Dr. Luo is associate clinical professor in the Department of Psychiatry and Biobehavioral Sciences at the University of California in Los Angeles; past president of the American Association for Technology in Psychiatry (AATP) in New York City; and Gores Informatics Advocacy chair at the AATP.
Disclosure: Dr. Luo reports no affiliation with or financial interest in any organization that may pose a conflict of interest.
Telemedicine is generally viewed as use of video conferencing in the delivery of health care. However, it encompasses the various technologies, including E-mail and the telephone, in creating a connection between the provider and patient. Despite its clear potential to deliver health care to patients in rural settings or facilitate the reach of specialty providers to a larger patient population, telemedicine has somewhat faded in the technology and medicine limelight. This column reviews some of the early promises for telemedicine, examines various barriers in implementation and adoption of telemedicine, and explores the opportunities to return telemedicine to the forefront of medical care.
The 1990s were the beginnings of telemedicine that grew along side of the development of the World Wide Web. Balch and Tichenor1 described how at East Carolina University (ECU) School of Medicine telemedicine was used to reach rural areas of eastern North Carolina, where there was a shortage of healthcare providers. From 1992–1996, they conducted >1,000 consultations, with 55% in dermatology. In addition to consultations to rural clinics, specialists at ECU provided consultations to the emergency rooms. The network also provided family medicine grand rounds to the rural sites.
One of the major benefits of telemedicine is its ability to reach special populations such as rural patients who need deaf services. In South Carolina, the program for the Deaf and Hard of Hearing used a video conferencing program to provide psychiatric care.2 Jill Afrin, MD, an American Sign Language fluent psychiatrist, would normally travel 14 hours per week to treat clients around South Carolina. Using a desktop video conferencing system from PictureTel, she could communicate with patients in three community health centers without leaving her office, instead of traveling 50% of her time and seeing significantly fewer patients.
Zarate and colleagues3 studied the use of video conferencing for evaluating patients with schizophrenia, with particular emphasis on the impact of the video quality on assessment rating measures such as the Brief Psychiatric Rating Scale (BPRS), the Scale for the Assessment of Positive Symptoms (SAPS), and the Scale for the Assessment of Negative Symptoms (SANS). They compared in-person patient visits to low-quality (182 kilobits/second bandwidth) and high-quality (384 kilobits/second bandwidth) telemedicine sessions. Patients with schizophrenia were actually quite satisfied with their virtual visit and preferred the telemedicine visit over the in-person visit. Total scores on the BPR and SAPS were comparable to live rating for both low and high quality. SANS was comparable to live rating only at high quality since at low quality sessions there is difficulty rating negative symptoms.
Shea and colleagues,4 in the Informatics for Diabetes Education and Telemedicine project, studied the difference in diabetes management for usual care versus telemedicine intervention in an older, ethnically-diverse, and medically underserved patient population in New York City. Patients in the intervention group had home telemedicine units installed with dial-up Internet access, which also had blood glucose monitors attached to upload data. Nurses made visits via telemedicine to check on patients and implemented both direct video conference-based educational modules and store-forward self-paced modules from the Website established for the project. Although both groups demonstrated reductions in hemoglobin A1C, blood pressure, and low-density lipoprotein levels, the telemedicine intervention group achieved statistically significantly greater levels. Although many pilot studies demonstrate the impact of telemedicine, this study had much more statistical power with its 1,665 participants, 884 of whom had the telemedicine intervention.
Hardware issues are an obvious barrier to implementing and establishing telemedicine. In 1996, the average personal computer cost $2,500 and video conferencing systems, such as the PictureTel, Compression Laboratories, Sony, and VTEL, ranged from $20,000–$60,000.5 At that time, Integrated Service Digital Networks (ISDN) were the primary most reliable and direct data transmission service, which provided 384 Kbps rates both upstream and downstream. A listserv posting indicated that Bell Atlantic charged from $120–$240 of usage charges for 100 hours of residential ISDN service.6 In comparison, monthly dial-up Internet access by America Online in 1996 was $50 for unlimited number of hour’s access at 28.8 Kbps. Today, Web cameras which transmit video and audio are quite inexpensive at $30, but in 1996, Creative Labs Inc. sold the ShareVision PC3000 for $9,995. This product worked over regular analog phone lines but was compatible only with other ShareVision setups.
