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					INTERNATIONAL TELECOMMUNICATION UNION TELECOMMUNICATION DEVELOPMENT BUREAU
REGIONAL TELECOMMUNICATION DEVELOPMENT CONFERENCE FOR THE ARAB STATES
(AR-RTDC-96) Beirut (Lebanon), 11-15 November 1996 Document 23-E 1 October 1996 Original: English For Action

Agenda item: 3.3

PLENARY MEETING

SOURCE:

ITU-D STUDY GROUP 2 QUESTION 6/2 - IMPACT OF TELECOMMUNICATIONS IN HEALTH CARE AND OTHER SOCIAL SERVICES TELEMEDICINE AND DEVELOPING COUNTRIES ________ TELEMEDICINE AND DEVELOPING COUNTRIES

TITLE:

1

Introduction

Many developing countries have inadequate health care and medical services. Developing countries suffer from a shortage of doctors and other health care professionals. The inadequate infrastructures of telecommunications, roads and transport make it even more difficult to provide health care in remote and rural areas. Where clinics and hospitals exist, they are often ill-equipped and, especially, outside urban areas beyond the reach of normal communications. Developing countries face various problems in the provision of medical service and health care, including funds, expertise, resources, which relate to the lack of facilities and systems. Roads and transportation are inadequate and problems in properly moving or transporting patients are often encountered. For countries with limited medical expertise and resources, telecommunications can provide a solution to some of these problems. Telecommunications may help alleviate some of the shortages. Telemedicine services have the potential to improve both the quality of and access to health care regardless of geography. They enable medical and health care expertise to be accessed by under-served locations. Telemedicine offers an effective means to quickly improve the delivery of health care and medical service. It can help in emergencies from natural disasters, combating tropical diseases and meeting the particular requirements of dermatology, traumatology and the many other specialities of medicine. In the developed countries, there has been a rapidly growing interest in telemedicine and telehealth as a means to ease the pressure of health care on national budgets. It may well be that some of the

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technologies and experiences of the developed countries could be of help to developing countries in their desire to provide, especially, primary health care. Telemedicine and telehealth have many socio-economic benefits, can generate new sources of revenues for service providers and equipment suppliers and can optimize the use of available human and capital resources in developing countries. Applications such as telemedicine and telehealth should be of interest to telecom operators since they generate additional traffic over existing networks and offer the opportunity to extend limited networks. The telecom and health "industries" can achieve synergies. Telemedicine needs to be well managed, implemented carefully. The impact of telemedicine on health care structures can be significant. It also raises concerns about legality, liability, confidentiality, competition and other policy and regulatory issues. For these and other reasons, the World Telecommunication Development Conference convened by the ITU in Buenos Aires in March 1994 recommended that the ITU study the potential of telemedicine to meet some of the needs of developing countries. In particular, the Conference approved a Question on telemedicine which was assigned to ITU-D Study Group 2. The text of the Question is as follows: Statement of problem The widespread use of telemedicine services could allow universal health access and consequently facilitate the solution of the principal health problems connected with infectious diseases, paediatrics, cardiology, etc., particularly in areas where medical structures are inadequate or non-existing. Telemedicine mainly concerns two different aspects related respectively to telecommunications infrastructure and health care organization. Question The Study Group shall: 1. 2. 3. Define the technologies most suitable for telemedicine's most efficient diffusion to developing countries; Study the costs and benefits of different solutions taking into account the various solutions existing in the developing countries; Analyse the results of pilot projects, surveys, sectoral studies, etc. carried out by the various entities involved in order to better identify the main trends in technologies used for telemedicine; Foster the adoption of global standards required for systems and equipment in order to facilitate telemedicine and other social services; Produce a telemedicine handbook.

4. 5.

This report was prepared in response to the Question.

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2

Scope of the Report

This Report focuses on the possibilities of telemedicine and telehealth in developing countries. The Report surveys telemedicine experience around the world, different telemedicine applications and the technologies for diffusion of telemedicine. It reviews the costs and benefits of telemedicine and examines in particular the notion of a telemedicine value chain, i.e., how telemedicine and telehealth services can be delivered from the service provider to the end user in a cost-effective and profitable way. The Report notes some of the main trends in the development of telemedicine and telehealth services and examines the prospects and complexities inherent in the development of global telemedicine and telehealth standards. Based on the analysis of the Study Group, recommendations and guidelines are provided for developing countries who are considering the implementation of such services. The telemedicine industry appears to be growing rapidly, judging by the growing number of conferences on the subject and World Wide Web sites dealing with telemedicine services, but there are, as yet, few examples of commercial, profitable services. The developed countries of North America, Europe, Japan and Australia have considerable experience in telemedicine and telehealth. Based on research so far and the responses to the Telemedicine Questionnaire sent out to countries in helping to prepare this Report, it is clear that much of the telemedicine activity undertaken around the world depends upon subsidies from government, telecom carriers or international organizations. The situation is changing. A trend toward commercialization of telemedicine and telehealth provision is clearly discernible. In Europe, the European Commission (EC) has supported a large number of telemedicine/telehealth projects, about 45 in its Third Framework Programme and about double that under its current Fourth Framework programme, to the tune of more than 235 million ECU (1.3 ECU = US $1 in mid-1996) over an eight-year period. The EC has its telemedicine/telehealth programme squarely aimed at developing a competitive European telemedicine industry as well as improving the delivery of health care services to Europeans. There are many telemedicine and telehealth applications, some with very sophisticated -- and expensive -- technologies. Telemedicine applications using virtual reality technologies are being developed and demonstrated in the United States and United Kingdom. Such sophisticated and expensive technology is out of the reach of developing countries. What they need is low cost, low-tech solutions to the delivery of medical and health care as well as access to appropriate expertise, especially in the event of emergencies. Although telemedicine and telehealth have many socio-economic benefits, can generate new sources of revenues for service providers and equipment suppliers and can optimize the use of available human and capital resources in developing countries, it is important to recognize that investing in a telemedicine and telehealth delivery system will cost something and that something will be competing for scarce resources in developing countries. External support and funding, i.e., outside the developing countries, can be contemplated, but the sustainability of the delivery system -- of the value chain -- should be scrutinized carefully before committing significant capital. The success of the telemedicine service will depend heavily on which technologies and services are used, on how appropriate they are to particular countries, recognising that the situation can differ from country to country. Or, to put it another way, what may work in one country may not meet the needs of another country.

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This Report is intended to serve as a handbook for government administrations or operating agencies so that they can evaluate a range of possibilities and choices related to networks and applications, cost-benefit analysis and standards in order to identify the solutions appropriate to their needs and availability of resources. 3 Health care in developing countries

Out of the 51 million people who died in 1993 around the globe, 39 million deaths took place in the developing world and about 12 million in the developed world. Poor countries had three times more deaths than rich countries. Of the estimated 51 million deaths, communicable diseases such as tuberculosis and respiratory infections as well as maternal, perinatal and neonatal causes account for about 20 million or 40 per cent of global deaths, with 99 per cent of those in the developing world. In developing countries, most babies are not vaccinated, clean water and sanitation are not commonly available, nor are curative drugs and other treatments. Mothers dying in childbirth, reduced life expectancy, disability and starvation, mental illness, stress, suicide, family disintegration and substance abuse are common in developing countries. The main cause is poverty. According to the World Health Organization1, poverty is the main reason why the human race suffers in all walks of life. During the second half of the 1980s, the number of people living in extreme poverty increased, and was estimated at more than 1.1 billion people in 1990 -- more than one-fifth of humanity. Every year, more than 12.2 million children in developing countries die under the age of five from preventable causes -- preventable in many cases for just a few pennies each. There are widening disparities between rich and poor, between one population group and another, between age groups and between the sexes. According to 1993 calculations, a person in the least developed countries has a life expectancy of 43 years, compared to 78 in some developed countries. Some developing countries have less than US $4 to spend on health care per person per annum. According to the WHO, the biggest group of killers in the world today are infectious diseases and parasites. In the developing world, some 23 per cent of deaths among children under age 5 occur in the first week of life and 33 per cent within the first month. Most of these deaths are associated with the delivery itself or immediate complications and infections. Seven out of 10 babies in the developing world are born without the help of a trained attendant. This is where the problem lies. Developing countries do not have access to quality health care enjoyed by the developed countries. This is where telemedicine might be able to help. About 1 billion people worldwide do not have regular access to local health services. At the same time, cheap, effective, life-saving treatments sit unused on shelves while people are dying because in many areas of the world, the delivery systems to get them to the populations do not exist or are inadequate. Increasingly, there is a recognition that health services must be provided close to the people who need them and an integrated, cost-effective approach is necessary. Integration is the key to effective delivery of care. There cannot be high-technology hospitals in every part of every country, and there does not need to be. Instead a tier system should be created,

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Most of the data presented here has been taken from The World Health Report 1995 published by the World Health Organization.
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with established links between the various levels of the health services, with the peripheral health units seeing the majority of cases and the feeding through to district-level hospitals, which in turn can refer to patients to more specialized centres if need be. Telemedicine can help. As can be see later in this report, there are relatively inexpensive and affordable telemedicine systems that can be set up easily and are user friendly. But some developing countries will not be able to afford such systems and the costs of teaching the health staff to use these systems. This is where developed countries can help, because they can afford to help. It is ironic that in some parts of the world hundreds of millions of people suffer daily from a lack of basic health care while in other parts millions of people spend money on things which are not healthy. Think what a billion dollars could do to help immunize people against deadly diseases in developing countries. A billion dollars is not much money -- it is what Americans spend on beer every 12 days and what Europeans spend on cigarettes every five days. Developing countries are inevitably short of high level hospital infrastructures. The geographical distribution of existing hospitals and health services is far from ideal; usually they are limited to urban centres at county or district level. Referral hospitals with competent medical specialists, and using state of the art medical technology, such as scanners and other sophisticated diagnostic equipment are non-existent, or where they do exist are at best confined to a single metropolis. The inability of governments in developing countries to provide quality health services irrespective of geographical location is in part linked to the health service's organizational options, which currently imply mobilization of financial, material and human resources against a background of creating decentralized hospitals and health clinics. There is a growing recognition in many countries of the importance of placing greater priority on the provision of primary health care as a way of minimising the cost of direct medical care. The implementation of telematics in primary health care has lagged behind the application of telematics to the hospital environment for a number of reasons. One reason is the lack of investment in primary health care. Another important reason is the unstructured and dispersed nature of primary health care. As the policy to shift more health care from secondary to care is implemented and as demographic changes begin to have an impact, increasing demands are being placed on primary health care services. The need for coordination of health care services for individual patients is a major consequence and the application of telematics in this area has the potential to improve both the quality and efficiency of health care. The World Health Organization principles of primary health care are based on accessibility, continuity and comprehensiveness and are an important foundation on which to build. The approach should be both top-down and bottom-up. A strategic view of the service as a whole is necessary to determine the development of the telematic framework and infrastructure required to support the overall goals of the service. The needs of health care professionals caring for individual patients help to determine the services that should be developed. Telemedicine and telehealth have the potential for offering developing countries these qualitative and quantitative improvements: • Distance consultations, diagnosis and treatment by medical specialists practising in a national, regional or international hospital centre for referrals.

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•

Availability of quality health care in remote areas of the country, by deployment of mobile telecentres travelling from one village to another, or even local community centres which meet the joint requirements of several villages. Improvement in qualification of national specialists and health technicians, by opening up international medical databases. Overall improvement of service by centralization of resources (specialists, hardware and software packages). Effectiveness and efficiency in management of actions related to reduction of waiting times for consultations, and introduction of medical information systems.

• • •

Telemedicine and telehealth could reduce health costs in developing countries, potentially in these ways: For the patient: • • Cutting down on journeys to major health centres or for specialist consultations. Reduction of length of stay, and therefore cost of hospitalization, since the patient can be treated and checked up on at a distance. Reduction in operating costs through centralization and optimization of resources (expertise, laboratories, equipment, etc.). Reduction in costs of training and updating, improvement of specialists' qualifications through distance teaching and access to medical databases.

For providers of health services: • •

Telemedicine, by comparison with the usual health services, introduces added value and a positive impact at social, economic and cultural levels. Incidentally, its introduction into developing countries tackles several needs and constraints. 4 4.1 What are telemedicine and telehealth? Origins of telemedicine

There are differing views about the origin of telemedicine. Some say that telemedicine came about with the introduction of the telephone. Dr Alexander Graham Bell called "Come here, Watson, I need you." because he was feeling ill. Others say that telemedicine originated not long after the introduction of television. The initial idea behind telemedicine was, and is, to overcome time and distance barriers. From inception, the main focus has been on physical diagnosis and prognosis. Physical diagnosis usually requires visual information, hence one needs a device that would enable the physician to "see" the patient.2

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p. 6, The Specialist User of Current Innovative Technology: The Marketing of Telemedicine, by A. Aref. Unpublished thesis for BSc (Honours), South Bank University, London, May 1995.
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Among the early telemedicine efforts was the research and development work into telemetry undertaken by NASA. NASA scientists demonstrated successfully that their astronauts' physiological functions could be monitored by physicians on earth. Their telemetry and telecommunication systems for biomedical application were highly sophisticated for their time. NASA's scientists were originally concerned with the effects of zero gravity on their astronauts. They decided to constantly monitor their astronauts' physiological functions, such as blood pressure, respiration rate, ECG and temperature. NASA developed a medical support system which included diagnosis and treatment of in-flight medical emergencies as well as the development of complete medical delivery systems. NASA was not the only one to experiment with the integration of telecommunications systems into the practice of medicine. During the late 1960s and early 1970s, others were also experimenting with telemedicine. The first telemedicine system in which there was a regular interaction between physicians and patients was installed in Boston in 1967. A radiologist who worked at the Massachusetts General Hospital (MGH) set up a diagnostic "shop" in the medical station of Logan airport. Physicians passing through were invited to bring X-rays and patient data to a room on the passenger concourse. The X-rays were illuminated by an ordinary light box, scanned by a black and white television camera and the images transferred to a video monitor in the MGH's radiology department. The physician could discuss the case with MGH radiologists via an ordinary telephone line.3 The first interactive video link was established between the Nebraska Psychiatric Institute in Omaha and the Norfolk State Hospital, 112 miles away.4 These two experiments demonstrated that it was possible to undertake remote diagnosis through interactive television and that the transmission of medical data (e.g., X-rays) could be accomplished successfully without any significant loss of information in terms of its quality and detail.5 There were other early applications of telemedicine. One involved the Papago native American tribe in the late 1950s. Space Technology Applied to Rural Papago Advanced Health Care (STARPAHC) delivered health care to residents living in remote areas of the Papago Indian Reservation in Arizona. This was a joint effort between Lockheed, the National Aeronautics and Space Administration, and the United States Public Health Service. The project lasted about 20 years.6 Most of these projects used some form of video (black-and-white television, colour television, slow-scan transmission) to complement the most basic unit of telemedicine equipment, the telephone.7

