-interventional. Quite possibly in very near future more efficient robots will be built that can make even more complex tasks being carried out with greater ease and efficiency. However, again, the "human touch" that every ill-person essentially craves for, will be missing and hence these equipments are not expected to be very popular in the area of health care to any significant extent. [Top]