Clinical Practices in the Information Age:
An Introduction to Telemedicine
Technologies
Department of Computer Science/School of
Human Medicine
University of Wyoming
December 10, 1999
Click here for presentation slides
For more information, contact the author:
Rex E. Gantenbein, Ph.D.
The foundations of telecommunications
Applying telecommunications to health care
The challenges to telemedicine
Telemedicine, the application of telecommunications
technology to health care, requires the integration of technology, tools and training with
medical care practices and problems. Although it is not necessary to be an expert in all
these components to effectively use a telemedicine system, only through cooperation among
health professionals, computer system developers, telecommunication providers, and
educators can telemedicine achieve its potential to improve the delivery of health care,
particularly in rural or remote areas.
The purpose of this course is to introduce
students in the health sciences (including nursing, medical technology, and medicine) to
the fundamental concepts of telemedicine, including:
These concepts will be demonstrated through
lecture and by examples of existing telemedicine systems developed by local, regional,
national, and international organizations. Among the systems that will be discussed and
demonstrated are:
Other projects will be discussed and reviewed as
time permits.
Part 1: A vision for
telemedicine
Imagine this: a nationally known neurologist is
conducting rounds at the hospital in Thermopolis, Wyoming, as she does every two weeks.
After pulling up the latest X-rays and lab results on her computer for a particular
patient who has come in for a consult, the doctor asks a physician's assistant to describe
the patient's worsening tremor. The doctor then asks the patient to walk across the room,
touch her nose, and write her name. After watching the patient, the doctor and the PA make
a firm diagnosis, discuss a plan for treatment, and arrange a follow-up visit. Her rounds
complete, the doctor looks out her office window in Cheyenne, thinking about her rounds in
Sundance tomorrow, while the patient drives back to her ranch outside of town.
Telemedicine literally means medicine at a
distance. It is more narrowly defined as the integration of telecommunications,
information, human-machine interface, and medical-care technologies for the purpose of
enhancing the delivery of health-care. It can include the transfer of basic patient
information over computer networks (medical informatics), the exchange of images such as
radiographs or pathologies among geographically separated specialists, remote patient
interviews and examination through videoconferencing and remote monitoring, and
educational activities. With the rapid growth in telecommunications and computer
technology over the last few years, telemedicine has become an important part of medical
development, with the potential to greatly improve the quality of future health care.
People living in remote or rural environments have
limited access to basic health care. Geographic isolation, the scarcity of physicians and
clinics, and the difficulty of travel to larger cities where such care is available are
among the factors limiting this access. Efforts to encourage physicians and other health
professionals to establish practices in underserved areas have only been partly
successful.
Telemedicine is one way in which more and better health
care can be delivered to such remote areas, both in the United States and throughout the
world. The technology exists allowing health professionals to examine patients through
video links to remote clinics, to view medical images and patient records electronically
transmitted from one location to another almost instantaneously, even to review from afar
the results of biopsies or vital signs from a patient during an operation.
Telemedicine can also be used for educating health
professionals in rural or remote communities, and to give them access to up-to-date or
specialized information that might otherwise be difficult to obtain in a timely manner. It
can be used in public health programs and to assist local organizations in health-related
campaigns such as accident prevention, pre-natal care, etc. It may even be useful in
developing more cost-effective methods of providing health care in private clinics or
managed-care organizations, which present difficult computer integration and communication
challenges due to their size and geographic distribution.
(The above was adapted from the Western Governors'
Association Telemedicine Action Report.)
There are studies on the specific benefits of
telemedicine to the health care industry and on plans for its use:
(The above was adapted from "Industry Fact Sheet," a publication
of the NASA Telemedicine Technology Gateway / National Technology Transfer Center)
Part 2: The foundations of
telecommunications
Like telemedicine, the word
"telecommunications" is based on the Greek root tele (at/over a
distance); generally, telecommunications means the electronic transmission of information
over a distance. There are several forms of telecommunications that most of us take for
granted today, including telephones, radio, and television. With the advent of computers,
satellite communications, and computer networks, however, many new forms are becoming more
commonplace: electronic mail, videoconferencing, file sharing, even remote control over
tremendous distances (such as the Sojourner robot that is part of the Mars Pathfinder
mission).
