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Doug Neeley 214-673-9284
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Telemedicine & Advanced Technology Research Center
Comparison of Wireless Internet Access Providers Services
Telemedicine
Monday, October 02, 2000
ATA ACTION ALERT – Congressional Telemedicine Legislation
ATA Members in the United States are encouraged to contact your Senators and Representatives to push
for passage of legislation expanding Medicare coverage of telemedicine. The legislative language is
contained in several proposed bills before the Senate and House of Representatives. The leading bills that
contain the language are H.R. 4841, introduced by Rep. John Thune (R-SD) and S. 2505, introduced by
Sen. James Jeffords (R-VT). Congressional supporters hope to have language in the bills included in
amendments to the Balanced Budget Act, which may be enacted by Congress as early as the end of
September.
A hearing held on September 7, 2000 addressed many of the issues contained in the proposed legislation.
Transcripts of the hearings are available from the House Web site.
----------------------Action Requested:
Although there are numerous co-sponsors to the current bills (each bill has about 18 cosponsors), passage
of the language remains uncertain. Support from members of the House Ways and Means Committee,
which helped block passage of similar legislation last year, is especially important. Also, members of the
Senate Finance Committee are important for passage in the Senate.
A group of telemedicine advocates including Joe Tracy from Missouri and Rob Sprang from Kentucky
have prepared a script that can be used by those personally calling or e-mailing your member of Congress
about this issue:
PLEASE FILL IN YOUR SPECIFIC INFO AT AREAS THAT ARE CAPITALIZED. PLEASE NOTE
THE DIFFERENCE BETWEEN THE TWO SCRIPTS REGARDING THE JEFFORDS AND THUNE
BILLS.
IF CALLING A SENATOR:
My name is (NAME) and I am representing (TELEMEDICINE ORGANIZATION), which provides
healthcare services to patients in rural areas of (YOUR STATE). Our network is helping rural communities
provide healthcare services normally unavailable in their local hospitals and clinics through advanced
videoconferencing technology. The rural patients travel to their community healthcare facility and are
linked to specialists in large urban medical centers. Without this technology, many of these patients would
not, or could not travel to seek such care.
While many state Medicaid programs and private payors reimburse for telehealth consultations just like
traditional face to face consultations, the Balanced Budget Act of 1997 and HCFA's interpretation of that
Act prohibits reimbursement for nearly all telemedicine encounters. As a result rural and other underserved
patients are penalized by isolating them from vital healthcare services. People living in these areas have as
much right to Medicare benefits as any other American and allowing them to use telehealth to exercise that
right should not be considered an extraordinary benefit.
The take-home point is that telehealth is not a new or different medical service but is simply a new way to
deliver standard services to people in underserved areas. While Medicare reimbursement alone will not
make telehealth an automatic success the lack of Medicare reimbursement will most certainly mean failure
for the promise telehealth holds for providing adequate access to healthcare for Americans living in rural
and other underserved areas.
There have been many efforts during recent months to modify the BBA and we are asking that Senator
(SENATOR'S NAME) please support the inclusion of telehealth language into the "Medicare Give Back
Package". In order to be effective, the included language should be comparable to Senator Jefford's Bill
S.2505.
I hope we can count on Senator (SENATOR'S NAME) aggressive support of this issue.
IF CALLING A MEMBER OF THE HOUSE:
My name is (NAME) and I am representing (TELEMEDICINE ORGANIZATION) which provides
healthcare services to patients in rural areas of (YOUR STATE). Our network is helping rural communities
provide healthcare services normally unavailable in their local hospitals and clinics through advanced
videoconferencing technology. The rural patients travel to their community healthcare facility and are
linked to specialists in large urban medical centers.
Without this technology, many of these patients would not, or could not travel to seek such care.
While many state Medicaid programs and private payors reimburse for telehealth consultations just like
traditional face to face consultations, the Balanced Budget Act of 1997 and HCFA's interpretation of that
Act prohibits reimbursement for nearly all telemedicine encounters. As a result rural and other underserved
patients are penalized by isolating them from vital healthcare services. People living in these areas have as
much right to Medicare benefits as any other American and allowing them to use telehealth to exercise that
right should not be considered an extraordinary benefit.
The take-home point is that telehealth is not a new or different medical service but is simply a new way to
deliver standard services to people in underserved areas. While Medicare reimbursement alone will not
make telehealth an automatic success the lack of Medicare reimbursement will most certainly mean failure
for the promise telehealth holds for providing adequate access to healthcare for Americans living in rural
and other underserved areas.
There have been many efforts during recent months to modify the BBA and we are asking that
Representative (REPRESENTATIVE'S NAME) please support the inclusion of telehealth language into the
"Medicare Give Back Package." To be effective, the included language should be comparable to
Representative Thune's Bill H.R.4841.
I hope we can count on Representative (REPRESENTATIVE'S NAME) aggressive support of this issue.
-
---------------------
Monday, October 02, 2000
Telehealth Improvement and Modernization Act of 2000
(Introduced in the Senate)
click here to download the Word document
S 2505 106th CONGRESS 2nd Session
To amend title XVIII of the Social Security Act to provide increased access to health care for medicare
beneficiaries through telemedicine.
IN THE SENATE OF THE UNITED STATES
May 4, 2000
Mr. JEFFORDS (for himself, Mr. ROCKEFELLER, Mr. GRASSLEY, Mr. BREAUX, Mr.
MURKOWSKI, Mr. STEVENS, Mr. BOND, Mr. INOUYE, Mr. HARKIN, Mr. ROBERTS, Mr.
