Worldwide, people living in rural and remote areas ...



Literature Review of

Telehealth/Telemedicine

Jeff Pinnow

UCSD Summer Research Program

University of California, San Diego

August 17, 2001

Faculty Mentor: Hans-Werner Braun

San Diego Supercomputer Center

Worldwide, people living in rural and remote areas struggle to access timely, quality specialty medical care. Residents of these areas often have substandard access to specialty health care, primarily because specialist physicians are more likely to be located in areas of concentrated population[1]. Because of innovations in computing and telecommunications technology, many elements of medical practice can be accomplished when the patient and health care provider are geographically separated. This separation could be as small as across town, across a state, or even across the world. Broadly defined, telemedicine is the transfer of electronic medical data (i.e. high resolution images, sounds, live video, and patient records) from one location to another. This transfer of medical data may utilize a variety of telecommunications technology, including, but not limited to: ordinary telephone lines, ISDN, fractional to full T-1’s, ATM, the Internet, intranets, and satellites. Telemedicine is utilized by health providers in a growing number of medical specialties, including, but not limited to: dermatology, oncology, radiology, surgery, cardiology, psychiatry and home health care[2].

THE HISTORY OF TELEMEDICINE

The idea that doctors might treat patients without being in the same room with them is not new. Likewise, doctor-to-doctor consultation does not require physical proximity. Stretching the definition of "treatment," Dr. Sigmund Freud's letters to his patients might be examples of treatment at a distance[3]. Since the dawn of the information age to the present, doctors have been giving patients and each other advice by telephone. At a more technically sophisticated level, the astronauts from the earliest Apollo missions in the 1960s have had their bodily functions electronically monitored by NASA physicians[4].

In the early 1970s, as satellite transmission became more available, a number of pioneers in telemedicine began putting together systems to link physicians with often very remote clinics. One such effort supported Indian Health Service practitioners in Arizona and another reached the wilds of Alaska. The National Aeronautics and Space Administration (NASA) also was a pioneer in the 1960s with its satellite support of a telemedicine project, conducted by the National Library of Medicine (NLM), which provided health services to the Appalachian and Rocky Mountain regions and Alaska. In the 1970s, NASA also sponsored the STARPAHC (Space Technology Applied to Rural Papago Advanced Health Care) project, implemented with the Indian Health Service and the Department of Health, Education and Welfare on the Papago Indian Reservation in Arizona[5]. In many ways, these programs did essentially what telemedicine advocates are trying now to do again. They brought specialty consultation and treatment to people who would not otherwise have access to such care.

Early expansion of telemedicine was affected, however, by the cost and limitations of the technology[6]. Recent technological advances-such as fiber optics, integrated services digital networks(ISDN), and compressed video-have eliminated or minimized many of these problems, fostering a resurgence of private- and public-sector interest in the potential of telemedicine to lower costs, improve quality, and increase access to health care, especially for those who live in remote or underserved areas. The technology is not only better; it is also becoming cheaper[7]. While telemedicine has been practiced for more than 30 years, its current iteration is still in the early stages of development. One recent journal article remarked that: “Telemedicine is on its way (although it has not yet arrived)[8].” Others believe that telemedicine has now come into its own.

Having now come of age, telemedicine has the potential of having a greater impact on the future of medicine than any other modality. Telemedicine is, in the final analysis, bringing reality to the vision of an enhanced accessibility of medical care and a global network of health care[9].

With Congress, the health care industry, and consumers all searching for ways to reduce the costs of delivering health care, the potential of telemedicine has been receiving careful scrutiny. A number of bills directly related to telemedicine have been introduced in Congress. The Information Infrastructure Task Force is continuously considering the role that information technology can play in delivering health services more efficiently and effectively as part of the National Information Infrastructure (NII) initiative[10]. A task force subgroup of representatives from federal agencies is addressing the current status and potential of telemedicine. Telemedicine also has important international implications, and organizations like the World Health Organization and the European Commission have explored its potential as well[11].

