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The IMPULSE OF TELEMEDICINE
Basic telemedicine
Ann Med Milit Belg 1997; 11(4) : 161-163 / Telemedicine : technologies, costs, applications and challenges:
As we are nearing the end of a century that has
witnessed some impressive human realizations and
some radical changes in the way our society functions,
new doors are opening up for more innovations. For
the time being, biotechnologies and the “information
superhighway” are already re-modeling our
professional and social landscapes. Our increased
understanding of the living cell will change medicine
in many unsuspected ways, the increased speed of
information exchanges will impact most probably
human relations as well. At the interface of these new
fields of knowledge and experience, telemedicine
has the potential to alter the very nature of the
relationship between a patient and an health
professional. Whether technology will offer better
solutions to age-old problems or, by de-humanizing
even more an already technical relationship, create
more suffering will most probably depend on us.
Technology is never per se a solution, it is one of
many means to achieve a possible solution.
They are numerous definitions of telemedicine as will
be apparent when we will detail later some of its
aspects. The following one may sound radical but by
analogy with Alan Turing’s test for artificial intelligence
- i.e. a programmed machine that can fool a human
being into thinking he is dialoguing with a fellow
human -, telemedicine could be the environment that
could enable a patient to feel like he is actually in care
of a doctor although the latter one may be very far
away. We have to emphasize “feel”, because human
relations are not only verbal but physical, visual and
emotional. Such definition requires a technological
framework that was not present just a few years ago.
If historically telemedicine originated with the
transmission of medical data (by FAX for example) or
with communication links between remote health
care facilities, the appearance of highly reliable and
very fast communication links able to transmit huge
amounts of data (an image with a high definition can
contain millions of “pixels” or unit elements) is recent.
To be effectively usable, such links have to be nearly
universal - i.e. planetary - and the cost of data
transmission have to be cheap. The internet or the
(
1
) Med Cdt, Staff of the Military Medical Service, Bruynstreet, 1120
BRUSSELS
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2
) Med Maj, Staff of the Military Medical Service, Bruynstreet, 1120
BRUSSELS
Telemedicine :
technologies, costs, applications and challenges
“web” in jargon is a good example of such all-purpose
link. Other type of links are also possible, but ultimately
whatever the technique, cost and bandwidth (i.e. the
amount of the possible flow of informations) will be
the critical factors. Because of the explosion of the
electronic market, the cost of data transmission
decreased markedly in recent years and will probably
diminish even further. That actually may explain why
earlier attempts to use telemedicine never lasted
very long. A huge bandwidth or data-carrying capacity
for transmission lines is a must as it enables two-way
interactions with more than just voice. As a technology
may only flourish if it is economically sustainable, it is
not surprising that telemedicine may now enter the
stage in a more widespread way than before.
Is there a need for telemedicine? Just like the
internet, telemedicine as such originated within the
military. Because of the geographical dispersion of
armed forces during operations two-way high-
bandwidth communications were, very early, part of
the military landscape. Because of the difficulties to
physically move people to or from some difficult
environments, there was, and still is, a need to be
able to provide health care and support at a distance
no matter where and when. This situation applies
regardless of a state of conflict: distance, medical
availability and emergency create the need. A
submarine or a polar station may need a X-ray
specialist, telecommunications is assuredly cheaper
than to provide the required personnel or to evacuate
-if not needed- a patient. The same reasoning applies
to the civilian sector: remote communities in Canada
for example can be effectively “serviced” by an array
of all possible medical subspecialities like in a major
city. Not to mention developing countries facing a
shortage of medical personnel at all levels. Where
roads and medical expertise are scarce telemedicine
is a viable option. But there is much more than
distance to telemedicine…
Even in developed societies, in the health care sector,
a lot of time and resources are wasted. It is not
uncommon for a patient to be handled by several
specialists before a diagnosis or a correct opinion can
be formulated. Tele-expertise, or the consultation of
