Introduction to the practice of telemedicine

Abstract

Telemedicine is the delivery of health care and the exchange of health-care information across distances. It is not a technology or a separate or new branch of medicine. Telemedicine episodes may be classified on the basis of: (1) the interaction between the client and the expert (i.e. realtime or prerecorded), and (2) the type of information being transmitted (e.g. text, audio, video). Much of the telemedicine which is now practised is performed in industrialized countries, such as the USA, but there is increasing interest in the use of telemedicine in developing countries. There are basically two conditions under which telemedicine should be considered: (1) when there is no alternative (e.g. in emergencies in remote environments), and (2) when it is better than existing conventional services (e.g. teleradiology for rural hospitals). For example, telemedicine can be expected to improve equity of access to health care, the quality of that care, and the efficiency by which it is delivered. Research in telemedicine increased steadily in the late 1990s, although the quality of the research could be improved--there have been few randomized controlled trials to date.

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EDUCATION AND PRACTICE Fundamentals
"Introduction to the practice of telemedicine
John Craig* and Victor Patterson*
w

Department of Neurology, Royal Victoria Hospital, Belfast, UK;
w
Centre for Online Health, University of Queensland, Brisbane,
Australia
Summary
Telemedicine is the delivery of health care and the exchange of health-care information across distances. It is not
a technology or a separate or new branch of medicine. Telemedicine episodes may be classified on the basis of:
(1) the interaction between the client and the expert (i.e. realtime or prerecorded), and (2) the type of
information being transmitted (e.g. text, audio, video). Much of the telemedicine which is now practised is
performed in industrialized countries, such as the USA, but there is increasing interest in the use of telemedicine
in developing countries. There are basically two conditions under which telemedicine should be considered:
(1) when there is no alternative (e.g. in emergencies in remote environments), and (2) when it is better than
existing conventional services (e.g. teleradiology for rural hospitals). For example, telemedicine can be expected
to improve equity of access to health care, the quality of that care, and the efficiency by which it is delivered.
Research in telemedicine increased steadily in the late 1990s, although the quality of the research could be
improved – there have been few randomized controlled trials to date.
Introduction
One of the great challenges facing humankind in the
21st century is to make high-quality health care available
to all. Such a vision has been expressed by the World
Health Organization (WHO) in its health-for-all strategy
in the 21st century.
1
Realizing this vision will be difficult,
perhaps impossible, because of the burdens imposed on
a growing world population by old and new diseases,
rising expectations for health, and socioeconomic
conditions that have, if anything, increased disparities in
health status between and within countries.
Traditionally, part of the difficulty in achieving
equitable access to health care has been that the
provider and the recipient must be present in the same
place and at the same time. Recent advances in
information and communication technologies,
however, have created unprecedented opportunities for
overcoming this by increasing the number of ways that
health care can be delivered. This applies both to
developing countries with weak or unstable economies
and to industrialized countries. The possibilities for
using information and communication technologies to
improve health-care delivery (‘health telematics’) are
increasingly being recognized. The WHO has stated that
with regard to its health-for-all strategy it recommends
that the WHO and its member states should:
yintegrate the appropriate use of health telematics in
the overall policy and strategy for the attainment of
health for all in the 21st century, thus fulfilling the
vision of a world in which the benefits of science,
technology and public health development are made
equitably available to all people everywhere.
2
Such a commitment to improve health-care delivery,
by utilizing information and telecommunications
technologies, is also being considered by those with the
financial means to do so, for example, the participants
in various European Commission projects. At the
national and subnational level, there is also evidence of
governmental interest in the benefits that these
technologies might bring to health care. For example,
in the UK, information technology including
telemedicine is at the heart of the government’s
strategy to modernize and improve the NHS.
3
Telemedicine, the area where medicine and infor-
mation and telecommunications technology meet, is
probably the part of this revolution that could have the
greatest impact on health-care delivery.
Journal of Telemedicine and Telecare 2005; 11: 3–9
This paper is based on a chapter that will be appearing in: Wootton R,
Craig J, Patterson V, eds. Introduction to Telemedicine. 2nd edn. London:
Royal Society of Medicine Press (in press).
Correspondence: John Craig, Level 7C Outpatients, Royal Victoria Hospital,
Belfast BT12 6BA, UK
(Fax: þ44 28 9023 5258; Email: john.craig@royalhospitals.n-i.nhs.uk)

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What is telemedicine?
Telemedicine is the delivery of health care and the
exchange of health-care information across distances.