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p. 5, "The World as a Network", by N. Menhall & A.N. Tabbah, Telemedicine Times, 1994. p. 65-70, "Assessment of Telemedicine: Results of the initial experience", by R. Bashshur & J. Lovett, Aviation, Space and Environmental Medicine, 1977. p. 8, The Specialist User of Current Innovative Technology: The Marketing of Telemedicine, by A. Aref. Unpublished thesis for BSc (Honours), South Bank University, London, May 1995. p. 65-70, "Assessment of Telemedicine: Results of the initial experience", by R. Bashshur & J. Lovett, Aviation, Space and Environmental Medicine, 1977. p. 483-488, Technology and Clinical Applications, by D.A. Perednia, & A. Allen, Jama, 1995.
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Some early experiments used satellite communication. One of the first telemedicine projects using a satellite was conducted in Canada. In January 1976, a Canadian satellite, the Communications Technology Satellite (CTS), later renamed Hermes, was launched by NASA as part of a joint project with Canada's Department of Communications (DOC). Hermes was designed to serve the communications needs of remote areas of Canada. Three telemedical experiments were conducted using Hermes. The first was in June 1976 involved the Ontario Ministry of Health which used VHF radio and Hermes to test the feasibility of monitoring vital signs such as heart rate, respiration, temperature, ECG, when a patient was evacuated from a remote community in northern Ontario.8 The second experiment began in October 1976, when the University of Western Ontario started its five-month trials, using Hermes to link the University Hospital in London (Ontario), the Moose Factory General Hospital and the Kashechewan Nursing Station on James Bay. The system was used for medical consultations, data transmission (e.g., ECGs, X-rays, heart sounds) and some continuing education.9 The third project, in 1977, involved Memorial University in St. John's, Newfoundland. It enabled Memorial medical staff to broadcast a television programme from St. John's to hospitals in Stephenville, St. Anthony, Labrador City and Goose Bay. Hermes was used to support an on-going medical education programme. Thus, it can be seen that the use of telemedicine grew out of a need to provide medical diagnoses for patients in remote areas who were unable to travel. There also was a need to help small towns by providing doctors with technology that would allow them to keep abreast of advances in medicine and to consult with other physicians. From these beginnings, the interest in telemedicine has continued to grow. Today, telecommunications networks are being developed to transmit information about patients to doctors and information from doctors to patients, faster than ever before, and eventually from any location. These same networks can be used to provide access to on-line patient records and medical libraries, to facilitate communications among medical specialists around the country, and make available standardized medical information and insurance data more readily. Telemedicine technology is advancing and will continue to do so. Although much of the more sophisticated technologies such as virtual reality are still expensive, the cost of some technologies is dropping, so that telemedicine should become more affordable to more people, regions and countries than ever before. 4.2 Definitions

Telemedicine means, literally, "medicine at a distance". The term was coined in the 1970s by Thomas Bird.10 Several different definitions of telemedicine and telehealth are current now. ____________________
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p. 386-387, Telemedicine in Canada, by A.M. House, & J.M. Roberts, CMA Journal, August 1977. p. 386-387, Telemedicine in Canada, by A.M. House, & J.M. Roberts, CMA Journal, August 1977. p. 7, "GETS : Global Emergency Telemedicine Services : (Feasibility study)", a proposal to CEC Director General XIII, June 1995.
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The European Commission has defined telemedicine as "Rapid access to shared and remote medical expertise by means of telecommunications and information technologies, no matter where the patient or relevant information is located."11 Telemedicine is "the practice of medical care using interactive audiovisual and data communications. This includes medical care delivery, diagnosis, consultation and treatment, as well as education and the transfer of medical data".12 Telemedicine has been described as "patient-care oriented telehealth".13 "Telemedicine is the use of telecommunication technology to assist in the delivery of health care."14 "Telemedicine is a system of health care delivery in which physicians examine distant patients through the use of telecommunications technology."15 "Telemedicine and telehealth - the use of telecommunications and informatics for medical and health purposes."16 "Telemedicine - the interactive transmission of medical images and data to provide patients in remote locales with better care."17 "Telemedicine is the delivery of medical care to patients anywhere in the world by combining telecommunications and medical expertise."18

•

• • • • • •

Other related terms such as telehealth and telecare have also been used. "Telehealth refers to the use of telecommunication technologies to make health and related services more accessible to health care consumers and providers in rural, or otherwise underserved areas."19 In recent years, many countries around the world are giving a higher priority to primary health care. Telecommunications can be used to deliver telehealth services, aimed at maintaining the "wellness" of society or improving the general health of society. Telehealth can be distinguished from telemedicine in the sense that telehealth is the provision of a service to those who are not

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p. 18, "Research and technology development on telematics systems in health care : AIM 1993". Annual Technical Report on RTD: Health Care. European Commission, Directorate General XIII. The Advisor on Informatics of the World Health Organization. p.153, "Telehealth: the delayed revolution in health care" by G.W. Brauer in Medical Progress through Technology, 1992 Conference Proceeding by J. Harrison, 1994 J. Preston, 1993. M. Gott, 1995. p. 36-44, by F. Hamit, 1995. p. 1495, "Making Global Telemedicine Practical and Affordable: Demonstrations from the Middle East" by M. Goldberg, & H. Sharif, & D. Rosenthal, & S.B. Schaffer, & T. Flotte, & R. Colvin, & J. Thrall, American Journal of Roentgenology, 1994 p.152, "Telehealth: the delayed revolution in health care" by G.W. Brauer in Medical Progress through Technology, 1992
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necessarily ill, hurt, wounded or otherwise afflicted, who in fact are already well and want to stay that way by following healthy practices of diet, nutrition, lifestyle, exercise, etc., and by taking steps to avoid illness and disease, for example, in regard to sanitation. The common element in these different definitions is the use of telecommunications to deliver medical and health care services to patients wherever they are. Telemedicine and telehealth can be regarded as examples of the use of telematics for health. Telematics for health, however, has a broader definitional scope since it also includes informatics or information technology aimed at improving the efficiency of health care even within a single hospital or health administration. The European Commission, for example has a division called "Telematics for health" and the scope of their work is not just telemedicine or telehealth. It also includes considering applications of information technology to improve the health care systems in Europe. Telemedicine generally refers to the use of telecommunications and medical technologies to provide any or all of the following forms of information exchange, i.e., data, audio and/or visual communication between physician and patient or between physician and health care professional in geographically separate locations and to facilitate the exchange of information for medical, healthcare, research and/or educational purposes. 5 Types of telemedicine services

Telemedicine and telehealth can be used for a whole set of practices aimed at increasing well-being. If telemedicine is to be defined correctly then it must involve some form of telecommunication, otherwise it could not be labelled telemedicine. Another feature of telemedicine is the transmission of data, whether it is in the form of an X-ray, patient's medical record or monitoring vital signs, e.g., heart rate, blood pressure, etc. Telemedicine involves diverse technologies and applications. It can be characterized by the type of information sent (such as radiographs or clinical findings) and by the means used to transmit it. Many areas of medical practice have potential telemedicine applications. Telemedicine can be useful for situations in which: • • physical barriers prevent the ready transfer of information between patients and health care providers; and the availability of information is key to proper medical management.20

For the purpose of this report, telemedicine services can be categorized as being of three main types -- audio, visual and data. Within each of the broad types of services are several types of services. In each case, examples are supplied. 5.1 Audio

The simplest telemedicine service is when one health care professional consults another by telephone.

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p. 483, "Telemedicine Technology and Clinical Applications", by D.A. Perdenia & A. Allen, JAMA, Feb. 1995.
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Private health insurers have already seen the potential for using the plain old telephone in health care delivery. PPP Healthcare in the United Kingdom has introduced a customer helpline staffed by nurses. It takes about 500 calls a week from policy-holders who do not think their problem is serious enough for them to visit their GP. Others just want more information about their condition in plain English.21 5.2 Visual (image transfer)

The different types of images produced and transferred in radiology departments today are identified below: 5.2.1 Teleradiology

Radiology is the scientific study of X-rays and other high-energy radiation used in the medical profession. Strictly speaking, teleradiology refers to the electronic transmission of radiological images from one location to another for the purpose of interpretation or consultation.22 In reality, the term has grown to include other related types of image transfer as described below. The term teleradiology is rather limited. It covers X-rays, computed tomography (CT), magnetic resonance (MRI), and ultrasound and could include nuclear medicine, thermography, fluoroscopy, and digital subtraction. Each of those applications can produce an image of the patient's anatomy and/or pathology. Because there are other types of images (e.g. photographic and microscopic) available to a diagnostician, use of a broader term is perhaps desirable. For example, tele-imaging may be a better term to use as part of the area of image transfer in telemedicine.23 5.2.1.1 X-ray

These images are taken by passing X-rays through a portion of the body and recording the amount of X-radiation that is not absorbed. An X-ray is the most frequently used mode of medical imaging. 5.2.1.2 Computed tomography (CT)

X-rays are also used in CT. To generate a CT image, the patient lies on a table, which passes through a donut-shaped scanner. The X-rays that pass through the patient are digitized by detectors on the opposite side of the scanner. CT scanners allow an image of the tissue density to be computed like a slice through the patient. A three-dimensional model can be computed from multiple scans. The surgeon planning the surgery can manipulate the image using the computer. 5.2.1.3 Magnetic resonance (MR)

MR machines today are used increasingly in modern hospitals because of the fact that the patient is not exposed to dangerous radiation and no injection is required. An MR machine consists of a table on which the patient lies and which goes through a kind of tunnel. As the patient goes through, he or she is surrounded by extremely powerful electromagnets. The magnets are used to align the ____________________
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p. 8, "Health Screens" by Isabel Berwick in Smart Talk, the magazine for residential Mercury customers, Spring 1996. Standard for teleradiology. American College of Radiology. Reston, VA, 1994. p. 153, "Telehealth: the delayed revolution in health care", by G.W. Brauer, Medical Progress through Technology, 1992.
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atomic nuclei in the body, and this alignment is then distributed by a radio frequency pulse. The nuclei return to their former orientation and emit radiation which is picked up by a receiver coil. The analysis of this radiation identifies the concentration of certain atoms within the body. 5.2.1.4 Ultrasound (U/S)

As its name implies, ultrasound involves passing a high-frequency sound wave (2-4 MHz) into the patient's body. The reflected waves are then recorded. The medical staff are able to obtain information on the elastic and mechanical properties of human tissue. Like MR, the patient is not exposed to X-rays or injections. Both MR and ultrasound are able to detect soft tissue, such as tumours and lesions. Ultrasound is the preferred non-invasive diagnostic tool in many medical specialities, including cardiology, internal medicine, obstetrics, gynaecology and emergency medicine. It is less expensive than MR and CT scans. 5.2.1.5 Nuclear medicine (NM)

The basic principle of nuclear medicine is injecting the patient with a radioactive substance and detecting the gamma rays that are emitted, which represent the flow of blood through blood vessels. The equipment consists of a ring of detectors, which is positioned around the patient lying on an examination table. Two types of machines are used. One is for Single Photon Emission Computed Tomography (SPECT); the other is Positron Emission Tomography (PET). The SPECT machine picks up all gamma-ray photons emitted from the body, which can be used to construct two-dimensional images. PET relies on the fact that when positrons are emitted from the radioactive substance, they are utterly destroyed by interaction with electrons. As a result, two gamma rays travelling in opposite directions are produced. Most of the background noise in the image is removed. There is a slight difference in the arrival times of the gamma rays at the detectors which can be used to estimate the position of the emission, a phenomenon which permits construction of a three-dimensional image. 5.2.1.6 Thermography

This uses infrared detectors to measure heat radiated from the surface of the skin. Although it can be used to follow the course of a disease, it is not particularly accurate for diagnosis. 5.2.1.7 Fluoroscopy (Angiography)

This technique is used to study patient physiology, such as heart beat and respiration. The patient is injected with a contrast agent, and a series of digital X-ray images are made at regular time intervals. The physician can view them in real time or can store them on a magnetic tape for future viewing on a video tape recorder (VCR). The speed of the viewing can be increased or decreased. The one disadvantage of this radiological method is that the patient may require repeated exposure to X-rays. 5.2.1.8 Digital subtraction angiography (DSA)

Here an X-ray is taken by using digital detectors. When this is completed the patient is injected with a contrast material, such as iodine, which is opaque to X-rays, i.e., it does not penetrate the contrast substance. After this operation, another X-ray is taken with the patient positioned exactly as before, and the two digital images are numerically subtracted. The final image highlights the contrast agent without confusion from shadows of other body parts. This can be used to detect blockages in blood vessels.

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5.2.1.9

Image capture

The first step in the teleradiology process is capturing the image(s) for interpretation. Production of a plain radiograph in digital form can be done either by computed radiography or by converting it to a digital form from the original analogue radiograph.24 Images derived from CT, MRI, ultrasound or nuclear medicine are produced digitally at the outset. Alternatively these can be captured by a video frame grabber using the analogue video signal. These are what most radiology departments use. Normal analogue X-rays need to be converted into digital form, either by using a laser digitizer or a charge coupled device (CCD) scanner. Advances in compression technology and improvements in the telecommunication infrastructure will enable radiology departments to capture digital images directly. Once the image is converted into digital , it can be compressed for more efficient storage and/or transmission via telecommunications to a distant location. Examples of teleradiology As mentioned above, one of the first teleradiology uses was in 1967. X-rays were viewed through a video monitor. A video camera was used to record the image. Today the methods and equipment used are much more sophisticated than they were 30 years ago although there are still examples where a video camera is used to record images. Although there were teleradiology experiments conducted in the 1970s and 1980s, the examples given here are from 1990 onwards. • Teleradiology at long distances A demonstration was performed between Massachusetts General Hospital (MGH) and two sites in the Middle East; Abu Dhabi in the United Arab Emirates (UAE) and Riyadh in Saudi Arabia in 1994. The system that was used for teleradiology included a film digitizer, which was an RSTAR product (Model FDS-100) used for image acquisition and which included a Lumiscan 150 laser digitizer with computer equipment for input of history and demographic information. The digitizer had a resolution of 1664 x 2020 x 12 bits. An RSTAR diagnostic workstation (Model DWS-2000) was used to display the digitized images. It was installed at both the transmitting and receiving ends of the system. The workstation allows the user to manipulate the images to his liking, i.e. to magnify a particular part of the image. To transmit a radiograph from the remote site, the radiograph was digitized, appropriate demographic information was entered and the image was compressed using data compression software. This was done by using a wavelet-based algorithm, produced by Aware, on a Sun SparcStation 10.25 The time for the compression took approximately one minute per radiograph. Although direct digital capture of CT and MR is possible it was not implemented for this demonstration. They were digitized in the same manner as normal radiographs.

