INTERNATIONAL TELECOMMUNICATION UNION TELECOMMUNICATION DEVELOPMENT BUREAU

REGIONAL TELECOMMUNICATION DEVELOPMENT CONFERENCE FOR THE ARAB STATES
(AR-RTDC-96) Beirut (Lebanon), 11-15 November 1996 Document 23-E 1 October 1996 Original: English For Action

Agenda item: 3.3

PLENARY MEETING

SOURCE:

ITU-D STUDY GROUP 2 QUESTION 6/2 - IMPACT OF TELECOMMUNICATIONS IN HEALTH CARE AND OTHER SOCIAL SERVICES TELEMEDICINE AND DEVELOPING COUNTRIES ________ TELEMEDICINE AND DEVELOPING COUNTRIES

TITLE:

1

Introduction

Many developing countries have inadequate health care and medical services. Developing countries suffer from a shortage of doctors and other health care professionals. The inadequate infrastructures of telecommunications, roads and transport make it even more difficult to provide health care in remote and rural areas. Where clinics and hospitals exist, they are often ill-equipped and, especially, outside urban areas beyond the reach of normal communications. Developing countries face various problems in the provision of medical service and health care, including funds, expertise, resources, which relate to the lack of facilities and systems. Roads and transportation are inadequate and problems in properly moving or transporting patients are often encountered. For countries with limited medical expertise and resources, telecommunications can provide a solution to some of these problems. Telecommunications may help alleviate some of the shortages. Telemedicine services have the potential to improve both the quality of and access to health care regardless of geography. They enable medical and health care expertise to be accessed by under-served locations. Telemedicine offers an effective means to quickly improve the delivery of health care and medical service. It can help in emergencies from natural disasters, combating tropical diseases and meeting the particular requirements of dermatology, traumatology and the many other specialities of medicine. In the developed countries, there has been a rapidly growing interest in telemedicine and telehealth as a means to ease the pressure of health care on national budgets. It may well be that some of the

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technologies and experiences of the developed countries could be of help to developing countries in their desire to provide, especially, primary health care. Telemedicine and telehealth have many socio-economic benefits, can generate new sources of revenues for service providers and equipment suppliers and can optimize the use of available human and capital resources in developing countries. Applications such as telemedicine and telehealth should be of interest to telecom operators since they generate additional traffic over existing networks and offer the opportunity to extend limited networks. The telecom and health "industries" can achieve synergies. Telemedicine needs to be well managed, implemented carefully. The impact of telemedicine on health care structures can be significant. It also raises concerns about legality, liability, confidentiality, competition and other policy and regulatory issues. For these and other reasons, the World Telecommunication Development Conference convened by the ITU in Buenos Aires in March 1994 recommended that the ITU study the potential of telemedicine to meet some of the needs of developing countries. In particular, the Conference approved a Question on telemedicine which was assigned to ITU-D Study Group 2. The text of the Question is as follows: Statement of problem The widespread use of telemedicine services could allow universal health access and consequently facilitate the solution of the principal health problems connected with infectious diseases, paediatrics, cardiology, etc., particularly in areas where medical structures are inadequate or non- existing. Telemedicine mainly concerns two different aspects related respectively to telecommunications infrastructure and health care organization. Question The Study Group shall: 1. 2. 3. Define the technologies most suitable for telemedicine's most efficient diffusion to developing countries; Study the costs and benefits of different solutions taking into account the various solutions existing in the developing countries; Analyse the results of pilot projects, surveys, sectoral studies, etc. carried out by the various entities involved in order to better identify the main trends in technologies used for telemedicine; Foster the adoption of global standards required for systems and equipment in order to facilitate telemedicine and other social services; Produce a telemedicine handbook.

4. 5.

This report was prepared in response to the Question.

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2

Scope of the Report

This Report focuses on the possibilities of telemedicine and telehealth in developing countries. The Report surveys telemedicine experience around the world, different telemedicine applications and the technologies for diffusion of telemedicine. It reviews the costs and benefits of telemedicine and examines in particular the notion of a telemedicine value chain, i.e., how telemedicine and telehealth services can be delivered from the service provider to the end user in a cost-effective and profitable way. The Report notes some of the main trends in the development of telemedicine and telehealth services and examines the prospects and complexities inherent in the development of global telemedicine and telehealth standards. Based on the analysis of the Study Group, recommendations and guidelines are provided for developing countries who are considering the implementation of such services. The telemedicine industry appears to be growing rapidly, judging by the growing number of conferences on the subject and World Wide Web sites dealing with telemedicine services, but there are, as yet, few examples of commercial, profitable services. The developed countries of North America, Europe, Japan and Australia have considerable experience in telemedicine and telehealth. Based on research so far and the responses to the Telemedicine Questionnaire sent out to countries in helping to prepare this Report, it is clear that much of the telemedicine activity undertaken around the world depends upon subsidies from government, telecom carriers or international organizations. The situation is changing. A trend toward commercialization of telemedicine and telehealth provision is clearly discernible. In Europe, the European Commission (EC) has supported a large number of telemedicine/telehealth projects, about 45 in its Third Framework Programme and about double that under its current Fourth Framework programme, to the tune of more than 235 million ECU (1.3 ECU = US $1 in mid-1996) over an eight-year period. The EC has its telemedicine/telehealth programme squarely aimed at developing a competitive European telemedicine industry as well as improving the delivery of health care services to Europeans. There are many telemedicine and telehealth applications, some with very sophisticated -- and expensive -- technologies. Telemedicine applications using virtual reality technologies are being developed and demonstrated in the United States and United Kingdom. Such sophisticated and expensive technology is out of the reach of developing countries. What they need is low cost, low-tech solutions to the delivery of medical and health care as well as access to appropriate expertise, especially in the event of emergencies. Although telemedicine and telehealth have many socio-economic benefits, can generate new sources of revenues for service providers and equipment suppliers and can optimize the use of available human and capital resources in developing countries, it is important to recognize that investing in a telemedicine and telehealth delivery system will cost something and that something will be competing for scarce resources in developing countries. External support and funding, i.e., outside the developing countries, can be contemplated, but the sustainability of the delivery system -- of the value chain -- should be scrutinized carefully before committing significant capital. The success of the telemedicine service will depend heavily on which technologies and services are used, on how appropriate they are to particular countries, recognising that the situation can differ from country to country. Or, to put it another way, what may work in one country may not meet the needs of another country.

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This Report is intended to serve as a handbook for government administrations or operating agencies so that they can evaluate a range of possibilities and choices related to networks and applications, cost-benefit analysis and standards in order to identify the solutions appropriate to their needs and availability of resources. 3 Health care in developing countries

Out of the 51 million people who died in 1993 around the globe, 39 million deaths took place in the developing world and about 12 million in the developed world. Poor countries had three times more deaths than rich countries. Of the estimated 51 million deaths, communicable diseases such as tuberculosis and respiratory infections as well as maternal, perinatal and neonatal causes account for about 20 million or 40 per cent of global deaths, with 99 per cent of those in the developing world. In developing countries, most babies are not vaccinated, clean water and sanitation are not commonly available, nor are curative drugs and other treatments. Mothers dying in childbirth, reduced life expectancy, disability and starvation, mental illness, stress, suicide, family disintegration and substance abuse are common in developing countries. The main cause is poverty. According to the World Health Organization1, poverty is the main reason why the human race suffers in all walks of life. During the second half of the 1980s, the number of people living in extreme poverty increased, and was estimated at more than 1.1 billion people in 1990 -- more than one-fifth of humanity. Every year, more than 12.2 million children in developing countries die under the age of five from preventable causes -- preventable in many cases for just a few pennies each. There are widening disparities between rich and poor, between one population group and another, between age groups and between the sexes. According to 1993 calculations, a person in the least developed countries has a life expectancy of 43 years, compared to 78 in some developed countries. Some developing countries have less than US $4 to spend on health care per person per annum. According to the WHO, the biggest group of killers in the world today are infectious diseases and parasites. In the developing world, some 23 per cent of deaths among children under age 5 occur in the first week of life and 33 per cent within the first month. Most of these deaths are associated with the delivery itself or immediate complications and infections. Seven out of 10 babies in the developing world are born without the help of a trained attendant. This is where the problem lies. Developing countries do not have access to quality health care enjoyed by the developed countries. This is where telemedicine might be able to help. About 1 billion people worldwide do not have regular access to local health services. At the same time, cheap, effective, life-saving treatments sit unused on shelves while people are dying because in many areas of the world, the delivery systems to get them to the populations do not exist or are inadequate. Increasingly, there is a recognition that health services must be provided close to the people who need them and an integrated, cost-effective approach is necessary. Integration is the key to effective delivery of care. There cannot be high-technology hospitals in every part of every country, and there does not need to be. Instead a tier system should be created,

1

Most of the data presented here has been taken from The World Health Report 1995 published by the World Health Organization.
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with established links between the various levels of the health services, with the peripheral health units seeing the majority of cases and the feeding through to district-level hospitals, which in turn can refer to patients to more specialized centres if need be. Telemedicine can help. As can be see later in this report, there are relatively inexpensive and affordable telemedicine systems that can be set up easily and are user friendly. But some developing countries will not be able to afford such systems and the costs of teaching the health staff to use these systems. This is where developed countries can help, because they can afford to help. It is ironic that in some parts of the world hundreds of millions of people suffer daily from a lack of basic health care while in other parts millions of people spend money on things which are not healthy. Think what a billion dollars could do to help immunize people against deadly diseases in developing countries. A billion dollars is not much money -- it is what Americans spend on beer every 12 days and what Europeans spend on cigarettes every five days. Developing countries are inevitably short of high level hospital infrastructures. The geographical distribution of existing hospitals and health services is far from ideal; usually they are limited to urban centres at county or district level. Referral hospitals with competent medical specialists, and using state of the art medical technology, such as scanners and other sophisticated diagnostic equipment are non-existent, or where they do exist are at best confined to a single metropolis. The inability of governments in developing countries to provide quality health services irrespective of geographical location is in part linked to the health service's organizational options, which currently imply mobilization of financial, material and human resources against a background of creating decentralized hospitals and health clinics. There is a growing recognition in many countries of the importance of placing greater priority on the provision of primary health care as a way of minimising the cost of direct medical care. The implementation of telematics in primary health care has lagged behind the application of telematics to the hospital environment for a number of reasons. One reason is the lack of investment in primary health care. Another important reason is the unstructured and dispersed nature of primary health care. As the policy to shift more health care from secondary to care is implemented and as demographic changes begin to have an impact, increasing demands are being placed on primary health care services. The need for coordination of health care services for individual patients is a major consequence and the application of telematics in this area has the potential to improve both the quality and efficiency of health care. The World Health Organization principles of primary health care are based on accessibility, continuity and comprehensiveness and are an important foundation on which to build. The approach should be both top-down and bottom-up. A strategic view of the service as a whole is necessary to determine the development of the telematic framework and infrastructure required to support the overall goals of the service. The needs of health care professionals caring for individual patients help to determine the services that should be developed. Telemedicine and telehealth have the potential for offering developing countries these qualitative and quantitative improvements: • Distance consultations, diagnosis and treatment by medical specialists practising in a national, regional or international hospital centre for referrals.