THOMAS, Mr. BINGAMAN, Mr. CONRAD, Mr. KERREY, and Mr. EDWARDS) introduced the
following bill; which was read twice and referred to the Committee on Finance
A BILL
To amend title XVIII of the Social Security Act to provide increased access to health care for medicare
beneficiaries through telemedicine.
Be it enacted by the Senate and House of Representatives of the United States of America in Congress
assembled,
SECTION 1. SHORT TITLE; TABLE OF CONTENTS.
(a) SHORT TITLE- This Act may be cited as the 'Telehealth Improvement and Modernization Act of
2000'.
(b) TABLE OF CONTENTS- The table of contents of this Act is as follows:
Sec. 1. Short title; table of contents.
Sec. 2. Revision of telehealth payment methodology and elimination of fee-sharing requirement.
Sec. 3. Elimination of requirement for telepresenter.
Sec. 4. Reimbursement for medicare beneficiaries who do not reside in a HPSA.
Sec. 5. Telehealth coverage for direct patient care.
Sec. 6. All physicians and practitioners eligible for telehealth reimbursement.
Sec. 7. Telehealth services provided using store-and-forward technologies.
Sec. 8. Construction relating to home health services.
Sec. 9. Effective date.
SEC. 2. REVISION OF TELEHEALTH PAYMENT METHODOLOGY AND ELIMINATION OF FEESHARING REQUIREMENT.
Section 4206(b) of the Balanced Budget Act of 1997 (42 U.S.C. 1395l note) is amended to read as
follows:
'(b) METHODOLOGY FOR DETERMINING AMOUNT OF PAYMENTS'(1) IN GENERAL- The Secretary shall pay to-'(A) the physician or practitioner at a distant site that provides an item or service under subsection (a) an
amount equal to the amount that such physician or provider would have been paid had the item or service
been provided without the use of a telecommunications system; and
'(B) the originating site a facility fee for facility services furnished in connection with such item or service.
'(2) APPLICATION OF PART B COINSURANCE AND DEDUCTIBLE- Any payment made under this
section shall be subject to the coinsurance and deductible requirements under subsections (a)(1) and (b) of
section 1833 of the Social Security Act (42 U.S.C. 1395l).
'(3) DEFINITIONS- In this subsection:
'(A) DISTANT SITE- The term 'distant site' means the site at which the physician or practitioner is located
at the time the item or service is provided via a telecommunications system.
'(B) FACILITY FEE- The term 'facility fee' means an amount equal to-'(i) for 2000 and 2001, $20; and
'(ii) for a subsequent year, the facility fee under this subsection for the previous year increased by the
percentage increase in the MEI (as defined in section 1842(i)(3)) for such subsequent year.
'(C) ORIGINATING SITE'(i) IN GENERAL- The term 'originating site' means the site described in clause (ii) at which the eligible
telehealth beneficiary under the medicare program is located at the time the item or service is provided via
a telecommunications system.
'(ii) SITES DESCRIBED- The sites described in this paragraph are as follows:
'(I) On or before January 1, 2002, the office of a physician or a practitioner, a critical access hospital, a
rural health clinic, and a Federally qualified health center.
'(II) On or before January 1, 2003, a hospital, a skilled nursing facility, a comprehensive outpatient
rehabilitation facility, a renal dialysis facility, an ambulatory surgical center, an Indian Health Service
facility, and a community mental health center.'.
SEC. 3. ELIMINATION OF REQUIREMENT FOR TELEPRESENTER.
Section 4206 of the Balanced Budget Act of 1997 (42 U.S.C. 1395l note) is amended-(1) in subsection (a), by striking ', notwithstanding that the individual physician' and all that follows
before the period at the end; and
(2) by adding at the end the following new subsection:
'(e) TELEPRESENTER NOT REQUIRED- Nothing in this section shall be construed as requiring an
eligible telehealth beneficiary to be presented by a physician or practitioner for the provision of an item or
service via a telecommunications system.'.
SEC. 4. REIMBURSEMENT FOR MEDICARE BENEFICIARIES WHO DO NOT RESIDE IN A HPSA.
Section 4206(a) of the Balanced Budget Act of 1997 (42 U.S.C. 1395l note), as amended by section 3, is
amended-(1) by striking 'IN GENERAL- Not later than' and inserting the following: 'TELEHEALTH SERVICES
REIMBURSED'(1) IN GENERAL- Not later than';
(2) by striking 'furnishing a service for which payment' and all that follows before the period and inserting
'to an eligible telehealth beneficiary'; and
(3) by adding at the end the following new paragraph:
'(2) ELIGIBLE TELEHEALTH BENEFICIARY DEFINED- In this section, the term 'eligible telehealth
beneficiary' means a beneficiary under the medicare program under title XVIII of the Social Security Act
(42 U.S.C. 1395 et seq.) that resides in-'(A) an area that is designated as a health professional shortage area under section
332(a)(1)(A) of the Public Health Service Act (42 U.S.C. 254e(a)(1)(A));
'(B) a county that is not included in a Metropolitan Statistical Area;
'(C) an inner-city area that is medically underserved (as defined in section 330(b)(3) of the Public Health
Service Act (42 U.S.C. 254b(b)(3))); or
'(D) an area in which there is a Federal telemedicine demonstration program.'.
SEC. 5. TELEHEALTH COVERAGE FOR DIRECT PATIENT CARE.
