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Telemedicine in China
Richard K.C. Hsieh *, N. Magnus Hjelm, Joseph C.K. Lee, John W. Aldis
601 Stacy Court, Towson, MD 21286 -2940, USA
Abstract Telemedicine has been shown to have a considerable impact in medical education, conferencing and consultation. As a result, the People’s Republic of China has been keen to develop telemedicine. In her attempts to further the development of telemedicine, China has looked to the progress of medical services in Western countries such as Europe and North America. The United States of America, however, has exceeded the rest in exchange of health-care information and telemedicine technologies with China. Although China has been enthusiastic about the exchange, telemedicine in China requires development in the technical infrastructure and professional infrastructure. © 2001 Elsevier Science Ireland Ltd. All rights reserved.
Keywords: China; International collaborations; Telemedicine; Telemedicine infrastructures
1. Introduction and background For the past decade, it has been a privilege to work with colleagues in Mainland China on Telemedicine. Our collective effort has been to demonstrate and evaluate telemedicine for its promise in medical education, conferencing and consultation. We felt strongly that our Chinese colleagues were ready to join with Asia, Europe, and the United States in telemedicine. This paper attempts to cover several issues related to telemedicine in Mainland China.
* Corresponding author. E -mail addresses: email@example.com (R.K.C. Hsieh), firstname.lastname@example.org (N.M. Hjelm), email@example.com. hk (J.C.K. Lee), firstname.lastname@example.org (J.W. Aldis).
China is a large country and is rapidly modernizing. In reporting about telemedicine in China as well as reporting about all technology associated with computer and communication applications in China, one can never be sure whether one’s information is up to date, complete and accurate. Our main objective in this paper is to share the information we may have so that others will have a lead to develop future contacts in China. If one attempts to trace the development of Western medical and health service in China, one might say China, like many other developing countries, has looked at the models of the former Soviet Union, Europe and North America to deal with many of her problems. Since 1978, however, the United States has exceeded all other ‘‘developed’’ countries in
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medical conferences and medical consultation in China is pursued in two avenues. information across distance’ . Rapidness is a particularly important characteristic in the application of telemedicine in medicine since it can support the timely delivery of medical services and medical information to people living in isolated mountains. American health-care technologies and the American system of medical education are considered to be among the strongest in the world. however. As in most other countries. information.C. no matter where the patient or the relevant information is located’. Telemedicine in context Telemedicine is deﬁned as the ‘Delivery of healthcare and the exchange of health care 108 . By and large. in addition to the delivery of services to people living in rural and isolated regions. There are thousands of Chinese students receiving graduate education in the United States medical. 3. computers and telecommunication. It opens a new way to reduce the problem of shortage of medical personnel. the medical educators in China want to include in their curricula the recent advances in molecular biology. Hsieh et al. This deﬁnition differs with an earlier deﬁnition proposed by Vassallo only in one aspect — the speed of the delivery of health care and the exchange of health-care information: ‘Rapid access to shared and remote medical expertise by means of telecommunications and information technologies. the United States is also the most generous in the offering of technical assistance to their colleagues in China. dental and nursing schools.  The use of electronic information and communication technologies to provide and support health care across distance is to fulﬁll the requirement of ‘rapidness’. One is the direct collaboration between a Chinese medical institution 2. In China. The international collaboration on telemedicine as a tool to improve the medical education. Another motivation of applying telemedicine in China. along with other newer developments in science and technology. islands and deserts.140 R. is its promise to conduct more medical conferences with international medical institutions. is founded on the promise that it is an excellent mechanism to balance the considerable difference between the level of access to medical resources between the large cities to rural and the remote regions. / International Journal of Medical Informatics 61 (2001) 139–146 exchange of experiences of health-care technologies with China . For example. family members and medical personnel who must to travel when medical needs arise. These scholarly exchanges have brought new vision to medical professionals in China. The leaders of hospital centers want to incorporate the application of the latest technologies in the delivery of medical services and they also want to include in their teachings of young health professionals the newer diagnostic and curative strategies for the management of illness and health. International collaboration China has a national policy to encourage international collaborations for her modernization initiatives. and it is a sensible mechanism to alleviate difﬁculties for the patient. The telemedicine program in China. It is only natural that the initiation of telemedicine began in major cities. and facilities) in her major cities. China has the highest concentration of medical resources (personnel. and there are more American professors lecturing in Chinese medical and health institutions every year. and to offer continuous medical education by domestic medical centers of excellence.K.