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24 25

p. 107, "Quality Assurance in Teleradiology", by D.A. Forsberg, Telemedicine Journal, 1995. p. 1496, "Making Global Telemedicine Practical and Affordable: Demonstrations from the Middle East" by M. Goldberg, H. Sharif, D. Rosenthal, S.B. Schaffer, T. Flotte, R. Colvin, & J. Thrall, American Journal of Roentgenology, 1994.
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The compressed images were transmitted over dial-up telephone lines. Inverse multiplexing technology was used so that four telephone lines could be used simultaneously for data transmission.26 Telecommunication equipment was also used. These were a NetBlazer ST multiprotocol router which was supplied by Telebit. This device performed the inverse multiplexing. Also high-speed modems by Motorola Codex were used. The data that arrived at the receiving end were decompressed and displayed on a high-resolution video monitor for interpretation. The network protocol used was Transmission Control Protocol/Internet Protocol (TCP/IP). • Teleradiology using low cost equipment A telemedicine project funded by British Telecom has demonstrated low cost teleradiology applications. The project involves a video link between the Minor Treatment Centre at the South Westminster Centre for Health, run by nurse practitioners, and the Accident and Emergency centre at Belfast's Royal Victoria Hospital. The equipment which is supplied by BT comprises a series of off-the-shelf components, including a VC 7000 Video Phone with a "Sharp View Cam" handheld video camera that anyone can buy in a high street shop.27 The telecom link is an ISDN line. Teleradiology in this example is a very simple operation. The "Sharp View Cam" is connected to the VC 7000 Video Phone. The nurse at the Minor Treatment Centre places the X-ray on a normal light box and positions the "View Cam" so that it captures the image of the X-ray. This way, the emergency physician at Belfast is able to see the X-ray and make a diagnosis. If the image is not very clear, then the physician at Belfast can ask the nurse to adjust the video camera until he is satisfied that the image is clear enough for diagnosis. • Teleradiology (using ultrasound) British Telecom (BT) is also funding a telemedicine project which deals with foetal scanning. Foetal medicine deals with the diagnosis and treatment of diseases in the unborn child. This field of gynaecology uses ultrasound scanners. The trial links the Centre for Foetal Care (a national centre for excellence in foetal medicine) at Queen Charlotte's Hospital in West London (which provides expert advice) with the Maternity Unit at St. Mary's Hospital, Newport, Isle of Wight.28 The two sites are linked by an ISDN line. The equipment used at St Mary's Hospital included a BT VC2300 video codec. The video codec digitizes and compresses the video image from the ultrasound scanner. This product is manufactured by BT and has been specifically designed for the transmission of real-time foetal ultrasound images over ISDN networks. Next to the scanner there is a small, floor mounted, mobile control console.

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26

p. 1497, "Making Global Telemedicine Practical and Affordable: Demonstrations from the Middle East" by M. Goldberg, H. Sharif, D. Rosenthal, S.B. Schaffer, T. Flotte, R. Colvin, & J. Thrall, American Journal of Roentgenology, 1994. p. 25, The Specialist User of Current Innovative Technology: The Marketing of Telemedicine, by A. Aref. Unpublished thesis for BSc (Honours), South Bank University London, May 1995. p. 23, The Specialist User of Current Innovative Technology: The Marketing of Telemedicine, by A. Aref. Unpublished thesis for BSc (Honours), South Bank University London, May 1995.
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A low light camera which is mounted on the wall within the scanning room captures a general view of the patient during the scan. The control console is used by the sonographer to decide which images are sent to the consultant. In order for the sonographer to be sure the correct image is being viewed by the specialist, the console has a small LCD monitor, which displays the image being transmitted. The equipment at Queen Charlotte's Hospital is similar with one exception. They have a large TV screen on which the ultrasound scan is viewed. There is also a small video camera mounted on top of the TV which is focused on the consultant. In the first six months of operation, the link was used for 39 consultations involving 29 patients. In 25 cases, a definitive diagnosis was made using the telemedicine link and physical referral was avoided. In 20 of the 25 cases, the patient was counselled face-to-face over the link, while in the remainder it was deemed to be more appropriate for this to be carried out by the staff in the Isle of Wight.29 • Teleradiology using nuclear medicine There have been numerous trials of high speed data transmission. In Canada, the objective of one such trial was to study how accurate and acceptable nuclear medicine images can be when transmitted between two hospitals hundreds of kilometres apart. The participating hospitals were equipped with personal computers running an Elscint communications software package. This package offers a data transfer rate of 19.2 kbit/s utilising standard telephone lines. Using special modems and synchronous/asynchronous converters, transmission speeds up to 56 kbit/s were attained while delivering high quality images. 5.2.2 Telepathology

Pathology is the area of medical science which deals with the causes and nature of disease, and with the bodily changes wrought by disease. Telepathology involves rendering diagnostic opinions on specimens at remote locations using computer and telecommunications technologies.30 In pathology, there is a large amount of information (diagnostic and prognostic) available from the examination of biopsy material that requires an extensive knowledge of diseases and their clinical implications. Hence consultations are an important practice in pathology. Also pathologists frequently need opinions from those who specialize in various diseases. Special studies on a pathology specimen are frequently performed after the initial evaluation of the microscopical preparations. Sometimes these studies cannot be performed at the referring site and hence the pathology material would have to be sent to the consultative site for processing. This process takes time (which the patient might not have), and it costs money. Also pathological specimens need to be kept under special conditions where external bacteria cannot be allowed to enter their environment otherwise they would be ruined and an examination of the specimen will not be possible.

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29

p. 149, "Point to point telemedicine using ISDN", by A. Darkins, N. Fisk, P. Garner and R. Wootton, Telemed 95: Medicine on the SuperHighway, Conference Proceedings, November 1995 p. 95, "Current Issues in Telepathology", by S.B. Schaffer & T.J. Flotte, Telemedicine Journal, 1995.
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Telepathology can minimize these limiting factors. There are two ways to do this in pathology: remote dynamic screening by robotic video microscopy and remote diagnosis from selected still video microscopical images. To any pathologists the former is the most attractive system; however, it requires very high speed telecommunications links. The other method, though cheaper than the former, has the disadvantage of significant reduction in the data. There are systems that combine limited robotic capabilities with high-resolution still images. Other options available are image compression which can increase the number of images that can be transmitted (e.g., over a limited telecommunications infrastructure). JPEG is the standard that is used currently for compression technology. Examples of telepathology • A demonstration was performed between Massachusetts General Hospital (MGH) and Riyadh in Saudi Arabia in 1994. A histopathological slide specimen was transmitted from Riyadh to the MGH over normal telephone lines. The images were observed through a high definition monitor. The images were scanned and compressed. Then they were transmitted to the MGH where decompression of the images took place, and where the images were read by pathologists. In Norway, a remote, robotic video microscope telepathology system was set up for experimentation, via a dedicated 2 Mbps point-to-point telecommunications link. In a Swiss project, a hybrid system combining the limited robotic capabilities with high resolution images was set up using a dial-up (switched ISDN) 64 kbps connection. In Japan, a study was conducted in the use of telepathology in kidney and liver transplantation pathology. Again ISDN was used for communications, and the images were acquired at 450 lines of horizontal resolution.

• • •

The projects mentioned above were relatively low cost applications. 31 5.2.3 Teledermatology

Dermatology is that branch of medical science which deals with the skin and its diseases. Teledermatology involves image transfer because dermatologists must be able to look at the affected area of the skin in order to make a diagnosis. A voice only consultation via the telephone will not do. Example of teledermatology • Teledermatology has been carried out successfully in Wales (United Kingdom) where consultants diagnose patients' skin problems remotely using videophones. A commercial videophone card and minicamera are attached to each surgery's personal computer and a high definition camcorder is also available if more detailed images are needed.32 Eight general practice surgeries in Montgomeryshire are involved in this scheme which covers 30 GPs and 65,000 patients.

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31

For more detail, refer to "Current Issues in Telepathology", by S.B. Schaffer & T.J. Flotte, Telemedicine Journal, 1995. p. 23, "Just pick up the phone and say aah", by Charles Arthur, New Scientist, May 1995.
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In the past, a patient with a dermatological problem that his GP cannot solve would have been sent for an appointment with a consultant in Bronglais hospital in Aberystwyth, 80 miles away from Montgomeryshire. However, it has taken several months to get some routine outpatient appointments in Bronglais. With the introduction of teledermatology, the patients have no need to travel to the hospital. They now visit their GP, who operates the videophone and camera as requested by the consultant. Pictures from the camcorder are captured by the computer and sent to the hospital electronically. These remote consultations were followed up by face-to-face meetings to check whether the dermatologist's diagnosis was the same in each case. According to Stewart Low, who is in charge of the scheme for the Institute of Health Informatics which is the academic body that organized the trial, "of 24 patients, 22 were given the same diagnosis face-to-face as by videophone. The other two could not be diagnosed at either meeting".33 This system costs around £2,000 for the videophone and £900 for the camcorder both off the shelf equipment. There is no need to purchase PCs because most surgeries have ones that are powerful enough to run the system. The link-up required a fast, ISDN telephone line. British Telecom and IBM are funding this exercise. Among the benefits is the elimination of patients' waiting time. Consultants also save time. In remote areas, they can spend up to two-thirds of their time travelling between appointments. According to Low, "that's all time that could be spent seeing patients".34 The drawback of this application is the lack of normal contact with the patient. This may produce an dissatisfying consultation for both the specialists and the patients. Teledermatology therefore can be well suited for the control and follow-up of patients who have already been examined by the dermatologist in the normal manner. 5.3 5.3.1 Data On-line access to databases

Many hospitals and private practitioners exchange radiology, biology, clinical physiology and financial data using the X.400 and EDIFACT standards. Among the data exchanged could be records of the outcome of treatments, a pictorial database of poisonous plants; email for administrative purposes; bulletin boards for the exchange of information between clinicians; and the transmission of patient records, referral letters and test results between GPs and hospitals. Many hospitals, clinics and other health institutions around the world use computer systems for patient, administrative and financial applications. Many have stored their medical records and databases electronically. Doctors can retrieve information about their patients instantly, print out prescriptions to give to their patients and retain an electronic record of the prescription at the same time. Telemedicine can be used to keep patient records up to date. Visiting doctors can access patient records and update the data from a distance.

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33 34

p. 23, "Just pick up the phone and say aah", by Charles Arthur, New Scientist, May 1995. p. 23, "Just pick up the phone and say aah", by Charles Arthur, New Scientist, May 1995.
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There are many specialized medical databases, especially in the developed countries. They generally required access via computer and particular protocols. In some instances, access can be free, in others, the user pays for access, for connect time or for both. • Internet Medical databases, such as MEDLARS, MEDLINE and others, can be accessed via the Internet. MEDLINE contains 8 million articles in 20 languages. Bruda, the German printing and publishing group, together with Hewlett-Packard, Digital Equipment, Sun Microsystems and Netscape have produced a commercial Internet service called Health Online. The service is based on Netscape's publishing system and browser software and uses Digital's advanced encrypted "tunnelling" technology to provide users with a secure on-line service over public switched telephone lines. The service provides doctors with access to medical databases, information on medical products, news of conferences, summaries of medical news, publications, and discussion forums. • Picture Archival and Communications System (PACS) PACS is a network where different departments in a hospital are able to communicate with each other and to transfer patient records, hospital accounts and other administrative records. Image retrieval of X-rays, MRIs, CTs, etc., is also possible. • Fax Today faxes have become universally associated with information exchange. This is another way a health professional can obtain anything from patient medical history to information on the latest drugs in the market. 5.3.2 Telemetry

Telemetry has been described as providing a means for monitoring and studying human and animal physiological functions from a remote site.35 One of the first telemetry experiments was conducted by NASA when physicians on earth began monitoring astronauts' physiological functions while they were in space. More recently, Telemedic Systems Ltd, a United Kingdom company based in Taunton, Surrey, has developed a briefcase kit for monitoring the vital signs of patients in remote areas and transmitting the data to hospitals or doctors some distance away. This telemedicine application of telemetry was demonstrated at the G-7 ministerial conference on the Information Society and Development in Midrand, South Africa in May 1996. Telemedic Systems has been negotiating agreements for production of its telemetry system for use on board aircraft. United Airlines is one of the first airlines to announce its intentions to provide such a service to passengers. When it goes into commercial production, the kit is expected to include a lap-top computer where the information will be gathered electronically, and retransmitted to a doctor who will be able to give advice based on the information he or she has received.

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35

p. 153, Telehealth: the delayed revolution in health care. by G.W. Brauer, Medical Progress through Technology, 1992.

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5.4 5.4.1

Utilization of services Teleconsultation

Telemedicine networks offer the opportunity for consultations between doctors and others in healthcare. Consultation can take place via telephone, email, videoconferencing, etc. The consultation can be in real time (as with telephony) or store-and-forward techniques can be used (as with email). Teleconsultation has been described as a special form of clinical information exchange.36 The simplest example of this application uses only the telephone, i.e., a doctor can ask another doctor for a second opinion via the telephone. In today's world, a doctor can have a video consultation with a specialist who might be in another country. It is also possible for a paramedic with a headset equipped with a camera and a microphone (such as the CamNet system) to consult via satellite with a doctor while the former is dealing with an emergency. Teleconsultation is more than just information exchange. It could also include a form of therapy. Examples of teleconsultations With the advent of computer networks, it has become easier to obtain information. The Internet in particular has facilitated international information gathering. Many doctors today are adding email communications to alert patients of routine test results or to answer simple questions. Also doctors, specialists and other health workers can communicate with each other via email either giving or receiving advice. • The Mayo Clinic in America has an extraordinary concentration of world-class experts who cover almost every medical speciality. With Mayo's Arizona and Florida branch locations, its Rochester site has set up a three-way telemedicine link in order to make full use of these specialists. The three sites communicate via high-quality videoconferencing.37 Norwegian Telecom Research and the medical experts at the University Hospital of Tromso (UHT) in Norway have developed telemedical applications within many fields of medicine. One of those applications is a video conference system based on a broadband network which is the basis for a regular contact between general practitioners in rural areas and doctors at UHT in the fields of dermatology, otorhinolaryngology and psychiatry. To take psychiatry as an example, the remote patient, situated in his or her own room, and the psychiatrist at the UHT can see and hear each other through a television screen. This can be called teletherapy. The difference in this kind of therapy is the patient has a remote control and whenever he does not like what the psychiatrist is saying to him he can switch off the television screen. There is a question of the extent to which a patient is willing to "open up" to a physician viewed on a TV screen. The two United Kingdom projects mentioned above are using British Telecom technology for videoconferencing. The Minor Treatment Centre and Queen Charlotte's Hospital in London are linked to Belfast's Royal Victoria Hospital and the Isle of Wight's St Mary's

•

•

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36

p. 154, "Telehealth: the delayed revolution in health care" by G.W. Brauer, Medical Progress through Technology, 1992 p. 115, "Telemedicine: Remote Control Health Care", by Amy Roffmann Nev, Hemispheres, September, 1995.
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Hospital respectively by a teleconsultation system. In both projects, the heart of the videoconferencing technology is a BT videophone. 5.4.2 Tele-education