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05. by opening up international medical databases. 6.-6AR-CRDT-96/23-E • • • • Availability of quality health care in remote areas of the country.2 2 p. 11. Physical diagnosis usually requires visual information. economic and cultural levels.). London. improvement of specialists' qualifications through distance teaching and access to medical databases. by comparison with the usual health services.10. and introduction of medical information systems. hence one needs a device that would enable the physician to "see" the patient. since the patient can be treated and checked up on at a distance. Dr Alexander Graham Bell called "Come here.96 TMP_E\ITU-D\CONF-D\CRDT96\AR\000\023E. laboratories. For providers of health services: • Reduction in operating costs through centralization and optimization of resources (expertise. Improvement in qualification of national specialists and health technicians.1 Origins of telemedicine There are differing views about the origin of telemedicine. Incidentally. From inception. potentially in these ways: For the patient: • Cutting down on journeys to major health centres or for specialist consultations.WW7 (34900) . Others say that telemedicine originated not long after the introduction of television. 4 What are telemedicine and telehealth? 4. or even local community centres which meet the joint requirements of several villages. Unpublished thesis for BSc (Honours). I need you. Some say that telemedicine came about with the introduction of the telephone. Telemedicine. equipment. its introduction into developing countries tackles several needs and constraints. • Reduction in costs of training and updating. by deployment of mobile telecentres travelling from one village to another. Watson. Effectiveness and efficiency in management of actions related to reduction of waiting times for consultations. May 1995. South Bank University. etc. • Reduction of length of stay. by A." because he was feeling ill. Telemedicine and telehealth could reduce health costs in developing countries. introduces added value and a positive impact at social. Aref. hardware and software packages). to overcome time and distance barriers. and therefore cost of hospitalization. and is. The Specialist User of Current Innovative Technology: The Marketing of Telemedicine. The initial idea behind telemedicine was. Overall improvement of service by centralization of resources (specialists.03 11. the main focus has been on physical diagnosis and prognosis.

65-70. Menhall & A.6 Most of these projects used some form of video (black-and-white television. Space Technology Applied to Rural Papago Advanced Health Care (STARPAHC) delivered health care to residents living in remote areas of the Papago Indian Reservation in Arizona. "Assessment of Telemedicine: Results of the initial experience". 11.-7AR-CRDT-96/23-E Among the early telemedicine efforts was the research and development work into telemetry undertaken by NASA. NASA's scientists were originally concerned with the effects of zero gravity on their astronauts. colour television.5 There were other early applications of telemedicine. Bashshur & J. p. & A. 65-70. During the late 1960s and early 1970s. Space and Environmental Medicine. 1994. 1995. respiration rate. 8. Unpublished thesis for BSc (Honours). by D. by N. the telephone. 1977. May 1995. Perednia. Aref. 483-488.. p. such as blood pressure. p. The Specialist User of Current Innovative Technology: The Marketing of Telemedicine.03 11. Telemedicine Times. Allen. and the United States Public Health Service. A radiologist who worked at the Massachusetts General Hospital (MGH) set up a diagnostic "shop" in the medical station of Logan airport. 1977. They decided to constantly monitor their astronauts' physiological functions. slow-scan transmission) to complement the most basic unit of telemedicine equipment.N.10. The X-rays were illuminated by an ordinary light box. Space and Environmental Medicine. others were also experimenting with telemedicine.A.05. Technology and Clinical Applications. Jama. The physician could discuss the case with MGH radiologists via an ordinary telephone line. NASA was not the only one to experiment with the integration of telecommunications systems into the practice of medicine. Aviation. London. NASA developed a medical support system which included diagnosis and treatment of in-flight medical emergencies as well as the development of complete medical delivery systems. Physicians passing through were invited to bring X-rays and patient data to a room on the passenger concourse. scanned by a black and white television camera and the images transferred to a video monitor in the MGH's radiology department.g. Their telemetry and telecommunication systems for biomedical application were highly sophisticated for their time.96 5 6 7 TMP_E\ITU-D\CONF-D\CRDT96\AR\000\023E. by R. by R.7 3 4 p. Lovett. This was a joint effort between Lockheed.3 The first interactive video link was established between the Nebraska Psychiatric Institute in Omaha and the Norfolk State Hospital. NASA scientists demonstrated successfully that their astronauts' physiological functions could be monitored by physicians on earth. Lovett. X-rays) could be accomplished successfully without any significant loss of information in terms of its quality and detail. 112 miles away. the National Aeronautics and Space Administration. One involved the Papago native American tribe in the late 1950s. "Assessment of Telemedicine: Results of the initial experience". 5. p. Tabbah. ECG and temperature. The first telemedicine system in which there was a regular interaction between physicians and patients was installed in Boston in 1967. "The World as a Network". Aviation. The project lasted about 20 years.4 These two experiments demonstrated that it was possible to undertake remote diagnosis through interactive television and that the transmission of medical data (e. Bashshur & J.WW7 (34900) . by A. South Bank University.

Telemedicine technology is advancing and will continue to do so. August 1977. literally. X-rays. 7. Labrador City and Goose Bay. These same networks can be used to provide access to on-line patient records and medical libraries. The system was used for medical consultations. later renamed Hermes. Hermes was designed to serve the communications needs of remote areas of Canada. p. and make available standardized medical information and insurance data more readily. by A. There also was a need to help small towns by providing doctors with technology that would allow them to keep abreast of advances in medicine and to consult with other physicians. Anthony. 386-387.g. Roberts. Today.03 11. telecommunications networks are being developed to transmit information about patients to doctors and information from doctors to patients. so that telemedicine should become more affordable to more people.10. the interest in telemedicine has continued to grow. by A. Newfoundland. respiration. and eventually from any location.M. Three telemedical experiments were conducted using Hermes.M. John's. "GETS : Global Emergency Telemedicine Services : (Feasibility study)". temperature. & J. ECGs. was launched by NASA as part of a joint project with Canada's Department of Communications (DOC). in 1977. House. using Hermes to link the University Hospital in London (Ontario). CMA Journal. "medicine at a distance". House. Roberts. 11. involved Memorial University in St. One of the first telemedicine projects using a satellite was conducted in Canada. Although much of the more sophisticated technologies such as virtual reality are still expensive. a Canadian satellite. In January 1976. a proposal to CEC Director General XIII. August 1977.-8AR-CRDT-96/23-E Some early experiments used satellite communication.9 The third project. From these beginnings. June 1995.10 Several different definitions of telemedicine and telehealth are current now. Telemedicine in Canada. Telemedicine in Canada. the Moose Factory General Hospital and the Kashechewan Nursing Station on James Bay. CMA Journal. Hermes was used to support an on-going medical education programme.M. it can be seen that the use of telemedicine grew out of a need to provide medical diagnoses for patients in remote areas who were unable to travel.WW7 (34900) . The term was coined in the 1970s by Thomas Bird. regions and countries than ever before.05. & J.96 9 10 TMP_E\ITU-D\CONF-D\CRDT96\AR\000\023E. 8 p. 4. the cost of some technologies is dropping.. John's to hospitals in Stephenville. when the University of Western Ontario started its five-month trials. when a patient was evacuated from a remote community in northern Ontario. data transmission (e. 386-387. p.2 Definitions Telemedicine means. the Communications Technology Satellite (CTS). It enabled Memorial medical staff to broadcast a television programme from St. ECG.8 The second experiment began in October 1976. Thus.M. to facilitate communications among medical specialists around the country. faster than ever before. The first was in June 1976 involved the Ontario Ministry of Health which used VHF radio and Hermes to test the feasibility of monitoring vital signs such as heart rate. St. heart sounds) and some continuing education.

"18 Other related terms such as telehealth and telecare have also been used. Colvin. American Journal of Roentgenology. "Making Global Telemedicine Practical and Affordable: Demonstrations from the Middle East" by M. Telecommunications can be used to deliver telehealth services. "Telehealth refers to the use of telecommunication technologies to make health and related services more accessible to health care consumers and providers in rural. "Research and technology development on telematics systems in health care : AIM 1993". 1993.the interactive transmission of medical images and data to provide patients in remote locales with better care.05. or otherwise underserved areas. 1495. Schaffer.12 Telemedicine has been described as "patient-care oriented telehealth"."19 In recent years. "Telehealth: the delayed revolution in health care" by G. 1994 J. Hamit. 1992 11. Gott.10. 1994 p.W. 18. p. Flotte.152.-9AR-CRDT-96/23-E • • • • • • • • The European Commission has defined telemedicine as "Rapid access to shared and remote medical expertise by means of telecommunications and information technologies. This includes medical care delivery. diagnosis. & T. p. 1992 Conference Proceeding by J.WW7 (34900) ."17 "Telemedicine is the delivery of medical care to patients anywhere in the world by combining telecommunications and medical expertise. The Advisor on Informatics of the World Health Organization. 1995. Telehealth can be distinguished from telemedicine in the sense that telehealth is the provision of a service to those who are not 11 p. European Commission.W. Brauer in Medical Progress through Technology. consultation and treatment. & S. Sharif."14 "Telemedicine is a system of health care delivery in which physicians examine distant patients through the use of telecommunications technology."16 "Telemedicine ."15 "Telemedicine and telehealth . by F. & D. Thrall. aimed at maintaining the "wellness" of society or improving the general health of society. & J. no matter where the patient or relevant information is located.03 11. Harrison. Directorate General XIII.the use of telecommunications and informatics for medical and health purposes. 36-44. & H. Brauer in Medical Progress through Technology. Annual Technical Report on RTD: Health Care. p. many countries around the world are giving a higher priority to primary health care. M.B.13 "Telemedicine is the use of telecommunication technology to assist in the delivery of health care."11 Telemedicine is "the practice of medical care using interactive audiovisual and data communications. "Telehealth: the delayed revolution in health care" by G. Goldberg. Preston. as well as education and the transfer of medical data". 1995. Rosenthal.96 12 13 14 15 16 17 18 19 TMP_E\ITU-D\CONF-D\CRDT96\AR\000\023E. & R.153.