In the meantime, significant enhancements to the delivery of health care services through electronic communication technology were being vigorously developed, tested and implemented in two specific fields. The U.S. Department of Defense undertook a major investment in, and continues to utilize, telemedicine technology for use with combat and isolated military personnel. In the civilian sector, criminal justice systems began to utilize long-distance telemedicine technology to deliver medical consultation and treatment services for prison inmates in distant prisons primarily as a means to reduce ballooning medical costs due to the dramatic increase in prison populations. Both of these fields have developed significant enhancements to both the technological and medical service components of the telemedicine field, now more easily transferable to civilian use[12].

Regarding costs, satellite technology has dropped in cost sufficiently to allow its use by at least some health care delivery systems. However, a second development is more important by far. The creation and increasingly wide dissemination of broadband telephone networks has made telemedicine an economically feasible undertaking for individuals and institutions interested in trying it. It also has created a market driven incentive for communications companies to be helpful in such efforts. In a similar way, the hardware and software that are used in these applications are growing less expensive. Most of the telemedicine systems currently in place or in development use this ground-based technology[13].

From a specifically rural perspective, the cost differential for communications services between urban and rural areas has been an inhibiting factor. The Telecommunications Act of 1996, however, contains important provisions that, once fully implemented, will alleviate this problem. In May 1997, the Federal Communications Commission (FCC) adopted the Universal Services Order, through which rural health care providers are ensured access to communications services at rates comparable to their urban counterparts. This is a broad-based objective that includes, but is not limited to, health applications. It should have the effect, however, of encouraging the development of telemedicine services.

Several other factors have contributed to the rebirth of interest in telemedicine. The widespread availability of personal computers is a factor of great importance. More and more people, including doctors, are less and less put off by computers, and computers lie at the heart of these systems. Also, the use of teleconferencing by business has spurred development of the technology that is now being explored for clinical applications[14]. Finally, specialists continue to be located largely in urban cities, while many patients reside in rural areas of the country. Getting them together is a recalcitrant problem that this technology may help to solve.

TELEMEDICINE'S POTENTIAL EFFECTS

Parts of the United States that are sparsely populated continue to have difficulty attracting and retaining health professionals, as well as supporting local hospitals and clinics. An earlier Office of Technology Assessment (OTA) report outlined the ongoing problems of delivering adequate, high-quality health care to people who live in rural areas[15]. Since the report was released in1990, the problems rural residents face in accessing health care have not changed substantially, although there have been some selected improvements. Although access to physicians continues to be limited and rural hospitals continue to close, the financial picture for rural hospitals that remain open has improved somewhat[16]. One physician, discussing the potential benefits of telemedicine, described the problems facing rural health care this way:

“What do you call a place the size of New York State with almost no medical, surgical, or pediatric subspecialists? . . . Western Kansas. This area has been medically underserved for generations”[17].

Subspecialty access has not been the only difficulty. There are also serious problems with the retention of primary care physicians, the provision of nursing education and emergency room coverage, and the financial health of rural hospitals. The primary challenge has been geographic, and until recently there did not seem to be any way adequately to confront the challenge[18]. There are a number of reasons why isolated areas have difficulty attracting and retaining health care professionals. Medical practice is often more demanding and less lucrative than in larger centers. Providers may also feel isolated from mentors, colleagues, and the information resources necessary to support them personally and professionally. Equipment may be less up to date and facilities less than adequate. Similar problems often plague the delivery of health care to large inner-city populations. Telemedicine is a tool that may help address the problem of provider distribution by improving communication capabilities and providing convenient access to up-to-date information, consultations, and other forms of support[19].

The use of telecommunications to deliver health services has the potential to reduce costs, improve quality, and improve access to care in rural and other underserved areas of the country. Although the extent of this potential is largely speculative at this time, researchers are beginning to address telemedicine’s impacts. According to one article:

... telemedicine may be unique in having potential for introducing low-cost, high efficiency components that may, under certain conditions, increase access to care while possibly limiting increases in cost by enhancing health outcomes[20].

Clinical Applications

Telemedicine is broadly defined as the use of information technology to deliver medical services and information from one location to another; however, there are differences if opinion regarding what the definition should include[21]. Most agree that it includes applications in areas such as pathology and radiology, as well as consultations in specialties such neurology, dermatology, cardiology, and general medicine. While some consider certain forms of medical education with this definition, others would exclude the use of video to transmit purely didactic classroom lectures where there is no direct interaction between student and teacher. Whatever the definition, telemedicine implies a closer link between the telecommunications infrastructure and the health care system that includes the entire range of teleservices[22].

