History and Development of Telemedicine

The concept of telemedicine is not new, if it is defined as ‘medicine at distance’. Health care professionals have been using telephones to communicate directly with patients and among themselves since the turn of the century. „When a patient calls his physician and is told to ‘take two aspirin’, this is an example of telemedicine; likewise, consulting with a colleague at a separate location is another example“ [Weinstein, 1989, p. 40]. If telemedi-cine is seen in the context of professional health care support for remote facilities, it already dates back to the 1920s, when radio was used to link public health physicians standing watch at shore stations in order to assist ships at sea that had medical emergencies

3 Anonymous, „Telepathology“, http://www.pathit.com/telepath/intro_1.html

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[Williams, 1995]. Several years later in 1956, at the University of Nebraska's department of psychiatry further telemedical operations had been introduced. Interactive audio communi-cation links had been evolved to link seven state hospitals to true telepsychiatric consulta-tions, assuming that the isolation of the therapist from the patients had almost no effect on group sessions. At that time television and telephone as the available technology had been used to deliver health care to remote locations in a specialty that fundamentally required motion observation and interaction [Wyman, 1994; Müller, 1996, p. 9]. The offered appli-cations had been very basically, but nevertheless they improved the health services for remote locations at that time.

In the early 1960's the National Aeronautics and Space Administration (NASA) developed telemedicine for biomedical monitoring and medical care for astronauts. Daily private medical video conferences between the crew surgeon and shuttle crew members allowed to monitor constantly the crew's condition on video. Data about EKG, heart rate, oxygen con-sumption, heat production, suit carbon dioxide levels, etc. were sent to NASA's Mission Control Center at the Johnson Space Center for examination [Ferguson, 1995/(1), p. 36]. In a next step, the medical findings with the space crew were adapted to other medical serv-ices, where physicians started to consult with their colleagues, view patients, access medi-cal records and detailed X-ray, CT, scan and other imagery [Kukkonen, 1995, p. 268].

Soon NASA started to offer and use its medical capabilities and competence internationally [Goldin, pp. 9-14, 1995; Merrell, 1995, pp. 15-18].

Beginning in 1975, NASA provided S-band television, education, and support for health, search and rescue efforts, as well as for agriculture purposes in India, Canada, France, the Pacific Basin and the former Soviet Union by using the ‘Applications Technology Satel-lite-6’. In 1989, NASA was able to provide telemedicine assistance and educational

opportunities for the medical community in the aftermath of earthquakes in Soviet Armenia with these health care applications [Ausseresses, 1995, p. 144; Llewellyn, 1995, p. 31;

Grams, 1995, pp. 165-170; Rao, 1995, pp. 297, 299]. NASA further offer medical help via telemedicine at another earthquake in Mexico, at mud slides in South America, at a gas explosion and railway accident in UFA, Russia, or in the aftermath of the political turmoil in Moscow in October 1993 [Blanton, 1995; Ferguson 1995/(1), p. 36].

In the 1970s some other US-telemedicine projects were supported by the former Depart-ment of Health, Education, and Welfare (now Health and Human Services), the National Science Foundation, the former Office of Economic Opportunity, and the National Aero-nautics and Space Administration. The objective of these projects was to improve health care delivery at an affordable price and with minimal disruption to the existing system of care. However most of these first generation telemedicine projects failed by poor planning and design of the system, limitations in technology and networks, poor standards, missing efficiency and quality, people's limited experience with them, missing incentives for physi-cians to use the offered equipment, and the absence of further subsidies [Bashshur, 1995, p.

84; Grigsby, 1995/(1), p. 19]. It is obvious that in the future it is important to avoid the repetition of the failures being made and to maximize the benefits which occur from new telemedicine systems.

Regarding the development of computing technology and the number of new telemedicine projects in the present, a major change can be recognized. This process can be traced down to the fact that computers became much faster and cheaper, and allow much better data processing, which is especially important for the exchange of images and sound. The pos-sibility of communication via satellite and the digital transfer of data via ISDN-lines

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improved the quality of information exchange, too. In addition, the Internet's⁴ superstruc-tured links among computer networks around the globe became available not just for researchers but also for a broad public, which further increased the development of tele-medicine applications.

The possibility of an easy access to information and of a faster communication by using the Internet lead to a change in the way of people’s thinking. Concepts for a closer cooperation between the health care providers were developed and the idea of telemedicine was more and more settled down in the mind of health care participants. Soon several federal agen-cies, e.g. in the USA the Health Care Financing Administration (HCFA), the Office of Rural Health Policy, or the US Department of Defense, begun with the introduction of telemedicine programs, often by using their own state’s resources to build state-of-the-art telemedicine systems [Perednia, 1995/(3)].

