“Defined simply, telehealth and telemedicine involve the use of electronic communication technology as a method of delivering both health education and medical care” (CTTC, 2003, para. 1).

Other definitions include a broader range, such as using “telecommunications and information technologies to share information, and to provide clinical care, education, public health, and administrative services at a distance” (OAT, 2006, para. 1).

“Dissolving barriers such as distance, time, geography, weather, and economics, tele-health and tele-medicine (TH/TM) applications are designed to bring services to the clients rather than the traditional formula of clients to services” (CTTC, para. 1). This is an important aspect of telehealth (TH) since “the common goal of any tele-application is to increase access and ease of care, especially for under-served and isolated populations” (CTTC, para. 1).

Craig and Patterson (2005) suggest that most of the advances in telemedicine (TM) have taken place in the last 20 to 30 years. However, they
also point out that bonfires were used in the Middle Ages to transmit information about bubonic plague from one village to neighboring villages.

Postal services and telegraphy, developed in the mid-19th century, and then the telephone, all aided in the transmission of medical information across a distance.

The earliest known transmission of stethoscope sounds by telephone is thought to be 1910.

Radio communications (first by Morse code, followed by voice) near the end of the 19^th century were used for medical support for seamen. They describe the development of the Seaman’s Church Institute of New York (1920) and the International Radio Medical Center (1938) as two early organizations providing medical consultations to passengers and crews of ships. These services were later expanded to air travel.

Venable (2005) describes the connection of seven state hospitals in four states via a closed-circuit telephone system in the 1950s. This program was supported by the National Institute of Mental Health. Craig and Patterson (2005) suggest that TM developed further because of organizations with special interests (e.g., NASA).

In the 1950s, the television was first used to help medical personnel monitor patients remotely in clinical situations. In 1964, the first interactive, closed-circuit television system was established.

TM developed further as remote rural locations were connected by interactive video with health care providers.

More recent developments include the move from analog to digital transmissions, falling costs of computing, and the explosion of mobile phones and satellite communications.

According to ATA (2005), there are several delivery mechanisms:

British Columbia (2001), describes a TH system as being divided into three distinct elements that integrate the services between remote and main sites:

Practicing

Reimbursement schema

Protection from fraud and abuse

Informedix (2006) has a Med-eMonitor System that could be the medication compliance and adherence solution for disease management (DM) programs as well as drug trials. This system integrates a “portable patient-interactive monitoring device, hardware, software, and networked communications system to enable CATV programs, pharmaceutical and biotechnology companies, and medical researchers to efficiently monitor and manage patients’ medication compliance, protocol adherence, clinical response, and drug safety” (Informedix, para. 7). According to Informedix, this system “improved mean medication adherence rates to over 92% compared to a baseline medication adherence rate of 40%” (para. 2). They also found that it decreased “Hemoglobin A1c (HbA1c) levels by an average of 18.5% in a 3-month period (p<.002), in a medication management program involving Type II Diabetes patients in Montana” (para. 2). This will have a tremendous effect on health care initiatives and costs since “a reduction in HbA1c is associated with improved lifespan and morbidity and a significant reduction in health care costs in the treatment of diabetes patients” (para. 2).

Shea et al. (2006) compared diabetes control outcomes in a group who received CM and monitoring via a home telemedicine unit (HTU) with a control group who received usual care by their primary physician. The HTU provided videoconferencing, remote data upload and monitoring of blood glucose and blood pressure; a Web portal for data storage and access by both patients and clinicians, and messaging with nurse case managers; and access to an educational Website. They report positive and statistically significant differences in clinical outcomes (hemoglobin A1c, blood pressure, and LDL cholesterol) between the TM and usual care groups at one year follow up.

Conversely, Farmer et al. (2005) were unable to demonstrate statistically significant differences in hemoglobin A1c between their TH and usual care groups of young adults with Type 1 diabetes. However, they report that the TM system was equally effective in monitoring patients and that patients valued and accepted the system.

