International Journal of Medical Informatics 61 (2001) 139 146

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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 Peoples 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: richard@hsiehnet.com (R.K.C. Hsieh), magnus-hjelm@hotmail.com (N.M. Hjelm), joelee@cuhk.edu. hk (J.C.K. Lee), jwaldis@email.msn.com (J.W. Aldis).

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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 ones 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

1386-5056/01/$ - see front matter 2001 Elsevier Science Ireland Ltd. All rights reserved. PII: S 1 3 8 6 - 5 0 5 6 ( 0 1 ) 0 0 1 3 6 - 8

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exchange of experiences of health-care technologies with China [1]. In China, American health-care technologies and the American system of medical education are considered to be among the strongest in the world. By and large, the United States is also the most generous in the offering of technical assistance to their colleagues in China. There are thousands of Chinese students receiving graduate education in the United States medical, dental and nursing schools, and there are more American professors lecturing in Chinese medical and health institutions every year. These scholarly exchanges have brought new vision to medical professionals in China. For example, the medical educators in China want to include in their curricula the recent advances in molecular biology, computers and telecommunication, along with other newer developments in science and technology. 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. As in most other countries, China has the highest concentration of medical resources (personnel, information, and facilities) in her major cities. It is only natural that the initiation of telemedicine began in major cities. The telemedicine program in China, however, 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.

information across distance [2]. This denition differs with an earlier denition 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, no matter where the patient or the relevant information is located. [3] The use of electronic information and communication technologies to provide and support health care across distance is to fulll the requirement of rapidness. 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, islands and deserts. It opens a new way to reduce the problem of shortage of medical personnel, and it is a sensible mechanism to alleviate difculties for the patient, family members and medical personnel who must to travel when medical needs arise. Another motivation of applying telemedicine in China, in addition to the delivery of services to people living in rural and isolated regions, is its promise to conduct more medical conferences with international medical institutions, and to offer continuous medical education by domestic medical centers of excellence.

3. International collaboration China has a national policy to encourage international collaborations for her modernization initiatives. The international collaboration on telemedicine as a tool to improve the medical education, medical conferences and medical consultation in China is pursued in two avenues. One is the direct collaboration between a Chinese medical institution

2. Telemedicine in context Telemedicine is dened as the Delivery of healthcare and the exchange of health care

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and a Western medical institution. Another is a three-party collaboration adding the Medical Faculty of the Chinese University in Hong Kong and its teaching hospital, the Prince of Wales Hospital (CUHK). The successful collaboration with CUHK and the Prince of Wales Hospital is reported in a separate paper in this issue.

4. 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). MEDLARS is the acronym for a collection of biomedical databases including the well-known bibliographical database MEDLINE, which is important to all medical researchers, educators, and clinicians. 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. Due to the relatively poor quality of the telecommunication infrastructure in China and the high cost of international (long-distance) telephone calls, CAMS decided to start a MEDLARS service with a leasing of data tapes from NLM. 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. This batch processed search service continued for many years, although

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medical professionals in China, like their colleagues in the United States, could use a PC with the online connection to NLM in Bethesda, Maryland (USA) to conduct their own required searches without the service of an intermediary since 1988 [4]. 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. Beginning in 1990, the advancement in local- 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. The Proceedings of Medinfo 92 (The International Medical Informatics Associations triannual conference), for example, included many papers reporting telecommunication applications. They are the transmission of text, graphics and radiographic images on X-terminal workstations; the use of e-mail on a health-care bulletin board; the support of medical information on patients who are under a home-care system; and the use of multimedia workstation for cooperative clinical trials. [5] A much larger number of telemedicine applications can be found in a book published in 1996 by the Institute of Medicine (USA). This publication, entitled Telemedicine, A Guide to Assessing Telecommunication in Healthcare, is the outcome of the Committee charged by the Institute of Medicine with the responsibility to evaluate clinical applications on telemedicine [6]. China has been using telephones for medical consultation between national medical centers and their afliated hospitals and clinics. A major difference from this new wave of

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telemedicine applications is the use of realtime audio and visual signal communication. It requires a very reliable telephone network, a higher bandwidth communication system, and computer-based video conferencing equipment. In other words, the telemedicine application requires a reliable and broadband telecommunication infrastructure and audio video-related equipment.

minimum of 384 mho/s by ISDN for medical consultation and conference). These facilities are available in China, but they are not commonly accessible by all medical institutions in all cities.