10. 483. 11. Within each of the broad types of services are several types of services.03 11. The common element in these different definitions is the use of telecommunications to deliver medical and health care services to patients wherever they are. It can be characterized by the type of information sent (such as radiographs or clinical findings) and by the means used to transmit it.. JAMA. for example has a division called "Telematics for health" and the scope of their work is not just telemedicine or telehealth. etc.WW7 (34900) .A. Many areas of medical practice have potential telemedicine applications. Allen. healthcare. etc. hurt. research and/or educational purposes.. If telemedicine is to be defined correctly then it must involve some form of telecommunication.e. The European Commission. Telemedicine can be useful for situations in which: • physical barriers prevent the ready transfer of information between patients and health care providers. in regard to sanitation. 5. Telemedicine generally refers to the use of telecommunications and medical technologies to provide any or all of the following forms of information exchange.96 TMP_E\ITU-D\CONF-D\CRDT96\AR\000\023E. by D. i.audio. 1995. and by taking steps to avoid illness and disease. patient's medical record or monitoring vital signs. exercise. Another feature of telemedicine is the transmission of data. 5 Types of telemedicine services Telemedicine and telehealth can be used for a whole set of practices aimed at increasing well-being. wounded or otherwise afflicted. heart rate. Feb. blood pressure. Telemedicine involves diverse technologies and applications.g. and • the availability of information is key to proper medical management. Telematics for health..10 AR-CRDT-96/23-E necessarily ill. Perdenia & A. examples are supplied. It also includes considering applications of information technology to improve the health care systems in Europe. In each case. visual and data. data. lifestyle. nutrition. however. for example. 20 p. "Telemedicine Technology and Clinical Applications"..05. e.20 For the purpose of this report. audio and/or visual communication between physician and patient or between physician and health care professional in geographically separate locations and to facilitate the exchange of information for medical. Telemedicine and telehealth can be regarded as examples of the use of telematics for health. telemedicine services can be categorized as being of three main types -. has a broader definitional scope since it also includes informatics or information technology aimed at improving the efficiency of health care even within a single hospital or health administration. who in fact are already well and want to stay that way by following healthy practices of diet. otherwise it could not be labelled telemedicine. whether it is in the form of an X-ray.1 Audio The simplest telemedicine service is when one health care professional consults another by telephone.

1. The X-rays that pass through the patient are digitized by detectors on the opposite side of the scanner. tele-imaging may be a better term to use as part of the area of image transfer in telemedicine.10. the term has grown to include other related types of image transfer as described below. 8.22 In reality. "Health Screens" by Isabel Berwick in Smart Talk.W. An MR machine consists of a table on which the patient lies and which goes through a kind of tunnel. magnetic resonance (MRI). 5. Standard for teleradiology.11 AR-CRDT-96/23-E Private health insurers have already seen the potential for using the plain old telephone in health care delivery. fluoroscopy. A three-dimensional model can be computed from multiple scans.2.1.. p. VA. use of a broader term is perhaps desirable. The magnets are used to align the 21 p.05. teleradiology refers to the electronic transmission of radiological images from one location to another for the purpose of interpretation or consultation. 5.96 22 23 TMP_E\ITU-D\CONF-D\CRDT96\AR\000\023E. PPP Healthcare in the United Kingdom has introduced a customer helpline staffed by nurses. Spring 1996. Because there are other types of images (e. and ultrasound and could include nuclear medicine. he or she is surrounded by extremely powerful electromagnets. For example. CT scanners allow an image of the tissue density to be computed like a slice through the patient. by G.WW7 (34900) . It takes about 500 calls a week from policy-holders who do not think their problem is serious enough for them to visit their GP.3 Magnetic resonance (MR) MR machines today are used increasingly in modern hospitals because of the fact that the patient is not exposed to dangerous radiation and no injection is required. photographic and microscopic) available to a diagnostician.1. and digital subtraction. To generate a CT image. the magazine for residential Mercury customers. The surgeon planning the surgery can manipulate the image using the computer. Medical Progress through Technology. Brauer. thermography.23 5.2 Visual (image transfer) The different types of images produced and transferred in radiology departments today are identified below: 5. It covers X-rays. 1992. "Telehealth: the delayed revolution in health care". Reston. 1994.g.2 Computed tomography (CT) X-rays are also used in CT.1 X-ray These images are taken by passing X-rays through a portion of the body and recording the amount of X-radiation that is not absorbed.2. American College of Radiology. As the patient goes through. An X-ray is the most frequently used mode of medical imaging. 153.1 Teleradiology Radiology is the scientific study of X-rays and other high-energy radiation used in the medical profession.2. The term teleradiology is rather limited.2. Others just want more information about their condition in plain English. the patient lies on a table. 11.03 11. which passes through a donut-shaped scanner.21 5. Strictly speaking. Each of those applications can produce an image of the patient's anatomy and/or pathology. computed tomography (CT).

. Both MR and ultrasound are able to detect soft tissue. The nuclei return to their former orientation and emit radiation which is picked up by a receiver coil. which is opaque to X-rays. 5. such as heart beat and respiration. TMP_E\ITU-D\CONF-D\CRDT96\AR\000\023E. 5.10. There is a slight difference in the arrival times of the gamma rays at the detectors which can be used to estimate the position of the emission. Like MR.1. This can be used to detect blockages in blood vessels. the patient is not exposed to X-rays or injections. it does not penetrate the contrast substance.7 Fluoroscopy (Angiography) This technique is used to study patient physiology.1.03 11. The equipment consists of a ring of detectors. The final image highlights the contrast agent without confusion from shadows of other body parts.4 Ultrasound (U/S) As its name implies. it is not particularly accurate for diagnosis.1. i. 5. Most of the background noise in the image is removed. they are utterly destroyed by interaction with electrons. which represent the flow of blood through blood vessels.e. gynaecology and emergency medicine. including cardiology. a phenomenon which permits construction of a three-dimensional image. two gamma rays travelling in opposite directions are produced. The medical staff are able to obtain information on the elastic and mechanical properties of human tissue. The speed of the viewing can be increased or decreased.2.1. obstetrics. 5.2. Ultrasound is the preferred non-invasive diagnostic tool in many medical specialities. and a series of digital X-ray images are made at regular time intervals. and the two digital images are numerically subtracted.8 Digital subtraction angiography (DSA) Here an X-ray is taken by using digital detectors. The physician can view them in real time or can store them on a magnetic tape for future viewing on a video tape recorder (VCR). After this operation. As a result. Although it can be used to follow the course of a disease.1. another X-ray is taken with the patient positioned exactly as before. which is positioned around the patient lying on an examination table. It is less expensive than MR and CT scans. The reflected waves are then recorded.. When this is completed the patient is injected with a contrast material. the other is Positron Emission Tomography (PET). and this alignment is then distributed by a radio frequency pulse. The SPECT machine picks up all gamma-ray photons emitted from the body.2. internal medicine. One is for Single Photon Emission Computed Tomography (SPECT). such as iodine. Two types of machines are used.5 Nuclear medicine (NM) The basic principle of nuclear medicine is injecting the patient with a radioactive substance and detecting the gamma rays that are emitted. 5.05.96 . The one disadvantage of this radiological method is that the patient may require repeated exposure to X-rays.2. which can be used to construct two-dimensional images. The patient is injected with a contrast agent. The analysis of this radiation identifies the concentration of certain atoms within the body.2.6 Thermography This uses infrared detectors to measure heat radiated from the surface of the skin.WW7 (34900) 11.12 AR-CRDT-96/23-E atomic nuclei in the body. PET relies on the fact that when positrons are emitted from the radioactive substance. ultrasound involves passing a high-frequency sound wave (2-4 MHz) into the patient's body. such as tumours and lesions.

Flotte. Colvin. to magnify a particular part of the image. i. A video camera was used to record the image. one of the first teleradiology uses was in 1967. H.25 The time for the compression took approximately one minute per radiograph. This was done by using a wavelet-based algorithm.1.24 Images derived from CT. 1496. R. p. Once the image is converted into digital . ultrasound or nuclear medicine are produced digitally at the outset. It was installed at both the transmitting and receiving ends of the system. X-rays were viewed through a video monitor. Goldberg. it can be compressed for more efficient storage and/or transmission via telecommunications to a distant location. 24 25 p. "Quality Assurance in Teleradiology". An RSTAR diagnostic workstation (Model DWS-2000) was used to display the digitized images. either by using a laser digitizer or a charge coupled device (CCD) scanner. produced by Aware. on a Sun SparcStation 10. appropriate demographic information was entered and the image was compressed using data compression software. T. 11.B..10. Forsberg.03 11. • Teleradiology at long distances A demonstration was performed between Massachusetts General Hospital (MGH) and two sites in the Middle East.96 TMP_E\ITU-D\CONF-D\CRDT96\AR\000\023E. The digitizer had a resolution of 1664 x 2020 x 12 bits. the examples given here are from 1990 onwards. D. by D. Normal analogue X-rays need to be converted into digital form. They were digitized in the same manner as normal radiographs. & J.WW7 (34900) . Although there were teleradiology experiments conducted in the 1970s and 1980s. Abu Dhabi in the United Arab Emirates (UAE) and Riyadh in Saudi Arabia in 1994. Telemedicine Journal.9 Image capture The first step in the teleradiology process is capturing the image(s) for interpretation. MRI. The workstation allows the user to manipulate the images to his liking. These are what most radiology departments use. Alternatively these can be captured by a video frame grabber using the analogue video signal.05.13 AR-CRDT-96/23-E 5. "Making Global Telemedicine Practical and Affordable: Demonstrations from the Middle East" by M. the radiograph was digitized. Rosenthal.A. Production of a plain radiograph in digital form can be done either by computed radiography or by converting it to a digital form from the original analogue radiograph. S. 1995. American Journal of Roentgenology. Thrall. Sharif. To transmit a radiograph from the remote site. Schaffer. The system that was used for teleradiology included a film digitizer.2. Examples of teleradiology As mentioned above.e. 107. which was an RSTAR product (Model FDS-100) used for image acquisition and which included a Lumiscan 150 laser digitizer with computer equipment for input of history and demographic information. Today the methods and equipment used are much more sophisticated than they were 30 years ago although there are still examples where a video camera is used to record images. 1994. Advances in compression technology and improvements in the telecommunication infrastructure will enable radiology departments to capture digital images directly. Although direct digital capture of CT and MR is possible it was not implemented for this demonstration.

28 The two sites are linked by an ISDN line. by A. then the physician at Belfast can ask the nurse to adjust the video camera until he is satisfied that the image is clear enough for diagnosis. 1497.26 Telecommunication equipment was also used.B. by A. 23. The Specialist User of Current Innovative Technology: The Marketing of Telemedicine. This device performed the inverse multiplexing. The project involves a video link between the Minor Treatment Centre at the South Westminster Centre for Health. including a VC 7000 Video Phone with a "Sharp View Cam" handheld video camera that anyone can buy in a high street shop. Rosenthal. The Specialist User of Current Innovative Technology: The Marketing of Telemedicine. American Journal of Roentgenology. The nurse at the Minor Treatment Centre places the X-ray on a normal light box and positions the "View Cam" so that it captures the image of the X-ray. T. These were a NetBlazer ST multiprotocol router which was supplied by Telebit. Flotte. The equipment used at St Mary's Hospital included a BT VC2300 video codec. Aref. Inverse multiplexing technology was used so that four telephone lines could be used simultaneously for data transmission.27 The telecom link is an ISDN line. 1994. Unpublished thesis for BSc (Honours).03 11. Thrall. Isle of Wight. mobile control console. p. May 1995. & J. Teleradiology in this example is a very simple operation. Also high-speed modems by Motorola Codex were used. South Bank University London. Sharif. The network protocol used was Transmission Control Protocol/Internet Protocol (TCP/IP). Goldberg. Aref. 25. Next to the scanner there is a small. Teleradiology using low cost equipment A telemedicine project funded by British Telecom has demonstrated low cost teleradiology applications. The "Sharp View Cam" is connected to the VC 7000 Video Phone..10. p. This way. the emergency physician at Belfast is able to see the X-ray and make a diagnosis. Mary's Hospital. Foetal medicine deals with the diagnosis and treatment of diseases in the unborn child. Schaffer. H. The equipment which is supplied by BT comprises a series of off-the-shelf components. The data that arrived at the receiving end were decompressed and displayed on a high-resolution video monitor for interpretation.96 27 28 TMP_E\ITU-D\CONF-D\CRDT96\AR\000\023E. R. If the image is not very clear. Unpublished thesis for BSc (Honours). "Making Global Telemedicine Practical and Affordable: Demonstrations from the Middle East" by M. Colvin. This product is manufactured by BT and has been specifically designed for the transmission of real-time foetal ultrasound images over ISDN networks.14 AR-CRDT-96/23-E • • The compressed images were transmitted over dial-up telephone lines. May 1995. Newport. 11. run by nurse practitioners. floor mounted. S. This field of gynaecology uses ultrasound scanners. The video codec digitizes and compresses the video image from the ultrasound scanner. D. South Bank University London. and the Accident and Emergency centre at Belfast's Royal Victoria Hospital. 26 p. The trial links the Centre for Foetal Care (a national centre for excellence in foetal medicine) at Queen Charlotte's Hospital in West London (which provides expert advice) with the Maternity Unit at St.WW7 (34900) .05. Teleradiology (using ultrasound) British Telecom (BT) is also funding a telemedicine project which deals with foetal scanning.

