Teresa Smith Welsh
The development of telecommunications and computer technology since the 1960s Space Age has implications for the improvement of the quality of health care for those who live in remote or isolated areas where access to quality health care has traditionally been a problem (Samuelson, 1986) (Zundel, 1996).
Telemedicine, the use of two-way telecommunications technology, multimedia, and computer networks to deliver or enhance health care, is a growing trend internationally, with the United States, Canada, the United Kingdom, and Scandinavia among the leaders in developing this field (Basher et al., 1975) (Foote, 1976) (Basher and Lovett, 1977) (Picot, 1985) (Cronin, 1995). Telemedicine also has military and urban applications, but this paper focuses on the development and use of telemedicine in home health and trauma care in rural areas of East Tennessee, an area of great need and with great potential for the improvement of health care and mortality rates.
Telemedicine is defined by the Telemedicine Information Exchange (1997) as the "use of electronic signals to transfer medical data (photographs, x-ray images, audio, patient records, videoconferences, etc.) from one site to another via the Internet, Intranets, PCs, satellites, or videoconferencing telephone equipment in order to improve access to health care." Reid (1996) defines telemedicine as "the use of advanced telecommunications technologies to exchange health information and provide health care services across geographic, time, social, and cultural barriers."
According to the Telemedicine Report to Congress (1997), "telemedicine can mean access to health care where little had been available before. In emergency cases, this access can mean the difference between life and death. In particular, in those cases where fast medical response time and specialty care are needed, telemedicine availability can be critical. For example, a specialist at a North Carolina University Hospital was able to diagnose a rural patient's hairline spinal fracture at a distance, using telemedicine video imaging. The patient's life was saved because treatment was done on-site without physically transporting the patient to the specialist who was located a great distance away."
In addition, the 1997 report states that "Telemedicine also has the potential to improve the delivery of health care in America by bringing a wider range of services such as radiology, mental health services, and dermatology to underserved communities and individuals in both urban and rural areas."
The practice of medicine through telecommunications, or telemedicine, may be dated to the early 1960s when the National Aeronautics and Space Administration (NASA) first put men in space. Physiological measurements of the astronauts were telemetered from both the spacecraft and the space suits during NASA space flights. These early efforts were enhanced by the development of satellite technology which fostered the development of telemedicine.
NASA funded telemedicine research projects in the late 1960s and early 1970s. According to Basher, Armstrong, and Youssef (1975), there were fifteen telemedicine projects active in 1975.
One pioneer telemedicine project, STARPAHC, or Space Technology Applied to Rural Papago Advanced Health Care, was developed by NASA to deliver health care to the Papago Indian Reservation in Arizona. The project, which ran from 1972-1975, was implemented and evaluated by the Papago people, the Indian Health Service, and the Department of Health, Education, and Welfare. The goal was to provide health care to the isolated Papago Reservation. A van, which carried a variety of medical instruments including electrocardiograph and x-ray machine, was staffed by two Indian paramedics. The van was linked to specialists at the Public Health Service Hospital by a two-way microwave transmission (Telemedicine Research center, 1997).
In 1974, NASA conducted a study with SCI Systems of Houston to determine the minimal television system requirements for accurate telediagnosis. A high-quality videotape was made of an actual medical exam conducted by a nurse but supervised by a physician watching on closed-circuit television. These videotapes were systematically electronically degraded to less than broadcast quality. The original and degraded videos were then shown to randomly selected groups of physicians who attempted to reach a correct diagnosis (Telemedicine Research center, 1997).
The results, reported in "Final Report: Video Requirements for Remote Medical Diagnosis" (SCI Systems, Inc., 1974), included: 1) statistical significance between the means of the standard monochrome system and the lesser quality systems did not occur until the resolution was reduced below 200 lines or until the frame rate was below10 frames a second; 2) there was no significant difference in the overall diagnostic results as the pictorial information was altered; 3) there was no significant difference in remote treatment designations of TV system type that would cause detriment to patients; and 4) the supplementary study of transmissions of 25 cases using televised radiographic film showed no diagnostic differences between the televised evaluations and direct evaluations if the televised evaluations were above 200 lines and special optical lenses and scanning techniques were utilized (Telemedicine Research center, 1997).
In 1989, NASA conducted the first international telemedicine project, Space Bridge to Armenia/Ufa, after a powerful earthquake struck the Soviet Republic of Armenia in December 1988. An offer of medical consultation was extended to the Soviet Union by several medical centers in the United States. Telemedicine consultations were conducted under the guidance of the US/USSR Joint Working Group on Space Biology using video, audio, and facsimile between a medical center in Yerevan, Armenia and four medical centers in the United States. This project was extended to Ufa, Russia to aid burn victims there after a fiery railway accident (Telemedicine Research center, 1997).