In the seventies, 15 telemedicine projects had been introduced, but non of them survived due to bad technical equipment and efficiency. At the end of the decade on one hand a lot of money had been spend for expensive satellite supported analogue systems and on the other hand a lot of effort was put in the development of digital systems for the transfer of radiology images. These technologies became improved over the eighties, especially in USA, Canada, Italy, Norway, Finland and Australia [Müller, 1996, p. 10]. However, the elementary growth of telemedicine projects came with the introduction of high resolution scanners and cameras, and digital technology, which advanced the quality of the exchanged images. In addition faster and cheaper computers with more capacity in relation with satel-lite connections and ISDN-lines assisted the development of telemedicine projects, too.

In 1993 there were ten to fifteen operational telemedicine programs in the United States (excluding teleradiology). In 1994 twenty-five to thirty of such programs were already actively involved in patient care. In 1995 additional forty to fifty systems were described in various stages of development [Grigsby, 1995/(1), p. 23]. At the end of 1996 the introduc-tion telemedicine applicaintroduc-tions already mushroomed [Perednia in Ziegler, 1995].

Telemedicine Networks

In the USA clinical telemedicine programs were set up in more than 40 states, and it is likely that many physicians will be directly or indirectly involved with clinical telemedicine by the year 2000. A similar development can be noticed in other industrialized countries all over the world. A lot of them are using or planning to use interactive video consultation, and it is estimated that at least 70 large electronic medical networks are currently under construction [Perednia, 1995/(3)]. This development is driven by the assumption that tele-medicine will improve both, access to certain types of specialty care and the overall quality of the care provided. Comprehensive tele-health networks were established that could serve many functions, including the provision of diagnostic services of pathologists and radiolo-gists at remote sites. Consequently the politics and economics of a managed care approach to health services delivery is now accompanied by telemedicine applications. Driven by the

4 The Internet is a ‘network of networks’, linking thousands of universities, business, and individuals around the world [Swett, 1995, p.

598]. It was originally started by the U.S. Defense Department to exchange information quickly among researchers. In 1980, there were 200 computers on it, mostly at academic institutions. By 1991 there were 727.000 computer linked, and in 1995 more like 2 millions of users were already using the Internet for data transfer [Clements, 1995; ADA, 1995]. Today more than 25 million people are using the Internet, with an estimated growth rate of 10% per month, mostly in the United States, Canada, and Europe are using the Internet. The development of the Internet was one of the driving forces for the development of telepathology applications, since it is often used as the

‘road’ for the data and image exchange.

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national effort to develop the electronic information highway⁵ ‘virtual medical networks’

will emerge, in which each participant is able to exchange data and images or request medical information from other participants [Matthies, 1998, p. 99].

Some examples of national and international telemedicine networks may support the described developments. One of the first networks in the USA were the Eastern Montana Telemedicine Network, the West Texas MEDNET, the SYNAPSE system of Nebraska, or the Trans-American Medical Referrals (TA-MRI) of Miami, Florida. In Europe the French Communicable Disease Network was set up, and in the Netherlands the Dutch Health Service began in 1985 [Parsons, 1992, p. 431]. In Germany the Bavarian Government has developed and integrated the network „BAYERN ONLINE⁶“ with several telemedicine pilot projects [Bär, 1998; pp. 55 ff.]. As soon as these telemedicine networks showed posi-tive results, some commercial providers expected to gain new markets and started to set up telemedical network services, too. For example, the German network provider Telecom followed the strategy to link up all 110 000 private doctors, 18 000 pharmacies, 3.000 hos-pitals, 1.500 radiologists, 300 laboratories, and health insurance companies to a huge data exchange network. The interest of Telecom is obvious, since a network providing company earns money each time their ‘wires are glowing’ [Koch, 1998]. Similar networks to connect health care providers are in development by ‘digital GmbH’ and ‘DGN Service GmbH’⁷ [Lindemann, 1998, pp. 31 ff.; Fahlbusch, 1998, pp. 37 ff.].

5 The electronic information highway is a term which is used to describe the network of digital signal pathways that is replacing other types of electronic communication

6 More details see: http://www.bayernonline.de

7 digital Equipment GmbH, Niederlassung Hamburg, Bereich Gesundheitswesen, Kieler Str. 103, 22769 Hamburg; DGN Service GmbH, Heerdter Lohweg 35, 40549 Düsseldorf;

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