MS FRCSE FFAEM
Honorary Consultant in Emergency Medicine
Central Middlesex Hospital
Telemedicine has been practised at a distance for centuries (eg, a physician assessing a plague patient across a river), but it is only lately, with the development of electronic communication, that the practice has burgeoned. Electronic telemedicine started with telegraphy in the mid-19th
century and was followed by telephony and radiocommunication, which have been skilfully practised for many years. It was the development of videoconferencing systems that made telemedicine the most exciting topic in medicine today.
The adoption of any innovation is initially very slow because of initial scepticism, but when it passes a certain point the number of users suddenly rises exponentially until the innovation reaches a point of saturation in the market. Witness what happened with mobile phones. Telemedicine has reached breakthrough point, and its future is in the hands of healthcare managers all over the world. In North America, the number of programmes has been doubling every year since 1994, with a much bigger increase between 1998 and 2006. However, it is in the developing world that it is being applied aggressively. In Europe, the attitude has been cautious because many healthcare providers saw poor returns from the implementation of expensive and badly functioning computer systems. Perhaps this scepticism is an advantage as it will prevent gullibility and stop unscrupulous suppliers from duping clients. But even in Europe, there has been a steady increase in telemedical applications, usually by groups of enthusiasts.
Large research funds for collaborative telemedicine projects between the member countries of Europe are now easily available, and the private sector gets a chance if there are good and credible partners in the bid. There have been criticisms about how these research and implementation funds have been handled, but experience has taught the EU bureaucrats a lesson or two that they are applying with some enthusiasm. Clearly Europe will get its act together by developing guidelines, standards, compatibility of equipment, and so on.
Peripherals Image, sound and other digital information have to be captured in analogue or digital form by a variety of peripheral devices. Among many others, these include:
- Digital still cameras, which capture one image and forward it across to another site. They are used in teledermatology, where one view is often sufficient for a specialist to make a diagnosis.
- Video cameras have the advantage of being able to show real-time moving images of a part of the body from different angles, and are an excellent method of conducting a consultation in which the consultant and the patient can see each other. For a good system it is necessary to use more than one camera.
- Electronic diagnostic devices such as stethoscopes, ophthalmoscopes and otoscopes are now being used more often, although they are not as ubiquitous as cameras.
- Monitoring devices such as ECGs, which permit home monitoring of patients, especially babies, are commonplace.
- Output from digital imaging such as plain digital radiography, CT and MRI has been adopted with enthusiasm by some groups in the USA. In Europe, managers are busy exploring the possibility of having digital radiology images reported in India for a much lower cost.
- Microscopes, as used in telehistopathology.
Codecs A codec (encoder/decoder) is able to convert analogue images into digital ones, and vice versa. Some peripheral devices capture an analogue image, which is converted by the codec into a digital one, but there is an increasing tendency to make the outputs available in digital form, thus obviating the need for codecs. The information needs to be transmitted rapidly, so it is common for the digital information to be compressed. It is important that in the process of compression and decompression the information is not changed perceptibly. Once digitised, compressed and transmitted, information received at the other end is decompressed and is available to be visualised and heard on a TV screen or a computer monitor. Much of these functions are within the capability of laptops with appropriate software.
Transmission An important component of telemedicine is the transmission of image and sound to and from the distant site. Rapid transmission is important, so bandwidth matters. The common method of transmission is the use of ISDN (integrated services digital network), which transmits at a bandwidth of 384 kbit/s(6) (the fastest internet modem transmits at 56 kbit/s). Practical experience indicates that transmission below 384 kbit/s means there can be a compromise in picture quality. When the bandwidth is doubled, there is a clear improvement. Bandwidths above 768 kbit/s are useful when it is important to judge movement. Other methods of transmission include broadband, wireless networks, radio, satellite and fibreoptic networks. Wireless telemedicine offers the greatest potential.
Monitors and TV screens Computer monitors are satisfactory for still images, but a much higher degree of resolution is required for teleradiology. TV screens can be larger and are available as advanced, flicker-free HDTV screens. They are useful in tele-education.
Many of the applications of telemedicine have been in the rural setting, where a patient may have to travel many miles to be able to get to an outpatient department and see a specialist. There will be an explosion in the use of telemedicine because of the pressures for change in the urban setting. It is probably true that there are too many hospitals trying to do the same things not very effectively. Mergers will be a fact of life, and the only way of providing equity in healthcare will be to rationalise services by the relative strengths of departments. Consultant numbers have not increased as rapidly as were required by the regulations of junior doctors’ hours of work, and the public now wants consultant provided services. The only way to deliver will be to reduce the number of locations where services, especially surgical ones, are delivered. There is also pressure to rationalise and improve emergency services, and the concept of the Virtual Night Hospital – where one emergency physician and one radiologist sit in any one of a group of participating hospitals to advise junior doctors over a telemedical link – has generated a great deal of interest.