The prefix ‘tele’ derives from the Greek for ‘at a
distance’; hence, more simply, telemedicine is
medicine at a distance. As such, it encompasses the
whole range of medical activities including diagnosis,
treatment and prevention of disease, continuing
education of health-care providers and consumers, and
research and evaluation.
Telecare is a related term and refers to the provision,
at a distance, of nursing and community support to a
patient. Similarly, telehealth refers to public health
services delivered at a distance, to people who are not
necessarily unwell, but who wish to remain well and
independent. In effect, however, despite repeated
discussions about what constitutes telemedicine, telecare
and telehealth and what their differences are, all involve
the transfer of information about health-related issues
between one or more sites, so that the health of
individuals and their communities can be advanced. In
other words, the information is moved, not the
providers or the recipients of health care. Nowadays, the
transfer of information is generally facilitated by the use
of some kind of telecommunications network. An
umbrella term encompassing all health-related activities
carried out over a distance by such information and
communication technologies is ‘health telematics’. With
this in mind, telemedicine, as an integral part of health
telematics, might be defined as:
Rapid access to shared and remote medical expertise
by means of telecommunications and information
technologies, no matter where the patient or the
relevant information is located.
4
What telemedicine is not
Telemedicine is not a technology or a separate or new
branch of medicine, or for that matter even new. It is
also not the panacea that will cure all of the world’s
health-related problems or a means by which health-
care workers can be replaced. It is also not an activity
for antiquarians or Luddites, who range from those
who are simply not at ease with the use of electronic
machinery, right through to those who feel that
telemedicine threatens the very fabric of the practice of
medicine, and as such should be actively opposed.
Equally, however, it is not the sole territory of
‘computer nerds’ or ‘technophiles’. In fact, the
tendency of these individuals to concentrate on the
technical rather than the practical when discussing
telemedicine may explain the antipathy of some
clinicians towards practising medicine this way.
Sensible, practical presentations by those who have
actual experience of telemedicine have the potential to
change the minds of those health-care workers who feel
that telemedicine is not for them, either because it is
‘gimmicky’, industry-driven and therefore ‘less than
respectable’, or unfathomable. Finally, and probably
most important, for the most part telemedicine is far
from being a mature discipline, and much work remains
to be done to establish its place in health-care delivery.
Types of telemedicine
The common thread for all telemedicine applications is
that a client of some kind (e.g. patient or health-care
worker) obtains an opinion from someone with more
expertise in the relevant field, when the parties are
separated in space, in time or both. Telemedicine
episodes may be classified on the basis of:
the interaction between the client and the expert and
the type of information being transmitted.
The type of interaction is usually classified as either
prerecorded (also called store-and-forward) or realtime
(also called synchronous). In the former, information is
acquired and stored in some format, before being sent,
by an appropriate means, for expert interpretation at
some later time. Email is a common method of store-
and-forward interaction. In contrast, in realtime
interactions, there is no appreciable delay between the
information being collected, transmitted and disp-
layed. Interactive communication between individuals
at the sites is therefore possible. Videoconferencing is a
common method of realtime interaction.
The information transmitted between the two sites can
take many forms, including data and text, audio, still
images and video pictures. Combining the type of
interaction and the type of information to be
transmitted allows telemedicine episodes to be classi-
fied as in Figure 1. In certain applications, such as
teleradiology, a technique that involves the transmission
of digital radiographs between institutions, it is possible
for the interaction to be either prerecorded or realtime;
the latter requires that the expert be available to give an
opinion as the image is taken and transmitted.
History of telemedicine
Most telemedicine has clearly occurred in the last
20–30 years, concomitant with advances in
J Craig and V Patterson Practice of telemedicine
4Journal of Telemedicine and Telecare Volume 11 Number 1 2005

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information technology. If, however, telemedicine is
considered to be any medical activity performed at a
distance, irrespective of how the information is
transmitted, its history is much older. An early example
of medicine at a distance, be it one of the first public
health surveillance networks, was in the Middle Ages,
when information about bubonic plague was
transmitted across Europe by such means as bonfires.
With developments in national postal services in the
mid-19th century, the means by which more personal
health-care delivery at a distance could be performed
was facilitated, and the practice of physicians providing
diagnosis, and directions for a cure, was established.
In the mid-19th century, telegraphy – signalling by
wires – also began and was quickly deployed by those
providing and planning for medical care. This included
its use in the American Civil War to transmit casualty
lists and order medical supplies, with later techno-
logical developments permitting X-ray images to be
transmitted. In much of Europe and the USA, the
telegraph was rapidly superseded by the telephone as a
general means of communication, but in Australia it
survived for much longer because of the enormous
distances involved.