Only three things are necessary to achieve
communication: a sender, a receiver, and a medium that transmits
information from the first to the second. This is true even in human, face-to-face
conversation! (What is the medium here? If you are speaking, it is the air that carries
sound waves from you to your listener; if you are gesturing or using sign language, it is
light, which carries the image of your movements.) However, to support long-distance
communications (i.e., farther than your voice or vision will allow you to hear or see
someone), technology is necessary. Electronic devices like telephones, TV cameras, or
computers allow you to create information that is then transmitted through media such as
cables, satellite systems, or computer networks.
Most of these systems interpose switches or routers in
the medium that relay information from one intermediate point to another, deciding along
the way how to get an electronic message to its intended destination in the best manner.
These decisions are made with the help of communications protocols, which are
simply standards for information transfer that all senders, receivers, and routers
involved in a transmission agree to use. (These protocols are the reason that you can talk
to someone using a different long-distance telephone service than you do, or why you can
send E-mail to a friend, even if you're using a Macintosh and he/she is using a PC.)
Much of the interest in telecommunications recently has
come about because of the phenomenal growth of the Internet, which is a term for
the tens of thousands of interconnected networks from academic, military,
government, and commercial entities worldwide. The agreement by all users on specified
protocols for communication on the Internet allows any computer with an Internet
connection to communicate with any other connected computer, no matter where each of them
are. The Internet encompasses millions of computers and several different media, ranging
from telephone lines to fiber-optic links to microwaves to satellite transmissions.
It should be noted that "Internet" with a
capital "I" refers to a specific world-wide collection of networks that is
managed by a private consortium of universities and commercial companies. (Development has
started on "Internet 2," a new internet to be managed by the U.S. government,
among others, that will focus on research and science. Other internets can exist; if these
interconnected networks are completely internal to an organization or company, they are
sometimes called "intranets" to distinguish them from "the Internet.")
The Internet itself originated in 1969 as an experimental network of 4 computers at UCLA
by the Advanced Research Projects Agency (ARPA) of the U.S. Department of Defense. The
goal of the project was to develop a communications system that could withstand a nuclear
attack. The idea was to use computers to send messages from anywhere to anywhere,
eliminating the need for a central command post and creating a communications system that
could operate even if large portions of the "network" were destroyed.
By 1972, ARPANET included 50 universities and military
research sites. It was largely a research environment until the late 1980s, when the
military turned control of the backbone, or main trunk lines, of the network over to the
National Science Foundation. Meanwhile, several other networks in smaller areas of the
country were being created for the purpose of accessing large computers at regional sites
by means of telephone or microwave links. Private, "local area" networks were
becoming more and more popular, as universities and industry found them useful to share
data among the increasing numbers of computers being used. Eventually, these public and
private networks were interconnected (hence, "Internet") to enable any computer
to access another computer anywhere else. The Internet Society was set up in 1992 to
promote the use of the Internet. NSF gave up its sponsorship in April 1995 to a consortium
of private sponsors, including the Society. (A good description of the Internet's
evoltuion through Arpanet and NSFNet is found in section 1.5 of the book Computer
Networks, Third Edition by Andrew S. Tanenbaum.)
Access to the Internet requires very little -- a
computer, a modem or networking hardware, a network link (direct: university, employer,
commercial link or on-line service: AOL, Prodigy, CompuServe, MS Network), and driver
software. This collection of technology allows a computer in one place to access files on
another computer; requests and responses are sent through gateways to remote sites. The
software that controls the network finds the various sites by name and domain (.gov, .mil,
.edu., .com) and sets up a connection between the requesting computer and the responding
one.
Gateways
connect regional networks throughout the US and the world to each other. Currently, the
University of Wyoming and the state's community colleges are all connected via the Wyoming
State Network, an array of leased lines and state-owned digital microwave, providing T-1
bandwidth. The bandwidth of this network is used for government voice and data
communications, law enforcement and library needs, and Internet access with enough
bandwidth remaining for a compressed video network. The compressed video network is
primarily used to deliver University courses. However, state government agencies and the
private sector have increased utilization of the system. The State
Telecommunications Council coordinates this network. Local support for networking is
provided by UW's Division of
Information Technology.
The Internet (and most other internets) support
telecommunications in a number of ways. The ability to compose, send, and receive electronic
mail between users has been around since the early days of ARPANET. Newsgroups
are specialized forums in which users with a common interest can exchange messages on
technical and nontechnical topics. (Chat rooms are real-time, interactive versions
of newsgroups, where people can send messages back and forth to those who are connected to
the "room" at that time.) Using programs such as "telnet" or
"rlogin," users on the Internet can perform a remote login on any other
connected computer, as long as they have authorization and an account for that computer. A
user can also make copies of files from other computers onto their own, using programs for
file transfer such as FTP.
