Health care at a distance, or telehealth, has been practiced for decades using less sophisticated communications technologies than we currently associate with telehealth. The National Aeronautics and Space Agency (NASA) played an important role in the early development of telehealth. The remote monitoring of crew, spacecraft, and environmental health has been an integral part of NASA operations. Similarly, the United States (U.S.) military has been actively involved in telehealth research and applications as a means of bringing medical expertise to those injured in battle with less risk of injury to health care personnel. In the 1960s, the Nebraska Psychiatric Institute became one of the first facilities in the United States to develop a two-way link via microwave technology to provide education and consultations between specialists and general practitioners. NASA’s efforts at enhancing satellite communications provided the opportunity to pilot telehealth in more remote locations such as Alaska in the early 1970s (4). Satellite technology also facilitated the development of the Telemedicine Centre at Memorial University of Newfoundland (MUN) in 1977. Using simple, low-cost audio-conferencing technology, the MUN program linked hospitals, community colleges, university campuses, high schools, town halls, and education agencies throughout the province for educational programs and transmission of medical data (5). In the 1980s, there was a flurry of telehealth activity in North America as well as around the world, with new projects in Australia, New Zealand, the United Kingdom, France, and Norway. Early projects were largely focused on the technical feasibility of telehealth and often were developed around a single application and single clinical “champion.” Because of the high capital costs of these projects, they were also extremely dependent on grant funding. Many came to end when funding expired or the clinical champion moved on to other areas of research interest.

In the late 1980s and early 1990s, telehealth technology became more robust and less expensive, making telehealth a more viable alternative for health care service delivery. The past decade has seen rapid expansion of telehealth sites and applications. The Telemedicine Information Exchange currently lists more than 160 telehealth programs internationally (6). A better understanding of the human factors associated with telehealth success has allowed improved planning, deployment, and management of telehealth programs. However, the majority of telehealth activity worldwide still remains grant funded or hospital supported with consequent vulnerability to annual funding cycles. Today’s projects focus on assessing sustainability. It is becoming apparent that telehealth solutions have to be integrated within the traditional healthcare system to be sustainable. With careful attention to cost-effectiveness and quality services, telehealth is destined to become a standard component of health service delivery.

There are two main types of communications in telehealth. Asynchronous, or store-and-forward, involves the capture and later transmission of data or images for dissemination or interpretation. Teleradiology, the sending of radiographs, computed tomography (CT) scans, or other digital scans, is the most common store-and-forward application of telehealth in use today, and is often integrated into larger picture archiving and communication systems (PACS). Pathology and dermatology are other specialties that typically use store-and-forward technology for remote diagnosis. Synchronous, or real time, implies the transmission of information instantly and is primarily associated with the use of videoconferencing to support face-to-face consultation between a patient in one location and a provider in another. Almost all medical specialties have found an application for the use of videoconferencing technology and with the addition of appropriate peripheral medical devices, such as stethoscopes, otoscopes, and examination cameras, a comprehensive examination can be conducted remotely. Some telehealth applications use a combination of store-and-forward and videoconferencing technologies to allow both the review of still images and interactive consultation with peers and patients. In all cases, the clinical requirements must drive the technical solution. The price and performance of telehealth technology has improved dramatically over recent years and in many cases, off-the-shelf hardware now provides the necessary functionality at much lower cost than systems specifically designed for telehealth. All equipment should comply with accepted technical standards to ensure quality, flexibility, and compatibility between systems.

In addition to end points, telehealth requires a telecommunications network to facilitate the exchange of information. Although telecommunications infrastructure in urban settings has developed remarkably over the past decade, the primary focus of telehealth has been to serve rural and remote populations where connectivity continues to be a considerable challenge. Requirements for bandwidth (communication channel capacity) vary depending on the application. The higher the bandwidth, the more information can be sent in a measured time period. POTS (plain old telephone system) may be appropriate for transmitting low volumes of nonurgent X-ray images between two destinations for a teleradiology service. Larger volumes of images or a need for urgent interpretation would require a higher bandwidth solution. Similarly, higher bandwidth is required to support quality interactive videoconferencing for clinical applications. Although urban sites may be able to choose between a number of suitable solutions such as ISDN (Integrated Services Digital Network), DSL (digital subscriber lines), or high-speed cable, geographically remote communities may only have access to the necessary bandwidth through satellite or other high-cost wireless solutions. Telecommunications costs for rural education and health care networks in the United States
are heavily subsidized through the Universal Service Fund, a fund generated through contributions from telecommunications companies. In Canada, the federal government continues to support the deployment of broadband to many rural, northern, and isolated communities through initiatives such as the Broadband for Rural and Northern Development and the National Satellite Initiatives. In some cases, sharing infrastructure costs with other sectors, such as education, justice, or industry, may improve the viability of telehealth in a small, remote community. The availability of low-cost telecommunications solutions is critical to the expansion and sustainability of telehealth in many of the neediest areas, including developing countries.

The advent of IP (Internet Protocol) videoconferencing is impacting the design and operations of telehealth networks everywhere. Traditional copper-based networks required dedicated connections so telehealth was often limited to a single site or “suite” within a health care facility. With line installation, monthly line rentals, and long-distance charges associated with each session, telecommunications costs often accounted for as much as 15% to 25% of total telehealth costs (2). With advances in digital video compression, composite audio and video signals can now be carried over typical IP network circuits either on a LAN (local area network) within a health center, across a broader WAN (wide area network), or private network. With nearly ubiquitous access, telehealth can be available on every physician’s desktop, at the patient bedside, and throughout every hospital and primary health care facility—providing access wherever and whenever healthcare services are delivered. Although there is a fixed cost associated with an IP network, there is little or no additional cost associated with actual use. As a result, the actual per session cost for telehealth declines with increasing utilization. In addition to long-term cost savings, the convergence of voice, video, and data onto a single network will ultimately allow telehealth to interface with other health information, including PACS and electronic health records. Issues surrounding network quality, bandwidth requirements, and security continue to be refined but telehealth over IP networks is becoming an attractive option for many programs.