Teleradiology The ability to view an X-ray image at a distance is and will become even more commonplace because of the inevitable proliferation of digital radiology.1 If the image is already digitised, then it is relatively simple to transmit to or from a remote site. For some years, neurosurgeons have been using telemedicine to look at CT scans so that they can advise general surgeons on the need for surgery or transfer in head injury cases. Many unnecessary transfers have been avoided. Plain X-rays are commonly taken in small community hospitals and have to be transported to the main hospital for an X-ray report before they are returned to the smaller hospital. A good teleradiology system will soon ensure prompt reporting and obviate transfers in which films are lost in transit. Europe will inevitably follow the USA in breaking up radiologist time to enable them to report on images taken at a variety of sites.
Remote trauma management A common application is when emergency physicians in the main hospital are looking at an injured part and viewing the X-rays on a screen before advising nurse practitioners in peripheral minor injury units.(2) Most such units are now considering adding new peripherals to expand the spectrum of cases that nurse practitioners are allowed to manage. Other innovative models will be produced (eg, urgent treatment centres [UTCs]), where a wider range of services is delivered by doctors and nurses. We have just been awarded a contract to run such a service and are in the process of linking it to our accident and emergency department. It is in the field of remote trauma management that there will be the greatest interest in British management circles. Telemedically supervised minor injury units will go some way in placating catchment populations whose accident and emergency departments are shut as part of the process of modifying district general hospitals. The savings accrued by such rationalisation will be substantial. In the rest of Europe, where distances can be even greater, there is definite interest in this direction.
Telepathology Telemedicine technology is used to provide hospitals without an onsite pathologist with a remote frozen-section service, and to give histopathologists a handy tool for obtaining second opinions from expert colleagues outside their own department.(3) The proliferation of daycare surgery in smaller locales will be enhanced if this technology is adopted. There have been several patient recalls all over Europe because of a scare that a particular histopathologist was fallible in his/her diagnosis. Slides can now be viewed at a distance, and already there are highly competent cancer networks being established.
Teledermatology In remote locations, GPs are usually very competent at managing a wide variety of conditions, but on some occasions require their patient with a skin rash to be assessed in an outpatient setting by a specialist. If the nearest hospital is many miles away, it is easier to obtain a specialist opinion from a dermatologist by telemedicine.(4) Patients are spared a long journey.
Home telenursing and telehealthcare District nurses have to visit the elderly for a number of reasons, but often it is just to check how they are getting on at home, whether they are taking their medication correctly, and so on, and this kind of function can be easily performed via telemedicine.(5) A UK-based study found that 16% of visits could be replaced by telenursing. In Japan, there is an expectation that it will save billions of yen because of the rapidly ageing population now placing a great strain on healthcare.
Telepsychiatry Telepsychiatry can be used between psychiatric nurses in group supervision and doctors participating in psychotherapy supervision. In Britain, it is possible for a consultant psychiatrist to talk to patients in a GP’s surgery and discuss the management with the patient and his/her doctor.(6 )
Other applications There are many other applications, and their variety and number will surely increase. Some of these are telemonitoring, tele-echocardiography, telecardiology, tele-ENT, tele-EEG, tele-EMG, tele-ambulance, tele-opthalmology and tele-education.
- McLaren P, Ball CJ, Summerfield AB, Watson JP, Lipsedge M. An evaluation of the use of interactive television in an acute psychiatric service. J Telemed Telecare 1995;1:79-85.
- Suramo I. Low-cost digital teleradiology. Eur J Radiol 1995;19:226-31.
- Tachakra S, Sivakumar A, Diaz-Guijarro Hayes J, Lynch M, Bak J. The use of telemedicine for remote trauma management in minor accident and treatment services. Eur Telemed 1998/99:103-4.
- Nordrum I. History and present status of real-time telepathology. Eur Telemed 1998/99:72-3.
- Loane M, Corbett R, Bloomer S, Eedy H, Gore H, Mathews C, Steele k, Wootton R. Diagnostic accuracy and clinical management by real time dermatology: results from the Northern Ireland arm of the UK Multicentre Dermatology Trial. J Telemed Telecare 1998;4:95-100.
- Allen A, Doolittle G, Boysen C, Komoroski K, Wolf M, Collins B, Whitten P. Quantifying home health visits that could be done electronically. Telemed J 1997;3:92.