Telemedicine can be used for a variety of purposes. Some applications of telecommunications in the health field have been in use longer than others. Teleradiology, for instance, has approximately 30 years experience and literature dating back from the early 1970’s. Other applications are newer, and as yet have produced few research results. Current telemedicine projects vary with respect to goals, organization, funding and technology. This diversity is shown in brief descriptions of some current telemedicine programs.

The full spectrum of telemedicine technologies is wide ranging[23]. The technologies begin with sensing devices including high definition still and video cameras, electronic microscopes, stethoscopes, ophthalmoscopes, otoscopes, dermascopes and imaging devices that can capture and transmit text, visual and sound images. An array of telecommunications technologies are then used to transmit information over low bandwidth standard telephone lines, high speed, wide bandwidth dedicated telephone lines or satellites. Computers, sophisticated peripheral equipment and software are then used to manage and enhance the delivery of the patient information and images[24].

Telemedicine, as an operating concept, integrates diagnostic technologies, medical information management resources and telecommunications into a unified, clinically useful system. For example, real time standard patient vital signs, medical records, and automated treatment plan transmissions down loaded off the Internet (low bandwidth data), can be combined with interactive video (moderate bandwidth data), and high resolution DICOM standard radiological images (high bandwidth data), to deliver to the desktop computer of a remotely located physician a fully integrated medical presence.

This technology integration provides the caregiver with access to the full universe of relevant patient and reference medical information in real time. A well conceived telemedicine system provides not only information pushed to the caregiver by standard clinical reports, records and interactive video, but also the ability to pull, on demand, additional information from the patient's past medical history or advisory information that resides in a medical decision support system[25].

The rapid growth of telemedicine is a worldwide phenomenon. However, the growth of telemedicine has not been uniform, either geographically or across all types of health care services. A nationalized health care system combined with the presence of many remote communities have spurred many countries in other parts of the world into investing in telemedical systems linking hospital centers with smaller clinics in remote villages[26]. Scandanavia, especially Norway, was one of the first areas to widely deploy telemedicine. Extensive projects using telemedicine to deliver health care have been established in France, the United Kingdom, Japan, Australia, and Canada[27]. Many other countries are in the process of setting up their own programs. Lesser-developed nations have shown a keen interest in using telemedicine to improve access to high quality health care but often lack either a telecommunications infrastructure or the resources to pay for such access.

In the United States health providers in a growing number of medical specialties use telemedicine including dermatology, oncology, radiology, surgery, cardiology, and mental health. The largest areas of utilization of telemedicine currently are:

• Teleradiology: In use for 30 years teleradiology involves the transmission of medical images (X-Ray, MRI, etc.) to a radiologist for interpretation. This was one of the first uses of telemedicine to receive full reimbursement under U.S. Medicare and is the single most widely deployed use of telemedicine in the country.

• Patient monitoring: Replacing holter-based monitoring systems used within hospitals remote patient monitors allow the patient to remain at home and deliver the monitoring data to the health professional through he telephone. The largest use is in cardiac monitoring with fetal and pulmonary monitoring also widely deployed. Typically, all three uses are covered under major insurance plans.

• Correctional care: Prison-based populations in the U.S. receive guaranteed health care coverage. However, due to the cost of transporting prisoners to a medical clinic, the remote location of many correctional care facilities, and the potential danger to civilian populations as a result of the prisoner transport, telemedicine is a large and growing application in correctional care.

• Federal populations: Many federal agencies have responsibility for large populations and have been heavily involved in using telemedicine in the delivery of care. These include the U.S. Department of Defense (DOD), Veterans Affairs (VA) and National Aeronautics and Space Administration (NASA). DOD has made one of the largest investments in the world in telemedicine research and development primarily aimed at bringing medical care to the soldier on the front lines of battle. The VA has numerous investments in telemedicine through its nationwide network of hospitals and health facilities, and since the beginning of the space program NASA has been a leader in the development of telemedicine for use in truly distant locations.

