A Brief History of Telemedicine

By Nancy Brown, May 30, 1995

Introduction

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

Trends observed nationally include:

• using telemedicine in correctional facilities and home health care settings, can significantly reduce the time and costs of patient transportation;
• fine-tuning the management and allocation of rural health care emergency services by transmitting images to key medical centers for long distance evaluation/triage by appropriate medical specialists;
• permitting physicians doing clinical research to be linked together despite geographical separation, sharing patient records and diagnostic images;
• improving medical education for rural health care professionals, where rotations are made possible by linking several community hospitals together with the sponsoring medical school.

In general, the numerous and ever expanding applications of telemedicine allows its users to reduce the burdens of inferior health care access through utilization of technology. Because of telemedicine, geographical isolation need no longer be an insurmountable obstacle to the basic needs of timely and quality medical care.

History of Telemedicine

While the explosion of interest in telemedicine over the past four or five years makes it appear that it's a relatively new use of telecommunications technology, the truth is that telemedicine has been in use in some form or other for over thirty years. The National Aeronautics and Space Administration (NASA) played an important part in the early development of telemedicine (Bashshur and Lovett 1977). NASA's efforts in telemedicine began in the early 1960s when humans began flying in space. Physiological parameters were telemetered from both the spacecraft and the space suits during missions. These early efforts and the enhancement in communications satellites fostered the development of telemedicine and many of the medical devices in the delivery of health care today. NASA provided much of the technology and funding for early telemedicine demonstrations, two of which are mentioned below. A book by Rashid L. Bashshur published in 1975 (Bashshur et al. 1975) lists fifteen telemedicine projects active at the time. There were several pioneering efforts not only in the US, but all over the world. A few of these and some later projects are worth examining briefly. To find articles about these programs, follow the links to the Bibliographic database, which will give you a reference and abstract (if available), which describes these programs. Many of these programs have other articles besides those listed which describe them. To find these, do a word search in the Bibliographic database on the project of interest.

Telemedicine Programs

Space Technology Applied to Rural Papago Advanced Health Care (STARPAHC)

One of the earliest endeavors in telemedicine, STARPAHC delivered medical care to the Papago Indian Reservation in Arizona. It ran from and was conceived by the National Aeronautics and Space Administration (NASA), engineered by NASA and Lockheed, and implemented and evaluated by the Papago people, the Indian Health Service and the Department of Health, Education and Welfare. Its goals were to provide health care to astronauts in space and to provide general medical care to the Papago Reservation. A van staffed by two Indian paramedics carried a variety of medical instruments including electrocardiograph and x-ray. The van was linked to the Public Health Service hospital and another hospital with specialists by a two-way microwave telemedicine and audio transmission. (Bashshur 1980).

Nebraska Medical Center

The Nebraska Psychiatric Institute was one of the first facilities in the country to have closed-circuit television in 1955. In 1964 a $480,000 grant from the National Institute for Mental Health allowed a two-way link between the psychiatric institute and Norfolk State Hospital, 112 miles away. The link was used for education, and for consultations between specialists and general practitioners. In 1971 the Nebraska Medical Center was linked with the Omaha Veterans Administration Hospital and VA facilities in two other towns. The psychiatric institute also experimented with group therapy (Benschoter, 1971).

Massachusetts General Hospital/Logan International Airport Medical Station

This station was established in 1967 to provide occupational health services to airport employees and to deliver emergency care and medical attention to travelers. Physicians at MGH provided medical care to patients at the airport using a two-way audiovisual microwave circuit. The Medical Station was staffed by nurses 24 hours/day, supplemented by in-person physician attendance during four hours of peak passenger use. Evaluation of diagnosis and treatment of the nurse-selected patients was made by participating personnel and independent physician observers. Analysis was also made of the accuracy of microwave transmission. Inspection, auscultation, and interpretation of roentgenograms and microscopic images were also performed. Necessary hands-on procedures were performed by the nurse-clinicians. (Murphy and Bird, 1974) and (Murphy et al, 1972).

Alaska ATS-6 Satellite Biomedical Demonstration

In 1971, 26 sites in Alaska were chosen by the National Library of Medicine's Lister Hill National Center for Biomedical Communication to see if reliable communication would improve village health care. It used ATS-1, the first in NASA's series of Applied Technology Satellites launched in 1966. This satellite was made available in 1971, and was still in use in 1975. The primary purpose was to investigate the use of satellite video consultation to improve the quality of rural health care in Alaska. Satellite ground stations permitting transmission and reception of black and white television were installed at four locations, and a receive-only television capability was installed at the Alaska Native Medical Center in Anchorage. All five sites had two-way audio. Two of the locations had no resident physician. Simultaneous two-way video capability was not available, although the one-way video could be switched for transmission from any site except Anchorage. This was an exploratory field trial, not a rigorous experiment. Evaluation of the project was done by the Institute for Communications Research at Stanford University. It was determined that the satellite system was workable, could be used effectively by health aides at the various locations, and could be used for practically any medical problems except emergency care (emergencies could not wait for scheduled transmission times). It was also determined that the "unique capabilities of the video transmission may play a critical role in 5-10% of the cases selected for video presentation. Otherwise, there was little measurable difference between the effect of video and audio consultation." (Foote et al, 1976) and (Foote, 1977).