Compatibility of various systems was clearly a problem. A direct data transmission connection between setups using ISDN provided security since the network was private although quite expensive. Present day cable and digital subscriber line (DSL) modems provide up to 3 Mbps (equals 3,000 kilobits) per second downstream and up to 300 Kbps upstream or upload for only $20/month. Although Verizon’s FiOS fiber optic Internet access is extremely fast at 30 Mbps download and 5 Mbps upload speeds for $42.99/month, it is not readily available.7 In remote rural areas, DSL and cable access are often not available. The bandwidth requirement for video and audio is certainly not met with dial-up Internet speeds of 56 Kbps. Satellite transmissions, such as HughesNet, can reach download speeds of 2 Mbps and 500 Kbps upload for their business plan, but costs $199.99/month.8 Lower speeds are available via satellite as well, such as WildBlue’s Value Pak at 512 Kbps download and 128 Kbps upload for $49.99/month.9 Clarke and colleagues10 have demonstrated in a simulation that even with low bandwidth satellite links, packet-switched protocols such as TCP/IP can support telemedicine well if not too may concurrent sessions are running.
Video transmission standards have made it possible to decrease costs by utilizing public networks such as the Internet in lieu of direct connections as well as utilizing different equipment at each site. The International Telegraph Union (ITU),11 a United Nations agency, creates international standards for telecommunications services. Standard video protocols supported by web cameras include H.263 and H.264, which involve different levels of compression of the audio and video data. H.263 is an ITU standard, designed for low bitrate communications such as video-conferencing and video-telephony applications, but it can be used for a wide range of bitrates. H.264, also an ITU standard, is a high-quality video compression algorithm and is suited for all types of applications with different ranges of bit rates. This technology is also known as AVC (Advanced Video Coding) or MPEG-4 Part 10 (ISO/IEC 14496-10).
Although the Internet provides an existing and inexpensive infrastructure to conduct telemedicine, security is of concern. For consultations conducted between urban and rural health clinics, the use of a virtual private network (VPN) connection ensures that any data exchange is conducted over a private channel on the public Internet. This setup requires knowledgeable staff to setup the VPN hardware or software as well as a fast Internet connection and video system to compensate for the performance degradation secondary to the encryption. This technical demand is one barrier to why telemedicine visits have largely been between medical facilities and not direct to patients in the comfort of home. Chen and colleagues12 have described a way to utilize a discrete key encryption/decryption system to enable telemedicine visits from providers at hospitals to patients at home.
One of the technological issues raised with telemedicine versus the “plain old telephone system” is reliability. Balch and Tichenor1 indicated that their center had to employ staff at each site in order to manage the daily operation of their network in order to troubleshoot any difficulties. In addition to technical staff, healthcare staff needed time to develop familiarity with the equipment, and good interpersonal communication between the technical staff and clinical staff is essential.
Technical difficulties with telemedicine, such as choppy video or prolonged latency in audio reception, are significant drawbacks to a satisfactory session.13 Staff and patients need to learn proper “etiquette” in how to conduct a video conferencing session to avoid confusion and distraction in the session, which may detract from the experience.14 Such etiquette includes avoiding rapid movements, awaiting turns to speak, and speaking slower if needed.
Backup systems need to be in place to address potential failures in areas such as data transmission, video and audio, and power. Pre-visit testing to validate a connection is important, particularly if telemedicine is conducted over the Internet with equipment from different manufacturers. At East Carolina University’s telemedicine program, the developers discovered that due to the technical requirements for their network connections, their own staff had to design and build their own alarm system to inform the engineering staff when their data connection was lost instead of relying on the phone company.1
Nesbitt and colleagues15 noted that in California, reimbursement was one barrier to the use of telemedicine, and in 1996, the Welfare and Institutions Code 14132.72 was passed that mandated reimbursement of telemedicine services. The experience at University of California (UC) Davis Telemedicine Program is that in rural areas, the majority of patients had Medicaid insurance coverage, whereas in suburban and urban areas private insurance and Medicare were the majority. Their experience has been that many private insurance companies have not developed a reimbursement policy for telemedicine and have made it difficult to get reimbursement by requiring significant explanation of the telemedicine visit, the role of the presenting provider, the role of the consultant, and paying the telecommunications costs. The Center for Telehealth and E-Health Law notes that only five states have a statutory requirement that private insurance cover telehealth services. These include Louisiana (1995), California (1996), Oklahoma (1997), Texas (1997), and Kentucky (2000).16
Licensure is a particularly significant barrier to the adoption of telemedicine by many practitioners. Most state medical boards have agreed that the practice of medicine occurs in the state where the patient is located.17 Therefore, physicians who wish to practice telemedicine are required to obtain a license in the state where the patient is located, which may be an expensive and time-consuming endeavor. Only 15 states have adopted an abbreviated licensing process for the purpose of telemedicine. Even this legislation does not help in eleven states that have laws explicitly requiring physical examination before the physician can prescribe.