It has also become apparent in recent years that an efficient, effective health care infrastructure requires not only access to expertise, but on-going medical education of health care professionals and the public. Education may improve the chances of early detection and reduce subsequent treatment requirements. Tele-education may help reduce the many of the demands on the health care system by focusing on prevention -- education on diet, hygiene, and the many other basic requirements for a physically healthy society. With the participation of local representatives, the telemedicine events create a forum for continuing medical education. In addition, the network infrastructure can also be used to access on-line services or participate in seminars through videoconferencing. The network presence also provides an opportunity to disseminate preventative health care information. Education and training are widely seen as the most important factor in achieving sustainable development, and certainly represent one of the major development activities which stand to benefit most from appropriate use of telecommunication. The possibilities of telecommunication in the delivery of education to vast unreached populations and in promoting the transfer of essential knowledge to and within developing countries holds promise. Telemedicine and telehealth services offer the opportunity for training and education. Paramedics or junior hospital staff can witness or be informed about particular medical techniques and practices. Tele-education consists of three areas: distance education, access to remote information and community health education.38 Distance education could involve a small rural teaching hospital linked to a major city teaching hospital. Students at the rural site can "attend" a lecture conducted by a professor at the big teaching hospital. Examples of tele-education • In the United Kingdom, a project for distance teaching of surgery uses the SuperJANET ATM video network to link six major universities in the United Kingdom. Also the system will utilize a multimedia information resource to maximize the use of the network facilities. In Norway, Kirkenes Hospital has modern echocardiography equipment for use by cardiologists. Echocardiography is the examination of the structure and function of the heart using reflected pulsed ultrasound. Because of staff shortages, the equipment at Kirkenes Hospital was not used very often. The University Hospital of Tromso (UHT) set up a video conference link with Kirkenes. UHT wanted to find out whether they could provide training in echocardiography via videoconferencing, thus enabling the physicians from Kirkenes to use the equipment on their own. A video conference studio was installed in Kirkenes. A camera was connected to the echocardiogram unit camera by an ordinary video cable. The instructor at UHT receives the images transmitted from this ultrasound unit. Hence physicians at Kirkenes Hospital while examining the patient receive instructions from experienced UHT heart specialists via the video conference. The patient benefits by not

•

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38

p.154, "Telehealth: the delayed revolution in health care" by G.W. Brauer, Medical Progress through Technology, 1992
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needing to travel in order to get treatment and the physicians at Kirkenes Hospital benefit from more training. • Community health education in North Carolina has benefited from the application of telecommunications with a system organized by East Carolina University College of Medicine in Greenville. The school has a family practice training programme where trainees live in rural areas and are supervised over the state telemedical network. This tele-education system gives these doctors access to resources that would not otherwise be available. The aim of the programme is to encourage these doctors, once they graduate, to set up their own practices or to join another in these areas. Another example of tele-education comes from Norway. It involves the Department of Otorhinolaryngology at the University Hospital in Tromso. Otorhinolaryngology is that part of surgical science which deals with diseases of the ear, nose and throat. Endoscopy is any technique for visual inspection of the internal organs. Today's modern instruments are usually flexible fibre-optic devices and additional facilities for biopsy. For the last 15 years, the department staff have travelled extensively in Finnmark county in Norway. Although the population enjoyed a good, decentralized medical specialist service, it was very expensive to carry out. Hence in 1991 the department decided to conduct a test on whether they could teach general practitioners (GP) endoscopic examination techniques using telematic instructions. It was to be transmitted via the existing telenetwork to a centrally placed specialist. The experiments involved 17 patients. They were examined under controlled conditions with simulated telecommunications between two video conference studios in Tromso. At one studio there was the GP and a specialist at the other. The GPs and the specialists agreed on the findings in all 17 patients. Another experiment was conducted between Tromso and Alta in the Finnmark county. Seven patients were examined. The transmission was of images from the nose and throat. Satellite transmission of otorhinolaryngology examinations from Alta to the far north islands of Svalbard have been conducted as well. The distance did not affect the quality of the transmission. Some of the benefits that resulted from the experiments included: – – – 5.4.3 less public spending due to the reduction of travel on the part of the specialist and the patient; an increase in the GP's level of confidence; an improvement in the flow of information from the GP and specialist, both with referred patients and in emergencies.

•

•

Medical emergencies and disaster relief

A major requirement in developing countries is the delivery of medical care in the event of an emergency. One third of the population of Latin America has no access to any medical care. In Africa, an even larger proportion of the population has no access to health care. Civil conflict, droughts and natural and man-made disasters can bring death and tragedy to thousands or even millions of people very quickly. Refugees arriving from remote and rural areas to other remote or rural areas or cities can place huge demands on quick medical relief, often in areas with no means of communications. Telemedicine can also be used in international disasters to assist relief workers by providing them with instant support from health care professionals not located at an emergency site. International

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organizations have long understood the potential of communication and information technologies and have used telemedicine applications to respond to natural disasters and complex emergencies around the world since the 1960s. Communications are vital for medical emergency services.39 Health care professionals in the field need the assistance of other medical professionals, especially those found in the emergency department of a hospital. The paramedic has to be able to warn the emergency medical staff that they are about to receive a patient in a critical condition so they can prepare for the case. Wireless communications technology may be applied to medical emergency services. Such technology can include radio pagers, radios, cellular telephones, mobile earth stations and personal communication services. Examples of telemedicine in emergencies • Reliefnet, a collaborative effort between the United States Department of State and the United Nations Department of Humanitarian Affairs, plans to create a telecommunications network [date?] that would improve the exchange of information related to decision-making and operational coordination of humanitarian emergencies with the goal of saving lives. This network would provide general information on humanitarian emergencies to a wider public including the media and would improve information flow between emergency relief offices and field operations in participating countries. When the highly contagious and deadly Ebola disease broke out in Zaire, several days lapsed before any news of the event was picked up by the outside world. An Inmarsat-M terminal was used as a communications medium when specialists first started to arrive. GETS The European Commission is planning a Global Emergency Telemedicine Service (GETS) as part of project under the G-7 initiative in Brussels in February 1995. GETS is providing a framework for 24-hour, multi-lingual telemedicine surveillance and emergency services around the world. It is a sub-project of the G7 Global Healthcare Applications. Its objective is to establish a transnational and multilingual health emergency system which will be able to improve the promptness and effectiveness of interventions and service management through telematic interconnections of the emergency points of care of all of the participants and services involved. This will be achieved by ensuring the continuous availability of qualified advice which in turn will be achieved by interconnecting different medical centres. The GETS project will also use mobile satellite communications. • MERMAID Medical Emergency Aid Through Telematics (MERMAID) is pilot project for a 24-hour-a-day multilingual telemedicine surveillance and emergency services in the maritime sector. It meets the objective of the G-7 and European Union policy for "Global Healthcare Applications". The overall objective of MERMAID is to establish a transnational and multi-lingual health emergency system which will make telemedical intervention more effective and widely available as well as improving service management ____________________
39

•

•

p. 51, "Wireless communications in medicine" by D.R. Yoho, European Hospital Management, 1995
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of the telematic interconnection of the emergency points of care and of all individuals and services involved. The start-up MERMAID service is aimed at about 100 ships equipped with ship earth stations. 5.4.4 Telesurgery/virtual reality

Telesurgery is basically surgery at a distance. This application is still years away from becoming widespread because of its complexity and relatively high cost in today's economic climate in developed countries, let alone developing countries. Experiments are, however, taking place. Biopsy specimens are being analysed at a distance today. Robotic arms are also being used on patients to remove tumours and for drilling holes in bones for attaching pins and supports. In the United States, cameras are being developed which move to follow the surgeon's eyes. The United States Army is the main organization conducting extensive research and experiments in this area of telesurgery. Telerobotics or telesurgery are now being developed in connection with image analysis machines such as magnetic resonance and computerized tomography. Examples of telesurgery • One telesurgery experiment has involved a link between the Netherlands and Hawaii, where a gall bladder operation took place. One of the surgeons was performing the operation while the other was giving advice via a television screen. The surgeon from the Netherlands has also been conducting experiments using a robot arm to operate an endoscope in a laparoscopic or key hole surgery. This accomplished, the next phase is to operate a robotic arm by remote control via a telephone line. In September 1995, the Politecnico di Milano made the first telesurgery for a prostate biopsy. A patient was in the hospital in Milan while the surgeon was some kilometres away in the Politecnico. The surgeon "operated" in front of a computer with an image of the prostate and through remote control was able to conduct the biopsy through use of robotics with only an assistant present in the hospital.

•

The one important factor that is missing from the telesurgery concept is replicating the surgeon's sense of touch. Peter Cochrane, head of BT Laboratories in the United Kingdom, believes that by the beginning of the 21st century synthetic skin with all the tactile qualities of human skin will be available. This will allow surgeons thousands of miles away from the patient to feel them as if they were in the same room. 6 Technologies for diffusion of telemedicine

Developing countries can benefit from using information technology and telecommunications networks to improve health care in remote and rural areas. Although advanced telemedicine applications may require sophisticated and expensive telecommunications infrastructure, some solutions require only basic infrastructure to provide health care services to remote areas. Most telemedicine applications can be found in the following categories: audio and videoconferencing, multimedia communications, data transfer with low, medium, and high bandwidth requirements. The prevalent range of network choices includes basic telephony, digital land line, cellular/wireless, satellite and broadband. When considering telemedicine and telecommunications technologies, it is important to evaluate not only capabilities and the cost/performance trade-offs, but also general technical development. Cellular, wireless and satellite technologies are options which should be considered in providing health care to remote locations.

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6.1 6.1.1

Telecommunications technologies Plain old telephone service

Basic telephony (or plain old telephone service (POTS) as it is sometimes described) can be delivered via wireline and wireless means. The telephone service can be delivered via fibre optic cable or copper wire or HF radio or digital satellite. In most developing countries, especially in remote and rural areas, relatively simple technologies, such as copper wire or HF radio, are used and consequently they often become the determining factor of the sophistication of telemedicine services available in these countries. 6.1.2 Cellular radio

Cellular radio provides mobile telephony and data transmission in the range of 2.4 to 16 kbit/s. Some computer manufacturers offer portable computers with interfaces to cellular phones. Among other things, cellular radio can be used for the transmission of ECG from ambulances to hospitals. Cellular telephones allow two-way communication via radio links established between the cellular telephones and radio sites located within a particular geographic area. They provide convenient and familiar means of communicating in medical emergencies.40 However, it is important to mention that there are several different and incompatible cellular standards in use around the world. In other words, global interconnectivity is not possible at this time. If used with a personal computer, a suitable modem and appropriate software, a cellular telephone can transmit and receive text, data and other communications. Also if a small scanner is added with a modem capable of fax transmission and the appropriate software, the computer can act as a fax machine capable of receiving and transmitting medical reports, biosignals, pictures and other printed material. 6.1.3 Radio

Radio pagers receive messages initiated by callers using a telephone. Messages can take several forms: the caller's actual voice, telephone number or a short text message. Some of today's pagers have voice and email. The caller is able to transmit voice or computer-composed text and information via telephone to the carrier. Recent advances in this technology make it possible for a caller to send large amount of medical data directly to the radio pager. Radios are used for two-way communications via a specified pre-set radio frequencies. The only drawback for hand held radios is the limited distance allowed (a few kilometres). Today though, through greater power and larger antennas it is possible to communicate over longer distances.

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40

p. 51, "Wireless communications in medicine", by D.R. Yoho, European Hospital Management, 1995
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6.1.4

Videophones

Videophones enable a GP and a specialist (or anyone for that matter) to see and talk to each other, exchange notes, discuss a case and examine a patient. Use of a videophone may eliminate the need for a patient to travel great distances for a specialist consultation. For the specialist, the benefit is that he or she can see more people in a wider geographical coverage, and the GP has the advantage of obtaining better information through contact with the specialist. Examples of videophones which have reached the market include the following: • VideoPhone 2500 AT&T has produced a VideoPhone which, according to the company, is the world's first personal video telephone. It lets you hear and see -- in colour, in motion -- the people you are talking to. The videophone is simple to install and use, it plugs into any standard electrical outlet and modular telephone jack. It has been designed to be compact and portable. AT&T's VideoPhone consists of a full colour motion video, with a 3.3-inch (diagonal) colour LCD video screen and a fixed-focus camera lens with 1 to 9 foot focal range from a tilt/swivel console. There are screen messages to remind the user when to press a button. The camera has a view indicator to help maintain position within camera range. It has a one-way video mode which lets you see without being seen, as well as a twoway mode, where both users can see each other. There is a multi-level focus control, screen brightness control and handset and speaker volume control. • BT VC 7000 BT has developed a number of products which can be used for telemedicine applications. The VC7000 Videoconferencing System has been used in a number of telemedicine pilot projects in the United Kingdom. It consists of a monitor, an integral camera, keyboard control, a telephone handset, loudspeaker, microphone and a codec. At its simplest, the VC7000 is basically a phone with a monitor where you can see the person you are talking to and vice-versa. The CCD colour camera is fixed with a tilt-only capability. It is possible to connect an external camera such as a Camcorder to the VC7000 in order to be more flexible and have more mobility. The screen is a 10-inch colour monitor. Although a handset is available, it has a hands-free mode when more people are present in the room. The VC7000 is user friendly, compact and easy to transport. BT's PC Videophone has the ability to convert a PC into a full motion, full colour multimedia terminal enabling the exchange of information (visual and written). Images, graphics, text and other applications can be shared by opening a "window" on the PC screen. The PC Videophone comprises a VC8000 multimedia communications card, a miniature video camera, an audio unit and a choice of application software supplied by IBM, Olivetti or ICL. The VC8000 multimedia card fits into the PC. The image for desktop videoconferencing is provided by a miniature video camera. It has tilt and swivel features which ensure easy framing of images. It has automatic exposure levelling. The audio unit is just a normal phone connected to the PC. One can either use it directly or from the PC. There is a built-in microphone and loudspeaker. 6.1.5 Satellites

Satellite technology has been used to deliver telemedicine services to areas that lack an advanced terrestrial network since the 1960s when health care professionals in Canada, Australia and the United States began experimenting with radio, telephone, microwave, two-way television, computer and satellite technology to link isolated and rural areas to urban medical practices.

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Delivery of health care and other social programmes in remote regions is hampered by lack of infrastructure and high transportation costs. Certain key elements of such programmes can be delivered by using existing telecommunications systems and technologies. Mobile satellite communications provide a medium for immediate as well as long term delivery of national health programmes to remote regions where other means would prove to be uneconomical. Applications include delivery of basic information to remote clinics; dealing with medical emergencies via live two-way communications, including video; teleconsultation, videoconferencing, access to specialized databases for retrieval of medical information; remote training of paramedics; interactive records management; supplies management; public health monitoring; and general administration. In other social programmes, mobile satellite communications can be used for activities such as tele-education, administration of community initiatives, and library catalogue access and book ordering. Mobile satellite communications are also invaluable in the event of natural and man-made disasters, particularly those severe enough to demand international assistance. Today's mobile earth stations are small, portable, and can operate from a variety of power sources, including a car battery. Their independence of fixed telecoms and power infrastructures permits the continuation or restart of health care after a disaster. 6.1.6 ISDN

Integrated Services Digital Network is a widely accepted standard for digital telecommunications. It is a modular standard allowing the user to configure his installation to his bandwidth needs (in multiples of 64 or 16 kilobits per second) and to access a wide range of additional services supplied either by the telecommunications operator of the network or by third parties. Bandwidth is a way of expressing the maximum flow of information that a link can carry. A wide bandwidth is often assumed to be necessary for realistic multimedia. The higher (or "broader") it is, the sharper the images transmitted, and the quicker the motion displayed, but also the higher the price. Multimedia telemedicine conference systems can be delivered over ISDN networks. Multimedia is the simultaneous use of text, sound, images, colour and motion. ISDN is not available in many countries, in particular, the developing countries. In addition, various interpretations of the standard may lead to interoperability difficulties. 6.1.7 Modems

Relatively low-cost modems offer data rates of up to 19.2 kbit/s which is faster than many telephone networks can deliver the data. Modems capable of much high data rates are on the market and are used for sophisticated applications such as videoconferencing. The latest modem technology (V.34 standard) has a higher resilience to noise on the line. The modems built to this standard are very robust. The V.34 standard provides speeds up to 28.8 kbit/s. Many modems are built to meet national PSTN specifications, which can differ from country to country. A big problem is that the audio transmit level for many modems (and fax machines) has been set too high, causing distortion. To counter the noise and distortion present on many communications links, it is essential to have data error correction enabled, either controlled by communications software, or by the modem's internal firmware.

