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100 years of telemedicine
Although hard to believe, this year we celebrate the 100th anniversary of telemedicine. The term telemedicine was coined in the 1970s by the American Thomas Bird and, literally translated, means “healing at a distance” (from Latin “medicus” and Greek “tele”). However, the origins of this evolving technology date back to the early 20th century, when Willem Einthoven, a Dutch physiologist, developed the first electrocardiograph in his laboratory in Leiden. With the use of a string galvanometer and telephone wires, he recorded the electrical cardiac signals of patients in a hospital 1½ km away. He stated: “Where there is a link, actual and figurative, between laboratory and hospital, and collaboration between physiologist and clinician, each remaining master in his territory, there one may fruitfully utilize these new electrical methods of research”. Einthoven’s electrocardiograph was very large but over the years was transformed into a mobile or even portable monitoring device. Nevertheless, he can be regarded as the first clinician scientist to develop and systematically apply a technique that is very similar to telemedicine in the modern sense. The results of his experiments were published in 1906.1 During the 1920s, Norwegian doctors provided advice for sick ship crew members at sea via radio link. In 1967, Bird and colleagues established an audiovisual microwave circuit between the Massachusetts General Hospital in Boston, USA, and the nearby Logan Airport. They conducted and evaluated >1000 medical consultations for airport employees and travellers who were ill.2 Since then, the number of scientific studies relating to telehealth has steadily increased, and many countries have launched their own electronic health (e-health) programmes, which combine medical informatics, public health and business. Telemedicine constitutes a small part of e-health and is particularly suitable for large geographical areas with a sparse, underserved population. Examples are Canada, India and Norway.3–5
The European Commission’s definition of telemedicine is “rapid access to shared and remote medical expertise by means of telecommunication and information technologies, no matter where the patient or relevant information is located”. Two complementary methods of transmitting data, images and sound can be differentiated: (1) the live technique, where the health professional has direct video contact with the patient; and (2) the store and forward technique, where information—for instance, an x ray—is acquired in one location and reviewed in another at a later stage. The Integrated Digital Service Network (IDSN) and broadband or global satellite networks, such as Intelsat and Healthnet, are used for high-speed data transmission. Most current definitions of telemedicine exclude medical advice given only via a telephone.6 Telepaediatrics, a new branch of telemedicine, enables doctors and patients to access expert knowledge and assessments, which otherwise could be achieved only with great difficulty, and which may not be financially feasible. This new technology can also assist paediatricians to fulfil their role as leaders of multidisciplinary teams through improved communication, education and teaching.7 During a typical telemedicine consultation, a paediatric nurse practitioner or technician carries out an examination or investigation at a distant healthcare facility, while a general paediatrician or paediatric subspecialist in a tertiary care centre monitors and evaluates the clinical findings or test results on a television screen.
Over the past few years, telemedicine has been increasingly used for the benefit of sick and disabled children, mainly in feasibility studies funded by research grants. Robinson et al8 set up two telemedicine clinics in rural areas of Texas, which were linked to the University of Texas Medical Branch, Texas, USA. A paediatric nurse conducted developmental assessments on 269 children with special needs, which were transmitted online to the evaluating team consisting of a neurodevelopmental paediatrician, various therapists, a psychologist and a dietitian. In a questionnaire survey, parents rated the service provided over a distance as satisfactory. The main benefits were reduced time off work and savings in travel costs.8 Several studies have investigated the possibility of performing echocardiography by means of telecommunication technology in children, including neonates. They found that diagnoses were reached faster and with the same accuracy as the face-to-face encounter. Telepaediatric cardiology did not, however, lead to an overall cost reduction.9,10 Teleradiology programmes have been in use since the 1970s, and today, many hospitals have established the picture archiving and communication system (PACS), which allows access to paediatric x rays, computed tomography, magnetic resonance imaging and ultrasound scans. More recently, concerns have been raised regarding the disadvantages of distancing the radiologist from the patient.11,12 Only a few research projects associated with telemedicine have been conducted in specialties related to paediatrics which are visually intensive—for instance, dermatology, clinical genetics and pathology.6 Child and adolescent psychiatry and child protection are highly sensitive areas where telemedicine may enable children to express their feelings more openly and to report disturbing experiences to healthcare workers, but there is little research evidence available in these areas.13,14 In the UK, a child or a young person is able to give evidence in court via a televideo link. This means the child does not need to be present in the same room as the defendant, which can be very stressful.