entitled Telemedicine. The successful collaboration with CUHK and the Prince of Wales Hospital is reported in a separate paper in this issue. Evolution and current application of telemedicine — evolution of telecommunication for medical application One of the earlier international collaborations in telecommunication for medical application (or telecommunication for information transfer) in China was to access MEDLARS from the United States National Library of Medicine (NLM). The Proceedings of Medinfo 92 (The International Medical Informatics Association’s triannual conference). Users who required bibliographic information on a particular medical subject heading would ask trained CAMS staff to formulate a search strategy as well as to run data tapes on its computer system instead of performing an online search.C. Another is a three-party collaboration adding the Medical Faculty of the Chinese University in Hong Kong and its teaching hospital. educators.  A much larger number of telemedicine applications can be found in a book published in 1996 by the Institute of Medicine (USA). and clinicians. Due to the relatively poor quality of the telecommunication infrastructure in China and the high cost of international (long-distance) telephone calls. This publication. for example. although 109 medical professionals in China. CAMS decided to start a MEDLARS service with a leasing of data tapes from NLM. could use a PC with the online connection to NLM in Bethesda. and the use of multimedia workstation for cooperative clinical trials. 4. A major difference from this new wave of . the advancement in local. This batch processed search service continued for many years. Maryland (USA) to conduct their own required searches without the service of an intermediary since 1988 .R. China has been using telephones for medical consultation between national medical centers and their afﬁliated hospitals and clinics. like their colleagues in the United States. / International Journal of Medical Informatics 61 (2001) 139–146 141 and a Western medical institution. is the outcome of the Committee charged by the Institute of Medicine with the responsibility to evaluate clinical applications on telemedicine . MEDLARS is the acronym for a collection of biomedical databases including the well-known bibliographical database MEDLINE. the support of medical information on patients who are under a home-care system. The online access of information from NLM by biomedical professionals in China is increasing rapidly along with the more recent (1998) implementation of the Internet in national universities and major medical research centers in China. the use of e-mail on a health-care bulletin board. the Prince of Wales Hospital (CUHK). which is important to all medical researchers.and wide-area networks technology prompted a strong enthusiasm in telemedicine (using real-time video conferencing units to support health professionals who wish to exchange medical information with colleagues over vast distances) in the United States and other developed countries. graphics and radiographic images on X-terminal workstations. The Chinese Academy of Medical Sciences (CAMS) recognized its importance to her medical research and education community and thus formally established a Chinese International MEDLARS Center in the Institute of Medical Information in 1988 as a prerequisite to access MEDLARS from NLM. They are the transmission of text. A Guide to Assessing Telecommunication in Healthcare. Hsieh et al. included many papers reporting telecommunication applications. Beginning in 1990.K.