the practitioners of reference in a field can save
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Ann Med Milit Belg 1997; 11(4) : 161-163 / Telemedicine : technologies, costs, applications and challenges
162
resources to the health care system as a whole and
time, frustration and money to the patient. The same
service can help medical trainees or even doubtful
colleagues in some occasions … who has never
dreamed to have a know-it-all genius in his pocket
during an exam? Alongside tele-expertise comes
telediagnostic. Medical imaging techniques and
anatomopathology have refined our powers to pose
a correct diagnosis. A microscopic image, a X-ray
plate or a NMR scan can be digitally processed and
sent back and forth between several specialists at
very low cost. Important and relevant databases can
be kept somewhere for everyone to access for
information or confirmation purposes. The same
technology that allows someone to read his favorite
newspaper on-line can be used to save someone’s
live. Information sharing is the key. What about
telemonitoring? Most of the industrialized countries
have an aging population. For the elderly a trip to the
clinic or the doctor’s office may be a real or a
dangerous challenge. For the physically-impaired,
for the chronic patient, for a person with a cardiac
condition… In most of these cases, necessary
routine exams could be performed with the help of a
visiting nurse, results of an electrocardiogram for
example could be read, interpreted immediately and
the needed actions - a change in medication dose or
decision to hospitalize- taken on the spot. An unstable
diabetic patient could be stabilized at home. With
telemonitoring, the length of a hospital stay and the
total number of hospitalizations could be reduced
with expected personal and economical benefits. And
last but not least, interactive procedures. It was
mentioned above, it is possible to virtually reconstruct
the consultation by electronically bringing together a
patient and his doctor. This makes possible medical
consultations and/or telesurgery. Several projects
are under way or under consideration.
Teleconsultations in neuropsychiatry, in dermatology,
in oto-rhino-laryngology have been tried with partial
success. Among practical problems were the
transmission of subtle color hues that are invaluable to
the clinical eye to pose a correct diagnosis. Some
surgical procedures are also possible. Tele-endoscopy
or simple procedures can be done by a remote surgeon
with the local help of other doctors or nurses. In this
“virtual” operating room, another technique called
Enhanced Reality (ER) may be promising. Imagine
looking through computerized goggles and seeing a
sectioned nerve ending with all its minute nerve fibers.
Enhanced reality will enable you to “filter and process”
your own field of vision and to see these microscopic
structures with computer-added blue or red colors for
example. This will help you as a surgeon to better
reconstruct the nerve structure therefore helping the
patient’s outcome. Examples can be too numerous for
an exhaustive listing. And it is the aim of our venue to
attract attention to the possible futures.
Is telemedicine financially viable? Will it cost more or
save tax money? We have already started to discuss
this aspect previously, but intellectual honesty requires
to state that telemedicine may save resources only
Table 1 : General types of telemedicine sytems and costs
Audiographic system
Description:
Still video and real-time audio over analogue phone lines
Applications:
Basic telemedicine consults. Full-color image transfer and annotation; applications in dermatology, telepathology,
orthopaedics, and low-resolution teleradiology
Costs
3.500 to 10.000 US$ per site
Basic desktop video-conferencing
Description:
Low-resolution real-time video-conferencing via ISDN or switched lines
Applications:
Face-to-face consults, image transfer, and interactive review as above; applications in CME, dermatology, telepathology,
orthopaedics, and low-resolution teleradiology
Costs:
Add-in options, total costs 7.000 to 15.000 US$
Basic telemedicine
Description:
Compressed video media-conferencing with high-frame-rate, high resolution video, document conferencing, graphic
annotation, transmission storage and retrieval, data exchange and multiwaycapability over T1 telephone lines, local area
network interconnectivity
Applications:
Interactive diagnosis and consults, mental heath and medical service delivery, CME, and high-speed data transfer.
Costs:
20.000 to 80.000 US$
Advanced telemedicine
Description:
High-resolution remote diagnostics system with compressed video media-conferencing at high resolution, document-
conferencing, graphic annotation, transmission storage and retrieval. May use various communications modes such as
fiber optics, cable, microwave, satellite, T1 telephone lines, as well as various combinations of all.