The telephone has been used for delivering health
services since its invention in the late 19th century,
and for 50 or so years remained the mainstay of
communication for such purposes. However, it was
realized as early as 1910 that the telephone could be
used for purposes other than voice communication;
amplified sounds from a stethoscope were transmitted
through the telephone network and similar devices are
still used today. Other uses for the ordinary telephone
network have since been realized and include the
transmission of electrocardiograms (ECGs) and
electroencephalograms (EEGs).
The next development of widespread significance
was at the end of the 19th century when communi-
cation by radio became possible. This was done initially
by Morse code and later by voice. Use of the radio to
provide medical advice for seafarers was recognized
very quickly, and in 1920 the Seaman’s Church
Institute of New York became one of the first
organizations to provide medical care using the radio,
with at least another five maritime nations establishing
radio medical services by 1938. One of these was the
International Radio Medical Centre (CIRM), whose
headquarters are in Rome, Italy. It was set up in 1935 and
in its first 60 years assisted with over 42,000 patients,
making it the largest single organization in the world to
use telemedicine to provide health care to seafarers.
5
Radio medical advice for passengers on long-distance air
journeys has also been provided more recently. For in-
flight medical incidents that require professional
assistance, and which occur at a rate of about 1 in 50,000
passengers carried, assistance can be obtained from on-
call health-care workers on the ground.
The birth of modern telemedicine
The recent development of telemedicine has been
facilitated on two fronts. First, there are the advances in
electronic methods of communication. Initially,
analogue methods were used, but now modern digital
communication techniques are the mainstay. Second,
telemedicine has developed because of the pioneering
efforts of a few organizations and individuals. The
former generally represented the interest of high-tech
ventures, such as the manned space-flight programme
of the National Aeronautics and Space Administration
(NASA) in the USA. While these were no doubt of great
importance in fostering the development of
telemedicine and telecommunications generally, the
efforts of a few individuals using readily-available
commercial equipment have arguably been just as
important for the development of telemedicine. It is
interesting to note that in the 40 or so years since these
individuals initiated their ventures things have
changed relatively little, as far as who is doing research
of practical value, and how it is being done.
A major influence on the development of tele-
medicine was the introduction of television. By the late
1950s, developments in closed-circuit television and
video communications were made use of by medical
personnel, who began to employ them in clinical
situations. As early as 1964, a two-way closed-circuit
television system was set up between the Nebraska
Psychiatric Institute in Omaha and the state mental
hospital in Norfolk, 112 miles (180 km) away.
6
The
system permitted interactive consultations between
specialists and general practitioners, and facilitated
education and training at the distant site. Another
early example of television linking doctors and patients
was at the Massachusetts General Hospital/Logan
International Airport Medical Station, which was
established in 1967.
7
This used a two-way audiovisual
Information transmitted
Still images Moving images
(video)
Interaction Real-time e.g. telepsychiatry
Pre-recorded e.g. teleradiology
Figure 1 Classification system for telemedicine episodes
J Craig and V Patterson Practice of telemedicine
Journal of Telemedicine and Telecare Volume 11 Number 1 2005 5

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microwave circuit and permitted care to be provided to
passengers and airport employees 24 h a day by nurses,
supplemented by physician expertise using the
audiovisual link. In an early report of the feasibility of
this method of delivering health care, the observations
of 1000 episodes were documented. It is noteworthy
that few reports of telemedicine projects since have
contained such numbers of episodes performed. More
recently, there has been a major growth in realtime
telemedicine with the wide availability of video-
conferencing. This has been made possible because of
improvements in digital communications and the
introduction of low-cost computing, many of the
videoconferencing systems now being based on PCs.
The recent developments of mobile phones and
satellite communications have allowed mobile
telemedicine. Early examples of such programmes were
the Alaska ATS-6 Satellite Biomedical Demonstration
from 1971 to 1975, which assessed the viability of
improving village health care in Alaska using satellite-
mediated video consultation,
8
and the Memorial
University of Newfoundland programme established in
1977, initially to provide distance education as well as
medical care to Canadians.
9
Where is telemedicine being done?
