Locations of Telemedicine Consultations

During the last decades the increasing availability of communication infrastructures created new possibilities for telemedical applications. Especially the developments and research findings of industrial applications provided a vital input for the design of telemedical applications in various disciplines and locations of medicine. One sector which pushed telemedicine applications was already mentioned with NASA's use of telemedicine for building a space-bridge to space shuttles.

4.1.1 Telemedicine at Prisons

One important issue for using telemedicine has been the state's costs and risk in providing health care in prisons. For example, California alone spends US-$ 380 million per year on prison health care. However, to treat a prisoner in an inadequate way can lead to high com-pensations when successfully brought to court. In 1990, a prison inmate won a case against the state of Florida with US-$ 1-million compensation. Therefore, Florida began to intro-duce telemedicine at prisons on a pilot basis [Blanton, 1995].

Regarding the fact that on one hand transporting a dangerous felon to an outside specialist includes a security risk and on the other hand bringing the specialist to the prison would also cause problems, telemedicine seems to be a good solution to serve prisons with a broad range of health care services. The University of Texas Medical Center, Galveston, Texas for example has installed a link with a local prison that allows physicians to ‘see’

about 50 patients per week. Compared to the costs and risk of transporting 50 prisoners to a medical facility with the cost of video-conferencing such trials proved to be reasonable [Moynihan, 1995]. Another connection was created between the Texas Tech University Health Sciences Center in Lubbock, Texas, and prison hospitals at the surroundings under the supervision of the Texas Department of Criminal Justice [Shoor, 1994]. Following that trace, North Carolina's largest prison (Central Prison in Raleigh) contracted the East Carolina University School of Medicine for providing medical consultations with the prison. To give a diagnoses about the condition of the patient, the medical expert at the University is using a video console. He interviews the patient while directing the prison nurse where to point the camera. Finally he will give qualified advise for the course of further treatment [Blanton, 1995].

4.1.2 Telemedicine on Ships

Another area for telemedicine utilization is at ships, where injured mariners may find that the nearest medical facility is hundreds of miles and several days away. As a result, quali-fied medical care is not available and accidental death rate on ships are almost 30 times higher than by injured land-based workers due to not appropriate and to late emergency health care interactions. Similar to the situation at prisons, the vessel owner is responsible for the health of his crew members. If an individual is seriously ill or injured, the owner is

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in a dilemma. He either can be very carefully and redirecting his ship to a harbor, which can cost for example by an oil tanker or a fishing boat during the high season hundred thousand dollars lost income and expenses, or he has to arrange an expensive helicopter evacuation for avoiding the risk of being sued for inadequate medical care. That is why 200 different organizations world-wide give tele-medical assistance to ships without a doctor on board.

In 1990, the MHS (Maritime Health Service), Seattle, initiated a health service in the North Pacific that enables medical officers on board of ships to communicate directly with a physician. In the beginnings, the Coast Guard was called via a single-side band radio for medical advise in an emergency case. However due to the lack of visual communication, the land-based physician could not be thorough and the patient had to rely on the experi-ence and interpretation of the on-board medical staff.

As technology advanced, MHS enabled physicians to interactively examine patients on ships by using personal computers equipped with digitizing boards, high-resolution moni-tors, and data links over standard telephone lines and satellite communication systems.

MedNet (Medical Consolation Network), a video communication application based on a video-conferencing system was introduced, which combined a small video camera with video digitizing, compression board and software. This way, appropriate and immediate assistance to medical situations could be offered for saving money and life. In addition, a central database contained information about the on-board personnel's level of medical expertise and about the inventory of medical supply on the spot, which enabled the con-sulting physician to access the available resources on board for treatment [Jarris, 1994].

Another very experienced organization is the CIRM (Foundation Centro Internazionale Radio Medico), located in Rome (Italy). Starting in 1935 with simple Morse code commu-nication, nowadays highly developed continuous (24 hours a day) telemedicine assistance is offered. CIRM employs 10 physicians, who can contact other specialists if necessary via net [Amenta, 1998, pp. 44-45]. A further European project is ‘Moebius’, which evaluates the use of satellite and ISDN connections to give medical support to a polar expedition ship [Detken, 1996, p. 102]. Even though telemedicine assistance cannot guarantee the same medical quality as this would be the case ashore, it essentially will improve the health care on ships.