"Current Issues in Telepathology". There is also a small video camera mounted on top of the TV which is focused on the consultant. This process takes time (which the patient might not have). Flotte. Using special modems and synchronous/asynchronous converters. which displays the image being transmitted. In 25 cases.03 11. In 20 of the 25 cases. 1995. Telemedicine Journal. there is a large amount of information (diagnostic and prognostic) available from the examination of biopsy material that requires an extensive knowledge of diseases and their clinical implications. "Point to point telemedicine using ISDN". Hence consultations are an important practice in pathology. Fisk. Schaffer & T. Conference Proceedings. and it costs money. Darkins. 29 p. by A.2.96 30 TMP_E\ITU-D\CONF-D\CRDT96\AR\000\023E. and with the bodily changes wrought by disease. the patient was counselled face-to-face over the link. while in the remainder it was deemed to be more appropriate for this to be carried out by the staff in the Isle of Wight. 5. Sometimes these studies cannot be performed at the referring site and hence the pathology material would have to be sent to the consultative site for processing. Also pathologists frequently need opinions from those who specialize in various diseases. In the first six months of operation.15 AR-CRDT-96/23-E • A low light camera which is mounted on the wall within the scanning room captures a general view of the patient during the scan. Wootton.10. The control console is used by the sonographer to decide which images are sent to the consultant. Telemed 95: Medicine on the SuperHighway. Telepathology involves rendering diagnostic opinions on specimens at remote locations using computer and telecommunications technologies. P. This package offers a data transfer rate of 19. by S. transmission speeds up to 56 kbit/s were attained while delivering high quality images. the objective of one such trial was to study how accurate and acceptable nuclear medicine images can be when transmitted between two hospitals hundreds of kilometres apart. 95.30 In pathology. The participating hospitals were equipped with personal computers running an Elscint communications software package..B. In order for the sonographer to be sure the correct image is being viewed by the specialist. Special studies on a pathology specimen are frequently performed after the initial evaluation of the microscopical preparations. the console has a small LCD monitor. N. November 1995 p.2 Telepathology Pathology is the area of medical science which deals with the causes and nature of disease. 11. a definitive diagnosis was made using the telemedicine link and physical referral was avoided.J. Also pathological specimens need to be kept under special conditions where external bacteria cannot be allowed to enter their environment otherwise they would be ruined and an examination of the specimen will not be possible.2 kbit/s utilising standard telephone lines. The equipment at Queen Charlotte's Hospital is similar with one exception.29 Teleradiology using nuclear medicine There have been numerous trials of high speed data transmission. Garner and R. the link was used for 39 consultations involving 29 patients.05. They have a large TV screen on which the ultrasound scan is viewed. In Canada. 149.WW7 (34900) .

g. 1995. Flotte. A histopathological slide specimen was transmitted from Riyadh to the MGH over normal telephone lines. by S.J. The images were scanned and compressed. Other options available are image compression which can increase the number of images that can be transmitted (e. refer to "Current Issues in Telepathology". A commercial videophone card and minicamera are attached to each surgery's personal computer and a high definition camcorder is also available if more detailed images are needed. via a dedicated 2 Mbps point-to-point telecommunications link. however. There are systems that combine limited robotic capabilities with high-resolution still images.WW7 (34900) . There are two ways to do this in pathology: remote dynamic screening by robotic video microscopy and remote diagnosis from selected still video microscopical images. The other method. a hybrid system combining the limited robotic capabilities with high resolution images was set up using a dial-up (switched ISDN) 64 kbps connection. a remote. Again ISDN was used for communications. Examples of telepathology • A demonstration was performed between Massachusetts General Hospital (MGH) and Riyadh in Saudi Arabia in 1994. The projects mentioned above were relatively low cost applications. JPEG is the standard that is used currently for compression technology. 31 5..000 patients.96 32 TMP_E\ITU-D\CONF-D\CRDT96\AR\000\023E.05. a study was conducted in the use of telepathology in kidney and liver transplantation pathology. has the disadvantage of significant reduction in the data. To any pathologists the former is the most attractive system. 23.10. "Just pick up the phone and say aah". p.2.. it requires very high speed telecommunications links.B. A voice only consultation via the telephone will not do. Schaffer & T.3 Teledermatology Dermatology is that branch of medical science which deals with the skin and its diseases. by Charles Arthur. though cheaper than the former.16 AR-CRDT-96/23-E Telepathology can minimize these limiting factors. May 1995. • In Norway. over a limited telecommunications infrastructure). • In Japan. New Scientist. and the images were acquired at 450 lines of horizontal resolution. • In a Swiss project. The images were observed through a high definition monitor. 11. robotic video microscope telepathology system was set up for experimentation. Example of teledermatology • Teledermatology has been carried out successfully in Wales (United Kingdom) where consultants diagnose patients' skin problems remotely using videophones. Then they were transmitted to the MGH where decompression of the images took place. and where the images were read by pathologists.03 11. 31 For more detail.32 Eight general practice surgeries in Montgomeryshire are involved in this scheme which covers 30 GPs and 65. Teledermatology involves image transfer because dermatologists must be able to look at the affected area of the skin in order to make a diagnosis. Telemedicine Journal.

They now visit their GP. With the introduction of teledermatology. Teledermatology therefore can be well suited for the control and follow-up of patients who have already been examined by the dermatologist in the normal manner. British Telecom and IBM are funding this exercise.3 Data 5.03 11. Doctors can retrieve information about their patients instantly. 33 34 p. and the transmission of patient records. These remote consultations were followed up by face-to-face meetings to check whether the dermatologist's diagnosis was the same in each case. by Charles Arthur. May 1995. "Just pick up the phone and say aah".400 and EDIFACT standards. clinics and other health institutions around the world use computer systems for patient.. Consultants also save time. it has taken several months to get some routine outpatient appointments in Bronglais. "that's all time that could be spent seeing patients". New Scientist.10. Many hospitals. 5. 23.96 TMP_E\ITU-D\CONF-D\CRDT96\AR\000\023E. New Scientist. administrative and financial applications. bulletin boards for the exchange of information between clinicians. who is in charge of the scheme for the Institute of Health Informatics which is the academic body that organized the trial. There is no need to purchase PCs because most surgeries have ones that are powerful enough to run the system. According to Stewart Low. ISDN telephone line.34 The drawback of this application is the lack of normal contact with the patient. 23. p. May 1995. "Just pick up the phone and say aah". This may produce an dissatisfying consultation for both the specialists and the patients. print out prescriptions to give to their patients and retain an electronic record of the prescription at the same time.3. by Charles Arthur. referral letters and test results between GPs and hospitals. Among the benefits is the elimination of patients' waiting time.33 This system costs around £2. clinical physiology and financial data using the X. Visiting doctors can access patient records and update the data from a distance. 80 miles away from Montgomeryshire. email for administrative purposes. However.WW7 (34900) . they can spend up to two-thirds of their time travelling between appointments. 22 were given the same diagnosis face-to-face as by videophone. biology. According to Low.05.000 for the videophone and £900 for the camcorder both off the shelf equipment. Pictures from the camcorder are captured by the computer and sent to the hospital electronically. who operates the videophone and camera as requested by the consultant. the patients have no need to travel to the hospital.17 AR-CRDT-96/23-E In the past. The other two could not be diagnosed at either meeting". "of 24 patients. a patient with a dermatological problem that his GP cannot solve would have been sent for an appointment with a consultant in Bronglais hospital in Aberystwyth. a pictorial database of poisonous plants. Telemedicine can be used to keep patient records up to date. Many have stored their medical records and databases electronically.1 On-line access to databases Many hospitals and private practitioners exchange radiology. 11. Among the data exchanged could be records of the outcome of treatments. In remote areas. The link-up required a fast.

WW7 (34900) 11. together with Hewlett-Packard. the German printing and publishing group. This is another way a health professional can obtain anything from patient medical history to information on the latest drugs in the market..18 AR-CRDT-96/23-E There are many specialized medical databases. In some instances. summaries of medical news. etc. Bruda.05. for connect time or for both. Medical Progress through Technology. Brauer. 35 p. can be accessed via the Internet. is also possible. Sun Microsystems and Netscape have produced a commercial Internet service called Health Online. the user pays for access. a United Kingdom company based in Taunton. news of conferences. and discussion forums. Image retrieval of X-rays. This telemedicine application of telemetry was demonstrated at the G-7 ministerial conference on the Information Society and Development in Midrand. 5. South Africa in May 1996. Telehealth: the delayed revolution in health care. such as MEDLARS. Surrey. • Picture Archival and Communications System (PACS) PACS is a network where different departments in a hospital are able to communicate with each other and to transfer patient records. MEDLINE and others. hospital accounts and other administrative records.3. TMP_E\ITU-D\CONF-D\CRDT96\AR\000\023E. They generally required access via computer and particular protocols. 1992. information on medical products. MRIs. The service provides doctors with access to medical databases.96 .10. by G. the kit is expected to include a lap-top computer where the information will be gathered electronically. The service is based on Netscape's publishing system and browser software and uses Digital's advanced encrypted "tunnelling" technology to provide users with a secure on-line service over public switched telephone lines. • Fax Today faxes have become universally associated with information exchange. access can be free. in others. 153. United Airlines is one of the first airlines to announce its intentions to provide such a service to passengers. especially in the developed countries. Telemedic Systems has been negotiating agreements for production of its telemetry system for use on board aircraft.35 One of the first telemetry experiments was conducted by NASA when physicians on earth began monitoring astronauts' physiological functions while they were in space. has developed a briefcase kit for monitoring the vital signs of patients in remote areas and transmitting the data to hospitals or doctors some distance away.. • Internet Medical databases. Digital Equipment. and retransmitted to a doctor who will be able to give advice based on the information he or she has received.03 11.W. When it goes into commercial production. Telemedic Systems Ltd. CTs.2 Telemetry Telemetry has been described as providing a means for monitoring and studying human and animal physiological functions from a remote site. More recently. publications. MEDLINE contains 8 million articles in 20 languages.