(a) IN GENERAL- Section 4206 of the Balanced Budget Act of 1997 (42 U.S.C. 1395l note), as amended
by section 4, is amended-(1) in subsection (a)(1), by striking 'professional consultation via telecommunications systems with a
physician' and inserting 'items and services for which payment may be made under such part that are
furnished via a telecommunications system by a physician'; and
(2) by adding at the end the following new subsection:
'(f) COVERAGE OF ITEMS AND SERVICES- Payment for items and services provided pursuant to
subsection (a) shall include payment for professional consultations, office visits, office psychiatry services,
including any service identified as of July 1, 2000, by HCPCS codes 99241-99275, 99201-99215, 9080490815, and 90862, and any additional item or service specified by the Secretary.'.
(b) STUDY AND REPORT REGARDING ADDITIONAL ITEMS AND SERVICES(1) STUDY- The Secretary of Health and Human Services shall conduct a study to identify items and
services in addition to those described in section 4206(f) of the Balanced Budget Act of 1997 (as added by
subsection (a)) that would be appropriate to provide payment under title XVIII of the Social Security Act
(42 U.S.C. 1395 et seq.).
(2) REPORT- Not later than 2 years after the date of enactment of this Act, the Secretary shall submit a
report to Congress on the study conducted under paragraph (1) together with such recommendations for
legislation that the Secretary determines are appropriate.
SEC. 6. ALL PHYSICIANS AND PRACTITIONERS ELIGIBLE FOR TELEHEALTH
REIMBURSEMENT.
Section 4206(a) of the Balanced Budget Act of 1997 (42 U.S.C. 1395l note), as amended by section 5, is
amended-(1) in paragraph (1), by striking '(described in section 1842(b)(18)(C) of such Act (42 U.S.C.
1395u(b)(18)(C))'; and
(2) by adding at the end the following new paragraph:
'(3) PRACTITIONER DEFINED- For purposes of paragraph (1), the term 'practitioner' includes-'(A) a practitioner described in section 1842(b)(18)(C) of the Social Security Act (42 U.S.C.
1395u(b)(18)(C));
and
'(B) a physical, occupational, or speech therapist.'.
SEC. 7. TELEHEALTH SERVICES PROVIDED USING STORE-AND-FORWARD TECHNOLOGIES.
Section 4206(a)(1) of the Balanced Budget Act of 1997 (42 U.S.C. 1395l note), as amended by section 6,
is amended by adding at the end the following new paragraph:
'(4) USE OF STORE-AND-FORWARD TECHNOLOGIES- For purposes of paragraph (1), in the case of
any Federal telemedicine demonstration program in Alaska or Hawaii, the term 'telecommunications
system' includes store-and-forward technologies that provide for the asynchronous transmission of health
care information in single or multimedia formats.'.
SEC. 8. CONSTRUCTION RELATING TO HOME HEALTH SERVICES.
Section 4206(a) of the Balanced Budget Act of 1997 (42 U.S.C. 1395l note), as amended by section 7, is
amended by adding at the end the following new paragraph:
'(5) CONSTRUCTION RELATING TO HOME HEALTH SERVICES'(A) IN GENERAL- Nothing in this section or in section 1895 of the Social Security Act (42 U.S.C.
1395fff) shall be construed as preventing a home health agency that is receiving payment under the
prospective payment system described in such section from furnishing a home health service via a
telecommunications system.
'(B) LIMITATION- The Secretary shall not consider a home health service provided in the manner
described in subparagraph (A) to be a home health visit for purposes of-'(i) determining the amount of payment to be made under the prospective payment system established
under section 1895 of the Social Security Act (42 U.S.C. 1395fff); or
'(ii) any requirement relating to the certification of a physician required under section 1814(a)(2)(C) of
such
Act (42 U.S.C. 1395f(a)(2)(C)).'.
SEC. 9. EFFECTIVE DATE.
The amendments made by this Act shall apply to items and services provided on or after the date of
enactment of this Act.
++++++++++
Telemedicine:
A Brief Overview
Developed for the Congressional Telehealth Briefing
June 23, 1999
Telemedicine utilizes information and telecommunications technology to transfer medical information for
diagnosis, therapy and education. The information may include medical images, live two-way audio and
video, patient medical records, output data from medical devices and sound files. The telemedical
interaction may involve two-way live audio and video visits between patients and medical professionals,
sending patient monitoring data from the home to a clinic or transmitting a patient medical file from a
primary care provider to a specialist.
Once confined to expensive demonstrations of extending medical care to patients in remote areas,
telemedicine is quickly becoming an integral component in the delivery of modern health care regardless
of geographic or socioeconomic status. In the U.S. and many other nations most of the governmentfunded demonstration programs have supported the creation of hub and spoke telemedicine systems
linking an academic medical center at the hub with primary care clinics at the spokes. These demonstration
programs, paralleling the evolution of U.S. health care systems, have been beneficial in proving the
efficacy and effectiveness of telemedicine.
Although still new, telemedicine is rapidly changing. Taking advantage of new developments in
telecommunications, lowered technology costs and the establishment of the Internet the growth of
telemedicine over the next five to ten years may have a profound and revolutionary effect on the delivery
of medical care throughout the world. Hub and spoke systems are now linking into broader networks,
expanding their reach and effectiveness.
New applications are making it practical for direct communications between patient and provider and
physician and specialist. In this way telemedicine can bring medical services directly to the point of need.
It can empower consumers into becoming a primary provider of their own health and wellness by bringing
healthcare to the patient rather than the patient to the provider. By providing direct links between the
general practitioner and major medical centers it can also sustain the education of the physician.