services from some local telephone companies were inadequate in meeting the teleconferencing requirement. A telemedicine video conferencing unit (VCU) requires a minimum of 384 k/s or multiple lines of 64 k/s bi-directional ﬂow of signals. telephone and telegraph (PTT) authority to begin cooperative agreements with foreign telecom companies toward the modernization of China’s telecommunication infrastructure. Suitable technical infrastructure for information technology One factor limiting the development of telemedicine in China is the telecommunication infrastructure. they have difﬁculty meeting the requirements for conducting medical teleconferencing using VCU at medical universities. In other words. Hsieh et al. China had a relatively slow pace in the modernization of her telecommunication infrastructure. For the transmission of medical images such as radiographs and microscope images. it is too early to fully evaluate its success . connectors at the sub-station. This demonstration project brought out several major points for telemedicine in China. but when international medical universities approached their Chinese colleagues to participate in telemedicine conferences in that year. China 5. could be the switches in the main station. In China. and computer-based video conferencing equipment.142 R. As one of the ﬁrst demonstration projects in (1996). There was no shortage of enthusiasm to engage in the demonstration and development of telemedicine in China. minimum of 384 mho/s by ISDN for medical consultation and conference). heretoforth not examined.C. / International Journal of Medical Informatics 61 (2001) 139–146 telemedicine applications is the use of realtime audio and visual signal communication. Since that time. and in all other countries where telemedicine is promoted. These facilities are available in China.K. an even wider bandwidth is required. a higher bandwidth communication system. 6. There were some modern telephone communication systems available in major Chinese cities by 1994. or the switchboard within the university campus.  The required technical requirement includes audio-visual conferencing equipment. Until 1978. the resumption of trade with the United States led the Chinese post. the telemedicine application requires a reliable and broadband telecommunication infrastructure and audio– video-related equipment. The Chinese University of Hong Kong Faculty of Medicine has provided technical and ﬁnancial support to several major medical universities on the Mainland in their initiation of telemedicine programs. but they are not commonly accessible by all medical institutions in all cities. This arrangement will potentially save both travel times and costs. and a network with sufﬁcient bandwidth for transmitting sound and vision of good quality (a 110 . in a local community. a teleconference between Beijing and Hong Kong accommodated over 1000 persons. It requires a very reliable telephone network. Although major cities in China have reliable telephone services for voice-grade signal transmission. These are. The problem. basic requirements for telemedicine: (a) a suitable community infrastructure for information technology. Development of telemedicine Telemedicine by today’s deﬁnition is the use of computer communication and technology for face-to-face meetings linking many people independent of distances between the sites. (b) professional and organizational infrastructure and (c) adequate funding.
This medical person has a strong interest in telemedicine but also has many responsibilities in the medical institution. International collaborators have donated some of the telemedicine equipment used in China today. Dalian. Hsieh et al. Telegram and Telephone authority made an ISDN service available in Beijing. the presentation and exchange of information during a telemedicine conference must not deviate from the standard medical protocol and procedures familiar to medical personnel attending the conference. there is a shortage of trained supporting technical and managerial staff. 8. / International Journal of Medical Informatics 61 (2001) 139–146 143 has planned to jump over the implementation of the faster and wider bandwidth integrated service digital network (ISDN) and began an even wider bandwidth satellite system in the second decade of next century. These hospital-based computerized information systems are essentially business systems to record and tabulate patient expenditures. Therefore. the University of Maryland College of Medicine (US). Shanghai. this ISDN service was used for the May 1999 teleconference on ‘‘Evidence-based Traditional Chinese Medicine: Acupuncture and Herbal Medicine’’. the George Washington Medical Center (US) and the Chinese University of Hong Kong Faculty of Medicine. Also. The purchasing of VCU and the installation of telephone lines are expensive in China. Current application of telemedicine 7.C. the administration of VCU may or may not be assigned to managers of the computer centers. That is. In relative terms. The contact person for telemedicine (see Section 8) is frequently a professor of a medical department. but they are a one-time expense. The rational seems to be that the medical faculty should retain direct control of the operation of a telemedicine service. they are still much more costly. Once a teleconferencing system is installed. the Royal Society of Medicine (UK).R. the telecommunication costs incurred with each consultation or educational conference are 111 . This ISDN service was utilized successfully in 1997 for pediatric case conferences conducted between the afﬁliated Pediatric Hospital of the Shanghai Medical University and the afﬁliated Queen Mary’s Hospital of Hong Kong University. In most Chinese medical university and hospital settings where telemedicine programs have been started. between 1994 and 1999.K. Some medical centers have imported patient-monitoring equipment for intensive care units where computers can help in the monitoring of patients’ vital signs. and medical universities themselves have purchased much more. Wuhan and other major cities in China. She or he must seek the support of qualiﬁed technical and managerial staff (both qualitatively and quantitatively within the same institution) for the telemedicine team. due to a popular demand by the business community. Canton. Computer-based audio-video teleconference systems in medical centers are a relatively late arrival compared to hospital computer information systems (HIS) in China. However. This teleconference was participated by staffs of the Chinese Academy of Traditional Medicine. While satellite systems can offer the highest bandwidth for telecommunication. and to collect fees from patients or third-party payers. telemedicine programs in China are an expensive investment for the medical centers. Professional and managerial infrastructure Hospitals in China began using computer applications quite early. the National Chinese Post.