videoconferencing. • The Mayo Clinic in America has an extraordinary concentration of world-class experts who cover almost every medical speciality. The Internet in particular has facilitated international information gathering. To take psychiatry as an example. 154.. and the psychiatrist at the UHT can see and hear each other through a television screen. i. by Amy Roffmann Nev. Teleconsultation has been described as a special form of clinical information exchange. Teleconsultation is more than just information exchange. etc. it has become easier to obtain information. The Minor Treatment Centre and Queen Charlotte's Hospital in London are linked to Belfast's Royal Victoria Hospital and the Isle of Wight's St Mary's 36 p.1 Teleconsultation Telemedicine networks offer the opportunity for consultations between doctors and others in healthcare. its Rochester site has set up a three-way telemedicine link in order to make full use of these specialists. 1992 p. Brauer. In today's world. Many doctors today are adding email communications to alert patients of routine test results or to answer simple questions.10. 115.36 The simplest example of this application uses only the telephone. One of those applications is a video conference system based on a broadband network which is the basis for a regular contact between general practitioners in rural areas and doctors at UHT in the fields of dermatology. 11.37 • Norwegian Telecom Research and the medical experts at the University Hospital of Tromso (UHT) in Norway have developed telemedical applications within many fields of medicine. 1995. the remote patient.WW7 (34900) . otorhinolaryngology and psychiatry. situated in his or her own room. It could also include a form of therapy.03 11.W. a doctor can have a video consultation with a specialist who might be in another country.. Consultation can take place via telephone.05. There is a question of the extent to which a patient is willing to "open up" to a physician viewed on a TV screen. "Telemedicine: Remote Control Health Care". specialists and other health workers can communicate with each other via email either giving or receiving advice. September. a doctor can ask another doctor for a second opinion via the telephone. Examples of teleconsultations With the advent of computer networks. With Mayo's Arizona and Florida branch locations. The difference in this kind of therapy is the patient has a remote control and whenever he does not like what the psychiatrist is saying to him he can switch off the television screen. • The two United Kingdom projects mentioned above are using British Telecom technology for videoconferencing. This can be called teletherapy. Hemispheres. email. The consultation can be in real time (as with telephony) or store-and-forward techniques can be used (as with email).96 37 TMP_E\ITU-D\CONF-D\CRDT96\AR\000\023E.19 AR-CRDT-96/23-E 5.4 Utilization of services 5. "Telehealth: the delayed revolution in health care" by G.e. Also doctors. The three sites communicate via high-quality videoconferencing.4. It is also possible for a paramedic with a headset equipped with a camera and a microphone (such as the CamNet system) to consult via satellite with a doctor while the former is dealing with an emergency. Medical Progress through Technology.

The instructor at UHT receives the images transmitted from this ultrasound unit. the telemedicine events create a forum for continuing medical education.WW7 (34900) . thus enabling the physicians from Kirkenes to use the equipment on their own. hygiene.154. The University Hospital of Tromso (UHT) set up a video conference link with Kirkenes. the equipment at Kirkenes Hospital was not used very often. "Telehealth: the delayed revolution in health care" by G.10. Tele-education consists of three areas: distance education.20 AR-CRDT-96/23-E Hospital respectively by a teleconsultation system. Examples of tele-education • In the United Kingdom.education on diet. Also the system will utilize a multimedia information resource to maximize the use of the network facilities.W. the heart of the videoconferencing technology is a BT videophone.38 Distance education could involve a small rural teaching hospital linked to a major city teaching hospital. UHT wanted to find out whether they could provide training in echocardiography via videoconferencing. Kirkenes Hospital has modern echocardiography equipment for use by cardiologists. effective health care infrastructure requires not only access to expertise. The possibilities of telecommunication in the delivery of education to vast unreached populations and in promoting the transfer of essential knowledge to and within developing countries holds promise. Students at the rural site can "attend" a lecture conducted by a professor at the big teaching hospital. Education may improve the chances of early detection and reduce subsequent treatment requirements. In addition.. Medical Progress through Technology. and certainly represent one of the major development activities which stand to benefit most from appropriate use of telecommunication. access to remote information and community health education. The patient benefits by not 38 p. 1992 11. the network infrastructure can also be used to access on-line services or participate in seminars through videoconferencing. Telemedicine and telehealth services offer the opportunity for training and education. Hence physicians at Kirkenes Hospital while examining the patient receive instructions from experienced UHT heart specialists via the video conference. Paramedics or junior hospital staff can witness or be informed about particular medical techniques and practices. • In Norway. and the many other basic requirements for a physically healthy society. Brauer. A camera was connected to the echocardiogram unit camera by an ordinary video cable. but on-going medical education of health care professionals and the public. The network presence also provides an opportunity to disseminate preventative health care information. 5. In both projects.05.96 TMP_E\ITU-D\CONF-D\CRDT96\AR\000\023E. Tele-education may help reduce the many of the demands on the health care system by focusing on prevention -. A video conference studio was installed in Kirkenes. a project for distance teaching of surgery uses the SuperJANET ATM video network to link six major universities in the United Kingdom.2 Tele-education It has also become apparent in recent years that an efficient. With the participation of local representatives.4. Echocardiography is the examination of the structure and function of the heart using reflected pulsed ultrasound.03 11. Because of staff shortages. Education and training are widely seen as the most important factor in achieving sustainable development.

4.05. The distance did not affect the quality of the transmission. Satellite transmission of otorhinolaryngology examinations from Alta to the far north islands of Svalbard have been conducted as well. At one studio there was the GP and a specialist at the other. International TMP_E\ITU-D\CONF-D\CRDT96\AR\000\023E. One third of the population of Latin America has no access to any medical care. • Another example of tele-education comes from Norway. Hence in 1991 the department decided to conduct a test on whether they could teach general practitioners (GP) endoscopic examination techniques using telematic instructions. – an improvement in the flow of information from the GP and specialist. to set up their own practices or to join another in these areas. This tele-education system gives these doctors access to resources that would not otherwise be available. Endoscopy is any technique for visual inspection of the internal organs. It involves the Department of Otorhinolaryngology at the University Hospital in Tromso. The experiments involved 17 patients. In Africa..96 . decentralized medical specialist service. – an increase in the GP's level of confidence. Civil conflict. Telemedicine can also be used in international disasters to assist relief workers by providing them with instant support from health care professionals not located at an emergency site. The GPs and the specialists agreed on the findings in all 17 patients. 5. Some of the benefits that resulted from the experiments included: – less public spending due to the reduction of travel on the part of the specialist and the patient. Although the population enjoyed a good. an even larger proportion of the population has no access to health care. It was to be transmitted via the existing telenetwork to a centrally placed specialist.WW7 (34900) 11. droughts and natural and man-made disasters can bring death and tragedy to thousands or even millions of people very quickly. For the last 15 years. once they graduate. The aim of the programme is to encourage these doctors. the department staff have travelled extensively in Finnmark county in Norway.3 Medical emergencies and disaster relief A major requirement in developing countries is the delivery of medical care in the event of an emergency. They were examined under controlled conditions with simulated telecommunications between two video conference studios in Tromso. Refugees arriving from remote and rural areas to other remote or rural areas or cities can place huge demands on quick medical relief. Seven patients were examined. The school has a family practice training programme where trainees live in rural areas and are supervised over the state telemedical network. The transmission was of images from the nose and throat. • Community health education in North Carolina has benefited from the application of telecommunications with a system organized by East Carolina University College of Medicine in Greenville. • Another experiment was conducted between Tromso and Alta in the Finnmark county.03 11.10.21 AR-CRDT-96/23-E needing to travel in order to get treatment and the physicians at Kirkenes Hospital benefit from more training. Today's modern instruments are usually flexible fibre-optic devices and additional facilities for biopsy. often in areas with no means of communications. both with referred patients and in emergencies. it was very expensive to carry out. nose and throat. Otorhinolaryngology is that part of surgical science which deals with diseases of the ear.

Such technology can include radio pagers.96 TMP_E\ITU-D\CONF-D\CRDT96\AR\000\023E.. The paramedic has to be able to warn the emergency medical staff that they are about to receive a patient in a critical condition so they can prepare for the case. The GETS project will also use mobile satellite communications.WW7 (34900) . An Inmarsat-M terminal was used as a communications medium when specialists first started to arrive. Communications are vital for medical emergency services.10. It meets the objective of the G-7 and European Union policy for "Global Healthcare Applications". • GETS The European Commission is planning a Global Emergency Telemedicine Service (GETS) as part of project under the G-7 initiative in Brussels in February 1995.03 11. The overall objective of MERMAID is to establish a transnational and multi-lingual health emergency system which will make telemedical intervention more effective and widely available as well as improving service management 39 p. 1995 11. This will be achieved by ensuring the continuous availability of qualified advice which in turn will be achieved by interconnecting different medical centres.39 Health care professionals in the field need the assistance of other medical professionals. a collaborative effort between the United States Department of State and the United Nations Department of Humanitarian Affairs. especially those found in the emergency department of a hospital. Yoho. It is a sub-project of the G7 Global Healthcare Applications. Examples of telemedicine in emergencies • Reliefnet. Its objective is to establish a transnational and multilingual health emergency system which will be able to improve the promptness and effectiveness of interventions and service management through telematic interconnections of the emergency points of care of all of the participants and services involved.R. plans to create a telecommunications network [date?] that would improve the exchange of information related to decisionmaking and operational coordination of humanitarian emergencies with the goal of saving lives.05. Wireless communications technology may be applied to medical emergency services. mobile earth stations and personal communication services. This network would provide general information on humanitarian emergencies to a wider public including the media and would improve information flow between emergency relief offices and field operations in participating countries. • When the highly contagious and deadly Ebola disease broke out in Zaire. cellular telephones. GETS is providing a framework for 24-hour. "Wireless communications in medicine" by D. several days lapsed before any news of the event was picked up by the outside world. radios. European Hospital Management.22 AR-CRDT-96/23-E organizations have long understood the potential of communication and information technologies and have used telemedicine applications to respond to natural disasters and complex emergencies around the world since the 1960s. • MERMAID Medical Emergency Aid Through Telematics (MERMAID) is pilot project for a 24-hour-a-day multilingual telemedicine surveillance and emergency services in the maritime sector. 51. multi-lingual telemedicine surveillance and emergency services around the world.