6. Suitable technical infrastructure for information technology One factor limiting the development of telemedicine in China is the telecommunication infrastructure. Until 1978, China had a relatively slow pace in the modernization of her telecommunication infrastructure. Since that time, the resumption of trade with the United States led the Chinese post, telephone and telegraph (PTT) authority to begin cooperative agreements with foreign telecom companies toward the modernization of Chinas telecommunication infrastructure. There were some modern telephone communication systems available in major Chinese cities by 1994, but when international medical universities approached their Chinese colleagues to participate in telemedicine conferences in that year, 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 ow of signals. Although major cities in China have reliable telephone services for voice-grade signal transmission, they have difculty meeting the requirements for conducting medical teleconferencing using VCU at medical universities. The problem, heretoforth not examined, could be the switches in the main station, connectors at the sub-station, or the switchboard within the university campus. For the transmission of medical images such as radiographs and microscope images, an even wider bandwidth is required. China

5. Development of telemedicine Telemedicine by todays denition is the use of computer communication and technology for face-to-face meetings linking many people independent of distances between the sites. This arrangement will potentially save both travel times and costs. In China, and in all other countries where telemedicine is promoted, it is too early to fully evaluate its success [7]. There was no shortage of enthusiasm to engage in the demonstration and development of telemedicine in China. The Chinese University of Hong Kong Faculty of Medicine has provided technical and nancial support to several major medical universities on the Mainland in their initiation of telemedicine programs. As one of the rst demonstration projects in (1996), a teleconference between Beijing and Hong Kong accommodated over 1000 persons. This demonstration project brought out several major points for telemedicine in China. These are, in a local community, basic requirements for telemedicine: (a) a suitable community infrastructure for information technology, (b) professional and organizational infrastructure and (c) adequate funding. [8] The required technical requirement includes audio-visual conferencing equipment; and a network with sufcient bandwidth for transmitting sound and vision of good quality (a

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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. While satellite systems can offer the highest bandwidth for telecommunication, they are still much more costly. However, between 1994 and 1999, due to a popular demand by the business community, the National Chinese Post, Telegram and Telephone authority made an ISDN service available in Beijing, Shanghai, Canton, Dalian, Wuhan and other major cities in China. This ISDN service was utilized successfully in 1997 for pediatric case conferences conducted between the afliated Pediatric Hospital of the Shanghai Medical University and the afliated Queen Marys Hospital of Hong Kong University. Also, this ISDN service was used for the May 1999 teleconference on Evidence-based Traditional Chinese Medicine: Acupuncture and Herbal Medicine. This teleconference was participated by staffs of the Chinese Academy of Traditional Medicine, the Royal Society of Medicine (UK), the University of Maryland College of Medicine (US), the George Washington Medical Center (US) and the Chinese University of Hong Kong Faculty of Medicine.

Computer-based audio-video teleconference systems in medical centers are a relatively late arrival compared to hospital computer information systems (HIS) in China. Therefore, the administration of VCU may or may not be assigned to managers of the computer centers. The rational seems to be that the medical faculty should retain direct control of the operation of a telemedicine service. That is, 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. In most Chinese medical university and hospital settings where telemedicine programs have been started, there is a shortage of trained supporting technical and managerial staff. The contact person for telemedicine (see Section 8) is frequently a professor of a medical department. This medical person has a strong interest in telemedicine but also has many responsibilities in the medical institution. She or he must seek the support of qualied technical and managerial staff (both qualitatively and quantitatively within the same institution) for the telemedicine team.

8. Current application of telemedicine 7. Professional and managerial infrastructure Hospitals in China began using computer applications quite early. These hospital-based computerized information systems are essentially business systems to record and tabulate patient expenditures, and to collect fees from patients or third-party payers. Some medical centers have imported patient-monitoring equipment for intensive care units where computers can help in the monitoring of patients vital signs. In relative terms, telemedicine programs in China are an expensive investment for the medical centers. International collaborators have donated some of the telemedicine equipment used in China today, and medical universities themselves have purchased much more. The purchasing of VCU and the installation of telephone lines are expensive in China, but they are a one-time expense. Once a teleconferencing system is installed, the telecommunication costs incurred with each consultation or educational conference are