Today, telemedicine represents the experiences,
opinions, perceptions and interests of a vast number of
individuals and organizations. Most operational
telemedicine services, of which the majority concern
diagnosis and clinical management at a distance, are in
industrialized countries, especially the USA, Canada,
Australia and the UK. Telemedicine also includes tele-
education, and distance treatment, e.g. telesurgery. The
latter area remains the subject of media interest, but
there is little practical experience. Teleradiology is the
branch of telemedicine which has been integrated best
into the fabric of clinical practice. So well integrated is
it that figures on its use are impossible to come by.
A recent survey of teleconsultation activity
(excluding teleradiology) in the USA found that over
85,000 teleconsultations were done in 2002, performed
by more than 200 programmes, in over 30 specialties.
10
Mental health, paediatrics, dermatology, cardiology
and orthopaedics accounted for almost 60% of these
teleconsultations, with approximately 50% using
interactive video, the rest prerecorded or non-video
technology (Figure 2).
This survey also identified 52 telemedicine
programmmes outside the USA, with Canada (10),
Australia (9) and the UK (9) being the major
contributors. Elsewhere in Europe, Norway has a
National Centre for Telemedicine based at Tromsø and
both Finland and Russia have functioning telemedicine
programmes. Hong Kong has established programmes
in the rehabilitation of older people,
11
and there is a
telemedicine service for burns patients in Australia.
12
In
South America, Argentina has seen its telemedicine
applications collapse.
13
Despite most telemedical services being concentrated
in industrialized countries, there are several lines of
1992 1994 1996 1998 2000 2002
1992 1994 1996 1998 2000 2002
1992 1994 1996 1998 2000 2002
Number of programmes
0
50
100
150
200
250
Average teleconsultations
(per programme)
0
200
400
600
800
1000
1200
1400
1600
1800
2000
Total teleconsultations (1000s)
0
20
40
60
80
100
(a)
(b)
(c)
Figure 2 Teleconsultation activity (excluding teleradiology) in the
USA. (a) Number of telemedicine programmes; (b) average
number of teleconsultations per programme; (c) total number of
teleconsultations in the USA each year. Data from Grigsby
10
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evidence to suggest their adoption globally, including
within developing countries. The first of these is
witnessed in the number of conferences and meetings
that are occurring with increasing frequency through-
out the world, and the diversity of nations that are
represented at them. Africa epitomizes the paradox
of telemedicine, that the areas that would benefit
most from it do not have the resources to utilize
it. There are functioning networks in South Africa
and in Mali,
14
the latter linked to a hospital in
Geneva. There are several other telemedicine
networks linking the industrialized and developing
worlds; including those run by the Swinfen Chari-
table Trust
15
and the Medical Missions for Children.
16
This is an area that is likely to grow in the future.
Research
The output of papers on telemedicine-related subjects
as indexed on MEDLINE has been fairly constant at
about 1000 papers annually over the last five years.
17,18
Prior to that, there had been a period of rapid growth in
annual output from about 100 in 1994. Although
almost 50% of recent papers originate in the USA,
Finland and Norway produce the greatest number of
publications per head of population (Figure 3). One
specialist journal, Journal of Telemedicine and Telecare,
published 13% of all papers but, encouragingly, over
50% of MEDLINE-indexed journals have published at
least one article on telemedicine.
17
There has been an
increasing number of randomized controlled trials
published
19,20
and also some systematic reviews. The
results of the latter are rather critical of much of the
telemedicine literature, and one even suggests that
much of it should not have passed the peer-review
process.
21
The correspondence subsequent to this
review did question the relevance of such academically
rigorous analyses to telemedicine, the aim of which is
not to replace face-to-face medicine and take over the
world, but more usually to improve people’s health in
certain well defined situations. Telemedicine has a
number of separate attributes – feasibility, acceptability,
cost, effectiveness, safety, sustainability – and the
importance of studying each of these systematically
will vary from application to application. For example,
to use telemedicine to support an Antarctic expedition
requires only that feasibility be demonstrated, since
acceptability and cost are less relevant. In contrast,
using telemedicine for a single specialty in a large
region needs considerably more attributes to be
studied. The paradox here is that if research is tightly
controlled to meet the strict requirements of the writers
of systematic reviews, it may become less relevant to
real-life situations and therefore less likely to be
introduced into clinical practice.
Why is telemedicine being done?
The frequent references to telemedicine in the medical
and lay literature and the increasing number of
politicians who appear to be interested in its use are
very noticeable. McLaren and Ball have argued that the
reason for such interest is that ‘Technology has the
power to mesmerise. It is for this reason that
telemedicine has a high profile’.
22
While there is no
doubt that for some this is true, there are basically two
reasons why telemedicine should be used:
there is no alternative to telemedicine;
telemedicine is better than existing conventional
services.