Choosing the right technology for telehealth is complicated in the face of declining equipment and telecommunications costs, inevitable capital depreciation, and rapid technical innovation. Clinical users of the equipment must be involved in purchasing decisions, as clinical and operational requirements will directly determine technical specifications; such involvement will also foster acceptance by the users. In general, a telehealth program should purchase the highest specification equipment available to meet user expectations at the lowest possible cost. Similarly, decisions regarding telecommunications infrastructure should be based on file size, immediacy, and volume of usage balanced by fiscal realities and whether or not funding or revenue streams can offset the associated capital and operating costs. Telehealth programs must also plan for equip- ment and network maintenance, support, and upgrading. Vendor relationships are crucial to the success of telehealth programs. In addition to price and technical specifications, appropriate service level agreements should be instituted to ensure high-quality, reliable, and state-of-the art telehealth operations.

The clinician’s duty of care and clinical case responsibility in the telehealth setting adhere to the same principles found in face-to-face encounters. The ethical and quality standards of practice governing clinicians are not altered by the use of telehealth. Proper documentation, including written consent when applicable, should be maintained for all telehealth encounters. The advantage of telehealth is that it permits health care to be delivered anywhere, with no recognition of borders; however, this inherent distinction from traditional in-person care also raises new issues surrounding regulations and policy related to health care practice (7) (see also Chapter 8).

Licensing of health professionals is typically a jurisdictional responsibility. If physicians and patients are located in different provinces or states, it is important to determine whether the locus of accountability will be the patient site or provider site. If the service is deemed to occur at the patient site, the physician may be required to obtain appropriate licensing and credentialing as if practicing in person at that site. A number of policy options to overcome these licensing issues have been proposed including “universal” licensure, a special-purpose license for telehealth, and mutual agreements, but there is still a significant need to harmonize standards to support cross-jurisdictional telehealth activities (7).

The absence of policies regarding physician reimbursement for telehealth consultations has historically been a significant barrier to the widespread adoption of telehealth. Early telehealth initiatives were often pilot projects or clinical trials located at hospitals or universities, and physician reimbursement was not a major concern as most physicians treated their participation as a research initiative or were compensated through alternative payment arrangements (salary or capitation). However, as more practitioners incorporate telehealth into routine practice, compensation has become a pivotal issue. Although many insurance plans still require patients to be seen in person by a physician in order to bill, others have developed specific fee codes for telehealth services; however, these often have significant limitations related to geographic location, specific facilities, number and types of services, and professional category. Canada’s publicly administered system is also inconsistent, with some provinces allowing direct reimbursement for telehealth services and others not. There is slow progress toward expanding telehealth reimbursement, but health care organizations should determine the policies in their jurisdiction regarding payment prior to implementing telehealth services.

All physicians engaging in telehealth consultations should verify with their insurance providers that telehealth is included within their malpractice insurance policies. To date, there has been very little litigation associated with telehealth, but there are some specific issues to be considered. Not all consultations are appropriate for telehealth. Providers must use their best clinical judgment to determine whether services can be safely and effectively provided by telehealth. In addition, a back-up process must be established to ensure that patients receive appropriate and timely care in the event of technical failure. Practitioners may require specialized training and expertise for telehealth and demonstrate acceptable technologic competence prior to providing telehealth services. Specific clinical protocols and guidelines may be necessary to ensure consistent, high-quality telehealth applications in some settings. At all times, telehealth services must adhere to basic quality assurance and professional standards of care (7).

Privacy of personal information related to the use of ICTs in health has been a developing issue over the last decade. Concerns over the use of technology to track everything from health care services to spending habits have spurred the development of policies to regulate the protection of individual privacy. Standards for maintaining the privacy of health information in a telehealth context do not differ from those in a face-to-face encounter; however, the introduction of technology adds privacy and security considerations (7). In addition to maintaining privacy through more traditional measures such as a private physical environment and organizational processes, delivery of telehealth requires attention to security of data during transmission and, in some cases, storage. Ensuring security in an ever-changing technologic environment requires a proactive and evolving approach (8). Ensuring confidentiality in a telehealth setting can be more challenging given the potential risks for interception, potential for a permanent video record, and additional people involved in each care session. This is compounded by the variety of equipment and complexity of transmitting images between two settings (9). As telehealth moves from single-room standalone applications to integration within direct patient care areas, such as the neonatal intensive care unit (NICU), the complexity of ensuring privacy increases.

The body of scientific literature related to the application of telehealth has been growing steadily over the last 30 years. A search for the keyword telemedicine on PubMed found only 24 references for the decade 1970 to 1979; this increased to 2,903 for 2000 to 2003. Several recent literature reviews have examined the current state of research knowledge related to telehealth, and most have determined that while telehealth shows promise, research and evaluation of telehealth is still maturing with few scientifically conclusive studies completed to date. The reviews completed to date have identified small numbers of studies which meet criteria for inclusion ranging from 7 for those requiring a randomized controlled trial to 50 when inclusion criteria were broadened to include any controlled design (10,11). The strongest studies examining clinical impacts have demonstrated support for telehomecare initiatives, management of chronic illness, psychiatry, dermatology, cardiology, teleradiology, transmission of digital images for neurosurgery consultation, and echocardiographic image transmission (10,11,12,13,14).