Video Requirements for Remote Medical Diagnosis

In 1974 NASA contracted with SCI Systems of Houston to conduct a study to determine the minimal television system requirements for telediagnosis. The experiment was conducted with the help of a simulated telemedicine system. First, a high-quality videotape was made of actual medical exams conducted by a nurse under the direction of a physician watching on closed-circuit television. This was the baseline for the study. Next, these videotapes were electronically degraded to simulate television systems of less than broadcast quality. Finally, the baseline and degraded video recordings were shown (via a statistically randomized procedure) to a large number of physicians who attempted to reach a correct medical diagnosis and visually recognize key physical signs for each patient. Six television systems were investigated: two systems were compatible with transmission over full bandwidth television channel, while the other four allowed more detailed investigation of the frame rate and horizontal bandwidth required for each medical case. The following four results were found: 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 reduced below 10 frames/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 as a function of TV system type that would cause detriment to patients; 4) the supplementary study of radiographic film televised transmission (25 cases) showed that no diagnostic differences occurred between the TV evaluations and the direct film evaluations for TV resolutions above 200 lines if special optical lenses and scanning techniques were utilized. (Davis, 1974).

Memorial University of Newfoundland (MUN)

MUN was an early participant in the Canadian Space Program. The joint Canadian/U.S. Hermes satellite provided Canadians with an opportunity to use satellite technology in distance education and medical care. Since 1977, The Telemedicine Centre at MUN has worked toward developing interactive audio networks for educational programs and the transmission of medical data. Among the guidelines followed were: use the simplest and least expensive technology; be flexible; involve the users from the beginning of the project; seek administrative support in hospitals, clinics and other agencies; and include evaluation. The MUN Teleconferencing System, a province-wide network consisting of five dedicated circuits, began programming in 1977. There are installations in all provincial hospitals, community colleges, university campuses, high schools, town halls and education agencies. MUN has been active in international teleconferencing, and played a significant role in the School of Medicine at the Univ. of Nairobi, Kenya in the 1960-70s. In 1985 MUN became involved in the International Satellite Organization (Intelsat), linking to Nairobi and Kampala, which later was extended to six Caribbean countries. MUN has been a model for the judicious and low-cost use of telemedicine technology . They have proven that many times there is no need for the higher-end, higher-cost videoconferencing equipment. (House and Roberts, 1977).

The North-West Telemedicine Project

This project was set up in 1984 in Australia to pilot test a government satellite communications network (the Q-Network). The project goals were to provide health care to people in five remote towns south of the Gulf of Carpentaria. Two-thirds of these people were Aborigines or Torres Strait Islanders. The Q-Network consisted of 20 two-way earth-stations and 20 one-way (television-receivers only) earth stations. The hub of the network was the Mount Isa Base Hospital. All sites were supplied with a conference telephone, fax, and freeze-frame transceivers. Evaluation for the project showed that the technology did improve the health care of these remote residents. While it was impossible to calculate the operating costs of the telemedicine network separate from the other functions of the network, some healthcare costs were reduced. Fewer patients and specialists flew to and from these remote areas for routine consultations, and fewer patients were evacuated for emergency reasons. (Watson, 1989).

The NASA SpaceBridge to Armenia/Ufa

In 1989 NASA conducted the first international telemedicine program, Space Bridge to Armenia/Ufa. In December of 1988 a massive earthquake hit the Soviet Republic of Armenia. An offer was extended from the United States to the Soviet Union for medical consultation from the site of the disaster in Armenia to several medical centers in the U.S. Under the auspices of the U.S./U.S.S.R Joint Working Group on Space Biology, telemedicine consultations were conducted using one-way video, voice, and facsimile between a medical center in Yerevan, Armenia and four medical centers in the U.S. The program was extended to Ufa, Russia to facilitate burn victims after a terrible railway accident. This project demonstrated that medical consultation could be conducted over a satellite network crossing political, cultural, social, and economic borders. (Pers. Commun. Chuck Doarn, NASA, January 1996). The last ten years have seen a steady increase in the number of telemedicine projects throughout the U.S. and internationally. As more government funding became available in the early 90s, and as technology costs continue to decrease, telemedicine is possible for a wider spectrum of users. An article in Telemedicine Today, Spring 1995 (Allen and Allen 1995) lists the top twenty interactive television telemedicine sites in the U.S. by number of consultations for 1994. The Active Telemedicine Projects in the TIE lists over 130 sites internationally.

Descriptions of these and other early projects may be found in the Programs database or the Bibliographic database. A search using the text word of the project you are interested in, or a search using "telemedicine" as a keyword and "history" as a subcategory will bring up these citations. Many will have abstracts, and the full citations will allow you to obtain these documents from your local library or from the TIE's Document Delivery Service.

Nancy Brown M.L.S., was the Research Librarian for the Telemedicine Research Center, in Portland, Oregon. She was also the Project Manager for Telemedicine Information Exchange (TIE). She has demonstrated the TIE at national and international meetings and has published several articles and a book chapter on the provision of Web-based information on telemedicine, as well as a compilation of telemedicine literature for the Medical Library Association.