Even with all these features, most of which have been
available for several years, usage of the Internet was pretty much the province of
research groups, universities, and a few big companies until 1989, when a group of
high-energy physics researchers at a University in Switzerland developed a technology for
distributing results over the Internet. This technology evolved into the World-Wide Web,
which many people today think is synonymous with the Internet itself. Certainly, Web
technology has driven the transition of the Internet from an academic research tool to a
household word.
The foundation of the Web is a loosely organized group
of computers (sites) accessible from the Internet containing files that can be viewed
using browser software (Netscape Navigator and Microsoft Internet Explorer are
the most popular). Computers on the Web store files using a text-based computer language,
HTML, that is viewed by a browser as hypermedia (pictures, words and hyperlinks
to other sites related to the one currently being viewed). "Clicking" on a link
in a document gives the user access to a document associated with that link. The document
may be on the same computer as the first or on another computer, anywhere on the Internet.
(Following these links, or looking for those links that are interesting using search
software like AltaVista or Yahoo, is "surfing the Net.")
Soon after the Web's introduction, organizations with
Internet access began providing Web sites as a means of presenting information to
"surfers" both local and global. With the privatization of the American
Internet, providing commercial space on the Web became a very important part of
maintaining it. Today, many big and small companies are using the Web for marketing and
other commercial applications. In addition, there are incredible amounts of information
available through the Web and other Internet sites (examples: art, science, personal data,
resumes, forms, …). Web "pages" now support not only text, but images,
sound, video, even interactive (live) communication.
With the growth of the Web, Internet access is a big
business! A survey
by CommerceNet and Nielsen Media Research in 1995 found that 16% of the people over the
age of 16 in the US and Canada had access to the Internet. About 10% of the adult
population had used it recently (8% of those had used the WWW). However, a follow-up study six months later reported that access to the Internet had
jumped by 50% (from 16% of the adult population to 24%) in 6 months. More interestingly,
the number of recent users had increased to 17%, over half of whom were
"newcomers" – that is, had not been Internet users six months earlier. Current
results indicate that of the 220 million people over the age of 16 in the US &
Canada:
There are some other interesting statistics about Web
users, which were collected as part of a 1995 survey by the Georgia Tech
(University) Research Corporation: in general, women comprised 31.5% of the Internet
users; the average age of users in America was 33.9 years (in Europe, they were a little
younger); of those studied, nearly one-quarter had used the World-Wide Web for less that
six months, and 43% had used for less than a year. Of those using the Web, 77% used it for
"browsing"; 64% for entertainment; 53% for education; and only 19% for shopping.
The recent crisis at America OnLine
precipitated by their ubiquitous advertising for new subscribers (over 5 million new users
in just two years, which has made access to AOL's computers and routers difficult at
times) attests to the growing popularity of the Internet, and the Web in particular. There
are predictions that over one-third of all households (38 million) in North America will
be on-line by the year 2000.
Part 3: Applying
telecommunications to health care
Telemedicine
is defined as the use of modern telecommunications and information technologies for the
provision of clinical care to individuals at a distance and the transmission of
information to provide that care. Telemedicine is not one specific technology but a means
for providing health services at a distance using telecommunications and medical computer
science. It spans every echelon of health care, from first responder/emergency medical
systems to tertiary medical specialty consultations and home care.
By health care, I mean the diagnosis and treatment of
illness. (It should be noted that the author is NOT a health-care professional, and so
this description is by necessity a very coarse one.) The diagnosis of illness involves two
basic tasks: the collecting of information about the patient (both current and previous
conditions) and the analysis of that information to arrive at a conclusion about the
causes of the illness. Once the illness is diagnosed, then treatment consists of
determining the best course of action to ameliorate or improve the patient's condition.
To see how telecommunications can benefit health care,
consider first the gathering of information about the patient's health. This is done in
three basic ways:
How would telecommunications improve the delivery
of these services? In the past, medical records were kept on paper in files; when a
patient moved, or a clinic closed, the records had to be physically transferred to another
facility. These days, however, most records are kept as files on a computer. If these
records were available through an internetwork, then a patient's health history could be
reviewed without having to be physically transferred between one facility and another.