Technology
Depending on the need and availability of communications infrastructure, telemedicine uses a variety of
transmission modes including ISDN, T1, ATM, DSL, Satellite, Microwave, digital wireless, local wireline,
and the Internet. The combination of equipment and transmission technology enables the health providers
to relate with other providers or patients using either live audio and video or through "storing" and later
"forwarding" multimedia information such as when sending e-mail. Services such as specialist-assisted
surgery or psychiatric consultations usually require live video. The use of store and forward technology
can be more convenient and much more cost-effective except in certain areas where live transmissions are
required.
Only five years ago a "typical" telemedicine set-up cost close to $300,000. 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.
Current Utilization
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. 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. 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 both 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. 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. 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.
Key Federal Policy Issues
The major obstacles facing the use and deployment of telemedicine today are not in the development of
technology but in changing existing laws and regulations as well as the attitudes of many involved in the
traditional delivery of medicine.
Payment 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. 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.
State Medical Licensure: Currently each state requires separate medical licenses for physicians practicing
inside state boundaries. 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.
Other key policy issues: There are several other important issues and concerns that may require federal
policies. These include assuring appropriate use of the Internet for direct patient-provider consultations
and prescribing of medications, protection of appropriate entities from undue liability arising out of the use
of telemedicine, and maintaining patient privacy and confidentiality in the transmission of medical
information and electronic storage of personal medical information.
The Future: Three Focal Points
1.Telemedicine as an Export Service: People living in rural and remote areas throughout the world
struggle to access quality specialty medical care in a timely manner. The quality of medical institutions and
health professionals in the United States is often seen as a shining beacon to the world. Residents of many
nations often have substandard access to specialty healthcare through a shortage of trained specialists or an
inadequate health care delivery system. Because of innovations in computing and telecommunications
technology, many elements of medical practice can be accomplished when the patient and healthcare
provider are geographically separated. This separation could be across town, across a state, or even across
the world. Telemedicine allows major U.S. medical centers to export their services throughout the world
for use in patient consultations and medical training of health professionals in other nations. One looming
issue is the potential enactment of restrictive licensing laws by other nations to keep out U.S. health
providers, similar to measures adopted by several U.S. states.
2.Homecare: With the aging of the population in most developing nations, telehomecare has probably one
of the greatest potentials for rapid growth worldwide. In 1994, the U.S.-based National Association for
Home Care estimated that 15,000 providers delivered care to 7 million individuals requiring in-home
services because of acute illness and long-term health conditions. Throughout the decade the home
monitoring industry has developed electronic and telecommunication equipment which enables medical
care to be provided using telemedicine techniques rather than relying on in-person care to patients in their
homes. Increasingly, hospital technology is relocating to the home. Home care creates advantages in terms
of cost savings, but it also presents challenges for device manufacturers, untrained users and patients.
With more technologies moving into home-care and more and sicker patients being treated outside the
hospital, the home-care approach to healthcare is here to stay. Aging patterns across Europe closely
resemble the U.S. trend and in Asia, the rapidly changing demographic characteristics and the tradition for
caring for elders at home creates a challenge and a unique opportunity for the implementation of
telehomecare.
3.Internet: The next logical step is the use of the Internet as a vehicle for the delivery of medical care. In
fact this is happening in small steps today but we are poised to have it become a major factor in the
delivery of health care over the next five years. There are numerous companies that are quietly investing
in telecommunications delivery services and health care systems in an effort to emerge as a major player in
providing consultations, diagnoses, treatment and delivery of prescription medications all on-line usually
with the consumer paying for the services by credit card. This opens the potential for horizontal
monopolies for health care - the virtual on-line medical system. These services will be primarily in general
medical treatment at first but will eventually include specialty care services as well. This has created a
challenge in regulating the safe delivery of health care for nations with established medical systems as well
as international bodies.
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.
The promise of telemedicine is providing significantly improved and cost effective access to quality health
care. The potential of telemedicine is helping to transform the delivery of health care and improve the
health of millions of people throughout the world.
DWN info copied on TELE Medicine
Medical Informatics and Tele-Health Group
Information Issues in Telemedicine Systems - an Overview.
I. McClelland.
Review
Early medical computing was essentially an attempt to construct systems which would assist physicians in
decision making or investigations towards the production of complete hospital information systems (HIS)
according to Blois (1990). The earliest work was probably that carried out in the United States in the
MEDNET project. Other hospital application projects were carried out, starting at Massachusetts General
Hospital in Boston during the 1960's according to Blum (1986). The advent of personal computers in the
1970's led to developments away from large mainframe based HIS to a distributed architecture and early
distributed HIS's began to appear in the 1980's - Simborg et al (1983). Indeed, as early as 1970 it was
suggested that computers would have a revolutionary impact on medical education and even the selection
of health service trainees - Schwartz (1970).
During these early days of medical computing suggestions were made (Greenes (1970)) that there would be
a need for a dedicated programming language for medical systems. These ideas gave rise to MUMPS
(Massachusetts General Hospital Utility Multi-Programming System). MUMPS has continued to be very
popular in the medical computing domain as a basis for many patient record keeping and general hospital
information systems. MUMPS has appeared in many implementations running on a wide variety of
hardware and operating system configurations throughout the world.
Patient monitoring and acquisition of physiological data began in 1625 when Santorio published his
methods for measuring heart rate and body temperature based upon principles established by Galileo.
Eindhoven developed a string galvanometer for measuring ECG (Electrocardiogram) in 1903 and since
then ECG has become an important part of any clinicians battery of tests, particularly in the monitoring of
critically ill patients. Schubin and Weil were amongst the first to employ computer based physiological
monitoring during 1966 in the intensive care unit (ICU) at Los Angeles General Hospital according to
Gardner (1990) while algorithms were developed by Cox in 1969 to analyse ECG rhythm disturbances in
real time - Cox (1972). From these early research based beginnings only a small number of commercial
computer based monitors have successfully infiltrated the medical marketplace and these are typified by the
Maquette 7700 series and Hewlett Packard models. More recent research has been attempting to take this
patient monitoring a step further to provide remote monitoring and diagnostic facilities and has become
typified under the umbrella term of 'Telemedicine'.