they are looked upon by the program director from a different perspective. which are different from the traditional classroom teaching material.144 R. Many medical universities believe that continuous education programs might be more receptive to their former students when they do not have to travel to take continuous education courses and to teachers when they do not have to travel to teach. Hsieh et al. when the available telemedicine equipment. 1. However. More are planned for the future. dentists. A complete list of medical centers that have ISDN and satellite level of communication capability for telemedicine applications is difﬁcult to compile as changes are occurring almost daily in China. The university does not always budget for the recurring telecommunication expenditures. but in fact they may have inadvertently wasted valuable capital investment. Japan and the United States. Peking Union Medical College (PUMC) China Jin Wei (Golden Health Medical Network) Telemedicine Center Purpose: clinical consultation and teaching Communication support: dedicated satellite Number of points: 50 Bandwidth: 2 Mbps . When the volume of international and national conferences and consultation increases. facilities and personnel are not fully utilized. This paper is an attempt to cover some important sites using higher speed ISDN and real-time audio video conferencing units for telemedicine in China. There are many important telemedicine sites in China. each center will require more technical and managerial manpower to support the telemedicine facility and equipment — an area of concern among directors of telemedicine programs in China. The evidence-based diagnosis and treatment concepts in Western medicine have been discussed in telemedicine conferences by the faculty of TCM in China. not to mention their replacement cost. and therefore. All telemedicine programs in China have plans to offer continuous education programs for doctors. / International Journal of Medical Informatics 61 (2001) 139–146 considered ‘‘additional’’ expenses. Among them is the introduction of the scientiﬁc basis to Traditional Chinese Medicine (TCM). The list below is not arranged in any particular order. That is. It only offers a reference to those who wish to establish contacts in Mainland China. This recognition of the need for more specialized distant-learning material has already begun. Using telemedicine to offer continuous education programs for former students no longer assembled on campus is still in a ‘‘demonstration project’’ statues in China. There are many innovative applications of telemedicine in China. and each has a different level of telecommunication capabilities as well as international contacts.C.K. It is hoped that staffs of telemedicine programs in medical universities will increase their dialogues within and outside of their own institutions to share their experience and knowledge. they lose the opportunity to gain a full appreciation from their capital investment. Many telemedicine program directors in China believe they have saved money (for telecommunication) for their institution by not conducting medical conferences and education activities. and their faculties are already developing the special learning material in China. pharmacists and nurses away from medical universities. China has successfully participated in many national and international telemedicine conferences for clinical consultation as well as professional meetings. distantlearning programs will need new learning 112 material.