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Flow control is used to control the information exchange between the different elements in a data communications link. It allows the modem to regulate the amount of data fed to it by the computer. For the most efficient use of the data communications link while the modem operates in error correction/data compression mode, the modem buffer has to be filled with some data. This can be achieved by the computer sending data to the modem at a higher rate than the modem is sending. If the modem gets too much data waiting to be sent, it can signal to the computer to wait to avoid a buffer overflow and loss of data, and then to continue after the amount of waiting data in the queue has been reduced. There are two types of flow control: • • 6.1.8 end-to-end between modems. This can be handled by V.42 protocol; local flow control between the computer and the modem. Local flow control can be done by hardware or by software. Compression

PC-based software packages are available which can be used for data compression, a technique for reducing the volume of a file in order to use less storage space or less time for transfer through a network. It eliminates the redundancy that is contained in most files. It can only be used if the transmission system is very reliable for it reduces the possibility of correcting errors. "Loss-less" compression and decompression algorithms do not alter the file and allow compression by factors from 2 or 20 or more depending on the degree of redundancy in the uncompressed file. Most computer generated data, drawings, pictures, spreadsheets and ordinary text files contain redundant information which can be compressed into a smaller number of bytes without any information loss. The smaller the data file, the shorter the transmission time, the lower the telecom charges. There are two forms of data compression: • software compression is usually done before the real transmission, using a commercial widely available package such as PKZIP/PKUNZIP, PKARC and ARJ. It will add to the overall processing time (off line), but can provide savings on telecommunications charges; hardware data compression is usually built into the modem, and is active during the real time transmission, if switched on.

•

The ability to transmit medical images in the 1990s has been enhanced by the introduction of compression software. Using a series of sophisticated mathematical algorithms, compression software can reduce the number of digitized bits to be transmitted by ratios of up 30:1 without any loss of resolution on the receiving end. With fewer bits to be sent, complex images can be transmitted in even shorter periods of time, expanding the possible applications of telemedicine and resulting in lower costs. Compressed video is the process of transmitting only the essential motion in a sequence. In an ordinary television transmission, the whole scene is transmitted over and over again to show motion. With compressed video equipment the background is sent only once and after that only moving portions are sent which are integrated appropriately into the background. This requires much less capacity (carrier space) than television or full-motion transmission. Currently motion can be shown on the equivalent of two digital telephone lines. This motion appears somewhat blurred. Higher data speeds permit a smoother appearance of motion. However, even at slower speeds (i.e., the equivalent of two digital telephone lines) the amount of motion one can see could be quite acceptable in many teaching and some clinical situations. Use of this type of network would increase capacity for medical data transmission between hospitals.

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6.1.9

Data networks

Digital networks provide the voice and data integrity required for diagnostic purposes and are capable of supporting high bandwidth demands. X-25 is one of the earliest telecommunications standards for data transmission. It is of the "packetswitching" type. The volume of data is not sent in a continuous flow, but is split into packets which contain information on origin, destination and transmission error detection. This allows for more efficient management of communications resources: only the packets where an error is detected have to be re-sent, and the routing of different packets can be optimized, taking into account the density of traffic at any given moment on each segment of the network. X-400 is a standard for email which takes into account security and confidentiality requirements as well as complex file transfer needs. 6.1.10 Email Electronic mail is a service allowing different computer users to communicate through a network. It was initially developed for communication of "plain" text (i.e., with only one font type and no variation in size or density) within the UNIX community. It has evolved to suit all environments and more complex file transfers. Email can be delivered by various systems such as the Internet and X.400 networks. Many off-theshelf software packages are available, such as Lotus cc:mail, which can be used on the user's computer to provide a user friendly interface with the email networks. 6.1.11 Internet Internet is mainly a communication protocol (TCP/IP) and can be used by different equipment and networks. It can be used for electronic mail, file transfer, information servers. Today, more than a thousand World Wide Web servers are specialized in the medical field. Internet has grown very quickly in recent years and seems likely to continue to do so. Among limitations are its lack of confidentiality, absence of warranties in services. Today, there are more than 100,000 hospitals around the world with more than 50 beds, but of those hospitals, only a few hundred (in 1995) had any access Web sites. The Internet offers a considerable resource to the practice of telemedicine. This resource is of equal potential value to more developed and developing economies. The exponential growth of Internet access and usage now means that patients, medical professionals and organizations can jointly benefit from the wealth of information and support that is available. Specific examples of Internet usage include: • • • • • • • medical training; medical information access; patient care and support; remote diagnosis and consulting; emergency/epidemic support; teleworking for the disabled; preventative care education.

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The Internet provides an enormous medical and health care resource. This is of immense value to practising physicians and medical students alike. Due to the quantity of freely available, high quality information, this is of equal value to all medical professionals. In addition to these free resources, several proprietary and charge-based resources are now emerging that utilize Internet Protocols for access. The success of these closed-user services will depend upon the specific quality of content and the number of people that subscribe to them. Experience has shown that loyalty to similar online services is very low once users recognize and comprehend the free resources available on the Internet itself. Nevertheless, there are opportunities for specific, fee-based, high quality content. The utilization of the Internet by medical professionals and institutions has been relatively low. Research conducted by the National Library of Medicine in the United States during 1995 indicated that 75 per cent of teaching hospitals had Internet access but only 25 per cent of community hospitals had access. In March 1996, it was estimated that less than 1 per cent of all hospitals in the world currently have their own Web server. To encourage hospital usage of the Internet, the Health On the Net Foundation, based in Geneva, has embarked on a major project, entitled "the Global Hospital", that seeks to help new hospitals gain Internet access. The growth of Internet usage is now providing opportunities for individuals, medical professionals and health care providers to obtain information, communicate with professionals, deliver first line support and promote preventative medicine programmes. The Internet provides a low-cost communications tool with almost universal availability (173 countries had Internet access as of March 1996). The growth in access is prompting new initiatives that enable health care providers to deliver better support at lower cost. This is of immense importance considering the changing socio-demographics of many developed countries (longer life expectancy and declining fertility rates) and the escalating costs of health care providers. A specific example of such an initiative is the support being given to virtual support communities. These are groups of patients, and/or people caring for them that participate in newsgroups concentrating on specific medical conditions. The quality of information provided to participants is generally of a high level, often supported by contributions from medical professionals. Possibly of greater significance, however, is the social or community support provided between participants. This social support has demonstrated itself as a powerful tool in assisting patient recovery and in reducing physical visits to physicians and clinics. There is an enormous opportunity for health care providers to contribute to these support groups and encourage their patients to use them for complementary support. The Internet is a superb communications facility for such support communities, particularly in regions with low populations and limited health care. A regularly updated listing of such virtual support groups is maintained at the Health On the Net Webserver (http://www.hon.ch). This same server includes specific examples of benefits generated by such groups. The Internet also provides disabled individuals with an opportunity to achieve levels of social integration that were simply not possible before. This extends to personal income generation through teleworking from home or from a clinic. More advanced examples of telemedicine across the Internet are also now emerging. Transfers of medical image files using Internet Protocols, have greatly benefited from new compression techniques and are providing a real alternative to the high-cost bandwidth requirements. The quality

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of new videoconferencing and audio tools on the Internet are also providing a valuable resource for remote consultation and diagnosis. Other uses include emergency response support. In this case a virtual team of experts around the world can be quickly assembled to support teams working in epidemic areas and/or remote locations. Field personnel can utilize satellite communications for electronic mail and access to existing resource centres on the Internet. 6.1.12 ATM Asynchronous Transfer Mode is an open standard switching technique designed to route all types of digital information (data, graphics, voice, video and multimedia) over a common network. ATM is the result of a trade-off between speed, security and even distribution of traffic load over segments of the network(s). Error detection and correction are left to the sender and receiver rather than being built into the network. This is possible thanks to the low error rates of today's transmission lines and switching technologies.41 Asynchronous Transfer Mode (ATM) is a fast packet switched technology. In telecommunication, a packet is a message or a component of a message. The message contains an address, control and data signals, and these can be transferred as an entity within a data communications network. Packet switching is a method in which messages are assembled into one or more packets. The packets (or messages) are sent through a network, collected and then re-assembled into the original information at the destination. ATM uses packets with a 5-byte header and a 48-byte data payload. It is more efficient and faster than the traditional packet switching methods. Broadband ATM networks enable use of sophisticated applications which demand considerable network resources. These broadband networks need to be carefully evaluated for flexibility, accessibility and cost efficiencies. The cost of installing and using an ATM network is, so far, so high as to be prohibitive for most developing countries. 6.2 6.2.1 Telemedicine technologies Hardware

A wide range of different devices can be used in telemedicine. Essentially, however, health care professionals need devices which can capture and manipulate data so that it transmitted over a communications channel (which typically in developing countries is most likely to be a telephone line). Peripheral equipment (i.e., that is attached or connected to a modem or telephone) used in telemedicine can include the following: General equipment: • personal computer -- new software packages on the market are lowering the cost of teleconferencing. These software packages include shareware and whiteboarding software. New software also allows greater data compression than ever before, so that high capacity digital images can be transmitted over lower capacity networks. teleconferencing and videoconferencing equipment

•

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41

p. 11, Telematics for Health Care: Its impact? Its future? Produced by ACOSTA for AIM. December 1994.
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• • •

digital camera microphones digital scanners and image processing software. Once a digitized image has been captured in a computer, it can be manipulated and discussed by physicians separated by great distances. for radiology (X-rays, CT, ultrasound) -- While lightweight, portable ultrasound systems are the ideal diagnostic tool in remote areas, the limited availability of trained personnel has been a barrier to its use. High performance ultrasound systems using digital technology and satellite communication links will allow patients to be examined anywhere in the world while a trained physician in another location receives the image and provides diagnosis and treatment consultation to the local physician by phone.

Specialized medical equipment: •

• •

for dermatology -- video camera for cardiology -- digital sphygmomanometer (blood pressure) -- ECG (electrocardiogram)

•

other medical equipment -- electronic stethoscope -- microscope/endoscope adapter -- EEG (electro-encephalogram, or brain scan) -- portable monitoring unit. Such kits could be used by doctors or paramedics travelling in remote and rural areas.

6.2.2

Software

The following software and/or services were mentioned in responses to the Telemedicine Questionnaire. In some countries, software has been "purpose-built", designed by the service providers. Such software could be of interest to other countries. There also a number of commercial, off-the-shelf software packages designed for telemedicine applications. Systems using the above mentioned hardware and software particular applications such as teleradiology, teledermatology, telepathology and monitoring of vital signs. 6.2.3 Picture archiving and communications system (PACS)

PACS is basically a broadband telecommunications network. It is sometimes known as medicalimaging networks or medical image management system (MIMS), i.e., the interconnection of medical imaging systems between hospital radiologists, physicians offices and image storage facilities.42 At its simplest, it is a network facility enabling different hospital departments to retrieve and transfer patient records, hospital accounts, etc.

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42

For more detailed information on PACS see "Health Care", by D. Wright, Brodband: Business Services, Technologies and Strategic Impact. 1993
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Today it is being used in large hospitals and medical centres which might have several sites. These would include the main in-patient facilities, out-patient clinics, teaching facilities, medical office buildings with physicians' offices and the radiology departments where the imaging equipment and the radiologists' viewing stations can be found. With PACS it is possible for a physician to send an X-ray of a patient to a radiologist for an examination who might be based in another building, without having the need to actually go there himself. At the same time he can send the X-ray to a specialist for a second opinion. This is particularly important because of the present trend towards increased use of out-patient facilities and medical office buildings for imaging. Because of today's technology, PACS allows the image of the patient examination to be stored digitally along with the radiologist's report, which can be stored in the form of digitized voice. It is possible to think of PACS as a multimedia communication system. This is because all accesses by the physician, operating theatre, and out-patient departments (both local and remote) are made by multimedia access to the PACS storage, and result in the retrieval of the image and the associated radiologist's report. PACS is very useful because a physician and a radiologist can have a discussion without the need for either of them to travel to a specific place to meet. Instead, they can use a multimedia communication system, where the medical images can be displayed on their own screens. Each of them will have voice communications so they can discuss the medical case and also point out certain areas of the shared image using a computer mouse to illustrate the discussion. These multimedia discussions are extremely important when a physician has an emergency and urgently needs to consult with a radiologist at another site, either within the hospital or elsewhere. One of the primary benefits of a medical PACS is time savings in accessing images and radiologist's reports. There are six sources of time savings from the introduction of a PACS: • • • • • • • Referring physician access to the image and report is electronic. Discussion between physician and radiologist is electronic. Access of other hospital departments, outpatient clinics and remote sites is electronic. Other sites can send images and associated patient information to the hospital for Specialist evaluation electronically. Typing and proof-reading of the radiologists report is eliminated. Obtaining approval for medical procedures from insurers is facilitated. Faster treatment; in a study conducted at the hospital of the University of Pennsylvania, the average time between the completion of the patient examination and action being taken was 3.0 hours when PACS was used and 4.1 hours when not. Faster access to medical images, i.e., reduced waiting time. Faster processing of medical images. Reliable image availability. Facilitated consultations between physicians and radiologists. Film library staff time saving.

Other benefits of a PACS system:

• • • • •

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• • • • •

Radio technologists time saving. Lower operating costs. Lower X-ray doses; digital X-ray detectors require lower X-ray doses than film, resulting in less exposure of patients to X-rays, and increased life of X-ray tubes. Linking modalities; the ability to integrate different imaging modalities and display them on the same, or adjacent, screens is a convenience deriving from the introduction of a PACS. Voice annotation; annotating a radiologist's spoken report to a medical image using digitized voice storage saves word processing and editing time, and results in integrated information availability within the PACS.

Examples of PACS in a modern medical facility: The Hospital of the University of Pennsylvania has been using PACS since 1982. In 1982, the hospital decided to introduce PACS over several years, to all forms of imaging. This project involved the interconnection of MR scanners, viewing stations, and storage. The backbone is an 80-Mbps optical-fibre LAN connected to: • • • A satellite gateway, for receiving images from MR equipment at a remote site; a file server, for storing images on magnetic storage for interactive access, and an optical "jukebox" for archival storage; a router, connected via two lower speed LAN's to MR equipment and viewing stations.