Emerging networks in the U.S represent more than technology. They are building healthcare partnerships from physician offices to rural clinics and hospitals, schools and home care agencies to tertiary care centers[28]. These partnerships are becoming crucial to improving access and quality of care in healthcare systems. Successful telemedicine programs often support clinical activities, distance learning and continuing medical education programs across a common infrastructure using a range of technologies. Because of a severe shortage of healthcare professionals throughout rural areas there is clearly a need for this type of network and its services. The location of the telemedicine project and the types of services in demand determine what clinical tools and telecommunication technologies are used. The type of clinical applications and the volume of consultations determine the characteristics and costs of the use of telemedicine[29].

The following scenario is an illustrative composite of current and future applications as described in a number of recent examinations of telemedicine[30]:

Responding to an anonymous 911 call, emergency medical technicians find an unconscious patient collapsed in a local shopping mall 10:00 p.m. on a Saturday. He was reported to have been suffering from severe dizziness and collapsed prior to their arrival. Enroute to the hospital the emergency medical technicians use identification found in the patient's wallet and via a mobile radio link to the regional patient information repository get a summary of the patient's last ten medical encounters.

Of the ten encounters, six were routine examinations. But, four of the ten encounters were in an adjacent state with physician specialists. Two were with an endocrinologist, who has been treating the patient's diabetes, and two were with a cardiologist who has been treating his chronic high blood pressure. By the time the ambulance arrives at the emergency room of the small town community hospital, the physician on duty has already accessed the same regional database to review the patient's medical history. She has also contacted the on-call physician at the patient's primary care practice. The patient's medical history and primary care physician both indicate that the patient has a history of noncompliance in his daily requirement of insulin injections and high blood pressure control medications. Based on this information and a print out from the emergency room automated care plan database, the emergency room physician makes initial plans to order appropriate treatment, medications and follow-up visits.

After the initial stabilization, the patient regains consciousness and immediately complains of tightness in his chest. The small community hospital does not have a cardiologist available, but, is part of a regional alliance with a larger medical center in a nearby city. Using electronic diagnostic devices, high definition interactive video and high bandwidth telephone lines, the patient and the local physician conduct a real time consultation with the on call cardiologist at the regional medical center. The cardiologist receives transmissions that include the patient's vital signs, an echocardiogram, a complete digitized medical history and can talk with the patient and local physician while collaborating in a visual examination. The examination does not indicate an immediate cardiac emergency.

When the patient is discharged, all the information generated by the hospital visit, the structured assessment, objective findings, admission diagnosis, patient disposition information and laboratory tests are automatically entered into his electronic medical record. By the time the patient returns to his primary care physician for a follow-up, she has already received a complete report of all that took place in the hospital.

This example illustrates a number of the existing and potential telemedicine applications: remote access to patient information repositories, automated patient records, interactive video consultation and remote diagnostics[31]. In this case, the patient received comprehensive acute care that was enhanced by the efficient transport and management of medical information.

In this example, the initial emergency intervention was enhanced by the ambulance technicians and emergency room physician being informed early in the medical encounter of the patient's medical history. As a result, the timeliness of the initial diagnosis was substantially improved. The initial treatment at the emergency room was also better informed by access to the patient's primary care provider and to automated care plans. This resulted in care that was better tailored to the needs of the patient. The cost of an evacuation to the regional medical center was avoided and follow-up care by the patient's primary care physician was improved by the automatic update of the patient's hospital treatment records.

Non-Clinical Applications

Another emerging application for telemedicine is as an international marketing tool for medical services. Both the Massachusetts General Hospital in Boston, Massachusetts and the Mayo Clinic in Rochester, Minnesota have established telemedicine links into the Middle East. The Baylor College of Medicine is pursuing a significant telemedicine project that extends health care services into Eastern Europe and the Middle East. While in Europe, the Health Care International Hospital in Glasglow, Scotland is establishing a telemedicine network targeting Saudi Arabia and Italy[32]. From this perspective, telemedicine is not only a means of extending care to under-served populations in the United States, it is also a concrete strategy for opening international markets to the export of medical services.