TM can be used to facilitate home monitoring of chronic diseases such as diabetes, hypertension, renal disease, and dialysis; to aid in the provision of home nursing services; and to facilitate home births (Hjelm, 2005).

A remote continuous real-time wireless monitoring system for cardiology was tested on ten healthy volunteers. Researchers were able to demonstrate high reliability and efficacy of the system using Bluetooth technology, telemetry, and a mobile phone. Volunteers were also asked to keep a diary of activities during the testing period. Some interference with data collection was noted during peak network times and when the subject was in a moving vehicle (Jasemian and Arendt-Nielsen, 2005).

Venable (2005) suggests that TM may help prevent two of the most common medical errors—inaccurate diagnosis and failure to prevent injury through access to specialty consultation.

The efficacy of using store-and-forward (SAF) technology in addition to live videoconferencing with patients who needed dermatology diagnostic services was investigated by Baba, Seçkin, and Kapdagli (2005). They concluded that the combination of SAF and videoconferencing provided the most accurate diagnosis. In addition, 85% of the subjects were satisfied with the TM dermatology service and would participate in teledermatology in the future. Of them, 82% would want future consultations to also include the videoconferencing with the dermatologist.

One of the most well-known uses of TM is for off-hour diagnostic radiology services. Linking radiologists who reside in various time zones allows for prompt diagnosis and treatment of patients (Schindler, 2005).

Tele-ophthalmology services to Africa via a dedicated Internet site in a London-based eye hospital are described by Kumar et al. (2005). The network primarily provides clinical consultations for diagnosis and treatment, but has also been used for surgical telemonitoring (real time) and education of physicians in remote countries.

Rao (2005) describes a successful use of TM in India where there are inadequate numbers of hospital beds for the large population, few physicians practicing in rural areas where two-thirds of the population resides, and high maternal/child mortality rates. The initial project, developed in conjunction with the space program, focused on transmission of medical images, ECGs, and patient history to a specialist who suggests treatment to the patient. It has expanded to include assistance to remote physicians for complicated medical procedures, mobile TM in ambulances for better prehospital care, ophthalmology, and disease prevention and health promotion.

Daly et al. (2005) report on the efficacy of using TH to satisfy the physician visit rules for nursing home residents. They compared the data collected by a remote operator using a mobile electronic system (computer, monitor, live video and audio, stethoscope, otoscope, EKG, dermascope, and dentalscope) with data obtained in immediate live visits by the physician. Results indicated a high correlation between live and remote assessments of nursing home residents.
Reimbursement for remote visits remains an issue and will be discussed under barriers.

TM can also be effective in monitoring the health of prison populations, in reporting and tracking infectious diseases, and in supporting advanced practice nurses as they deliver care in rural areas. Nurse practitioners have performed advanced colorectal screenings while consulting with a physician specialist and provided chronic disease care management in cases of congestive heart failure, diabetes, and asthma. (Reed, 2005).

Case managers in home-based TH

Telephonic case management (TCM)

Shea et al. (2005) safeguarded patient data for their HTUs by use of a firewalled subnet for dedicated servers, encryption of all Internet data transfers, secure socket layer encryption for Web access, and authentication protocols for clinician access.

Venable (2005) advocates for the development of national standards for the security and transmission of private patient information during a TH service.

Equality of access to computers and the Internet and the acquisition of skills necessary to become proficient may be barriers to the implementation of TH.

Shea et al. (2005) did not require the subjects receiving home TH to be computer literate. Grant restrictions required that participants reside in medically underserved areas. They report that despite low education levels and little or no computer savvy, most subjects were able to learn the skills necessary to remain in the study. Resistance to the technology was reported among some of the primary care physicians who insisted on the use of telephone and fax communications with nurse case managers rather than web-based messaging.

Shea et al. (2005) report the cost of the home TM unit used in their study as $3,425. Additional costs include training, maintenance, and support for both the provider and the recipient. At present, most insurers are resistant to reimbursement for TM services because the clinical effectiveness has not been empirically demonstrated to their satisfaction.