In Victoria, British Colombia, the Victoria General Hospital has installed a PACS since 1987, which includes chest radiography, MRI, CT, DSA, and fluoroscopy imaging. The present system also links to the Royal Jubilee Hospital, in the same city, via a T1 link. The PACS handles 1,900 accesses to new images and 200 accesses to archival images per day.43 7 Costs and benefits of different solutions

The application of telemedicine in developing countries depends upon many factors, especially cost, but also others such as the availability of appropriate resources and expertise. The following diagram is rather primitive and not intended to be particularly accurate, rather it is intended to convey the idea of increasingly sophisticated, increasingly expensive telemedicine applications and the cost of hardware at one site.

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43

p. 434-436, "Health Care" by D. Wright, Broadband: Business Services, Technologies and Strategic Impact. 1993
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Telecommunications capacity xx gigabytes fibre coaxial cable satellite television radio telephone

Tools

Cost of user hardware at one site $300,000 + $40 - 50,000

virtual reality broadcast quality image exchange equipment videoconferencing slowscan camera multipurpose work station PC with shareware telemetry monitor

$20,000

9.6 kbit/s 7.1

telephone

$50

Socio-economic benefits of telemedicine

There is no doubt that telemedicine has the potential to improve the quality of health care. Telemedicine might evolve as a cost-effective alternative to some forms of health care delivery. However, among others, the economic, organizational, legal and ethical aspects have to be taken into account. A thoroughly performed cost/benefit evaluation will certainly be of a crucial importance for health care policy-makers when deciding if telemedicine should be generally introduced or not.44 The delivery of telemedicine services yields many socio-economic benefits, including those derived from national development objectives such as the following: • • • • • • • • health education of various segments or of the whole population; universal care provision: a much broader reach in rural and remote areas; employment opportunities for indigenous technicians and paramedics; dissemination of advanced technological knowledge; availability of regular or on-demand health care in remote areas helps slow population migration or attract people back to previously abandoned areas; helps attract required personnel (including but not limited to medical practitioners) to remote and rural areas with a positive impact on the local and national economies; improves the health indicators as set and followed by WHO and national government; improves the image of a country (important, for example, for attracting investment).

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44

"Economic Aspects of Telemedicine", by Thomas Sommer, Health Telematics, Director General XIII/C4, European Commission, April 1994.
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Cost savings Telemedicine could help some countries to cut health care costs. A substantial part of the cost of running hospitals is spent on what are essentially hotel services: bed, breakfast, lunch and evening meals. Although telemedicine costs today are not low, countries with high health care costs are interested in the prospect of telemedicine as a way to reduce costs and demands upon hospitals. A study made in 1992 by Arthur D. Little in the United States estimated that between $36 billion and $40 billion could be saved if the health care industry were to use more efficient telecommunications and telemedicine technologies. The more health care can become decentralized and administered efficiently in low-cost settings such as clinics with telecommunications links, the less dependent patients become on expensive, asset-based sites such as hospitals for speciality care. Reduced waiting lists Telemedicine could reduce hospital waiting lists if patients can be seen more quickly using telecom systems with the consequent reduction in hospital waiting lists. It can allow treatment to be given immediately. Reduced travel Some of those who use telemedicine can avoid the need to travel to far-away doctors and hospitals. It can save patients time and money by eliminating the need for a trip to the hospital. In the telemedicine service in the Canary Islands, the Centre of Advanced Technologies in Image Analysis (CATAI) receives three or four distant video consultations a week, so that 30 per cent of inter-island patient transfers were avoided and 3 per cent of national transfers. Routine medical visits to the smaller islands by health care workers were reduced by 20 per cent. The yearly savings are thus estimated at 35 million pesetas. Improved consultations and second opinions Telemedicine enables health care professionals to consult quickly with specialists many miles away, without the cost and risk of transporting an ill or injured patient long distances, perhaps over rough terrain. In the future, more and more people will be treated and diagnosed via telemedicine, especially patients in smaller hospitals which may not have the facilities of the larger ones. Telemedicine can provide access to centres of excellence for various specialities -- theoretically from anywhere in the world. Telemedicine allows the scarce resources of specialists and expensive equipment to be shared by a much greater number of patients. Doctors are no longer restricted by geographical boundaries; international specialists are able to spread their skills across continents, even to battlefields, without ever leaving their own hospitals. Universal service Those who have had no or limited access to medical care, especially in remote and rural areas, can take advantage of telemedicine services if they have or can use a telephone (and, better still, other telemedicine equipment too).

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Stress reduction Families are spared the stress and expense of visiting relatives who have had to go for treatment to a hospital in a distant city. Training and education It can help in medical education and training. For those health care professionals working in rural areas of developing countries, access to remote medical databases on the Internet, for example, could be a boon for keeping up to date with what is happening in their field, to share experiences and address questions to other doctors. Telemedicine can be an important source of case study material from every part of the world. Students in one place can watch an operation being performed by a surgeon or physician in another place. If telemedicine continues to grow, specialists will be able to track an increase in the incidence of a particular disease as it happens. It is not always possible to get students to attend or watch live operations, so the next best thing is to record the operations and play them back. This also allows the lecturer to stop the tape and explain further or even to do an "action replay". When the money is available, there is no reason at all why students shouldn't be able to watch live operations being conducted anywhere in the world and communicate directly with the surgeon. Revenues The provision of telemedicine and telehealth care services offers the possibility of making the most of tight health care budgets, but also offers revenue generation and employment opportunities. Telemedicine is a high-tech industry, comprising equipment manufacturers and service providers, who generate revenues from the sales of their products and services. Telecom networks can generate additional revenues if their networks are used for the provision of telemedicine and telehealth. Commercial service providers can also find opportunities in this sector of the economy, but as discussed below. 7.2 Delivery of telemedicine and telehealth : the value chain

Telemedicine challenges the leaders of the medical establishment to rethink the ways they provide their services and to address the medical needs of areas where such services are absent or in short supply.45 The Bangemann Report "Europe and the Global Information Society" recommendations to the European Council re interoperability of health care systems assumes an Information Systems Architecture, structured in three layers: • • • networks (e.g., telephone, satellites, cables), which carry the information; services (e.g., electronic mail, teleconferencing, interactive video) which allows people to use the networks; applications (e.g., health care) which offer dedicated solutions for user groups.

To deliver telemedicine and telehealth applications, telecommunications are certainly needed, but it is really necessary to look at the telehealth and/or telemedicine "value chain". How does the equipment supplier, telecom service provider, healthcare or medical service provider deliver their products or services to their client, who eventually is an end-user? How does or how should the ____________________
45

p. 8, GETS proposal to CEC/DG XIII, op. cit.
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value chain work, especially in the context of exploring potential export markets? Is the value chain commercially viable or otherwise sustainable? One could depict one configuration of the value chain as follows:

equipment supplier

hospital

system integrator

paramedic midwife docotor

patient

telecom operator

This is only one simplified example of a telehealth/telemedicine value chain. Other, more complex configurations are conceivable. The value chain for a real, commercial (or even partly subsidized) telehealth/telemedicine service could look quite different when there are several hundred users or sites compared to when there are only a few. Telehealth and telemedicine can be delivered in developing countries by at least three ways -- one is via a paramedic, midwife or doctor who travels from village to village with his (or her) satellite phone, ultra-sound scan and a few other pieces of equipment which enable him to consult with a distant hospital or service provider. Norway uses mobile emergency units. Australia is famous for its flying doctor service. Another is via installation of a telehealth or telemedicine service in a rural clinic or a small hospital or, thirdly, in a "telecentre" or community centre (which could be a church, school, post office, police station, etc.), where the communications needs of several user groups could be aggregated in order to maximize the utility and lower the cost of providing a community telecom service. Both approaches (or indeed any other that seems viable, practical and pragmatic) need to be validated. To adequately test one or more value chain configurations, there should be a sufficiently large-scale trials to provide meaningful results, to be of interest to all of the participants and to serve as models or "test-beds" for other developing countries. It is worthwhile having a good understanding of who the different players are in the value chain. Among those who could be the value chain are the following: • • • • • • • health care professionals, such as midwives, paramedics, nurses, general practitioners, physicians, medical specialists other professionals involved in the broader provision of health care (managers, researchers, epidemiologists, technicians, information engineers, statisticians, etc.) end users (patients) telecom operators service providers equipment suppliers informatics and computer suppliers

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• • • • • • • • • • • 7.3 7.3.1

biomed equipment manufacturers telecom and computer equipment manufacturers professional associations health management organizations individual experts universities or other academic research institutions hospitals insurance companies pharmaceutical companies the Ministry of Health (or equivalent) regulators and licensing authorities Cost-benefit analysis The need for cost/benefit assessment

Apart from the most trivial telemedicine applications, there is usually need to justify expenditures on telemedicine (i.e., procurement costs, running expenses, operating costs) versus expected benefits or revenues possibly generated. Various standard techniques for project analysis can be used, for instance a net present value (NPV) analysis, which may enable a comparison with the costs of the existing situation and other alternatives. Overall fundamental objectives of telemedicine should be kept in mind when conducting any economic feasibility study; they may include specific national policy objectives such as provision of universal care or those simply aimed at reducing the costs of health care provision among specific target population or in a specific target region. While a full-fledged cost/benefit analysis (for assessment or a feasibility study) could itself be costly and time consuming, particularly in the absence of readily available necessary inputs (described below), at least a thumb-nail sketch of both the costs and benefits is required to enable the planners, politicians and health care administrators to seriously address a proposal for a telemedicine project. An important factor to keep in mind when preparing a cost/benefit assessment is that telemedicine is conducted in a complex and ever-changing technological, medical and political environment. Costs and priorities can change rapidly, and cost/benefits assumptions valid a few years ago, or even last year, may no longer be valid now. Many countries have experienced that, over time, the cost-benefit ratios have improved: projects that could not receive funding in the past have become feasible and were approved later. Some concern has been expressed in the past that cost/benefit studies could do more harm than good if not conducted properly. This argues for properly conducted studies which include all known benefits - both direct and indirect -- as well as the economic and social benefits. Texts on these topics are widely available, so here is presented only a review of the most important elements to provide a workable and simple framework for analysis and assessment.

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7.3.2 a. • • • • •

Benefits of telemedicine Tangible direct benefits savings from reduced travel costs of specialists savings from reduced travel costs of patients savings on hospital accommodation of patients that can be treated remotely savings on hospital processing costs of patients that can be treated remotely savings due to provision of health care in remote clinics or mobile health units versus expansion of urban or regional hospitals (i.e. difference in cost of construction and running of facilities; wages differential; etc.) Intangible direct benefits

Tangible benefits are those the monetary value of which can be readily ascertained, for example:

b.

Intangible benefits are those that have a definite perceived value but the actual value is somewhat more difficult to determine, although in many instances it can be ascertained or estimated. Such intangible benefits include: • • • • • • • • • c. • • • • better opportunity for second opinion and consultations resulting in avoidance of delays or costly mistakes; reduced waiting time which can in some cases prevent serious complications or death; reduced loss of income for patients who need not travel; reduced expenses for family members who might otherwise accompany the patient improved effectiveness of specialists: broader reach, more patients seen due to reduced travel; improved overall health care management, both internally and externally; improved availability and reduced cost of training of local medical specialists; increased collegial support to medical personnel working in remote and isolated areas, resulting in increased job satisfaction; improved teaching and learning possibilities and opportunities. Indirect benefits increased revenues to (national) equipment providers, hospitals, telecom services providers and the like; enabling specialist and technical personnel to increase their knowledge and qualifications; facilitating decentralization of care and distribution of competence; promoting maximization of scarce central resources (specialists, diagnostics apparatus and computers, etc.).

These are benefits accruing to various players involved in the provision of telemedicine, such as:

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Another way of classifying benefits according to the target group:46 benefits to patients: e.g., faster diagnosis and treatment; reduction of additional examinations; improved treatment of coronary diseases; avoidance of inconvenience of travelling to another hospital or physician. benefits to clinicians: e.g., new opportunities to consult experts, broader base for decision making, avoidance of inconvenience of travelling, improved image quality and the opportunity to manipulate images. benefits to hospitals: e.g., reduced risk of images getting lost, faster and more precise diagnosis and treatment, better communication between sites, transport savings, more efficient use of equipment. benefits to other groups: e.g., relatives can be closer to patients and service, provision of an additional teaching resource for students, facilitates scientific/statistical analysis. Ranking of benefits Benefits have also been ranked47, following a survey, according to the degree of significance, as follows: – – – – – 7.3.3 Improved quality of treatment/patient care; more available information, greater accessibility; more timely information, faster and more precise decision-making ability; savings in time and costs for staff and specialists; improved communications compared with existing, advice more readily available to junior staff. Costs of telemedicine

These are usually quite readily identifiable, although care must be taken to avoid including costs that the national or private health service providers would have incurred regardless, or the costs of equipment that have already been obtained for a different reason. Similarly, costs of vehicles, telecom equipment and operators, if these factors are used not only for telemedicine, should be shared in relevant proportions. The costs fall roughly into three categories: capital expenditures, recurring operating costs, and indirect costs. There is a fourth cost to cost, which is the cost of evaluating projects. The United States Army is reported to have allocated some 30 per cent of investments in telemedicine for evaluation of systems. It should be kept in mind that costs of telecommunications are decreasing every year. The same can be said of the costs of computers, interfaces, software, etc., while, on the other hand, costs of personnel may be rising.

____________________
46

"Economic Aspects of Telemedicine", by Thomas Sommer, Health Telematics, Director General XIII/C4, European Commission, April 1994. R. Heath, Cost/Benefit Analysis, Final Report of the EC supported project TELEMED (1992), quoted in the Sommer article above.
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a. • • • • • • b. • • • • • • • c. • • 7.3.4

Capital expenditures cost of telecom equipment specifically used for telemedicine (or a proportion, if also used for other purposes ): cost of vehicles, boats, planes for mobile units (unless already available); cost of necessary hardware, software, interfaces, peripherals; cost of special diagnostics apparatus or modifications to the existing stock; import duties, one-time licence fees and similar; costs of modifications to remote clinics, if necessary. Operating expenses telecom expenses; maintenance of computers, specialized telemedicine apparatus; vehicles running expenses and maintenance; cost of telemedicine specialists and operators (when performing also non-telemedicine duties, only a relevant portion should be counted); administrative costs; insurance costs; training and skill maintenance costs. Indirect costs impact of competition for available funds in times of scarcity; balance of payment impact if funds need to be obtained externally. Simple framework for assessment

Cost/benefit analysis and economic and financial assessments should be done from several angles to obtain good understanding of all cost and benefits elements as well as their evolution in time. Such analyses will satisfy the requirements of government decision makers, policy planners and health care administrators. Key among the possible angles of view are: • • • overall feasibility in a country, regional or subregional setting; annual schedule of savings resulting from telemedicine applications; annual operating costs for the health centre responsible for running the programme;

It is important that the seemingly large initial, one-time set-up cost of a telemedicine programme is contrasted with all categories of benefits over a suitable period of time, say 5 or 10 years. All benefits can be annualized and used for constructing a series of cost/benefit ratios. In performing net present value (NPV) analysis, discounting should be done using appropriate social discount rates as opposed to commercial rates, to better reflect the value of a telemedicine programme to the community. It should be noted that not all categories of either benefits or costs are applicable in a particular programme or a country setting. In fact, most cost/benefit analyses can turn out to be very simple and straightforward.