Telemedicine technology has increased and the cost of equipment has decreased in the past ten years, resulting in an increase in the number of telemedicine research projects and increase in the scope of those projects. The Telemedicine Information Exchange (1997) lists over 130 telemedicine research sites. The 4th Annual Telemedicine Program Review (Grigsby and Allen, 1997) lists 80 active telemedicine programs in 1996, in 38 states and Washington, D.C., 8 of which use only store and forward technology and 72 of which use two-way interactive audio-visual technology. There are 1,032 total telemedicine sites (hubs and spokes) which performed 21,274 consultations, 91 percent (19,380) of which were interactive audio-visual and 9 percent (1,894) of which were store and forward.
Since 1993, when there were only twelve active programs in the US, the number of programs has doubled yearly, while program activity (number of consultations) has tripled since 1995. The top five types of consults in 1996 were: mental health (21%), trauma care (16%), cardiology (12%), dermatology (11%), and surgery (8%). Emergency or trauma telemedicine emerged in 1996 as one of the fastest growing applications of this technology (Ibid. 1997).
Early projects using telemedicine in rural health care proved to have great beneficial effects on patient survival and recovery, but the equipment was expensive and rather cumbersome (Park 1974)Grundy et al. 1977) (Grundy, Jones and Lovitt, 1982). As the cost and size of the equipment have come down, and the technical quality has gone up, telemedicine has become much more feasible to use in rural health care (Dakins 1995).
A telemedicine home healthcare project, "Rural Health Care Through Telemedicine: An Interdisciplinary Approach" was funded by the US Office of Rural Health Policy Rural Telemedicine Grant Program through the University of Tennessee Medical center Telemedicine Program in order to improve access to quality health services for the rural residents of Grainger County, Tennessee.
Grainger County has a population of 18,667 and no hospital. Primary medical care is provided by four clinics with three full-time and two part-time physicians. The patient to physician ratio is 4667:1, which is ten times the ratio for Tennessee and the United States. One of the clinics has had 18 physicians in 22 years, which graphically illustrates the problem of retaining health care professionals in isolated rural areas.
The geography of the area makes it difficult for people to go from their homes to medical care or for medical care to come to them. The Clinch Mountain, in the foothillls of the Appalachian Mountains, along with the Tennessee Valley Authority lake system, creates geographical barriers to health care delivery. There is severely limited road access, no public transportation, no taxi service, and long travel times within much of the county to the clinics.
For emergency care, the county has only three ambulances and no 911 service. Clinch Mountain divides the county, and, from 7:00 PM to 7:00 AM, there is no ambulance service north of the mountain which has an elevation of 2,200 feet.
The focus of the telemedicine project was to improve access to quality health services and to reduce the isolation of rural health care professionals in Grainger County. During this three year project, each of the four clinics was provided with interactive audio-video telemedicine equipment and training for its use in patient consultations. This enabled a primary care physician in one of the rural clinics to examine a patient in another. In addition, the clinic patients have access to consultations with specialist physicians at UT Medical center in Knoxville.
To improve emergency care, the county-owned EMS service received two EKG units which can transmit 12-lead EKG data from a patient to a clinic physician or the UT Medical center Emergency Department via cellular telephone. The EMS staff was trained on equipment use and procedures.
To support rural home healthcare patients, interactive audio/video equipment was provided to eight selected home care patients. Patients were able to communicate with healthcare providers using a small video camera with tripod and monitor, and videophone connected to a standard electric outlet and telephone line. Approximately ten trips saved to a patient's home pays for the cost of the equipment.
"Trauma Care Through Telemedicine: A Rural Network of Health Services Information in East Tennessee" was a project funded by a grant from the federal government to share information among ambulances, rural emergency departments, and a Level I trauma center at the University of Tennessee Medical center during the "Golden Hour," the initial care of trauma patients in which the proper medical treatment can mean the difference between life and death.
The project, which was funded through March 31, 1999, served seventeen counties in Appalachian Tennessee, building on an existing telemedicine partnership (the University of Tennessee Telemedicine Network) between Woods Memorial Hospital, LaFollette Medical center, Morristown-Hamblin Hospital, and the University of Tennessee Medical center, Knoxville, and also including rural emergency medical services in Campbell, Hamblin, and McMinn counties in Tennessee.
Technologies included: 1) a new method of providing still images from the accident site using digital cameras, computers, and cellular telephones; and 2) two-way consultation between rural physicians and regional trauma surgeons during resuscitation using compressed two-way audio/video via T-1 lines.
Emergency departments in the rural hospitals was equipped with interactive digital audio-video equipment and computers that are linked to the University of Tennessee Telemedicine Network (located at the University of Tennessee Medical center trauma center) by T-1 telecommunication lines. This connection allows the rural emergency department staff to have "real-time" consultations with specialists at the University of Tennessee trauma center. Medical patient information, such as x-rays, cardiograms, and diagnostic laboratory bloodwork, may be digitized and faxed to the trauma center via computers.