Other applications included in the broad definition of telemedicine are continuing medical education transmitted over telemedicine systems. The browsing and extraction of health care data from scattered databases, medical video-conferencing, voice recognition systems for medical report management, integrated electronic claims processing and inventory control[33].

The federal vision of health care within the National Information Infrastructure (NII) includes plans to develop national medical information standards, large data bases of medical records for public health research, instant health care provider access to electronic patient records, point of care data collection, and some type of regional or national medical records repositories[34]. These applications are designed to reduce incomplete treatments, provide better medical histories, eliminate contraindicated treatments and lower transport and storage costs of paper records. Supporters of telemedicine argue that digitized medical records management and intelligent communications networks could lower the indirect, administrative costs of health care delivery by $30 billion a year[35].

Telemedicine Issues

Like all applications of new technologies, there are barriers to widespread diffusion for telemedicine. Some of the problems are related to the technology, but most can be attributed to other factors.

Medical Efficacy and Cost Effectiveness

As it stands today, telemedicine has proven its value in support of the delivery of teleradiology, telepathology, general medical diagnosis, remote consultations, triage decision making, and emergency evaluations. It has also been used as an effective support for pre-transfer or admission coordination, follow-up medical care and post-operative appointments, and medication checks[36].

Only five years ago a "typical" telemedicine set-up cost close to $200,000. Today, with improvements in technology, innovations in data compression, and reductions in computing costs, the expense of the equipment required to conduct telemedical consults can be less than $5,000. For remote patient monitoring the cost of some monitors is now less than $300 each. The real costs today are not in purchasing hardware but telecommunications transmission, training of health professionals, and integrating telemedicine into existing health care systems[37].

Although there are many articles in the popular press about telemedicine, peer reviewed literature on its medical efficacy, safety and cost effectiveness is nearly nonexistent. Only a small number of studies address the issue of telemedicine's overall cost effectiveness and most of these are limited in scope and only narrowly review the cost of equipment in specific applications[38]. The American Telemedicine Association addressed this shortcoming with the initiation of the Telemedicine Journal, a peer reviewed quarterly publication dedicated to the study of telemedicine, in the fall of 1996.

In perhaps the widest ranging attempt to date, the Arthur D. Little consulting firm estimated in 1994 that remote diagnosis and consultation, medical records automation and comprehensive information management networking of health service operations could save up to $36 billion in annual national health care expenditures. This study is ambitious in its broad scope, but lacks the rigor or conceptual structure to form the basis for projecting the cost effectiveness of telemedicine technologies in a particular organization or on the health care delivery system as a whole[39]. The lack of comprehensive technical assessments and life cycle analysis at this point in a medical technology's development is not unusual. Rather, it follows the pattern that has typified the early development stages of medical technology in the American health care system[40].

With the benefit of hindsight, health care managers will have the opportunity to avoid this shortcoming as telemedicine diffuses. Too often, new technologies have just been layered on top of existing work processes, perhaps improving the marginal quality of care, but building additional costs into the health care system. Grigsby et. al. attribute up to 50% of the cost of medical care to the impact of new technologies on health care processes.

Reimbursement for Services

Medicare reimburses for several different types of telemedical interactions currently including: teleradiology, remote patient monitoring and live consultations with patients residing in remote health professional shortage areas. However, broad reimbursement for telemedicine services is still unavailable. In addition, it is largely unclear whether telemedicine is an allowable service under federally funded capitated payment or HMO programs[41]. The failure to allow for coverage of telemedical services has put a brake on the growth of telemedicine, restricted access to health services by many Americans and hampered the ability of the U.S. healthcare industry to use telemedicine in reducing costs and increasing the quality of care.

Lack of Research/Experience

Another barrier to telemedicine is the lack of research demonstrating its safety and efficacy, clinical utility, and cost-effectiveness[42]. This is a problem for potential users, payers, and policy-makers. No one knows for certain which medical conditions are best suited to the use of telemedicine. Clearly, some procedures are better suited to use of interactive video than others in terms of patient’s comfort level. Research on patient satisfaction with telemedicine is limited, but results indicate that in general they are pleased with it[43].