East Carolina University discovered that scheduling is important in telemedicine. With their multiple sites and limited resources, they needed an Online scheduling system so that rural sites could request specialty consults.1 Nesbitt and colleagues15 reported that specialties involving unique examination procedures or imaging techniques such as otolaryngology, dermatology, and orthopedics required only 30 minutes of examination time for initial and follow-up visits in contrast to interview-based consultations such as nutrition, behavioral health, and endocrinology, which required 60 minutes for the initial evaluation and 30 minutes for follow-up appointments. With this limited resource, UC Davis had an overall cancellation rate of 11.1% with great variability of 21% for infectious disease to 0% for rheumatology.
Emergencies are a challenging situation in telemedicine, in particular if the patient is out of state. The disadvantages are obvious in that the provider may not be familiar with local resources for emergency services. It makes sense that most telemedicine programs adopt the consultation model where there is a health practitioner available locally with the patient to manage any emergency. Hilty and colleagues18 describe new models of care via telemedicine, which include cross-cultural consultation to rural primary care, secured E-mail and telephone consultation for telepsychiatry and telepsychological services, and direct physician to physician consults.
Shore and colleagues19 describes how emergency telepsychiatry which provides direct psychiatric care requires protocols for emergency coverage after hours as well as ways to address legal issues such as involuntary commitments and duty to warn.
The slow rate of telemedicine adoption has many other facets to consider. The California Healthcare Foundation in 1999 forecasted that telemedicine as part of communication infrastructure and transaction services would be a trend in health care; however, it accurately predicted that telemedicine applications would develop slowly.20 The report cited lack of reimbursement and bandwidth limitations as barriers toward more widespread adoption.
Besides licensure, recruitment of specialists is a significant barrier since primary care physicians (PCPs) have many patients to refer.21 Some administrators also see that recruitment of PCPs is a barrier, especially since their traditional referral habits are difficult to break. Grigsby and colleagues21 also cite how a conundrum may exist if PCPs do not feel comfortable writing a prescription recommended by a specialist, who additionally do not feel comfortable writing a prescription based on a videoconference visit.
Although not explicitly described above, cost is a significant issue barrier to more widespread use of telemedicine. Many of the programs serving rural areas have been funded by grants, which are necessary to pay for videoconferencing equipment, peripheral devices such as dermatology cameras and digital stethoscopes, data transmission charges, maintenance contracts, clinical staff, technical staff, and professional fees.
Despite the many barriers toward more widespread usage of telemedicine beyond the rural area specialty consultation, some specialties thrive with the use of telemedicine. The Nighthawk radiology service based in Idaho is a perfect example where telemedicine meets a defined need extremely well.22 These radiologists provide consultation remotely by reading x-rays, magnetic resonance imaging scans, and computerized axial tomography scans. Licensure is not an issue since the physicians are licensed in the state where they provide consultation, and evening and early hours are not an issue since the remote radiologist is located in a different time zone.
The continuing trend toward new technologies every year helps decrease cost barriers. At the January 2008 Consumer Electronics Show in Las Vegas, Nevada, Creative introduced its In Person handheld videoconferencing unit.23 This device retails for <$1,000, and it has a 7” video screen with a built-in camera and microphone. It does not require a separate personal computer to run, and it connects to the Internet either wirelessly with 802.11g or wired local area network. It is compatible with the common H.263 and H.264 video standards.
Wireless Metropolitan Area Networks, a telecommunications technology aimed at providing wireless data transmission over long distances in a variety of ways, is an IEEE 802.16 standard known as Wireless MAN.24 It is also known by WiMAX, which was created by the WiMAX Forum, to promote conformance and interoperability of this standard. WiMAX is a long-range system, covering many kilometers and providing high bandwidth services that normally would be handled if DSL or cable modems were available. It typically uses licensed spectrum to deliver a point-to-point connection to the Internet from an Internet Service Provider to an end user. Different 802.16 standards provide different types of access, from mobile to fixed access. WiMAX will eventually eliminate the need for wireless Internet access via the cellular phone network.
Telemedicine certainly is not a technology whose time has passed nor has it been relegated to strictly serving the rural communities of the world. With today’s trends toward increasing consumer familiarity with technology, availability of hardware and Internet access at reasonable cost, and the growing consumer utilization of health care on the Internet, telemedicine is certainly poised to become more mainstream and widely adopted. Traffic problems and schedule conflicts may encourage patients to occasionally visit their physician via video conferencing. Corporate America has already invested significant dollars in videoconferencing technology to facilitate multi-site meetings, which reduce downtime from travel and impact on the environment. Videoconference-based treatment, such as EGetGoing’s Online group-therapy service for drug and alcohol addiction, has already been in place for 5 years.25 Perhaps the portrayal of health care in Star Trek is not too far away. PP
1. Balch DC, Tichenor JM. Telemedicine Expanding the Scope of Health Care Information. J Am Med Inform Assoc. 1997;4(1):1-5.