Shanghai Medical University Telemedicine program Purpose: clinical consultation. PUMC Sino-Japanese Collaboration — Telemedicine Purpose: Clinical services and teaching Communication support: dedicated satellite Number of points: 3 Bandwidth: 2 Mbps Video conferencing equipment: Polycom Initiation: 2000 Contact person: Prof. asynchronous transmission mode (ATM) Number of points: 2 and also multi-points Bandwidth: 384 kbps Video conferencing equipment: Picture Tel. Institute of Medical Informatics 3. education 113 and consultation Communication support: ISDN Number of points: 2 (point to point) Bandwidth: 384 kbps Video conferencing equipment: Picture Tel VCU Initiation: 1997 Contact person: Prof. Lee Bao-luo. Zhao Ying-kai. Beijing Hospital Telemedicine Purpose: Clinical consultation Communication support: ISDN Number of points: 2 Bandwidth: 384 kbps Video conferencing equipment: Polycom Initiation: 1997 Contact person: Prof.R. Medical Information Center 5.C. PUMC PUMC and Hong Kong University Link Purpose: Clinical consultation Communication support: ISDN Number of points: 2 (point to point) Bandwidth: 384 kbps Video conferencing equipment: Trandberg Initiation. Yang Zhen-hua. Dept of laboratory Medicine 4. end of 1999 Contact person: Prof. Hsieh et al. Beijing Medical University Telemedicine Purpose: clinical consultation and education Communication support: ISDN Number of points: 2 Bandwidth: 384 kbps Video conferencing equipment: Picture Tel VCU Initiation: 1998 Contact person: Prof. Medical Information Center 2. Chen Zhi-jun.8 kbps Video conferencing equipment: PC and monitor Initiation: 1996 Contact person: Prof. / International Journal of Medical Informatics 61 (2001) 139–146 145 Video conferencing equipment: Polycom Initiation: 1997 Contact Person: Prof. Chinese Academy of Traditional Medicine Telemedicine Center Purpose: medical conference. Duo Jia-qi. Medical Services. satellite. medical education and conferencing Communication support: ISDN. Chen Zhi-Jun. Medical Services. Polycom. Vcon . Chen Zhi-Jun.K. Medical Services. PUMC China Medical Board (NY) Telemedicine Service Network Purpose: Clinical consultation Communication support: telephone + modem + Internet servers/clients Number of points: 100 Bandwidth: 28.
(Eds. Telemed. et al.).). McCray (Eds. Telecare 5 (Suppl. Wooton. Royal Society of Medicine Press. UK. medical technologists. Telemedicine: Academic and professional aspects. 114 . p. J.J. Telmed and Telehealth Network. Vassallo. . Lee Bao-luo of the Medical Information Center. ZhaoYing-kai of the Institute of Medical Informatics.K. ATM Number of points: 2 and also multi-points Video conferencing equipment: Polycom Contact person: (information to be conﬁrmed) 8. p. J. Zhao Jia-Ao 6.  D. 1997. A Report of Secretary Califano’s visit to the PRC. 1999. Medical Informatics. and Prof. Twelve months’ experience with telemedicine for the British armed forces. Evolving Technology Thwarts Aim of Cost Analyses. / International Journal of Medical Informatics 61 (2001) 139–146 Initiation 1994 Contact person: Prof. 1992. Shortliffe.). 4. satellite. p.H. Field (Ed. Acknowledgements The authors wish to acknowledge help received from many colleagues. Sun Yet San University (Information to be added) 7.  J. Telemedicine — A Guide to Assessing Telecommunication in Health Care. Tongji Medical University Telemedicine Center Purpose: for education of leaders in education for middle level healthcare practitioners (nurses.T.J.146 R. physiotherapists. Hjelm. Int. PUMC. References  Cooperation in Health. Feb.  R.) Communication support: ISDN. Hsieh et al. 3. ATCM.  M. ATM Number of points: 2 Bandwidth: 384 kbps Initiation 2000 Contact person: Prof. medical education and conferencing Communication support: ISDN. Shantou Medical University Telemedicine program Purpose: clinical consultation.  M. 4 (1998) 289 – 292. 1996. Zhang Min-Cai. 1) (1995) 173 – 177. 2000. Location. Medinfo 92 Proc. Craig (Eds. Emery. Introduction to Telemedicine.). Medical Informatics Association. 1979. Van Bemmel.  E. DHEW. particularly Prof. National Academy of Science. J. etc. A.  S.C. Hong Kong Med. 2027.