Australasia
6% Asia
8%
Europe
40%
Americas
44%
Middle East
1%
Africa
1%
UK
34%
Germany
16% Other
13%
Italy
8%
France
5%
Finland
5%
Norway
4%
Spain
4%
Greece
4%
Switzerland
3%
Sweden
4%
Figure 3 Primary telemedicine research – origin of the research
papers published in the two specialist telemedicine journals
(Telemedicine Journal and e-Health and Journal of Telemedicine and
Telecare) from 1998–2003 (n¼2952)
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No alternative to telemedicine
Telemedicine clearly has a role in the case of
emergencies in remote environments such as the
Antarctic and in ships or aeroplanes, where it may be
difficult, if not impossible, to get medical care to the
patient in time. In countries with unstable or weak
economies, however, where health-care services are
often not a priority, telemedicine also permits access to
services that would not otherwise be available. An
example is the provision of medical services from the
city of Arkhangelsk in northwest Russia to other parts
of the region and exchange of knowledge and
experience between the University Hospital of Tromsø,
in northern Norway, and northwest Russia.
23
Telemedicine is better
Telemedicine has obvious advantages in remote or rural
areas where it improves access to health services,
obviating the need for patients and health-care workers
to travel. Even in urban areas, however, telemedicine
can improve access to health services and to infor-
mation. Telemedicine has also been shown to improve
the consistency and quality of health care.
24
It may
sometimes also be cheaper than conventional practice,
although, as previously mentioned, scientifically sound
economic appraisals of telemedicine applications are
only just beginning to appear.
Other reasons why telemedicine is being
done
Telemedicine is occasionally accused of being an
‘industry’ driven by commercial rather than consumer
interests. Certainly, of the numerous experimental and
operational telemedicine systems in use, or at the
drawing-board stage, some would appear to have been
set up primarily to produce financial benefits for the
providers (individuals or organizations) of the service,
rather than health benefits for the consumers.
Telemedicine principally practised for financial gain is
not confined to the manufacturers of equipment, but
includes health-care workers (real or fraudulent),
telecommunications networks and other organi-
zations. The technological advances that have been
necessary to develop telemedicine to its current state,
or which are likely to occur in the future, are driven
mainly by market forces; hence, there is a concern
that the reputation of telemedicine as a whole could
be damaged by the actions of those aiming to make
their fortune. This is especially likely if operational
services are set up without prior establishment of the
need for a particular application in a certain setting,
and evidence that the service as established is
effective and cost-effective. If there was ever an
argument for the need for research for all tele-
medicine applications prior to widespread adoption,
this is surely it.
Effects of telemedicine
In broad terms, telemedicine can be expected to
improve equity of access to health care, the quality of
that care and the efficiency by which it is delivered, by
enhancing communication up and down the health-
care pyramid. Widespread adoption of telemedicine
would permit decentralization; work previously done
in the secondary sector, for example, could be
performed in primary care and work previously done in
the primary care sector could be devolved to the
community level (Figure 4). Such changes, if
implemented in the developing world, could
potentially have the greatest effect, allowing under-
served people to benefit from a greatly improved
standard of health care. In all remote or rural areas,
however, telemedicine could have a great impact,
permitting among other opportunities, better
diagnostic and therapeutic services, faster and easier
access to medical knowledge, and enhanced
communication between health-care workers.
Conclusion
There is no doubt that telemedicine is effective in
certain situations. The transition to a world where
telemedicine is employed to the maximum will not be
realized, however, if governments and health-care
organizations do not produce strategies to encourage
its development. Wootton has summarized the
critical issues that will need to be addressed in such
strategies as part of a fourfold commitment: to
encourage and provide funding for telemedicine
Teaching Hospitals
District General Hospitals
Primary Care
Community Care
Personal Care
Figure 4 Telemedicine as a means for improving communication
up and down the health-care pyramid
J Craig and V Patterson Practice of telemedicine
8Journal of Telemedicine and Telecare Volume 11 Number 1 2005

research; to develop a plan for implementation (once
clinical effectiveness and cost-effectiveness have been
demonstrated); to assess the major structural changes
required within organizations to incorporate this
method of delivering health care; to develop a
process for training, formulation of practice
guidelines, quality control and continuing audit.
25
Other issues that will need to be addressed include
ethical and medicolegal concerns, human and
cultural factors, such as resistance to change, lack of
infrastructure, linguistic differences and illiteracy, and
technical and organizational factors. None of these
should be insurmountable.
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