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Criteria for telemedicine project selection and assessment Telemedicine should be implemented on a scale commensurate with the requirements (needs) of the health care policy and resources available. It is best to start with smaller scale and simple projects or pilots, and gradually expand as experience is gained. Care should be taken that technology (level, complexity, quantity) and specific applications are appropriate for the objectives selected. Here are some typical criteria and factors needed to be considered for a project selection. 1. • • • • 2. • • • • • 3. • • • 8 Health care criteria kind of patients and symptoms to be addressed by telemedicine skills needed for telemedicine practitioners what existing health care protocols need to be established or modified? how is the success of telemedicine going to be evaluated? Management criteria operational support needed administrative skills required training needs to be arranged for practitioners at either end of the telemedicine link technical requirements and skills necessary to implement telemedicine what is required to integrate telemedicine into overall health care scheme? Technology criteria equipment required for the initial set-up to achieve at least the minimum of set objectives requirements on the telecommunications side to operate telemedicine applications reliably type of training needed Main trends

Acceptance and further development of telemedicine will depend upon a number of factors, among which are the following: 8.1 TEN potential problems with telemedicine

1) Like many people, some physicians may resist use of a new technology which they don't understand. This is especially so, since physicians working in rural areas are often not very young. 2) There are few insurance providers who will cover risks associated with telemedicine consultations. 3) Rural consultations are not frequent and it may be difficult to run cost effective systems.

4) Some states in the United States may require that if a physician is to practise his/her profession in that state, the physician must be the owner of a licence, granted to him/her by that particular state. In other words, a physician will find it difficult to provide a telemedicine service outside his own state. 5) Confidential medical data regarding patients must be protected from unauthorized access. (Encryption and password security may help.)

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6) To be successful, telemedicine service providers must focus on the needs of the medical profession and the patient, and not force fit existing technology on these services. Customer focus must not be replaced by a product focus. 7) Some telemedicine systems and services require that users have compatible hardware at both ends of the communications link, which reduces interoperability and the benefits of access to different sources of telemedicine expertise. Similarly, the absence of standards in some aspects of telemedicine can also deter the cost-effective implementation of new telemedicine services. 8) Financing is often complex since telemedicine applications often involve different partners in a single venture (e.g., telecom operators and hospitals). 9) Telemedicine may not seem cost-effective since it often enhances the service rather than perform a process more efficiently. This may multiply demand for a previously inaccessible service, thereby increasing costs. 10) Systems management and organizational problems may defeat the successful implementation of technologies or services or intentions which all otherwise may be good. 8.2 Issues

As yet, there are a number of unresolved issues which need debate and further consideration before telemedicine can truly become widely accepted even in the developed countries. Definition There is no globally accepted definition of telemedicine. Returns and reimbursement Telemedicine services can be delivered either on a commercial or public basis. On a commercial basis, users pay for all components of the telemedicine service: remote consultations, telecom expenditures, amortization of investments, operational costs, maintenance, etc. Frequently, assistance contracts include payment of telemedicine in cases of emergency, e.g., American Express, Europe Assistance. On a public basis, the telemedicine service is delivered within the framework of a social establishment, where no difference is made between a plain consultation and a teleconsultation. Therefore, secondary consultations cannot easily be reimbursed and investment and telecom costs cannot easily be amortized. Public regulation will have to evolve with the generalization of telemedicine in public organizations. Who pays? In the end, one way or another, it is the consumer or the taxpayer who can expect to pay (they always do), but that is a facile answer to a complex problem where there are many diverse players in the telemedicine value chain(s) and where the consumers may be distant from the service providers. There are many different telemedicine projects taking place around the world and they are funded from a variety of sources, among which are: • • government subsidy or grant; university or hospital subsidy or grant;

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• • • •

under-written by a telecom operator directly or undertaken in a joint venture with an equipment manufacturer or other service provider; funded in whole or in part by international and regional organizations, such as the WHO, ITU, European Commission, etc; Inmarsat, Intelsat, SatelLife and other satellite operators have supported telemedicine projects and services; the military, particularly in the United States, has funded a significant amount of telemedicine research and projects.

In the next several years, it is likely that telemedicine projects and services will be funded from a variety of sources. As telemedicine services become commercialized, as the concept of managed health care is more widely implemented, the end user, the doctor or patient in developed countries, can expect to pay for the commercial service, either as a user of the service or as a taxpayer or through a private medical insurance plan. In developing countries, few individuals will be able to pay for telemedicine. Hence, the introduction of telemedicine (except for the very rich) will most likely require active support by governments. Diagnosis at a distance Are doctors willing to make judgements on the basis of information transmitted rather than seeing the patient face to face? The answer seems to be yes. At least one survey of doctors in the United States showed overwhelming support for telemedicine. Similarly, patients seem willing to take advantage of telemedicine services, especially if it means they can avoid unnecessary, costly or difficult travel to see the doctor. General practitioners and paramedics would like to have a second opinion or consultation or guidance from a specialist who may be many hundreds or thousands of kilometres away. Despite the evidence so far, there is still an issue with regard to the willingness of doctors today to make judgements on the basis of transmitted information. Legal issues: who is responsible for the patient? If a local doctor or paramedic treating a patient contacts a telemedicine service and sends digital ultra-sound images or X-rays for interpretation, who bears the responsibility toward the patient? Is it the local doctor or the specialist a thousand kilometres away? Although many telemedicine interactions are already crossing state and national boundaries, legal precedents for remote liability and licensing are not yet established. When a telemedicine consultation crosses state lines, does the provider have to be licensed in one state, the other, or both? If the community "standard of care" is to be upheld, which community standard applies? If the telemedicine services are available and a poor outcome results when they are not used, does this constitute malpractice? Today's patchwork of state regulation, accreditation, and liability is clearly incompatible with the widespread use of electronic medical services."48 Medical laws are based on who has a duty to whom. The doctor in direct connection (contract) with the patient is liable. Medical practices without clinical examinations may be contrary to medical ethics, but consultations between specialists who do not require patient contact (e.g., radiologists, pathologists, lab specialists) are partly exempt. What is more dangerous for the patient? Is treatment by telemedicine better than no or delayed treatment?

____________________
48

"Legal Issues", by D.A. Perodania & M.D. Allen, Journal of Telemedicine, 8 Feb 1995.
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Competition As in so many other sectors of the economy, competition is increasing in telemedicine services. There are telecom operators, equipment manufacturers and specialized service providers competing for local and global telemedicine markets. Some countries, such as Australia and Singapore, are competing to become regional hubs for telemedicine services. Alliances are common and undoubtedly will increase, as telemedicine requires expertise from several distinct disciplines. Privacy and confidentiality of information Medical data are frequently sensitive, confidential, private. Consequently, it is natural that there should be concerns about the security and confidentiality of health care data, especially when it is transmitted electronically from one location to another. One of the projects sponsored by the European Commission as part of its Third Framework Programme focused on this issue. The project was titled the Secure Environment for Information Systems in Medicine (SEISMED). Within the next few years, all European citizens could choose to have their medical histories stored on a database known as Hermes, currently under development. This would give doctors greater and more complete information on which to base advice. Security of data has three aspects: (1) confidentiality, (2) integrity (i.e., completeness and correctness and prevention of unauthorized modification) and (3) availability, i.e., accessibility and readiness for immediate use as well as when and where needed in a usable form. As information technology becomes increasingly sophisticated and accessible, questions may arise about how much information should be given to insurance companies who can fine tune their premiums to higher risk groups. There are concurrent issues about who should bear which costs. Acceptance The success of telemedicine, indeed the use of information technology in general, will depend upon how users -- patients, doctors, hospitals and governments -- accept it. Clearly, a service delivered via telecommunications is not quite so personal as being in the consulting rooms of a doctor, but on the other hand some people have limited or no access to any kind of medical care now. As telemedicine's acceptance grows, it will gradually put pressure on practices that are not networked. Structural changes in health care delivery If telemedicine is widely accepted, it will undoubtedly force some structural changes in the delivery of health care and medical services. It may be that, given the huge costs of health care now in the industrialized countries, governments may seek to promote telemedicine as a way of containing health care costs. If a patient can be dealt with via telecommunications, he or she will not need to visit the hospital. Hospitals today are major cost centres. On the other hand, much of the equipment used in telemedicine is still expensive (though costs are coming down) and network costs can be significant. Thus, while governments or health care service providers are "containing" some costs, they may also be expending greater sums on telemedicine equipment and services. 8.3 Technologies

Future telemedicine technologies Telesurgery may not be used in practice for another decade, but work is in progress in the United Kingdom, the United States and elsewhere towards achieving it. A conference on Virtual Reality in Surgery and Medicine was held in the United Kingdom in 1994. In March 1995, there was an

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international tutorial and conference on Interactive Technology in Medicine and Surgery in Leeds. The conference considered the progress and challenges of interactive technology in surgery and medicine. Interactive technologies, including virtual reality systems, may revolutionize the practice and delivery of medicine as well as other scientific and engineering disciplines by providing novel methods of visualising and manipulating complex images. The cost of using holograms and virtual reality systems is still high. Recent developments, however, have begun to reduce these costs, and have contributed to the emergence of interactive technology systems in a growing number of applications. 8.4 Service Providers

As noted elsewhere in this report, especially the section which reviews telemedicine in some countries, telemedicine is delivered by a variety of service providers, such as telecom operators, equipment manufacturers, hospitals, universities, governments, information service providers, system integrators, etc., often in alliances or joint ventures. In a few countries, pharmaceutical companies and suppliers are active. 9 9.1 Prospects for development of global standards Policy and regulatory situation

Delivery of telemedicine services may require a variety of licences, type approvals and other regulatory sanctions. Telecom operators require licences. Users of telecom equipment may require individual licences (there may be "class licences" obviating the need for individual licences). Equipment specifications may need to meet various standards at the national, regional and/or international levels. Service providers may need operator licences. Global services may require global standards. In the case of mobile satellite services, one of the mediums of telemedicine delivery, the existence of various regulatory and commercial barriers (e.g., high import duties) inhibits the use of mobile earth stations despite their successful application by various health and relief organizations such as the World Health Organization (WHO), Pan American Health Organization (PAHO), International Committee for the Red Cross (ICRC), International Federation of Red Cross and Red Crescent Societies (IFRC), Médecins Sans Frontières (MSF) and others. There is thus a need for more favourable regulatory regimes. As telemedicine becomes more of a commercial service, requirements may emerge for certain minimum standards. For example, the value of an image transmitted over a telecom network will increase as its resolution increases. If the image is too "coarse", its utility is limited and doctors will hesitate to make a diagnosis. Thus, it is conceivable that, as time goes on, a minimum resolution for transmitted images may emerge. Some new standards for compression algorithms seem likely. Many countries have yet to develop a policy and regulatory framework covering telemedicine issues, such as in regard to tariffs, licensing, standards, confidentiality of data, liability due to misleading or faulty images during transmission or any other stages.

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9.2

Telemedicine standards

One of the technical barriers to interconnect telemedicine centres around the world is the difficulties of exchanging and processing medical data from one site to another, due to lack of compatibility in format, equipment interfaces, etc. In Europe, a Technical Committee for Medical Informatics (TC 251) was established within the European Standardization Committee (CEN, Comité Européen de Normalisation). The objectives of CEN TC 251 are the organization, coordination and follow-up of standards development in health care informatics at the European level. CEN TC 251 is the only official vehicle for European consensus building and standardization in health care informatics. CEN TC 251 liaises closely with EWOS/EG-MED (European Workshop for Open Systems, Expert Group - Medical) which focuses on Open systems Interconnection (OSI) model of the International Standards Organization (ISO) and on functional profiles to be used in health care. CEN TC 251 also liaises with WEEB/MD9 (Western European EDIFACT Board, Message Development Group for Health Care) which specifically works on implementation of message standards following EDIFACT syntax-rules and directories. Worldwide, CEN TC 251 coordinates with ANSI-HISPP (American National Standards Institute, Health Care Informatics Standards Planning Panel), with IT/14 Standards Australia, with MEDIS-DC within MITI (Ministry of Trade and Industry in Japan) and many others.49 The liaisons between standards bodies have been depicted as follows:

ISO

WEEB

CEN

EWO

TC 251

HISPP Others ANSI

____________________
49

p. 33 of Telematics for Health Care, December 1994. Produced by ACOSTA (Accompanying Measure on Consensus Formation & Standardization Promotion) for AIM (Advanced Informatics for Medicine), an EC programme. This text and the accompanying diagram have been adapted from p. 33.
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In the United States, teleconsultation systems are approved by the Food and Drug Administration (FDA), medicare and insurance companies. DICOM (Digital Imaging and Communications in Medicine)/ACR-NEMA DICOM is a standard that was set up to define a standard network interface and data model for imaging devices that can facilitate information systems integration.50 In 1983, the American College of Radiology (ACR) and the National Electronic Manufacturer's Association (NEMA) both set up a joint committee to develop a standard for medical imaging communication. The result of the collaboration resulted in the ACR-NEMA Digital Imaging and Communications Standard 300-1985. This standard defined a point-to-point communications protocol, a set of command messages, and a data dictionary for image communications. Basically a 16-bit parallel electrical interface was specified to permit a direct connection between two pieces of imaging equipment or between an imaging device and a network interface unit. A second version of the standard was published in 1988. However it was not successful. The reason was that it did not conform to the seven-layer International Standards Organization (ISO) - Open Systems Interconnection (OSI) reference model for communication services, a model widely used in the communications industry. To give it a degree of independence from the standards body and to foster international collaboration, it was renamed DICOM which is a multiple-part document that specifies both an ISO compliant profile and an industry standard protocol stack (TCP/IP [transmission control protocolinternet protocol]). DICOM is a complex set of documents that provide detailed definition of a rich set of communication services and associated protocols. It is based on an object data model. The model represents an abstraction of certain aspects of the real world. The main advantage of DICOM is that it is applicable to networked environments. The standard provides a mechanism for manufacturers to claim conformance by clearly specifying which DICOM functions are supported.51 The use of the DICOM standard has made information exchange between PACS and various departmental information systems simpler. 9.3 Telecommunications standards

Modems There are different error correction protocols available today. The most widely used internal error correction protocol is that offered by ITU-T (formerly CCITT) Recommendation V.42 which defines error detection and correction techniques. V.42 Recommendation defines two different schemes: LAPM and an alternative procedure known as MNP (Microcom Network Protocol), a ____________________
50

p. 1381, "Specifying DICOM Compliance for Modality Interfaces". RadioGraphics, November 1993. p. 1382, "Specifying DICOM Compliance for Modality Interfaces". RadioGraphics, November 1993.
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secondary option, either of which can be configured as the method of error control. MNP allows to connect with older modems, but LAPM is first choice by two V.42 compliant modems. Error correction and compression The most commonly known compression schemes are V.42bis and MNP-5. V.42bis uses a string encoding algorithm called Blitz. It replaces frequently occurring strings of characters with code words. It maintains a dictionary of strings during transmission and will add new strings and delete old strings when necessary. The combination of V.42bis and V.42 claims to provide a 4-to-1 data compression. V.42bis can actually detect whether the data send has already been pre-compressed (for example by PKZIP). The modem will switch between compressed and uncompressed mode of transmission, never adding any overhead to the data sent. MNP-5 does not have this ability. It will always try to compress the data, even when it is already compressed, with the adverse effect that transmission time will be longer. Television needs high decompression rates in real time for smooth movement. This is only possible through small differences with original images. JPEG (Joint Photographic Expert Group) and MPEG (Motion Picture Expert Group) are the most commonly used standards for still and moving image compression.52 10 Guidelines and recommendations

In developing countries, the government department responsible for defining and implementing general policy on health and organising health services is generally the ministry for public health. Such bodies appear to be much more concerned with primary health care coverage for their populations. Telemedicine is still a utopian concept. Nevertheless, this report is concerned with the implementation of telemedicine developing countries and encouraging developing countries to consider telemedicine applications. Two complementary strategies might be suggested: • increase awareness in government circles. This implies holding seminars, symposia, conferences, presentations, and correspondence addressed to the health authorities and other bodies. The success of such action is linked to the synergy of actions initiated by the various international organizations (ITU, WHO, UNESCO etc.); introduce pilot projects so as to demonstrate the value of telemedicine to the decisionmakers and government departments responsible for organization of health services.