Furthermore, since images and video can be included and transmitted as part of a
computerized file through the WWW or a similar viewer, the patient's history could include
previous examinations, lab test results, X-rays, and so on, in addition to textual
descriptions of the results from previous health care. Such virtual patient records are
being developed today in projects such as TeleMed
at the Los Alamos National Laboratory in New Mexico and by commercial companies such
as PatientPro.
Other benefits would accrue from the ability to access
patient records on remote computers. If all records were stored in a standardized format, records from multiple remote sites could be searched for
symptoms similar to those observed in a patient. This could greatly enhance the chances of
a correct diagnosis of a particular illness, and possible suggest courses of treatment
that had been successful in other patients. New research could be made available more
easily and quickly through a similar, "just-in-time" searching process; this
would be particularly important to general practitioners, many of whom provide the only
health service in rural areas, as well as others who were unable to keep up with all the
latest research published in specialized medical journals. (However, telecommunications
technology can also this research more accessible through electronic libraries and on-line medical
journals.)
The support of videoconferencing through the Internet allows a health-care professional to
observe and interact with a patient who is not in the same physical location. While
existing technology such as closed-circuit television or compressed video already exists
for such observation, typically such systems are expensive and complex to set up and
maintain. Computer-based or desktop
videoconferencing is becoming easier and cheaper almost daily; digital cameras can be
set up to capture images at one or both ends of a transmission through products like PictureTel, while conferencing software like QuickTime allows recorded images and voices to be
transmitted over the network in both directions.
Obviously, videoconferencing can be used in other ways.
Many health-care professionals take advantage of the knowledge of others in the diagnosis
and treatment of difficult cases, either by individual consultation with specialists or
through medical "boards" that meet regularly to discuss new findings or unusual
conditions encountered. With the right supporting technology, such consults and meetings
can take place in cyberspace; videoconferencing allows interactive meetings to be held
without the participants being in the same room. When interactive discussion is not
necessary, E-mail or video recording could be used for asynchronous discussions,
where one person can "post" a query and others respond to it at some later time.
Responses can be directed to the individual making the query or to the entire group (in
essence, this is how a newsgroup functions).
Like patient records, lab results and images from
detailed examinations can be stored in computer file format, making them easier to search
and transfer to remote locations when needed. Teleradiology, the digitizing of X-rays and
transmitting them over the telephone, is probably the best-known example of this
application of the technology, and is being used in a number of programs, such as the University
of California - San Francisco Medical Center.
However, other forms of laboratory information could easily treated in the same way; in
fact, it is possible, thanks to digital technology that allows the direct recording of
health data from a patient into a computer, to share the collected data in real time over
an internet among several computers.
Health information that can be collected in digitized
form, such as heart/lung sounds, blood pressure, EKG, etc., can be easily transmitted to a
health-care professional without requiring his/her physical presence for the examination.
Combined with the ability to observe a patient "live" by videoconferencing, or
as a replay on recorded video, this greatly expands the notion of a remote
"examination," since the physician may actually have more information available
from the computer than a physician in the same room with a live patient but without the
computers. (This application stems from the pioneering work by NASA in the area of biotelemetry,
a technology that dates back to the earliest days of space life
sciences in the 1960s, and is now being used in such medical areas as fetal heart monitoring.)
Conclusion: The challenges
to telemedicine
Many computer and telecommunications technologies exist
that can enhance health care. However, it is essential that health-care professionals take
the time to learn about the possible applications of these technologies and their
usefulness in the proper circumstances. It is also important that technologists and
scientists in the computer and telecommunications fields learn to work with people in the
health-care industry and educate them about these possibilities, while learning about the
technology with which theirs will be integrated. By developing the appropriate technology
and tools in cooperation with trained health-care personnel, it is clear that great
improvements in the delivery of medical services to rural and remote areas can be made.
That is not to say that challenges do not exist,
however! There are several barriers inherent in overcoming distance in delivering health
care -- technological, political, and professional. Among them:
(Items 1 through 6 are adapted from the Western Governors'
Association Telemedicine Action Report.)
While these challenges are difficult, they can be
overcome with cooperation among health-care professionals, technology specialists, and
federal and state governments. Such cooperation is the key to telemedicine's achieving its
potential to improve health care, not only for residents of rural areas in the US, but
people everywhere.