4.1.3 Telemedicine at Airports

The first telemedical application in the flight business was tested at an airport. In 1968, an interactive television connection linked Boston’s Logan Airport to Massachusetts General Hospital. This way emergency patients could be seen by doctors by means of video cam-eras [Blanton, 1995; O’Brien, 1998].

In general, the situation of airline companies is similar to that of ship owners, because both are dealing with the transportation of passengers or goods. The affordability of world-wide travel and the increasing tendency for families to be widespread globally, coupled with the upsurge in multinational commerce and associated business travel lead to the situation that many passengers are not in the peak of health or physical fitness due to their age or medical condition when they fly. In short, more older and sick people are travelling by air. In addi-tion, the amount of air-travelling people increased, too.

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For example, each year British Airways (BA) transports over 30 million passengers to over 165 destinations in more than 75 countries. However, it comes as a big surprise that the number of in-flight medical incidents on British Airways requiring professional assistance is as few as 1 per 55.000 carried passengers (in total 600) in 1994. Lufthansa reported about 37 so called ‘unscheduled safety landings’ due to dangerous emergency cases. 50 % of them occurred due to heart problems in 1998. Although these numbers do not seem to be very high, the general public and the media are hungry for stories about medical dramas.

That is why the on-board life-saving operation, using improvised surgical equipment on a flight from Hong Kong, received world-wide publicity and led to renewed media interest in the provision of in-flight medical emergency and first-aid equipment. Such reactions force the highly competing aircraft companies to take action. BA answered with a 24-hours tele-phone advisory service. An aircraft captain is able to communicate via a high-frequency radio link with a BA-doctor ‘on call’ to get advise for the treatment of sick passengers. All crew members are trained and regularly reviewed to a very high standard in first aid and intermediate life support. Aircrafts carry comprehensive medical and first-aid equipment, like EKGs or electric shock devices. Doing so, telemedicine services are examined for ex-ploring ways in which the efficiency of the delivery of in-flight medical assistance can be improved [Bagshaw, 1996, p. 36; Stahr, 1998].

4.1.4 Telemedicine on Islands

One example for the use of telemedicine on islands is the project of the CATAI Associa-tion (Catedra Anatomia Patologica) at the University of La Laguna, Faculty of Medicine, in Tenerife, Canary Islands, Spain. CATAI is testing regular video-consultations in cytology, pathology, radiology and mammography [Ferrer-Roca, 1995/(2), pp. 151-163; Ferrer-Roca 1996, pp. 13-23]. Since the experts in Tenerife tested their carried out examinations with regard to diagnosis accuracy in pathology, this project will be described in more details at a later chapter, too (chapter: 4.1.3.6).

Another example is a telemedicine project in Portugal. Telemedicine services like telepathology, teledermatology, telecardiology, tele ORL (endoscopy), telepsychiatry, telematernal and foetal medicine are provided to the Azores Islands. These islands are approximately 760 sea miles apart from Lisbon. They have a total area of 2.335 km² and 250.000 inhabitants. The telemedicine project is intended to create a network between nine Azores Islands. If necessary, all tele-physicians are able to tele-consult with the medical experts of the major University Centers of Lisbon. In 1992 telepathology as frozen section services had been introduced between Lisbon and the Hospitals of Faro, Beja, and Castelo Branco [Goncalves, 1995/(2), pp. 285-287].

4.1.5 Disaster and Emergency Medicine, Telemedicine for Special Events

Telemedicine can play a fundamental part in disaster medicine. It’s necessary to assess the disaster damage, to quickly define the overall effects of the disaster's impact, to specify health care needs and available local resources, and to collect other valuable data as fast as possible to start with an efficient emergency interaction [Noji, 1995, p. 172; Young, 1995, pp. 175 ff.].

However these carefully designed programs and efficient tele-applications in predisaster, acute, and postdisaster rehabilitation are necessary to extend the coordination of routine and preventive health services. Since disaster medicine cannot exist in a vacuum but must

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be integrated with other disciplines and the participants involved, the ongoing medical needs and requirements have to be critically estimated and balanced with the preventive interactions and emergency care plans [Houtchens, 1990⁸]. Designing disaster and emer-gency programs and systems is not easy, because of its high complexity. Many activities have to be regarded precisely. For example problems have to be solved such as the record-ing of available material resources, the consideration of cultural, social, economical, politi-cal and organizational characteristics, or problems caused by incompatible and not stan-dardized technological systems. The capabilities and skill demands of individuals involved have to be determined, too. This allows to develop efficient education and training pro-grams for all involved emergency health practitioners [Llewellyn, 1995/(1), pp. 30-31].

