Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Found on www.________________________________ D.Neeley ( Call me for WWW addresses, I can not seem to import them into this .doc) Doug Neeley 214-673-9284 Medical Device Company What's New Welcome to Tele-Medical Services Website! 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]