There are many arguments to justify Telemedicine but perhaps most convincing are those outlined by
McNeilly and Pemberton (1968) who have shown that some 40% of deaths due to myocardial infarction
take place during the first hours of symptom onset. Guerci (1980) pointed out that it normally takes on
average around 3 hours until treatment is administered in this acute phase so if Telemedicine can contribute
towards a reduction in these time scales then it must surely have an important role to play in saving lives.
Anderson et al (1991) have shown how Telemedicine can be applied to ameliorate conditions for treatment
where specific medium to high risk patients can be identified. They developed and tested a defibrillator and
ECG monitoring device which can be remotely controlled by a clinician either by direct telephone line
or by cellular means. In the same work they stated this device to be successful with some 76% of calls to a
mobile coronary unit being backed up by remote monitoring of ECG while a clinician is in transit to the
patients house. In addition 4 defibrillation shocks were given remotely during the course of the study. A
similar study was carried out in Sweden by Thorborg (1990) and reported comparative successes.
There are however some disadvantages - Stults et al (1986) outlined training difficulties in use of the
equipment for staff and home users, whilst Copley et al (1977) noted that essential training of the
population in cardiopulmonary resuscitation has been difficult due to the supporting programs required.
More importantly, Gessman (1979) points out that the level of training required by the first responder
would be significantly reduced since it is the trained operator at the remote control station who will make
the decisions.
This area of Telemedicine thus shows potential life saving capabilities whilst possible reductions in training
time can be made safely for those first 'responders'.
Maclean et. al. (1995) outline how Telemedicine has been applied in North Sea oil exploration, trauma
care, radiology and maternity services in North West Scotland. From this analysis of the currently
developing telemedical care in Scotland, Maclean concludes that principles of remote health care may be
identified by training (as mentioned above), communications and research..
ISDN has contributed considerably to the success of Telemedicine, however, broadband (B-ISDN) which
offers greater bandwidth, when it becomes available will have an even greater impact. Many broadband
medical imaging trials have taken place using Metropolitan Area Networks (MANs)and / or Fibre
Distributed Data Interface (FDDI), Kohli (1989) outlines the detail of these. Broadband networks open up
considerable research possibilities in the areas of Picture Archiving and Communication Systems (PACS).
Using complex networks it becomes increasingly important that the man machine interface aspect is
studied carefully. Nakano (1990) realised this and has developed an ISDN terminal adapter with a much
more friendly user interface based around guidelines by Smith (1984).
User interface is critical in the Telemedicine area where many users lack experience with the technology
involved and if the user interface is not properly designed to satisfy these individuals, many mistakes will
be made. Since mistakes could be potentially costly the system must be designed to minimise their
occurrence. ISDN is complex technology and the number of set-up parameters can be very large under
certain conditions so software must isolate the clinician from network protocols.
User interface design was also foremost in the design of a Telemedicine system to record and assess blood
pressure. Arredondo (1991) has developed a simple to operate, portable blood pressure microcomputer with
a built in low speed modem. The user interface is also kept simple on the medical data gathering side
since most operations are single key presses using a rectangular LCD panel to indicate potential options
available on a set of four keys around its perimeter.
Care taken in this aspect of design was a contributory factor in the success of this project.
Ethical issues are as relevant in Telemedicine as in any other medical area. Telemedicine may enhance a
physicians ability to work efficiently for the patients benefit but we cannot ignore these ethical issues. Levy
(1990) outlines concerns of confidentiality from both a physicians and a service providers perspective.
Picard (1984) emphasises the fact that physicians owe a legally enforceable duty of confidentiality to their
patients. Boyle (1973) takes this one step further and says that this contractual duty of confidentiality in the
physician / patient relationship tends to result more by implication rather than by written contract.
It is therefore essential that Telemedicine does not detract from this confidentiality in any way. Numerous
examples have been raised by many writers and practitioners. There has been some public discussion
regarding confidentiality issues when medical details are being sent by fax. Fax machines were often
placed in non-secure or open environments to which non medical related staff had access. This kind of
confidentiality failure must be guarded against if Telemedicine is to succeed in the manner it is intended.
Other ethical questions which must be considered before any development of Telemedicine strategies takes
place include issues such as; 'Is telecommunications the best or least expensive way to deliver care? It may
cost more to examine and treat patients at a distance if physicians, in order to be legally protected must
exercise more judgement and order more tests. Is the system safe? Are there added risks to the patient by
not having the physician present ?
Telecommunication may be expensive especially if x-rays or other detailed information is transmitted.
(ISDN addresses this issue in that large amounts of data may be transmitted at relatively little cost and
speed). 'The utility of the system must be recognised by the user and not the provider' - Brown (1990).
Arredondo et al (1991) set up a Telemedicine system in order to improve accuracy of diagnosis and quality
of decisions to treat high blood pressure of individual patients. They also sought to improve access of the
community to the medical services available whilst being cost effective and being accessible to diverse
patient distributions. Their study is still continuing but the need to improve community access and manage
cost is foremost in this study. In this instance one sees how Telemedicine can be used to reduce cost and
improve patient care and this type of study goes some way toward answering the questions posed by Brown
(1990) above.