All the mentioned problems above become most obvious in emergency situations in less developed countries. There telemedicine is either non-existent or only rudimentary, as are capabilities to respond to large scale emergencies and disaster situations.

"Less developed countries often have neither the telecommunications infrastructure, nor the medical resources necessary to effectively employ telemedicine as part of their national disaster response strategy." [Ferguson, 1995/(2), p. 121]

For offering a satisfying disaster telemedicine service, the requirements to be met are similar to other telemedical health supports, but perhaps more difficult to accomplish. In 1992, to meet the challenges posed by catastrophic disasters, the US-government devel-oped, under the leadership of the Federal Emergency Management Agency (FEMA), a unified all-hazards response and recovery plan - the Federal Response Plan. The aim of this plan is to coordinate and integrate local, state and federal emergency responders to a network, which allows to answer emergency needs by bundle up all available resources in an efficient way. This was the foundation of the FEMA telemedicine emergency network [Yound, 1995].

Another project, which puts special effort in the development of a telemedicine emergency infrastructure, is the G7 Global Healthcare Applications Project (G.H.A.P.). A group of the seven most industrialized nations in the world (G7) came together for establishing a trans-national and multilingual health emergency system for the improvement of promptness and effectiveness of interventions and service management through telematic interconnections of the emergency points of care and of all actors and services involved⁹. Other EC-project, which are focus on emergency medical services, are GETS (Global Emergency Telemedi-cine Services), and MERMAID (Medical Emergency Aid through Telematics). Both offer a 24-hours multilingual and multidisciplinary telemedicine surveillance and emergency service around the world. And as a last example, the EC-project HECTOR (Health Emer-gency management and Coordination through Telematics Operational Resources) has the goal to fill the actual gap of an integrated and interoperable emergency network, which is able to react promptly and efficiently to any emergency situation¹⁰ [Detken, 1997, p. 72].

Telemedicine systems could not only be appropriate at emergency situations, but also at situations caused by specific events. For example, a teleradiology and two-way video link connected the medical facility of the Yale-New Haven Hospital emergency department in

8 http://www.it.hq.nasa.gov/~kmorgan/telemed_blue/references/disaster.html 9 More details see: http://www.ispo.cec.be/g7/projects/g7rep596.html

10 More details see: http://www2.echo.lu/telematics/health/gets.html / mermaid.html / hector.html

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Connecticut, USA, with the Yale Field House during the ‘Olympic World Games’ [Swett, 1995, p. 599]. Such mobile telemedical systems seem to be appropriate for many other events, too, which demand health care support just for a certain period of time.

4.1.6 Telemedicine for Developing Countries

Over 75% of the world’s population is located at third-world countries. This population is suffering from serious shortages of resources and capital, lack of trained manpower, large scale illiteracy, and an explosive growth in population with an inadequate support of health care services. Furthermore, natural disasters have not rarely contributed to the misery of these countries. The idea of establishing a global telemedicine operational system came up.

Therefore a cross-cultural understanding has to be developed between the global partners, no matter whether a national mobile telemedicine service is established or a cooperative link to an expert at a medical center in America or Europe is created. Telemedical services have to be made affordable to the developing countries, and the tendency to apply a rich man’s solution to the poor man’s problem should be avoided. It is necessary to develop universal telemedical solutions, which are appropriate, adequate, and cost-effective for the medical demands of participants [Rao, 1995, p. 300]. In addition a solution for the coordi-nation (who will coordinate which activities? - set up of responsibilities) and reimburse-ment (who will pay for which services?) for such third-world telemedicine services has to be found. In most developing countries the user does not pay for the telemedicine service so that in most countries telemedicine services have to be subsidized by the government or another party [Wright, 1997]. For this reason in 1994 the International Telecommunication Union established a study group, the European Telemedicine Collaboration Group, to in-vestigate telemedicine feasibility, to quantify the benefits, and to create recommendations and guidelines with particular reference to developing countries [Wootton, 1997/(2), pp.

23-26].

One special project which aims to promote the development of regional networks between universities of the developing countries and their European counterparts is the FOMTA project (Fundamentals of Modern Telemedicine in Africa). Using broadband technology, telediagnosis, teleconsultation, and other telemedicine services will be practiced to elimi-nate time-delaying due to the lack of infrastructures [Adeyinka, 1997]. Besides the activi-ties of FOMTA many other projects between first and third world countries are in the process of introduction.