The one important factor that is missing from the telesurgery concept is replicating the surgeon's sense of touch. but also general technical development. head of BT Laboratories in the United Kingdom.96 . The start-up MERMAID service is aimed at about 100 ships equipped with ship earth stations. taking place. Cellular. This accomplished. and high bandwidth requirements.4 Telesurgery/virtual reality Telesurgery is basically surgery at a distance. cameras are being developed which move to follow the surgeon's eyes. data transfer with low. Examples of telesurgery • One telesurgery experiment has involved a link between the Netherlands and Hawaii. Peter Cochrane.23 AR-CRDT-96/23-E of the telematic interconnection of the emergency points of care and of all individuals and services involved. The United States Army is the main organization conducting extensive research and experiments in this area of telesurgery.. let alone developing countries. Biopsy specimens are being analysed at a distance today.4. satellite and broadband. Most telemedicine applications can be found in the following categories: audio and videoconferencing. it is important to evaluate not only capabilities and the cost/performance trade-offs. The surgeon "operated" in front of a computer with an image of the prostate and through remote control was able to conduct the biopsy through use of robotics with only an assistant present in the hospital. 6 Technologies for diffusion of telemedicine Developing countries can benefit from using information technology and telecommunications networks to improve health care in remote and rural areas. believes that by the beginning of the 21st century synthetic skin with all the tactile qualities of human skin will be available. TMP_E\ITU-D\CONF-D\CRDT96\AR\000\023E. where a gall bladder operation took place.WW7 (34900) 11. 5. multimedia communications. This will allow surgeons thousands of miles away from the patient to feel them as if they were in the same room.10. Telerobotics or telesurgery are now being developed in connection with image analysis machines such as magnetic resonance and computerized tomography. the next phase is to operate a robotic arm by remote control via a telephone line. wireless and satellite technologies are options which should be considered in providing health care to remote locations. some solutions require only basic infrastructure to provide health care services to remote areas. When considering telemedicine and telecommunications technologies. The surgeon from the Netherlands has also been conducting experiments using a robot arm to operate an endoscope in a laparoscopic or key hole surgery. In the United States. medium.03 11. This application is still years away from becoming widespread because of its complexity and relatively high cost in today's economic climate in developed countries. Experiments are. The prevalent range of network choices includes basic telephony. Although advanced telemedicine applications may require sophisticated and expensive telecommunications infrastructure. A patient was in the hospital in Milan while the surgeon was some kilometres away in the Politecnico. however. Robotic arms are also being used on patients to remove tumours and for drilling holes in bones for attaching pins and supports. One of the surgeons was performing the operation while the other was giving advice via a television screen. cellular/wireless. the Politecnico di Milano made the first telesurgery for a prostate biopsy. • In September 1995.05. digital land line.

pictures and other printed material. a suitable modem and appropriate software. by D.R. Cellular telephones allow two-way communication via radio links established between the cellular telephones and radio sites located within a particular geographic area. data and other communications.4 to 16 kbit/s. The telephone service can be delivered via fibre optic cable or copper wire or HF radio or digital satellite. 51.1. Some of today's pagers have voice and email. 1995 11. They provide convenient and familiar means of communicating in medical emergencies. Among other things. Also if a small scanner is added with a modem capable of fax transmission and the appropriate software.1.05. Messages can take several forms: the caller's actual voice. global interconnectivity is not possible at this time. it is important to mention that there are several different and incompatible cellular standards in use around the world.40 However. especially in remote and rural areas.1 Plain old telephone service Basic telephony (or plain old telephone service (POTS) as it is sometimes described) can be delivered via wireline and wireless means. The caller is able to transmit voice or computer-composed text and information via telephone to the carrier.3 Radio Radio pagers receive messages initiated by callers using a telephone. 6. Radios are used for two-way communications via a specified pre-set radio frequencies.1 Telecommunications technologies 6. Yoho. Recent advances in this technology make it possible for a caller to send large amount of medical data directly to the radio pager. European Hospital Management..WW7 (34900) .1. relatively simple technologies. If used with a personal computer. cellular radio can be used for the transmission of ECG from ambulances to hospitals. Some computer manufacturers offer portable computers with interfaces to cellular phones. a cellular telephone can transmit and receive text. such as copper wire or HF radio. biosignals. are used and consequently they often become the determining factor of the sophistication of telemedicine services available in these countries.10.24 AR-CRDT-96/23-E 6. In most developing countries. 6. telephone number or a short text message. the computer can act as a fax machine capable of receiving and transmitting medical reports.96 TMP_E\ITU-D\CONF-D\CRDT96\AR\000\023E. "Wireless communications in medicine". In other words. through greater power and larger antennas it is possible to communicate over longer distances. Today though.03 11. 40 p.2 Cellular radio Cellular radio provides mobile telephony and data transmission in the range of 2. The only drawback for hand held radios is the limited distance allowed (a few kilometres).

10. For the specialist. Use of a videophone may eliminate the need for a patient to travel great distances for a specialist consultation.96 . the VC7000 is basically a phone with a monitor where you can see the person you are talking to and vice-versa. The camera has a view indicator to help maintain position within camera range. Olivetti or ICL. Images. The image for desktop videoconferencing is provided by a miniature video camera.WW7 (34900) 11. microwave. telephone. with a 3. It has a one-way video mode which lets you see without being seen. There are screen messages to remind the user when to press a button.25 AR-CRDT-96/23-E 6. The audio unit is just a normal phone connected to the PC. The videophone is simple to install and use.03 11. where both users can see each other. two-way television. computer and satellite technology to link isolated and rural areas to urban medical practices. discuss a case and examine a patient. • BT VC 7000 BT has developed a number of products which can be used for telemedicine applications. compact and easy to transport. the benefit is that he or she can see more people in a wider geographical coverage.05.4 Videophones Videophones enable a GP and a specialist (or anyone for that matter) to see and talk to each other. BT's PC Videophone has the ability to convert a PC into a full motion. The VC7000 is user friendly. an integral camera.1. One can either use it directly or from the PC. exchange notes. The screen is a 10-inch colour monitor. AT&T's VideoPhone consists of a full colour motion video. it plugs into any standard electrical outlet and modular telephone jack. It lets you hear and see -. Examples of videophones which have reached the market include the following: • VideoPhone 2500 AT&T has produced a VideoPhone which. screen brightness control and handset and speaker volume control. graphics. full colour multimedia terminal enabling the exchange of information (visual and written). and the GP has the advantage of obtaining better information through contact with the specialist. is the world's first personal video telephone. There is a multi-level focus control. TMP_E\ITU-D\CONF-D\CRDT96\AR\000\023E. according to the company. There is a built-in microphone and loudspeaker. The PC Videophone comprises a VC8000 multimedia communications card. as well as a two-way mode. in motion -. Although a handset is available. a telephone handset.5 Satellites Satellite technology has been used to deliver telemedicine services to areas that lack an advanced terrestrial network since the 1960s when health care professionals in Canada. The CCD colour camera is fixed with a tilt-only capability. It has automatic exposure levelling. It has been designed to be compact and portable.1. it has a hands-free mode when more people are present in the room. microphone and a codec. It has tilt and swivel features which ensure easy framing of images. It is possible to connect an external camera such as a Camcorder to the VC7000 in order to be more flexible and have more mobility.in colour.the people you are talking to.. an audio unit and a choice of application software supplied by IBM. 6. text and other applications can be shared by opening a "window" on the PC screen. a miniature video camera. It consists of a monitor. loudspeaker. The VC8000 multimedia card fits into the PC. At its simplest. keyboard control.3-inch (diagonal) colour LCD video screen and a fixed-focus camera lens with 1 to 9 foot focal range from a tilt/swivel console. The VC7000 Videoconferencing System has been used in a number of telemedicine pilot projects in the United Kingdom. Australia and the United States began experimenting with radio.

Mobile satellite communications are also invaluable in the event of natural and man-made disasters. supplies management. either controlled by communications software. The V. portable. and the quicker the motion displayed. The higher (or "broader") it is. teleconsultation. Bandwidth is a way of expressing the maximum flow of information that a link can carry.1. videoconferencing. In addition. It is a modular standard allowing the user to configure his installation to his bandwidth needs (in multiples of 64 or 16 kilobits per second) and to access a wide range of additional services supplied either by the telecommunications operator of the network or by third parties. remote training of paramedics. colour and motion. The modems built to this standard are very robust. The latest modem technology (V. In other social programmes. causing distortion.05. particularly those severe enough to demand international assistance. mobile satellite communications can be used for activities such as tele-education.26 AR-CRDT-96/23-E Delivery of health care and other social programmes in remote regions is hampered by lack of infrastructure and high transportation costs. Multimedia is the simultaneous use of text.WW7 (34900) 11. TMP_E\ITU-D\CONF-D\CRDT96\AR\000\023E. the developing countries.96 ..7 Modems Relatively low-cost modems offer data rates of up to 19. Their independence of fixed telecoms and power infrastructures permits the continuation or restart of health care after a disaster. A wide bandwidth is often assumed to be necessary for realistic multimedia. dealing with medical emergencies via live two-way communications. Many modems are built to meet national PSTN specifications. 6. in particular. images. and can operate from a variety of power sources. Applications include delivery of basic information to remote clinics.2 kbit/s which is faster than many telephone networks can deliver the data. To counter the noise and distortion present on many communications links.10. Modems capable of much high data rates are on the market and are used for sophisticated applications such as videoconferencing. A big problem is that the audio transmit level for many modems (and fax machines) has been set too high. but also the higher the price. interactive records management. or by the modem's internal firmware.1.34 standard provides speeds up to 28.03 11. the sharper the images transmitted. access to specialized databases for retrieval of medical information. ISDN is not available in many countries. Certain key elements of such programmes can be delivered by using existing telecommunications systems and technologies.8 kbit/s. it is essential to have data error correction enabled. including a car battery.34 standard) has a higher resilience to noise on the line. Mobile satellite communications provide a medium for immediate as well as long term delivery of national health programmes to remote regions where other means would prove to be uneconomical.6 ISDN Integrated Services Digital Network is a widely accepted standard for digital telecommunications. administration of community initiatives. Today's mobile earth stations are small. various interpretations of the standard may lead to interoperability difficulties. and library catalogue access and book ordering. including video. public health monitoring. which can differ from country to country. Multimedia telemedicine conference systems can be delivered over ISDN networks. 6. and general administration. sound.