Several organizations have formed to promote and coordinate telemedicine research activities and share research strategies. Examples are National Consortium for Telemedicine Evaluation and the Clinical Telemedicine Cooperative Group. The American Telemedicine Association also promotes research as part of a comprehensive agenda for telemedicine.

Privacy and Confidentiality

Privacy in health care information has been protected in two ways:

1) in the historical ethical obligations of the health care provider to maintain the confidentiality of medical information, and

2) in a legal right to privacy, both generally and specifically, in health information. Confidentiality involves control over who has access to information.

Other terms frequently used in privacy protection discussions are integrity and security. Integrity assures that information and programs are changed only in a specified and authorized manner, that computer resources operate correctly, and that the data in them are not subject to unauthorized changes. A system meeting standards for access allows authorized users access to information resources on an ongoing basis[44]. Security refers to the framework within which an organization establishes needed levels of information security to achieve, among other things, the confidentiality goals[45].

The use of telecommunications to deliver medical care may pose additional risks to the privacy of patients and their records. For example, the creation of a videotape of a consultation might pose a new privacy threat for the patient unless appropriate safeguards to control access to it are built into the process. The issue of who has access to this information will need to be considered and resolved in advance. Depending on the nature of the examination, the patient may also have privacy concerns in terms of who is actually present in each location during the consultation. Nonmedical personnel, such as a technician or facilitator, may be needed to assist in the consultation[46].

If a videotaped consultation becomes part of the patient’s medical record, it would be treated like other videotaped information on the patient (e.g., an angiographic procedure). In these cases, the usual privacy laws would apply. State laws governing the transmission and retrieval of patient medical records vary, and officials are concerned about user verification and access, authentication, security, and data integrity. A previous OTA study found that the present system of protecting health care information offers a patchwork of codes; state laws of varying scope; and federal laws applicable to only limited kinds of information, or information maintained specifically by the federal government[47]. The present legal scheme does not provide consistent, comprehensive protection for privacy in healthcare information, whether it exists in a paper or computerized environment.

Physician Licensing

Physicians must be licensed by the states in which they practice. Telecommunication facilitates consultations without respect to state borders and could conceivably require consultants to be licensed in a number of states.. Currently each state requires separate medical licenses for physicians practicing inside state boundaries[48]. Telemedicine challenges this by allowing for the practice of medicine across state lines. Some states have recently enacted restrictive laws to keep out health professionals licensed in other states. This has been viewed as efforts to protect the economic markets of the professionals residing within the state. This would be impractical and is likely to constrain the broader diffusion of telemedicine programs[49]. The implementation of national standards or the classification of physicians practicing telemedicine as consulting physicians may circumvent state rules. Another way to address the problem of licensing is to place the overall responsibility for the patient’s care in the hands of the referring physician and view a consultation in a different state as making a recommendation only.

Telehealth

The term telemedicine is defined as the use of information technology to deliver interactive two-way audio/visual communications to facilitate information exchange between a primary care physician and a specialist at some distance from each other[50]. With the explosion of health information available on the Internet, a broader term, telehealth, has been coined. Purchasers of healthcare want a continuum of services in this day and age, from health promotion to palliative care. Telehealth allows for all of these services to fall under an umbrella term, particularly the preventative component of healthcare.

eHealth

Another component of telehealth is eHealth. The medical profession has been developing telehealth technology for over 35 years. The integration of classic telemedicine and telehealth technologies with the Internet was the next logical step. Now that technology is ready for the merger, its sudden growth is staggering. A number of specialty sites already exist for billing, back office functions, marketing, medical records processing, communications, medical supplies and equipment[51]. eHealth refers to all forms of electronic healthcare delivered over the Internet, ranging from informational, educational and commercial "products" to direct services offered by professionals, non-professionals, businesses or consumers themselves. eHealth includes a wide variety of the clinical activities that have traditionally characterized telehealth, but delivered through the Internet. Simply stated, eHealth is making healthcare more efficient, while allowing patients and professionals to do the previously impossible.

Traditional telehealth programs are using the Internet for some basic functions. For example, in Madison, Wisconsin, patients diagnosed with AIDS, breast cancer, or a number of other conditions are supplied with a PC-based home health workstation called CHESS through their HMO program[52]. The computer supplies 60 to 80 megabytes of high quality information related to the patient's specific condition. It also functions as an electronic support group by linking patients (through a simple modem connection) to their health professionals, local community groups, and with people who share similar diagnoses. Studies have shown that these patients become more responsible for their self-care and require less clinical care[53].