Cost is a major factor in many feasibility calculations. However, the need to provide medical coverage to
physicians 'in the field' in underdeveloped countries so as to provide better healthcare has often been
paramount - not only underdeveloped countries but also rural locations. Greenfield (1990) shows how
Telemedicine is developing in Saskatchewan and outlines how new services are going to develop, examples
of which are; drug information and drug interaction databases, speciality disease therapy databases e.g.
oncology or infectious diseases. Laboratories can also provide certain services via electronic mail.
Cost calculations for Telemedicine can become very complex and may constitute a major barrier to more
widespread use of Telemedicine. Cost questions such as "Even if Telemedicine is cost effective, should it
be expected to pay for itself?" The problem is that very often obvious savings made by telemedical
consultations (for example reduced travel expenses and less time away from work) are not taken into
account in the current cost accounting model. Peredina (1995) points to exactly this problem and claims
that it has the paradoxical effect of increasing medical expenditure while the actual savings themselves
accrue to other areas of the economy and are not accredited to the savings made by Telemedicine per se.
Satellite and microwave radio systems have been investigated by many as a suitable alternative where
telephony infrastructure is non-existent or patchy. Despite low bit rates - typically 1200bps, INMARSAT, a
communication satellite supported by a consortium of international communities has been used since it
gives global coverage and can be used with a variety of relatively portable earth stations. Mukhedkar
(1990) has studied this because of its ability to allow emergency medical consultations to be carried out for
example in mid Africa. This has many benefits but perhaps most importantly the ability of a remote
medical team in a '3rd world' context to discuss / consult with their base using the English language thus
aiding accurate communication and, theoretically, a higher standard of medical care. Cost is relatively high;
Mukhedkar estimates the INMARSAT project to have cost some $170,000 US.
Even though expensive for developing countries, satellite is the only way to rapidly deploy high levels of
medical care. 'The healthcare system in developing countries has traditionally been the sector most
interested in using telecommunications to support its activities, primarily through two-way private radio
networks.
Major areas of interest have been the co-ordination of emergency evacuations, patient evaluation, in service
training of physicians, nurses and other medical staff. With the expansion and improvement of rural
telephone services, other valuable applications are being developed' - United States Agency for
International Development (USAID, 1987). Kenney (1990) outlines potential areas for the 'valuable
applications' from a telephony viewpoint; administrative and logical support such as ordering supplies,
transfer of patient records, diagnostic patient support, patient management support including decisions
about the need to transfer a patient to another facility, co-ordination of public health campaigns, epidemic
control, more efficient gathering of healthcare statistics etc.
As Telemedicine expands in its adoption all the ethical issues must be considered and developed. Relevant
clinical and technical standards already implemented within other spheres of medicine can be adopted with
little or no modification. Standards can be condensed into three main areas; information
structures and usage, technical standards, community safety and operation protocols for the clinical
management of patients, Abet (1992).
As ethics become entrenched within the Telemedicine community, greater acceptance of the techniques
will become evident. In 1993 the Georgia Telemedicine project became the first to receive a regional
agreement for Medicare and medicaid reimbursement for telemedical consultations both by the
state of Georgia and Aetna Life and Casualty (their carrier for the healthcare and financing administration
physician payments). The Georgia centre links two rural hospitals, a public health clinic and prison
facilities. These reimbursements cover any consultation made in a Telemedicine format - there are no
increased charges. The medical centre has been able to make considerable savings and details are outlined
by Parsons (1994). Concerns have been raised about Telemedicine equipment standards, confidentiality and
other ethical issues and grants have been given to the University of Colorado Centre for Health Policy
and Research to further study these issues.
Perdnia (1995) outlines many economic, legal and social issues of Telemedicine in the USA. Examples of
concern include telemedical consultations across state boundaries where consultants are licensed to operate
within individual states. Similarly, remote liability and legal precedents have not yet been set resulting in
further uncertainty.
Hospital information systems (HIS) have developed over the past 20 years. They were originally developed
to process financial information and were operated by clerks but new awareness has created emphasis
toward clinical data management with day to day operation carried out by physicians and nurses. D'Atri
(1993) outlines the need for an integrated HIS which encompasses the ability to include structured data
included in the conventional medical folder, free text included in medical reports, graphs from biosignal
detection equipment, lab analysis results and diagnostic images. D'Atri points out that at present there is not
an integrated system available to handle all these types of data simultaneously. The HELP (Health
Evaluation through Logical Processing) medical record and hospital information system has been
operational at LDS (Latter Day Saints) Hospital at Salt Lake City Utah for over 10 years where over 500
terminals at
bedsides and nursing stations provide access to the system. The HELP system interfaces to a financial and
clinical laboratory system where billing data is produced from the system for patients accounts and the
clinical laboratory system provides on-line data input directly from many laboratory instruments. The
system has been successful in that it enhances access to clinical records but it still needs modifications and
further development to allow more flexible modeling and integration of medical terminology - Pryor
(1988). These issues are being addressed by models such as GALEN - Rector (1994) and the Arden Syntax
-Hripcsak (1990). See section on knowledge based systems later for a further discussion.
PROMIS (Problem Oriented Medical Information System) was designed to be used routinely by the
clinician and had the overall design requirement to provide logical steps (in the form of screens to be
completed) to guide the clinician for all data collection as wells as queries to a knowledgebase for drug
interaction etc - Fischer (1980). It was unsuccessful due to its dogmatic and inflexible structure.
As medical systems begin to make greater use of ISDN and other data communications technologies as a
means of transmitting and retrieving data, database systems must be developed which will support the
medical fraternity with their specific needs. These may be classified within the generic hypermedia /
multimedia areas. In order to handle these within the database context; direct representation, flexible use of
complex objects, behavioural knowledge and some means of indexing multimedia data will be required.