03 11.42 protocol. Currently motion can be shown on the equivalent of two digital telephone lines. This can be achieved by the computer sending data to the modem at a higher rate than the modem is sending. Higher data speeds permit a smoother appearance of motion. and then to continue after the amount of waiting data in the queue has been reduced. Compressed video is the process of transmitting only the essential motion in a sequence. In an ordinary television transmission. However. expanding the possible applications of telemedicine and resulting in lower costs. complex images can be transmitted in even shorter periods of time.96 . • hardware data compression is usually built into the modem. For the most efficient use of the data communications link while the modem operates in error correction/data compression mode. and is active during the real time transmission. the whole scene is transmitted over and over again to show motion. It allows the modem to regulate the amount of data fed to it by the computer. This can be handled by V. compression software can reduce the number of digitized bits to be transmitted by ratios of up 30:1 without any loss of resolution on the receiving end. Using a series of sophisticated mathematical algorithms. It eliminates the redundancy that is contained in most files. Local flow control can be done by hardware or by software. a technique for reducing the volume of a file in order to use less storage space or less time for transfer through a network.05... pictures. the equivalent of two digital telephone lines) the amount of motion one can see could be quite acceptable in many teaching and some clinical situations.27 AR-CRDT-96/23-E Flow control is used to control the information exchange between the different elements in a data communications link.1. if switched on. It can only be used if the transmission system is very reliable for it reduces the possibility of correcting errors. Most computer generated data. the lower the telecom charges. There are two types of flow control: • end-to-end between modems.WW7 (34900) 11. There are two forms of data compression: • software compression is usually done before the real transmission. • local flow control between the computer and the modem.e. This motion appears somewhat blurred. The ability to transmit medical images in the 1990s has been enhanced by the introduction of compression software. With compressed video equipment the background is sent only once and after that only moving portions are sent which are integrated appropriately into the background. TMP_E\ITU-D\CONF-D\CRDT96\AR\000\023E. "Loss-less" compression and decompression algorithms do not alter the file and allow compression by factors from 2 or 20 or more depending on the degree of redundancy in the uncompressed file. 6. If the modem gets too much data waiting to be sent. drawings. Use of this type of network would increase capacity for medical data transmission between hospitals. but can provide savings on telecommunications charges. it can signal to the computer to wait to avoid a buffer overflow and loss of data. the modem buffer has to be filled with some data. The smaller the data file.10. spreadsheets and ordinary text files contain redundant information which can be compressed into a smaller number of bytes without any information loss. even at slower speeds (i. using a commercial widely available package such as PKZIP/PKUNZIP. With fewer bits to be sent.8 Compression PC-based software packages are available which can be used for data compression. the shorter the transmission time. This requires much less capacity (carrier space) than television or full-motion transmission. It will add to the overall processing time (off line). PKARC and ARJ.

6. TMP_E\ITU-D\CONF-D\CRDT96\AR\000\023E. Today. • preventative care education. It is of the "packetswitching" type. Among limitations are its lack of confidentiality. medical professionals and organizations can jointly benefit from the wealth of information and support that is available.10. This allows for more efficient management of communications resources: only the packets where an error is detected have to be re-sent. • patient care and support. Email can be delivered by various systems such as the Internet and X.WW7 (34900) 11. only a few hundred (in 1995) had any access Web sites.. • remote diagnosis and consulting.11 Internet Internet is mainly a communication protocol (TCP/IP) and can be used by different equipment and networks. with only one font type and no variation in size or density) within the UNIX community. Internet has grown very quickly in recent years and seems likely to continue to do so.03 11. • teleworking for the disabled. and the routing of different packets can be optimized. Specific examples of Internet usage include: • medical training. absence of warranties in services. there are more than 100. file transfer. The volume of data is not sent in a continuous flow. X-400 is a standard for email which takes into account security and confidentiality requirements as well as complex file transfer needs.28 AR-CRDT-96/23-E 6. The Internet offers a considerable resource to the practice of telemedicine. It was initially developed for communication of "plain" text (i. destination and transmission error detection.000 hospitals around the world with more than 50 beds. but of those hospitals. 6. Today.1. This resource is of equal potential value to more developed and developing economies. such as Lotus cc:mail. taking into account the density of traffic at any given moment on each segment of the network. The exponential growth of Internet access and usage now means that patients. more than a thousand World Wide Web servers are specialized in the medical field.e.400 networks.1. Many off-theshelf software packages are available.05. It has evolved to suit all environments and more complex file transfers.96 . but is split into packets which contain information on origin. • emergency/epidemic support. X-25 is one of the earliest telecommunications standards for data transmission..10 Email Electronic mail is a service allowing different computer users to communicate through a network.1.9 Data networks Digital networks provide the voice and data integrity required for diagnostic purposes and are capable of supporting high bandwidth demands. which can be used on the user's computer to provide a user friendly interface with the email networks. information servers. • medical information access. It can be used for electronic mail.

it was estimated that less than 1 per cent of all hospitals in the world currently have their own Web server. The growth of Internet usage is now providing opportunities for individuals. there are opportunities for specific. The growth in access is prompting new initiatives that enable health care providers to deliver better support at lower cost.WW7 (34900) 11. The quality of information provided to participants is generally of a high level. This social support has demonstrated itself as a powerful tool in assisting patient recovery and in reducing physical visits to physicians and clinics. More advanced examples of telemedicine across the Internet are also now emerging. The Internet is a superb communications facility for such support communities. several proprietary and charge-based resources are now emerging that utilize Internet Protocols for access. however. Research conducted by the National Library of Medicine in the United States during 1995 indicated that 75 per cent of teaching hospitals had Internet access but only 25 per cent of community hospitals had access. is the social or community support provided between participants. that seeks to help new hospitals gain Internet access. In addition to these free resources. often supported by contributions from medical professionals.hon. To encourage hospital usage of the Internet. These are groups of patients. A regularly updated listing of such virtual support groups is maintained at the Health On the Net Webserver (http://www. deliver first line support and promote preventative medicine programmes. Possibly of greater significance. This is of immense value to practising physicians and medical students alike.29 AR-CRDT-96/23-E The Internet provides an enormous medical and health care resource. The Internet provides a low-cost communications tool with almost universal availability (173 countries had Internet access as of March 1996).. particularly in regions with low populations and limited health care.03 11. communicate with professionals.96 .10. entitled "the Global Hospital". The Internet also provides disabled individuals with an opportunity to achieve levels of social integration that were simply not possible before. high quality information. A specific example of such an initiative is the support being given to virtual support communities. There is an enormous opportunity for health care providers to contribute to these support groups and encourage their patients to use them for complementary support. have greatly benefited from new compression techniques and are providing a real alternative to the high-cost bandwidth requirements. this is of equal value to all medical professionals. and/or people caring for them that participate in newsgroups concentrating on specific medical conditions. the Health On the Net Foundation. The success of these closed-user services will depend upon the specific quality of content and the number of people that subscribe to them.ch). high quality content. fee-based. Due to the quantity of freely available.05. The quality TMP_E\ITU-D\CONF-D\CRDT96\AR\000\023E. medical professionals and health care providers to obtain information. has embarked on a major project. Transfers of medical image files using Internet Protocols. In March 1996. This is of immense importance considering the changing socio-demographics of many developed countries (longer life expectancy and declining fertility rates) and the escalating costs of health care providers. This extends to personal income generation through teleworking from home or from a clinic. based in Geneva. This same server includes specific examples of benefits generated by such groups. The utilization of the Internet by medical professionals and institutions has been relatively low. Experience has shown that loyalty to similar on-line services is very low once users recognize and comprehend the free resources available on the Internet itself. Nevertheless.

video and multimedia) over a common network.1 Hardware A wide range of different devices can be used in telemedicine.1. a packet is a message or a component of a message.41 Asynchronous Transfer Mode (ATM) is a fast packet switched technology. The packets (or messages) are sent through a network. Other uses include emergency response support. The cost of installing and using an ATM network is.05. however..WW7 (34900) .12 ATM Asynchronous Transfer Mode is an open standard switching technique designed to route all types of digital information (data. Error detection and correction are left to the sender and receiver rather than being built into the network. Field personnel can utilize satellite communications for electronic mail and access to existing resource centres on the Internet. Essentially. 11.2 Telemedicine technologies 6. Telematics for Health Care: Its impact? Its future? Produced by ACOSTA for AIM. that is attached or connected to a modem or telephone) used in telemedicine can include the following: General equipment: • personal computer -. In telecommunication. so that high capacity digital images can be transmitted over lower capacity networks.30 AR-CRDT-96/23-E of new videoconferencing and audio tools on the Internet are also providing a valuable resource for remote consultation and diagnosis.. • teleconferencing and videoconferencing equipment 41 p.new software packages on the market are lowering the cost of teleconferencing. so far. In this case a virtual team of experts around the world can be quickly assembled to support teams working in epidemic areas and/or remote locations. 6. security and even distribution of traffic load over segments of the network(s). These software packages include shareware and whiteboarding software. The message contains an address. health care professionals need devices which can capture and manipulate data so that it transmitted over a communications channel (which typically in developing countries is most likely to be a telephone line). These broadband networks need to be carefully evaluated for flexibility. ATM is the result of a trade-off between speed. 6. control and data signals. graphics.10. New software also allows greater data compression than ever before. 11.e.2. Broadband ATM networks enable use of sophisticated applications which demand considerable network resources. Packet switching is a method in which messages are assembled into one or more packets. December 1994. Peripheral equipment (i.96 TMP_E\ITU-D\CONF-D\CRDT96\AR\000\023E. ATM uses packets with a 5-byte header and a 48-byte data payload. so high as to be prohibitive for most developing countries.03 11. This is possible thanks to the low error rates of today's transmission lines and switching technologies. voice. and these can be transferred as an entity within a data communications network. collected and then re-assembled into the original information at the destination. It is more efficient and faster than the traditional packet switching methods. accessibility and cost efficiencies.

electronic stethoscope -.05. Wright.digital sphygmomanometer (blood pressure) -.. In some countries.2. or brain scan) -.3 Picture archiving and communications system (PACS) PACS is basically a broadband telecommunications network. 1993 11. 6.. teledermatology.EEG (electro-encephalogram. Such software could be of interest to other countries. portable ultrasound systems are the ideal diagnostic tool in remote areas. physicians offices and image storage facilities. designed by the service providers. the limited availability of trained personnel has been a barrier to its use.96 TMP_E\ITU-D\CONF-D\CRDT96\AR\000\023E.31 AR-CRDT-96/23-E • • • digital camera microphones digital scanners and image processing software.microscope/endoscope adapter -.ECG (electrocardiogram) • other medical equipment -. etc. 42 For more detailed information on PACS see "Health Care". Such kits could be used by doctors or paramedics travelling in remote and rural areas. by D.video camera • for cardiology -.42 At its simplest. hospital accounts. Technologies and Strategic Impact. ultrasound) -. Once a digitized image has been captured in a computer.WW7 (34900) . i. CT. • for dermatology -. There also a number of commercial.2 Software The following software and/or services were mentioned in responses to the Telemedicine Questionnaire. 6.portable monitoring unit. High performance ultrasound systems using digital technology and satellite communication links will allow patients to be examined anywhere in the world while a trained physician in another location receives the image and provides diagnosis and treatment consultation to the local physician by phone. off-the-shelf software packages designed for telemedicine applications.2.While lightweight. It is sometimes known as medicalimaging networks or medical image management system (MIMS). software has been "purpose-built". it is a network facility enabling different hospital departments to retrieve and transfer patient records. Specialized medical equipment: • for radiology (X-rays. the interconnection of medical imaging systems between hospital radiologists.03 11. Brodband: Business Services. Systems using the above mentioned hardware and software particular applications such as teleradiology.e. telepathology and monitoring of vital signs.10. it can be manipulated and discussed by physicians separated by great distances.