Summary

In summary, telemedicine has significant potential for developing into an integral component of the global health care system. Currently there is an ongoing process of experimentation, evaluation and implementation of telemedicine applications in many urban and rural locations around the country, and the advocates for these technologies are numerous and enthusiastic[54]. However, The efficacy of these methods has not been fully demonstrated and the communications infrastructure that supports them is not universally available. Finally, the potential effects of their widespread implementation on the health care delivery system are unknown.

Significant hurdles remain, including legal and regulatory barriers and acceptance of the use of telemedicine by traditional medical establishments. But these barriers are starting to come down, and there is a growing body of research data that indicate how telemedicine can improve patient outcomes and reduce healthcare costs. Nevertheless, telemedicine will change the way providers practice. Some practitioners will miss the hands-on aspect of examining a patient that has been such an integral part of their medical training and experience[55]. While others will embrace the promise of reaching out and helping an infinite number of people electronically via telehealth or eHealth. Regardless, The potential of telemedicine is helping to transform the delivery of health care and improve the health of millions of people throughout the world.

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[1] Little, A.D. Telecommunications: Can it help solve America's health care problems? Cambridge, Mass.: Arthur D. Little, Inc.; 1992 p. 9

[2] Maheu, M., Whitten, P., & Allen, A. eHealth, Telemedicine & Telehealth: A comprehensive guide... New York: Jossey-Bass.

[3] Arthur D. Little, Inc. Telecommunications: Can it help solve America's health care problems? Cambridge, Mass.: Arthur D. Little, Inc.; 1992 p. 10

[4] Antezana, F., Telehealth and Telemedicine will Henceforth be part of the Strategy for Health for All. Internet, 1997;

[5] Reid, J., A telemedicine Primer: Understanding the Issues. Billings, MT.: Innovative Medical Communications; 1996 p. 18

[6] ibid., p. 21

[7]Bashur, R.,Sanders, J., Shannon, G. Telemedicine theory and Practice. Springfield, IL: Charles C Thomas; 1997

[8] E.A. Franken et al., "Telemedicine and Teleradiology: A Tale of Two Cultures," Telemedicine Journal, vol. 1, No. 1, spring 1995, p. 7

9 Michael E. DeBakey, "Telemedicine Has Now Come of Age," Telemedicine Journal, vol. 1, No. 1, spring 1995, p. 4

10 Eng, TR., Gustafson, DH., eds. Wired for Health and Well-Being; the emergence of Interactive Health Communication. Washington D.C.: Science Panel of Interactive Communication and Health, USDHHS Office of Public Health and Science, 1999, p. 11

11 ibid., p 11

[9] Yablonski, KK. How Telemedicine technology can save correctional funds. Correctional Technology vol. 1, No. 1: 1996 p. 4-5

[10] Michael E. DeBakey. Telemedicine Has Now Come of Age. Telemedicine Journal, vol. 1, No. 1, spring 1995, p. 4

[11] Hubbs, R. P., Rindfleisch, T. C., Godin, P., Melmon, K. L. Medical information on the Internet. Journal of the American Medical Association, 1998;280(15), p. 1363

[12] U.S. Congress, Office of Technology Assessment, Health Care in Rural America, OTA-H-434 (Washington, DC: U.S. Government Printing Office, September 1990).

[13] Health Care in Rural America," statement of the Office of Technology Assessment at a hearing of the Senate Committee on Agriculture, Nutrition, and Forestry, June 9, 1996.

[14] Hassol, A., Irvin, C., Gaumaer, G., Puskin, D., Mintzer, C., Grisby, J. Rural Applications of Telemedicine. Telemedicine Journal. 1997;3:215-225

[15] Ace, A. Telemedicine in Kansas: Introduction. Kansas Medicine, vol. 93, No. 12, December 1992, p. 322.