•

Computerization of health services management The organization of health services is an important factor for telemedicine, once the regulatory, legislative and quality control aspects which this implies are considered. The lightning fast development of computer-based information systems and medical informatics at present allows simultaneous access us to a variety of different types of documents: texts, numerical data, pictures, graphs, sound and voice messages. Multimedia medical records cannot be far away.

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p. 12, Telematics for Health Care: Its impact ? Its future?
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The development of numerous picture processing techniques has made it possible to improve picture management systems, from which PACS (Pictures Archiving and Communication System) has derived, and which is extensively used in the clinical and radiological environment in developed countries. Over the next decade, developments in this field will allow us to move on from PACS to the WWW (World Wide Web), so as to create a genuine medical network via the Internet, where access to a registered patient's record form will be possible anywhere in the world. While we talk about PACS, multipoint distribution networks for medical information and the Internet, management of health services in developing countries is still done manually on forms. Even referral hospitals use this archaic method of management. Introduction of telemedicine services comes up against the almost total absence of computerization in present day health services management. It is advisable to think in terms of introducing a computer tool and starting up medical information systems and high performance networks in order to promote: • • • exchange of information and data between scientists and experts; holding distant consultations by real time examination of diagnostic pictures; and interactive management of patients' medical records.

Need for basic infrastructures: telecommunications and medical technology Telecommunications Telecommunications constitute an essential link in introducing a telemedicine application. For reasons of reliability, authenticity, and security, the risks of breakdown or even of any corruption of links must be zero. Telemedicine demands a high degree of telecommunications network security, a high efficiency level, and adequate transmission capacity. For practical and economic reasons, security and reliability of telecommunications networks is a decisive factor for introducing telemedicine applications. But it is precisely in the developing countries that the existing infrastructures are largely obsolete and the transmission capacity of the arterial routes is inadequate for telemedicine. The need for advanced technologies is pressing. As far as transmission support capacities are concerned, in developing countries one would have to pass from 2.4 kbs/s transmissions to wide band subscriber loop transmissions starting from the existing access network (copper wire, Hertzian loop, radio-television systems), or gain access to the networks of the future by deployment of: • • installations on fibre optic cables to allow interactive multimedia flows; and/or VSAT networks, using satellites to relay signals in fixed point to point propagation mode.

Medical technologies In a modern health service, providing diagnoses, treatment and care depends on the quality of both the biomedical equipment and professional expertise. Developing countries are inevitably short of both equipment and well-trained experts. Acquisition of communications interfaces and suitable expertise is a need which must be taken into account in any strategy for introducing telemedicine in a developing country.

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Training requirements The requirements for training in telemedicine and distance health care are enormous in developing countries, and involve training in the three sectors which play a part in the provision of telemedicine services: telecommunications, medical technologies, and health services in the particular case. Financial constraints All the constraints and requirements mentioned above imply mobilization of major financial resources. Given the state of economic crisis which developing countries are experiencing, and the limited resources of a State which must cope with enormous demand for supply of services and basic infrastructure (roads, schools, electricity, telephones etc.), financial support for strategies to introduce telemedicine into developing countries must in essence rely on external finance. Such finance can be granted in the form of aid from industrialized countries, credits granted by backers, or support for implementation of pilot schemes for operational applications of telemedicine and distance health care by specialist international organizations, such as UNDP53, WHO, UNESCO and others. There is great potential for telemedicine applications in both the industrialized and the developing countries. While the most advanced services require facilities that may not be widely available in developing countries, there are many applications currently in use which require only basic infrastructure and resources. Observing technological barriers, Administrations should work together to ensure that policies are in place at the national level to expand and introduce interoperable telemedicine networks that can be used effectively to improve the quality of health care delivery worldwide. Any plan to create a health care system utilising telemedicine should address medical practice, continuing medical education (CME), and public wellness. Factors to consider in the implementation of telemedicine Identify the types of medical services where telemedicine could be useful, e.g., in primary health care or emergencies. Define telemedicine needs. For example, rural and remote hospitals may have no communications links with urban hospitals. Ambulance services may need some telemedicine equipment. Do market analysis in your country. Who could benefit and who can pay for such services? Remember that there are different technologies and services available which could meet particular needs. Some will be more expensive and complicated. Thus, countries should do a careful assessment to determine the most appropriate technologies, means of communications and services. Are telecommunications connections needed inside the country only or also outside the country? What telecom infrastructure is available or what could be made available? Do a cost-benefit analysis.

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Ensure a diversity of players are involved in the implementation of telemedicine services, including the Ministry of Health or other health care professionals, telecom operators, service providers, telemedicine equipment manufacturers. Raise awareness about potential telemedicine applications among health care professionals and telecom operators. Get some limited experience via pilot projects or demonstrations before implementing a large scale service. Check out what other countries have been doing, preferably including visits to some of those countries with relevant telemedicine experience. Seek advice from international organizations, such as the WHO, ITU, European Commission. Try to get some training in the use of the equipment and services. Ensure adequate organizational and administrative arrangements are established and sustainable. If the country is seeking a telemedicine service provider outside the country, then seek competitive bids and establish appropriate contracts. There are various national, regional and international organizations from whom some funding for telemedicine projects can be sought. Although it is worthwhile contacting these funding bodies, still the country should ensure the telemedicine services are self-sustaining in the medium to long term to avoid raising false expectations. Follow a gradual, step-by-step approach to the introduction of telemedicine services. Telemedicine should be a part of the overall health infrastructure, but it needs to be introduced in a balanced way so that it is not at the expense of higher priorities, such as clean water, nutrition, sanitation, etc. At the same time, countries should not be enamoured of high technology to the extent that they introduce such services to sectors or areas where other needs should be met first. National administrations should take steps to implement Resolution 36 (relating to telecommunications for disaster mitigation and disaster relief operations) of the ITU Plenipotentiary Conference, Kyoto, Japan, September 1994. The resolution urges administrations to take all practical steps to reduce and where possible to remove regulatory barriers and to strengthen transborder cooperation between states. 11 Glossary

ACR: American College of Radiology AIM: Advanced Informatics in Medicine (EU) Algorithm: A set of rules which specify a sequence of actions to be taken to solve a problem. Each rule is precisely and unambiguously defined so that in principle it can be carried out by machine. Angiocardiography: The radiological examination of the heart and great vessels after injection of a contrast medium. Angiography: The study of the cardio-vascular system by means of radio-opaque media. ATM: Asynchronous Transfer Mode. AT&T: American Telephone and Telegraph Company.

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BT: British Telecom. Codec: Codecs are used in telephone systems to convert analog voice signals into digital signals, which can be transmitted at higher data rates and with lower error rates. Contrast Medium: Substance (widely used in diagnostic radiology) injected into the bloodstream to increase the contrast in X-ray procedures; usually contains iodine. CCD: Charge-coupled device. It is a semiconductor device which relies on the short-term storage of minority carriers in spatially defined depletion zones on its surface. The charges thus stored can be moved about by the application of control voltages via metallic conductors to the storage points, in the manner of a shift register. CT: Computed Tomography; reconstruction of cross-sectional images of the body made by a rotating X-ray source and detector which move around the body and records the X-ray transmissions throughout the 360º rotation. Cardiology: The section of medical science concerned with the function and diseases of the heart. Dermatology: The branch of medical science which deals with the skin and its diseases. DICOM: Digital Image Communications In Medicine. DSA: Digital Subtraction Angiography is a radiological technique where an initial X-ray image is digitized and subtracted from another taken after the injection of contrast medium. As only the contrast in the blood vessels is added, high quality images of these blood vessels can be obtained after a small intravenous injection. ECG: electrocardiogram. A record of the electrical activity of the heart. Echocardiography: Echocardiography is the examination of the structure and function of the heart using reflected pulsed ultrasound. A camera can be connected to the echocardiogram unit camera by means of an ordinary video cable. EEG: ElectroEncephaloGraph. Instrument for study of voltage waves associated with the brain; effectively comprises a sensitive detector (voltage or current), a d.c. amplifier of very good stability and an electronic recording system. Endoscopy: Any technique for visual inspection of internal organs. Endoscope: An instrument for inspecting and photographing internal cavities of the body in medicine. Fibre-optics are normally used to both illuminate and inspect the inside of the human body from outside. Epidemiology: It is the study of disease in the population, defining its incidence and prevalence, examining the role of external influences such as infection, diet or toxic substances and examining appropriate preventative or curative measures. FEST: Framework for European Services in Telemedicine, a project funded by the European Commission under its Third Framework Programme. Fluoroscopy: Examination of objects by observing their X-ray shadow on a fluorescent screen. In medicine this technique is used to study patient physiology, such as heart beat and respiration. GETS: Global Emergency Telemedicine Service, a project funded under the European Commission's Fourth Framework Programme (1994-98) as a contribution to sub-project 4 of the G-7 Global Information Society theme on global health care.

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GP: General Practitioner. In the United Kingdom GP's are the non-specialists physicians who provide primary care to the community. Their surgeries are usually the first point of contact for the patient regarding anything other than a medical emergency. Gynaecology: The branch of medicine concerned with diseases in women. It is mainly those diseases of the genito-urinary tract. HERMES: Telematic HEalth care Remotenes and Mobility Factors In Common European Scenarios. ICRC: International Committee for the Red Cross. IFRC: International Federation of Red Cross and Red Crescent Societies. IMIA: International Medical Informatics Association. Inmarsat: International Mobile Satellite Organization, which provides satellites for maritime, aeronautical and land mobile communications. ISDN: Integrated Services Digital Network. It is a set of standards defined by the International Telecommunication Union and the International Telegraph and Telephone Consultative Committee of the ITU that defines a type of digital telecommunication service allowing the integrated transmission of voice, data and still pictures in digital form. ISO: International Standards Organization. ITU: International Telecommunication Union, the United Nations agency responsible for telecommunications. JPEG: Joint Photographic Experts Group. A standard for still and moving image compression. MDIS: Medical Diagnostic Imaging Support. MEDLARS: Medical Literature Analysis and Retrieval System. It is a collection of more than 25 databases in the biomedical field produced by the National Library of Medicine which is located in Bethesda, United States. MERMAID: Medical Emergency Aid Through Telematics, a project funded under the European Commission's Fourth Framework Programme. MPEG: Motion Picture Expert Group. A standard for still and moving image compression. MRI: Magnetic Resonance Imaging is the use of nuclear magnetic resonance of protons to produce proton density maps or images of the human body. NASA: National Aeronautics and Space Administration. It is responsible for civil space activities in the United States, both research and development. NEMA: National Electrical Manufacturers Association. NM: Nuclear Medicine is the application of radionuclides in the diagnosis or treatment of disease. NREN: National Research and Educational Network. Oncology: That part of medical science dealing with new growths (tumours) of body tissue. Ophthalmology: The study of the eye and its diseases. Otorhinolaryngology: That part of surgical science which deals with diseases of the ear, nose and throat.
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PACS: Picture Archival and Communications System. PAHO: Pan American Health Organization. Pathology: Pathology is the area of medical science which deals with the causes of disease, and with the bodily changes wrought by disease. PC: Personal Computer. PEACESAT: Pan-Pacific Education and Communication Experiments by Satellite. PET: Positron Emission Tomography. Pharmacology: The scientific study of the action of chemical substances on living systems. Psychiatry: The study of mental disorders. Radiology: Radiology is the scientific study of X-rays and other high energy radiation which is used in the medical profession. RCCS: Remote Clinical Communications Systems. SEISMED: Secure Environment for Information Systems in Medicine (EU). SPECT: Single Photon Emission Computed Tomography. SuperJanet: Super Joint Academic Network. TAMC: Tripler Army Medical Centre (Hawaii). TEACH: Training Education Applied to Community Health (Hawaii). Telecardiology: Teledermatology: Tele-endoscopy: Endoscopy is any technique for visual inspection of the internal organs. Today's modern instruments are usually flexible fibre-optic devices and additional facilities for biopsy. Tele-endoscopy is the transmission of digital images, especially of the ear, nose, throat and nasal passages. Telefluoroscopy: Telegynaecology: Telehaematology: Telemetry: It is a way of monitoring and studying physiological functions of a human being or animal, (i.e. heart rate or blood pressure etc.), from a remote site. Tele-obstetrics: Tele-oncology: Tele-ophthalmology: Telepathology: Telepathology is the transmission of images of cell or tissue samples for microscopic examination and evaluation. Distant consultations based on microscopic examinations of cell and tissue section by using distant microscope control is for transferring video, speech and data for controlling the microscope and different cameras. Telepharmacology:

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Telepresence: A technique in which a person has the virtual feeling of being at a chosen site even though he/she is not physically at the site. Telepsychiatry: Can be delivered via telephone help lines or videoconferencing equipment, between the patient and the specialist. Teleradiology: Teleradiology allows doctors, nurses and other health care providers to transmit images generated by magnetic resonance imaging (MRI) or computed tomography (CT) scans to each other, and to discuss diagnosis and treatment. X-rays, CAT scans, MRIs, mammograms and similar images can be transmitted over ordinary telephone lines. In addition, teleradiology enables interaction among hospitals, nursing homes, labs, pharmacies and other facilities, allowing personnel to view images, lab results, file data and then review and discuss them. Electronic film distribution and archiving can give physicians instant access to patient images without the film leaving the hospital's radiology department. Images are digitized and stored in a computer database. Problems of image availability, transport and storage can be eliminated. Teletherapy: Counselling, usually by telephone. TETRA: Telemedicine and Educational Technology Resources Agency. Thermography: The use of radiant heat emitted by the body to construct images of increased heat emission which can indicate tumours or inflammation. Ultrasound: It involves passing a high frequency sound wave (2-4 MHz) into the patients body. The reflected waves are then recorded and an image is formed. UNIX: TN for a well known operating system not tied to a particular computer manufacturer. It is a trademark of AT&T laboratories. UUCP: UNIX to UNIX copy. Widely used mail network connecting machines running UNIX operating system, often over ordinary telephone dial-up lines. WHO: World Health Organization, an agency of the United Nations, based in Geneva.

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