Halasz (1988) has outlined the emergence of these in database development tools.
Shneiderman (1989) suggests that the user must be allowed to directly manipulate the multimedia data
(graphics, images and text) which has been stored in the database. He points out that the current databases
allow the user to develop applications which will handle numbers and strings very efficiently but are weak
in the multimedia area apart from simple storage. This approach is supported by Morgenstern (1993) who
states that the user developed 'application systems' must be able to flexibly develop 'active databases'.
Morgenstern also outlines the difficulties of maintaining consistency within these types of applications
based on databases and suggests using various 'triggers' as a means of maintaining consistency. This is
beyond the remit of this article but is included to show the additional level of checks that must be made to
accommodate multimedia data.
Ishikawa (1993) also outlines problems with multimedia databases such as large amounts of data required
for images and the effects on performance. Database users must be able to define new types, operators and
access methods to allow the incorporation of new media facilities such as audio. Clinicians, like most
database users, require retrieval to be as fast as possible but this need will become more important when
diagnosis or images are being considered whilst 'on line' to a remote system, hence the emphasis on
multimedia database and development techniques.
The KBMS approach to multimedia databases is currently based around object-oriented principles as
proposed by Goldberg (1983) while Stefik (1986) supports this since complex objects can then be
supported directly. Multimedia must, according to Ishikawa (1993), be specified both structurally and
behaviourally and can therefore be modelled naturally by objects. Similarly, polymorphism may be used to
enable different implementations to be performed by the same function.
Object-oriented techniques are not without their drawbacks. Bloom (1987) indicates that current objectoriented techniques are not 'set oriented' while relational databases are. Bloom argues that this makes object
model semantics unclear to the user who is attempting to construct a model. Ishikawa (1993) sets out to
design and implement a model KBMS which they called 'Jasmine' with the purpose of solving the above
mentioned problems. Shipman (1981) proposed a functional data model which was used as the basis of this
approach and in order to reduce the effects of large audio or video/picture information sets, additional
techniques such as linear hashing as developed by Larson (1988) and nested relations have been used.
D'Atri (1993) attempts to model a typical patient folder and suggests that clinical data can be classified as
structured data, free text, images and biosignals. He suggests that the object oriented approach has more
benefits than disadvantages for this kind of problem. Bertino and Martino (1991) show how the modelling
capabilities of object oriented database management systems enable data and behavioural aspects to be
treated in an integrated way. In this way object oriented techniques have been utilised for a number of
knowledge based systems which have been modified to be used as a core for a HIS, an example of this is
MILORD (Multimedia Interaction with Large Object-oriented Radiological and clinical Databases), D'Atri
(1993).
Thus it is evident that to design a database for these on-line consultations and general Telemedicine
applications is a non-trivial task. Good database design is essential but assuming the database or data
management system core has been successfully constructed, it is equally important to ensure that the
human computer interface (HCI) is as good as is physically possible given current technological
constraints.
Human computer interaction can be defined as 'the discipline concerned with the design, evaluation and
implementation of interactive computing systems for
human use and with the study of major phenomena surrounding them' (ACM, 1992). Software designers
must adopt a user centred approach which encompasses
concepts of; consistency, compatibility with user's expectations, flexibility and control, explicit structure,
continuous and informative feedback, error prevention
and correction, user guidance and support, on-line help, visual clarity and logical sequencing. Careful
choice of metaphors, use of user interface design tools
and correct needs analysis and prototyping strategies all contribute towards a useable product.
D'Atri (1993) has been careful to adopt many of these principles when designing a patient folder interactive
multimedia database. Adoption of the correct interaction paradigms for medical databases have been
discussed by Di Felice (1989). Correct formulation of goals when querying the database is equally
important. In rich data models such as semantic networks a set of object names may be used to formulate a
goal without the user knowing how the objects are composed and their relationships to each other.
'Generalisations' are often made - a typical example is in 'query by example', (Zloof, 1977) as a means of
allowing the user to propose a goal.
Norman (1988) proposed the concept of the execution - evaluation cycle as a means to understanding how
humans interact with computer systems and how gulfs of execution and gulfs of evaluation develop. Dix
(1993) describes the gulf of execution as being 'the difference between the user's formulation of the actions
to reach the goal, and the actions allowed by the system. If the actions allowed by the system correspond to
those intended by the user, the interaction
will be effective'. Thus good interface design will aim to reduce this gulf. The gulf of evaluation is the
distance between the users expectation of the system state and the current physical state of the system.
Again good software design will minimise this gulf also. Normans model only considers the system as far
as the interface so Abowd and Beale (1991) developed an interaction framework which considers the
relationships between the system (core), user (task) and inputs and outputs provided by both the user and
system.
Spohrer (1991) postulates that an intelligent multimedia application is software that effectively integrates
artificial intelligence and multimedia technologies to enhance a users experience, while Hendler (1988)
points out that authoring intelligent multimedia applications is a complex task that requires teams of people
with diverse skills as in many instances different tools are used at each stage of the project. For example
prototyping the interface in Visual Basic or Hypercard, prototyping the expert system in Prolog or Lisp and
perhaps delivering the final product in C.
Similarly Kamata (1989) suggests that when designing a user interface one must incorporate the benefits of
paper based systems. Kamata outlines the benefits summarised as; high speed browsing, easy access, clues
given by chapter headings, management of material by position on desk etc. The user of ISDN coupled
with a desktop operating system such as windows allows the advantages of paper to be included whilst
ISDN provides the speed benefit of a fast network medium compared to slower modems. This opens up the
possibilities for remote monitoring of a data collection 'monitor' computer at a remote site. A full screen
sharing application may be set up which allows the contents of one computers screen to be presented on the
other with rapid updates for images and other data – ideal for a medical monitoring application.