Applications:
Remote patient examinations, consults, interview, intraoperative assistance, diagnostic procedures, and communications
of precise diagnostic information
Costs:
100.000 to 500.000 US$
Source : Military Medicine 1997 vol 162 p 306
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Ann Med Milit Belg 1997; 11(4) : 161-163 / Telemedicine : technologies, costs, applications and challenges
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Table 2: Examples of some telemedicine benefits
- Primetime III (US) - telemedicine in Bosnia
savings : only one of 63 documented teleconsults reviewed resulted in evacuation;
11% of 153 evacuations reviewed could potentially have been avoided with a teleconsult
- USS George Washington in the Indian Ocean savings : 30 evacuations avoided : 10.000 US$
(teleradiology)
- Somalia
savings : 63,000 US$ evacuation saved
- Medical College of Georgia
savings : 80% of patients seen via telemedicine did not need to be transferred from
the primary medical facility to a specialized care facility: 240 US$ per day per bed saved
- Rural hospital connected to a larger
savings of emergency room operating costs for the rural hospital: 47,500 US$ a year
community hospital
- Fort Jackson, South Carolina
reduction of time away from work or duty of soldier: 110 soldiers seen via elemedicine:
20% returned to training without going to the clinic
Source : GAO Report - february 1997
if used carefully within appropriate boundaries. The
start-up investments decreased markedly since 20
years. Prices for basic pieces of hardware have
gone from more than 500,000 US$ 20 years ago to
a few thousands these days, a complete basic
telemedicine installation with interactive possibilities
would cost anywhere between 20 or 80 thousand
US$. Some French estimations run around 30,000
US$. An advanced system would cost slightly above
100 thousand US$. This is still a sizeable investment
but it has to be balanced by the savings that the
techniques will bring. Just food for thought: with a
link between the Marshall Islands and Hawaii in the
Pacific Ocean, 15 evacuation trips at 2000 US$
were avoided in a year. Several thousands of X-ray
plates were transmitted from Bosnia to Germany for
analysis during the year 1996 and hence a lot of
people avoided also useless transfers. The bottom
line approach is that moving about information bits
cost much less than the transfer of patients! Still the
money invested so far into telemedical R&D is
impressive, the US army alone appropriates more or
less 700 millions of US$ (15 millions for teleradiology
only!) for the development of telemedicine. Real
cost-benefit studies are under way and many more
still need to be done to ascertain the choices and
give some unified strategy to bring telemedicine
from a “cyberdream” status to an effective health
care tool.
Table 3 : Framework of telemedicine projects according to US Department of Defence (DOD)
Class 1 Advanced telemedicine on the battle field : teleconsulatation using transmission of images via the tactical communication
network of the batalion
Class 2 Highly mobile medical vehicle equipped with imaging and telecom facilities
Class 3 Field hospital with internal digitized recording and archiving system, with high performance transmission facilities
- filmless,
wireless, nearly paperless
Class 4 Military network connected with civilian specialized hospitals
Class 5 Telesurgery : surgical procedures assisted by a remote located surgeon
Class 6 Individual ambulatory health monitoring system: electronic card giving permanent information about health status and
geographic location of the patient
Rem : These are different fields of military telemedicine; this list is neither sequential, nor hierarchical
A function of an organizational structure would be to
provide standards on telemedicine utilization. Not
all medical consultations require two-way interactive
video. Store and forward technology often represents
an efficient alternative to on-line communications.
The costs of telemedicine use are a function of
volume, time and band-width. High resolution photos
may be more informative and cheaper than more
consuming videos.
Another aspect that need not to be underscored are
the patient reactions. The patient-doctor relationship
is a very complex and strictly private one. It is the only
warrant of the needed trust that has to exist between
a suffering human being and a health professional.
The airing of private data into information networks
poses, if left as is, a threat to this special relationship.
Encryption will be needed. Legal frameworks will have
to be set up or amended to protect privacy rights. No
one wants a company or a competitor to misuse
confidential medical information to gain unfair
advantages. Then a last comes the question of the
“human-machine relationship”. This latter one is still
in the making… it is one thing to explain to a trusted
doctor some intimate details of one’s life, it is another
to discuss one’s intimacy with a machine devoid of
empathy or neutral at best. We can fairly say that here
comes the need for virtuality and some clever
applications of the Turing principle...
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