Ambulances in the rural counties were equipped with digital cameras and cellular telephones capable of transmitting digital pictures of accident scenes and patients to the local emergency departments which could then forward them to the University of Tennessee. Emergency technicians in the ambulances were trained in the use of the equipment, which has a two-way effect. By transmitting digital photos of the accident scene to the local emergency departments, preparations can be made to receive and properly treat the accident victim or victims immediately on arrival at the hospital, with consultations done as needed with the UT trauma center. In addition, photos of the accident scene and victims expedites decision-making about whether the patient or patients can be treated locally or sent via Lifestar Helicopter Service to the UT trauma center in Knoxville.
If research results prove the value of this project, that telemedicine from the University of Tennessee Medical center to smaller, rural emergency services can save lives and/or improve the level of health care, then the program may be permanently implemented and expanded to give greater access to trauma care in rural areas.
- American Telemedicine Association (1997).
- American Telemedicine Association, http://www.atmeda.org
- Association of Telemedicine Service Providers (1997).
- Telemedicine Today, http://www.telemedtoday.com
- Balas, E.A., F. Jaffrey, G.J. Kuperman, S.A. Boren, G.D. Brown, F. Pinciroli, and J.A. Mitchell (1997).
- Electronic Communication with Patients: Evaluation of Distance Medicine Technology, Journal of the American Medical Association, 8(2):152-9.
- Basher, R.L., P.A. Armstrong, and Z.I. Youssef (1975).
- Telemedicine: Explorations in the Use of Telecommunications in Health Care. Springfield, IL: Charles C. Thomas.
- Basher, R., and Lovett, J. (1977).
- Assessment of Telemedicine: Results of the Initial Experience. Aviation Space Environmental Medicine, 48(1):65-70.
- Conrath, David W., Earl V. Dunn, and Christopher A. Higgins (1983).
- Evaluating Telecommunications Technology in Medicine. Dedham, MA: Artech House, Inc.
- Cronin, Francis J.(1995).
- The Rural Economic Development Implications of Telecommunications: Evidence from Pennsylvania, Telecommunications Policy, 19: 545-60.
- Dakins, D.R. (1995).
- Urgent Care Applications Triage Trauma, Extend Rural Coverage, Telemedicine: The Monthly Newsletter of Telecommunications in Healthcare, 3(7): 1, 4-5.
- Dakins, Deborah, ed.(1997).
- Telemedicine and Telehealth Networks, http://www.telemedmag.com
- Fitz-Gibbon, Carol T. and Lynn L. Morris (1987).
- How to Design a Program Evaluation. London: Sage Publications.
- Foote, D.R. (1976).
- A Case Study Evaluation of a Satellite Video Telemedicine Project in Rural Alaska. Stanford University Press.
- Grigsby, Bill and Ace Allen (1997).
- 4th Annual Telemedicine Program Review, Telemedicine Today, August 1997: 30-42.
- Grundy, B.L., P. Crawford, P.K. Jones, M.L Kiley, A. Reisman, Y.H Pao, E.L. Wilkerson, and J.S. Gravenstein (1977).
- Telemedicine in Critical Care: An Experiment in Health Care Delivery, Journal of the American College of Emergency Physicians, 6(10): 439-44.
- Grundy, B.L., P.K. Jones, and A. Lovitt (1982).
- Telemedicine in Critical Care: Problems in Design, Implementation, and Assessment, Critical Care Medicine, 10(7):471-5.
- Indian Health Service (1997).
- Indian Health Service http://www.ihs.gov
- John Mitchell & Associates (1997).
- Telemedicine Links, http://www.jma.com.au/telelink.htm#networks
- National Aeronautics and Space Administration (1974).
- Final Report: Video Requirements for Remote Medical Diagnosis. Washington, D.C.: Government Printing Office.
- National Aeronautics and Space Administration (1997).
- Telemedicine History, http://www.it.hq.nasa.gov~kmorgan/telemed/
- Picot, J. (1985).
- Communications Technology in Canadian Health Care: Three Case Studies. British Columbia, Can: Simon Fraser University Press.
- Reid, Jim (1996).
- A Telemedicine Primer: Understanding the Issues. Topeka KS: Innovative Medical Communications.
- Samuelson, Kjell (1986).
- Telemedicine Systems for Knowledge Support, Education and Decision Making, ASIS, 86, 288-90.
- SCI Systems, Inc. (1974).
- Final Report: Video Requirements for Remote Medical Diagnosis. Houston TX: NASA Johnson Space Center.
- Telemedicine Research Center (1997).
- Telemedicine Information Exchange, http://tie.telemed.org
- United States Department of Commerce and United States Department of Health and Human Services (1997).
- Telemedicine Report to Congress, January 31, 1997, http://www.ntia.doc.gov/reports/telemed/
- United States Food and Drug Administration (1997).
- Telemedicine-Related Activities Report, http://www.fda.gov/cdrh/telemed.html
- Wootton, Richard, ed., Royal Society of Medicine (1997).
- Journal of Telemedicine and Telecare, http://www.qub.ac.uk/telemed/jtt
- Zundel, Karen M. (1996).
- Telemedicine: History, Applications, and Impact on Librarianship, Bulletin of the Medical Library Association, 84:71-79.