Discussion
From the above review it can be seen that Telemedicine as a 'discipline' in the academic sense has a lot to
offer in terms of providing greater standards of care to the patients through improved response times by
clinicians having the required information immediately available. The patient also benefits from
convenience factors such as being able to attend a local location for a consultation with a remote specialist.
This could take the form of either video conferencing or special monitoring equipment such as that
presented by Mukhedkar (1990) in his satellite based system.
Management is also facilitated by Telemedicine as 'expensive' consultants and doctors can be located in
one central site and remote diagnostics can be carried out which eliminates travelling time and associated
costs. Parsons (1994) has already alluded to these cost and time benefits.
An integrated multimedia based Telemedicine system which emulated the concept of a HIS would have
many benefits such as consistent user interface which has adopted appropriate clinical metaphors,
integrated patient records with facilities to store graphical information and reference this remotely etc.
At the present time object oriented techniques show the greatest promise for these developments. Despite
the problems, Bloom (1987) has already alluded to but there are also potentially large benefits to be gained
since these offer modular integration facilities for an integrated environment which, up to now would have
been very difficult to implement using existing software development techniques. Object orientation also
offers considerable benefits to the clinician using the system. Careful choice of object metaphors by the
software developer can greatly aid the clinician in using the system. For example visual representations of
patient folders and an ability to 'drag and drop' scans or other pictures to these folders, is a 'real life' way of
working which can easily be displaced onto the computer.
Good interface design is not necessarily a by-product of object-oriented design methodology so any future
developments in Telemedicine must take into account current comprehension of this domain. Kamata
(1989) has already been cited as emphasising the need to incorporate the benefits of paper based systems.
This is again coming back to the metaphor approach of many in the HCI area.
Current developments in communications and increased processing power made available on the desktop
means that any telemedical application can take advantage of multimedia constructs to maximise the
amount of relevant information given to the clinician. For example, real-time pictures can be transferred
along with sound to enable a dermatologist to see the skin and talk to the remote patient, or ECG data being
presented to a remotely sited cardiologist who can then talk to the clinician located beside the patient,
McClelland (1995). Increased bandwidth on demand offered at relatively low cost by services such as
ISDN is making these facilities obtainable.
Knowledge based systems based around picture or pattern recognition could then be added to help the
consultant or remote clinician make a diagnosis based upon a previously assembled knowledgebase.
However, "One cannot fully exploit the telecommunication perspective within medicine until the data,
information and knowledge have the same meaning at both ends" -McNair (1991).
All of the above are pointers to what can be developed in the near future to enhance Telemedicine and
make it a realistic operating environment in which the clinician can feel comfortable that she / he is being
given all the necessary information to make a well informed diagnosis. Similarly, the clinician will be
confident with the technology, whereby ease of use will be maximised and training minimised due to
appropriate metaphors delivered in an object oriented manner. When this situation develops, then and only
then will Telemedicine as a concept become detached from the crude use of remote monitoring tools or
dial-up information sources.
Return to NIBEC
The Northern Ireland Bio-Engineering Centre
University of Ulster
Jordanstown, Newtownabbey,
BT37 0QB, Northern Ireland
Tel:- (+44) 28 9036 6329
Fax:- (+44) 28 9036 6863
SINGAPORE (23 April 1998) - Tele-Medical Services Pte Ltd (TMS), Asia's first and only provider of
health monitoring services via the telephone, has established its headquarters at 27 Scotts Road.
Strategically located in the heart of Singapore, the new set-up will be fully operational from 30 April. In
close proximity to specialist clinics, medical centres, hospitals, health spas, gyms and other healthcare
providers, TMS will be able to work closely with them to provide comprehensive services to subscribers.
"Establishing a regional office along Scotts Road reflects our commitment in the business of healthcare
services. We have been in operation for
more than 18 months and have been encouraged by the positive response to innovative health monitoring
services, using state-of-the-art devices
that transmit signals via telephone networks. Health monitoring is a brand new way to keep fit. Currently,
we eat right and exercise to keep fit.
With monitoring, we can now gauge the results of the efforts and optimise our keep fit routine," said Dr
Daniel Goh, President and CEO of
Tele-Medical Services Pte Ltd.
Offering state-of-the-art trans-telephonic monitoring, TMS members can transmit electrocardiogram
(ECG), blood pressure and asthma readings
conveniently from anywhere, at anytime to the TMS Monitor Centre. The round-the-clock Monitor Centre
is manned by doctors and nurses who
analyse the incoming readings with past records, in real time, and provide the immediate advice.
TMS' unique LifeCare units are well-equipped and are despatched with a medical team led by a doctor. It
is like a 'Hospital-on-Wheels' and can
save lives and minimise damages under life threatening situations where every second counts. The
LifeCare service can not only provide on the
spot treatment to the patient but also provide the hospital with the patient's condition report prior arrival
through the LifeCare's telecommunication
network.
TMS' operations is sanctioned by a Medical Advisory Committee comprising of leading local cardiologists
and other specialists.
The new address of TMS is:
27 Scotts Road
Singapore 288222
Tel: (65) 733 6888
Fax: (65) 838 0826
For further enquires, please contact:
Ms. Jasmine Ee
Public Relations Manager
Tele-Medical Services Pte Ltd
Tel: (65) 733 6888
Fax: (65) 838 0826
Pager: 9222 7567
Email: [email protected]