Setting up a new high-quality telemedicine link is not inexpensive and therefore requires careful planning and repeated auditing. Apart from television monitors with integrated video and hand-held cameras, special stethoscopes, auroscopes, ophthalmoscopes and spirometers are available. However, examples of low-cost teleradiology projects can be found in developing countries which use digital images sent via e-mail or personal computers equipped with radiological film digitisers and appropriate software, and existing satellite links.15 In their systematic review, Jennett et al16 examined 82 research papers relating to paediatric telehealth. In all, 24 (30%) of these articles provided reasonable evidence for the socio-economic benefits of telemedicine, as defined by accessibility of services, decreased costs, client satisfaction and quality of care.16 This review shows that at present we cannot determine whether the advantages of telemedicine outweigh its disadvantages, some of which are outlined below.
Teleradiology can be regarded as a paradigm for other applications of telemedicine owing to its long history and the large number of studies carried out in this discipline.11,12,15,17–19 Teleradiology allows the transmission of radiological images from remote hospitals to expert radiologists in tertiary centres for evaluation and advice. This service can be delivered 24 h a day and reduces the need for transport of patients who can be treated locally. Interdisciplinary case conferences can be held between radiologists and clinicians to discuss complex images that are difficult to interpret. A teleradiology service faces several potential problems, which can be divided into legal aspects, communication and quality assurance. The reporting radiologist must be registered with a regulatory body in the European Union and must adhere to European Union-wide legislation regarding duty of care, health and safety, patient confidentiality and radiation exposure. The National Health Service (NHS) Trust purchasing the service remains fully responsible for the patient. Communication between the referring clinician and the radiologist can have a considerable effect on patient management, and standard teleradiology reduces the opportunity for a discussion between professionals. In addition, direct contact with the patient is no longer possible, which may be necessary for obtaining consent and to explain clinical findings. Teleradiology can compromise the quality and continuity of care if the reporting radiologist does not have complete access to the relevant clinical information and if he or she is not kept informed of the progress made by the patient. It is also important that the transmitted images be of a consistently high quality.
With the advent of the computerised administration of patient data, concerns have been raised about their security and confidentiality. In this respect, telemedicine poses a specific risk as it includes a recordable two-way audiovisual transmission of sensitive personal data from children, parents and health professionals.17,18 Consequently, written consent should be sought from the parent or carer before every telemedicine session, and every effort should be made to comply with the national data protection legislation. The Royal College of Radiologists has produced extensive guidance on this important area of concern.19
During the past decade, there has been a drive in the UK towards satellite paediatric ambulatory care units distributed around large paediatric (tertiary) care centres and staffed by general paediatricians or paediatric nurse practitioners and nurses. Telepaediatrics, which includes computer-aided prescribing, can help to ensure that a high standard of care is maintained in these ambulatory care units.20 Currently, nurses are able to independently prescribe and give drugs to patients using patient group directions—for instance, when giving nebulised salbutamol to patients with asthma. Alternatively, paediatricians based in a district general hospital could issue electronic prescriptions to children in nurse-led units.21,22
There is a requirement for a uniform, consistent and safe approach for developing paediatric telemedicine facilities in the UK, which can be achieved only through further qualitative and quantitative research into this subject. The following suggestions are examples of where telemedicine could be applied, but they are by no means exhaustive. In certain situations it can be difficult for general paediatricians to describe accurately the severity of a child’s illness, which often changes quickly, to their colleagues in the paediatric intensive care unit. A televideo link would allow the paediatric intensivist to assess the condition of the patient more accurately and assist with further management, thus improving the quality of care and possibly reducing the number of retrievals. In the UK, there are few supra-regional craniofacial teams that have the expertise to perform corrective surgery on children with craniosynostoses. A telemedicine consultation that includes the local paediatrician, the affected child and the specialist surgeon could be used as a screening tool, and may help to avoid long journeys. We work in a geographically large National Health Service Trust, which combines three district general hospitals and several community hospitals and nurse-led units. The Trust has four telemedicine units in operation for adult medicine and is currently evaluating their role in paediatrics.
On an international scale, paediatric telemedicine has already made a positive contribution to the quality of healthcare provided for children. We believe that telepaediatrics can be advantageous to children with acute and chronic illnesses in the UK in selected areas, but it must be evaluated in comparison with traditional forms of care through controlled trials (useful websites: http://www.amdtelemedicine.com,http://www.publictechnology.net,http://www.teis.nhs.uk/). The important issues of patient safety and confidentiality, clinical accountability and cost effectiveness have to be carefully considered before the introduction of this evolving technology.
100 years of telemedicine
Competing interests: None declared.