2. Straub K. Health care videoconferencing options cover wide range of applications, price, quality. Health Manag Technol. 1997;18(5):52-53,55-56.
3. Zarate CA Jr, Weinstock L, Cukor P, et al. Applicability of telemedicine for assessing patients with schizophrenia: acceptance and reliability. J Clin Psychiatry. 1997;58(1):22-25.
4. Shea S, Weinstock RS, Starren J, et al. A randomized trial comparing telemedicine case management with usual care in older, ethnically diverse, medically underserved patients with diabetes mellitus. J Am Med Inform Assoc. 2006;13(1):40-51.
5. Baig EC. A World of Talking Heads? Lower costs and more compatibility bring videoconferencing within everyone’s reach. Businessweek. Available at: www.businessweek.com/1996/20/b3475151.htm. Accessed January 15, 2008.
6. Love J. Pretty Good ISDN Cost Study. Available at: http://lists.essential.org/1996/info-policy-notes/msg00012.html. Accessed January 15, 2008.
7. Verizon FiOS. Available at: www22.verizon.com/content/ConsumerFios. Accessed January 15, 2008.
8. HughesNet. Available at: www.hughesnet.com. Accessed January 15, 2008.
9. WildBlue. Available at: www.wildblue.com. Accessed January 13, 2008.
10. Clarke M, Fragos A, Jones RW, Lioupus D. Optimum Delivery of Telemedicine Over Low Satellite Links. Available at http://ieeexplore.ieee.org/iel5/7934/21932/01019615.pdf?tp=&isnumber=&arnumber=1019615. Accessed January 15, 2008.
11. International Telecommunication Union: Audiovisual and Multimedia systems. Available at: www.itu.int/rec/T-REC-h. Accessed January 15, 2008.
12. Chen Z, Yu X, Feng D. A Telemedicine System Over the Internet. Available at: crpit.com/confpapers/CRPITV2Chen.pdf. Accessed January 15, 2008.
13. Hsiung R. E-Therapy. London, UK: Norton & Co; 2002.
14. Maheu M, Whitten P, Allen A. E-Health, Telehealth, and Telemedicine. San Francisco, CA: Josse-Bass; 2001.
15. Nesbitt TS, Hilty DM, Kuenneth Ca, Siefkin A. Development of a telemedicine program: a review of 1,000 videoconferencing consultations. West J Med. 2000;173(3):169-174.
16. Mandatory Private Payer Telehealth Reimbursement in States. The Center for Telehealth and E-Health Law. Available at: www.telehealthlawcenter.org/?c=129&a=1702. Accessed January 15, 2008.
17. Physician Licensure. The Center for Telehealth and E-Health Law. Available at: www.telehealthlawcenter.org/?c=155. Accessed January 15, 2008.
18. Hilty DM, Yellowlees PM, Cobb HC, Bourgeois JA, Neufeld JD, Nesbitt TS. Models of Telepsychiatric Consultation–Liaison Service to Rural Primary Care. Psychosomatics. 2006;47(2):152-157.
19. Shore JH, Hilty DM, Yellowlees P. Emergency management guidelines for telepsychiatry. Gen Hosp Psychiatry. 2007;29(3):199-206.
20. Mittman R, Cain M. The Future of the Internet in Health Care: Five-Year Forecast. California Healthcare Foundation. Available at: www.chcf.org/topics/view.cfm?itemID=12496. Accessed January 15, 2008.
21. Grigsby B, Brega AG, Bennett RE, et al. The slow pace of interactive video telemedicine adoption: the perspective of telemedicine program administrators on physician participation. Telemed J E Health. 2007;13(6):645-656.
22. NightHawk Radiology Services. Available at: www.nighthawkrad.net. Accessed January 15, 2008.
23. Creative inPerson. Available at: http://us.creative.com/products/product.asp?category=809&subcategory=810&product=17451. Accessed January 15, 2008.
24. The IEEE 802.16 Working Group on Broadband Wireless Access Standards. IEEE WirelessMAN 802.16. Available at: www.ieee802.org/16/. Accessed January 15, 2008.
25. eGetGoing. Available at: www.egetgoing.com. Accessed January 15, 2008.