[16] Bashur, R.L. Critical Issues in Telemedicine. Telemedicine Journal. 1997;3:113-126

[17] Bashur, R.L. On the Definition and Evaluation of Telemedicine. Telemedicine Journal, vol. 1, No. 1, spring 1998, p. 23.

[18] see Bashshur, op. cit., footnote 7

[19] Birger J. Nymo,N. Telemedicine. Telektronikk, vol. 89, No. 1, 1993, p. 4

[20] see Eng, TR., Gustafson, DH. op. cit., footnote 10.

[21] Grigsby, J., , Kaehny M., , Schlenker, R., Shaughnessy, P., & Beale, S. Literature review and analytical framework, report 1: Analysis of expansion of access to care through use of telemedicine and mobile health services. Denver, Center for Health Policy research. 1993. p. 19

[22] Dakins, D.R. Telemedicine and Telehealth Networks. Market Targets June 1997 p. 25-29

[23] Mitka, M,. Developing countries find telemedicine forges links to more care and research. Journal of the American Medical Association, 1997;280(15), 1295-1296.

[24] Ibid p. 1296

[25] Rettig, R. Medical Innovation Duels Cost Containment. Health Affairs, No. 13 p. 7-27

[26] Nitzkin, J., Zhu, N., Marier, R. Reliability of telemedicine examination. Telemedicine Journal. 1997;3:141-157

[27] Grigsby, J., Barton, P., Kaehny, M., Schlenker, R., Shaughnessy, P. Analysis of Expansion of Access to Care Through Use of Telemedicine and Mobile Health Services, Report 3: Telemedicine Policy: Quality Assurance, Utilization Review, and Coverage. Denver, Center for Health Policy Research 1994.

[28] See Grigsby et. al. op. cit. footnote 30

[29] see Mitka, M op. cit. footnote 26

[30] see Little, A.D. op. cit. footnote 1

[31] National Coordinating Office. Fact Sheet: Health care and the National Information Infrastructure. High Performance Computing and Communications Program. Washington D.C. 1994

[32] see Little, A.D. op. cit. footnote 1

[33] see Grigsby et. al. op. cit. footnote 30

[34] Sanders, J.H., and Bashshur, R.L. Challenges to the Implementation of Telemedicine. Telemedicine Journal. vol. 1, No. 2, summer 1995.

[35] See Grigsby et. al. op. cit. footnote 24

[36] ibid

[37] Geljins, A., & Rosenberg, N. The Dynamics of Technological Change in Medicine. Health Affairs, 13, 1996. p. 28-46

[38] see Sanders et. al. op. cit. footnote 37

[39] Karinch, M. Telemedicine, What the Future Holds for You when You’re Ill. Far Hills, NJ: New Horizon Press. 1995

[40] Perednia, D. & Allen, A. Telemedicine technology and clinical applications. Journal of the American Medical Association. 273;6: p. 483-488

[41] Pfleeger, C.P. Security in Computing. Englewood Cliffs, NJ: Prentice Hall, Inc. 1989, p. 5-6.

[42] U.S. Congress, Office of Technology Assessment, Protecting Privacy in Computerized Medical Information, Washington, DC: U.S. Government Printing Office, September 1993, p. 12-13.

[43] Ibid.

[44] Sanders, J.H. Telehealth Security Issues. Telehealth Journal, vol. 2 No. 4 winter 1996

[45] Yablonski, K.K. How Telemedicine technology can save HMO’s. Telehealth Networks. 3;2: p. 4-5

[46] ibid.

[47] Durkins, A., & Cary, M. Telemedicine and Telehealth: Principle, Policies, Performance, and Pitfalls. Springer Publishing Company. New York. 2000. p. 8-9

[48] Maheu, M., Whitten, P., & Allen, A. eHealth, Telemedicine & Telehealth: A comprehensive guide... New York: Jossey-Bass.

52 McDonald, C., Overhage, M., Dexter, P., Blevins, L., Meeks-Jonhson, J., Suico, J., Tucker, M., & Schadow, G.. Canopy computing: Using the Web in clinical practice. Journal of the American Medical Association, 1998;280(15), 1325-1329.

53 Ibid.

54 see Durkins et. al. op. cit. footnote 50

[49] see Sanders et. al. op. cit. footnote 47

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