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considered additional expenses. The university does not always budget for the recurring telecommunication expenditures, and therefore, they are looked upon by the program director from a different perspective. Many telemedicine program directors in China believe they have saved money (for telecommunication) for their institution by not conducting medical conferences and education activities, but in fact they may have inadvertently wasted valuable capital investment. That is, when the available telemedicine equipment, facilities and personnel are not fully utilized, they lose the opportunity to gain a full appreciation from their capital investment, not to mention their replacement cost. China has successfully participated in many national and international telemedicine conferences for clinical consultation as well as professional meetings. More are planned for the future. When the volume of international and national conferences and consultation increases, 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. All telemedicine programs in China have plans to offer continuous education programs for doctors, dentists, pharmacists and nurses away from medical universities. Using telemedicine to offer continuous education programs for former students no longer assembled on campus is still in a demonstration project statues in China. 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. However, distantlearning programs will need new learning

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material, which are different from the traditional classroom teaching material. This recognition of the need for more specialized distant-learning material has already begun, and their faculties are already developing the special learning material in China. There are many innovative applications of telemedicine in China. Among them is the introduction of the scientic basis to Traditional Chinese Medicine (TCM). The evidence-based diagnosis and treatment concepts in Western medicine have been discussed in telemedicine conferences by the faculty of TCM in China, Japan and the United States. There are many important telemedicine sites in China, and each has a different level of telecommunication capabilities as well as international contacts. 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. 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. A complete list of medical centers that have ISDN and satellite level of communication capability for telemedicine applications is difcult to compile as changes are occurring almost daily in China. The list below is not arranged in any particular order. It only offers a reference to those who wish to establish contacts in Mainland China. 1. 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

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Video conferencing equipment: Polycom Initiation: 1997 Contact Person: Prof. Chen Zhi-Jun, 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: 28.8 kbps Video conferencing equipment: PC and monitor Initiation: 1996 Contact person: Prof. Chen Zhi-Jun, Medical Services, 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; end of 1999 Contact person: Prof. Chen Zhi-jun, Medical Services, 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. Lee Bao-luo, Medical Information Center 2. Chinese Academy of Traditional Medicine Telemedicine Center Purpose: medical conference, education

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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. Zhao Ying-kai, Institute of Medical Informatics 3. 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. Yang Zhen-hua, Dept of laboratory Medicine 4. 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. Duo Jia-qi, Medical Information Center 5. Shanghai Medical University Telemedicine program Purpose: clinical consultation, medical education and conferencing Communication support: ISDN, satellite, asynchronous transmission mode (ATM) Number of points: 2 and also multi-points Bandwidth: 384 kbps Video conferencing equipment: Picture Tel, Polycom, Vcon

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Initiation 1994 Contact person: Prof. Zhao Jia-Ao 6. Sun Yet San University (Information to be added) 7. Shantou Medical University Telemedicine program Purpose: clinical consultation, medical education and conferencing Communication support: ISDN, satellite, ATM Number of points: 2 and also multi-points Video conferencing equipment: Polycom Contact person: (information to be conrmed) 8. Tongji Medical University Telemedicine Center Purpose: for education of leaders in education for middle level healthcare practitioners (nurses, medical technologists, physiotherapists, etc.) Communication support: ISDN, ATM Number of points: 2 Bandwidth: 384 kbps Initiation 2000 Contact person: Prof. Zhang Min-Cai.

Acknowledgements The authors wish to acknowledge help received from many colleagues, particularly Prof. ZhaoYing-kai of the Institute of Medical Informatics; ATCM, and Prof. Lee Bao-luo of the Medical Information Center; PUMC.

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[1] Cooperation in Health. A Report of Secretary Califanos visit to the PRC. DHEW, 1979. [2] R. Wooton, J. Craig (Eds.), Introduction to Telemedicine, Royal Society of Medicine Press, UK, 1999, p. 4. [3] D.J. Vassallo, Twelve months experience with telemedicine for the British armed forces, J. Telemed. Telecare 5 (Suppl. 1) (1995) 173 177. [4] E.H. Shortliffe, et al. (Eds.), Medical Informatics, 2000. [5] J. Van Bemmel, A.T. McCray (Eds.), Medinfo 92 Proc. Int. Medical Informatics Association, 1992. [6] M.J. Field (Ed.), Telemedicine A Guide to Assessing Telecommunication in Health Care, National Academy of Science, Location, 1996, p. 3. [7] S. Emery, Evolving Technology Thwarts Aim of Cost Analyses, Telmed and Telehealth Network, Feb, 1997, p. 2027. [8] M. Hjelm, Telemedicine: Academic and professional aspects, Hong Kong Med. J. 4 (1998) 289 292.

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