At the same time he can send the X-ray to a specialist for a second opinion.e. i. • Access of other hospital departments.1 hours when not. • Discussion between physician and radiologist is electronic. • Typing and proof-reading of the radiologists report is eliminated. • Other sites can send images and associated patient information to the hospital for Specialist evaluation electronically. • Faster processing of medical images. These would include the main in-patient facilities.96 .. teaching facilities. Other benefits of a PACS system: • Faster treatment. the average time between the completion of the patient examination and action being taken was 3. • Faster access to medical images. It is possible to think of PACS as a multimedia communication system. either within the hospital or elsewhere. operating theatre. where the medical images can be displayed on their own screens. These multimedia discussions are extremely important when a physician has an emergency and urgently needs to consult with a radiologist at another site.32 AR-CRDT-96/23-E Today it is being used in large hospitals and medical centres which might have several sites. and result in the retrieval of the image and the associated radiologist's report.WW7 (34900) 11.. This is particularly important because of the present trend towards increased use of out-patient facilities and medical office buildings for imaging.03 11. With PACS it is possible for a physician to send an X-ray of a patient to a radiologist for an examination who might be based in another building. TMP_E\ITU-D\CONF-D\CRDT96\AR\000\023E. and out-patient departments (both local and remote) are made by multimedia access to the PACS storage. There are six sources of time savings from the introduction of a PACS: • Referring physician access to the image and report is electronic. • Reliable image availability. PACS is very useful because a physician and a radiologist can have a discussion without the need for either of them to travel to a specific place to meet. • Facilitated consultations between physicians and radiologists. One of the primary benefits of a medical PACS is time savings in accessing images and radiologist's reports.0 hours when PACS was used and 4. • Obtaining approval for medical procedures from insurers is facilitated.10. PACS allows the image of the patient examination to be stored digitally along with the radiologist's report. • Film library staff time saving. they can use a multimedia communication system. outpatient clinics and remote sites is electronic. in a study conducted at the hospital of the University of Pennsylvania.05. Each of them will have voice communications so they can discuss the medical case and also point out certain areas of the shared image using a computer mouse to illustrate the discussion. reduced waiting time. which can be stored in the form of digitized voice. without having the need to actually go there himself. This is because all accesses by the physician. out-patient clinics. medical office buildings with physicians' offices and the radiology departments where the imaging equipment and the radiologists' viewing stations can be found. Because of today's technology. Instead.

and an optical "jukebox" for archival storage.33 AR-CRDT-96/23-E • • • • • Radio technologists time saving.900 accesses to new images and 200 accesses to archival images per day. for storing images on magnetic storage for interactive access. for receiving images from MR equipment at a remote site. increasingly expensive telemedicine applications and the cost of hardware at one site. The PACS handles 1.96 TMP_E\ITU-D\CONF-D\CRDT96\AR\000\023E. 1993 11.. Examples of PACS in a modern medical facility: The Hospital of the University of Pennsylvania has been using PACS since 1982. DSA. viewing stations. and increased life of X-ray tubes.WW7 (34900) . 434-436. and results in integrated information availability within the PACS. to all forms of imaging. annotating a radiologist's spoken report to a medical image using digitized voice storage saves word processing and editing time. Lower X-ray doses. British Colombia.43 7 Costs and benefits of different solutions The application of telemedicine in developing countries depends upon many factors. MRI. digital X-ray detectors require lower X-ray doses than film. via a T1 link. The following diagram is rather primitive and not intended to be particularly accurate. in the same city. Lower operating costs. The present system also links to the Royal Jubilee Hospital. The backbone is an 80-Mbps optical-fibre LAN connected to: • A satellite gateway. which includes chest radiography. rather it is intended to convey the idea of increasingly sophisticated. In Victoria. or adjacent. • a router. Wright. Broadband: Business Services. and storage. and fluoroscopy imaging. 43 p. Linking modalities.03 11. This project involved the interconnection of MR scanners. connected via two lower speed LAN's to MR equipment and viewing stations.05. the Victoria General Hospital has installed a PACS since 1987. CT.10. "Health Care" by D. In 1982. • a file server. Voice annotation. but also others such as the availability of appropriate resources and expertise. the ability to integrate different imaging modalities and display them on the same. resulting in less exposure of patients to X-rays. screens is a convenience deriving from the introduction of a PACS. especially cost. the hospital decided to introduce PACS over several years. Technologies and Strategic Impact.

11. 44 "Economic Aspects of Telemedicine". Director General XIII/C4. • helps attract required personnel (including but not limited to medical practitioners) to remote and rural areas with a positive impact on the local and national economies. including those derived from national development objectives such as the following: • health education of various segments or of the whole population. • employment opportunities for indigenous technicians and paramedics.34 AR-CRDT-96/23-E Telecommunications capacity xx gigabytes fibre coaxial cable satellite television radio telephone 9.44 The delivery of telemedicine services yields many socio-economic benefits.. legal and ethical aspects have to be taken into account.WW7 (34900) .000 $50 There is no doubt that telemedicine has the potential to improve the quality of health care. However. • universal care provision: a much broader reach in rural and remote areas. for attracting investment).6 kbit/s 7. • improves the image of a country (important. Telemedicine might evolve as a cost-effective alternative to some forms of health care delivery. • dissemination of advanced technological knowledge.05. for example.000 + $40 . organizational.1 Tools Cost of user hardware at one site $300. • availability of regular or on-demand health care in remote areas helps slow population migration or attract people back to previously abandoned areas.10. April 1994. A thoroughly performed cost/benefit evaluation will certainly be of a crucial importance for health care policy-makers when deciding if telemedicine should be generally introduced or not.000 virtual reality broadcast quality image exchange equipment videoconferencing slowscan camera multipurpose work station PC with shareware telemetry monitor telephone Socio-economic benefits of telemedicine $20. by Thomas Sommer. European Commission. among others. the economic. Health Telematics. • improves the health indicators as set and followed by WHO and national government.96 TMP_E\ITU-D\CONF-D\CRDT96\AR\000\023E.03 11.50.

Universal service Those who have had no or limited access to medical care. the less dependent patients become on expensive.03 11. Reduced travel Some of those who use telemedicine can avoid the need to travel to far-away doctors and hospitals. especially patients in smaller hospitals which may not have the facilities of the larger ones.05. It can save patients time and money by eliminating the need for a trip to the hospital. A substantial part of the cost of running hospitals is spent on what are essentially hotel services: bed. breakfast. without ever leaving their own hospitals. perhaps over rough terrain. more and more people will be treated and diagnosed via telemedicine. especially in remote and rural areas. Reduced waiting lists Telemedicine could reduce hospital waiting lists if patients can be seen more quickly using telecom systems with the consequent reduction in hospital waiting lists. can take advantage of telemedicine services if they have or can use a telephone (and.96 . In the future. countries with high health care costs are interested in the prospect of telemedicine as a way to reduce costs and demands upon hospitals. other telemedicine equipment too).. asset-based sites such as hospitals for speciality care. the Centre of Advanced Technologies in Image Analysis (CATAI) receives three or four distant video consultations a week.10.35 AR-CRDT-96/23-E Cost savings Telemedicine could help some countries to cut health care costs. lunch and evening meals. even to battlefields. Telemedicine can provide access to centres of excellence for various specialities -. international specialists are able to spread their skills across continents. The more health care can become decentralized and administered efficiently in low-cost settings such as clinics with telecommunications links. better still.WW7 (34900) 11. so that 30 per cent of inter-island patient transfers were avoided and 3 per cent of national transfers. The yearly savings are thus estimated at 35 million pesetas. without the cost and risk of transporting an ill or injured patient long distances. TMP_E\ITU-D\CONF-D\CRDT96\AR\000\023E. Telemedicine allows the scarce resources of specialists and expensive equipment to be shared by a much greater number of patients. Little in the United States estimated that between $36 billion and $40 billion could be saved if the health care industry were to use more efficient telecommunications and telemedicine technologies.theoretically from anywhere in the world. A study made in 1992 by Arthur D. Routine medical visits to the smaller islands by health care workers were reduced by 20 per cent. Although telemedicine costs today are not low. It can allow treatment to be given immediately. Improved consultations and second opinions Telemedicine enables health care professionals to consult quickly with specialists many miles away. In the telemedicine service in the Canary Islands. Doctors are no longer restricted by geographical boundaries.

which carry the information. op. • applications (e. To deliver telemedicine and telehealth applications.03 11. 11. Revenues The provision of telemedicine and telehealth care services offers the possibility of making the most of tight health care budgets. Commercial service providers can also find opportunities in this sector of the economy. electronic mail. but it is really necessary to look at the telehealth and/or telemedicine "value chain".. comprising equipment manufacturers and service providers..10.g.36 AR-CRDT-96/23-E Stress reduction Families are spared the stress and expense of visiting relatives who have had to go for treatment to a hospital in a distant city. cit. interactive video) which allows people to use the networks. Telemedicine is a high-tech industry.g. who generate revenues from the sales of their products and services. but as discussed below. How does the equipment supplier. telecom service provider. but also offers revenue generation and employment opportunities. • services (e. could be a boon for keeping up to date with what is happening in their field. This also allows the lecturer to stop the tape and explain further or even to do an "action replay". 7. GETS proposal to CEC/DG XIII.. who eventually is an end-user? How does or how should the 45 p. It is not always possible to get students to attend or watch live operations.WW7 (34900) . to share experiences and address questions to other doctors. When the money is available. cables). Students in one place can watch an operation being performed by a surgeon or physician in another place. health care) which offer dedicated solutions for user groups.45 The Bangemann Report "Europe and the Global Information Society" recommendations to the European Council re interoperability of health care systems assumes an Information Systems Architecture. structured in three layers: • networks (e.96 TMP_E\ITU-D\CONF-D\CRDT96\AR\000\023E.g. 8. Telecom networks can generate additional revenues if their networks are used for the provision of telemedicine and telehealth.. If telemedicine continues to grow.2 Delivery of telemedicine and telehealth : the value chain Telemedicine challenges the leaders of the medical establishment to rethink the ways they provide their services and to address the medical needs of areas where such services are absent or in short supply. so the next best thing is to record the operations and play them back.05. access to remote medical databases on the Internet. for example. teleconferencing. Telemedicine can be an important source of case study material from every part of the world. healthcare or medical service provider deliver their products or services to their client. specialists will be able to track an increase in the incidence of a particular disease as it happens. telephone. Training and education It can help in medical education and training. satellites. For those health care professionals working in rural areas of developing countries. there is no reason at all why students shouldn't be able to watch live operations being conducted anywhere in the world and communicate directly with the surgeon. telecommunications are certainly needed.

.96 . general practitioners. technicians. The value chain for a real. statisticians.WW7 (34900) 11. To adequately test one or more value chain configurations. physicians. Both approaches (or indeed any other that seems viable.one is via a paramedic. epidemiologists. Among those who could be the value chain are the following: • health care professionals. nurses. etc. there should be a sufficiently large-scale trials to provide meaningful results.05. researchers. where the communications needs of several user groups could be aggregated in order to maximize the utility and lower the cost of providing a community telecom service.) • end users (patients) • telecom operators • service providers • equipment suppliers • informatics and computer suppliers TMP_E\ITU-D\CONF-D\CRDT96\AR\000\023E.10. Australia is famous for its flying doctor service. It is worthwhile having a good understanding of who the different players are in the value chain.). information engineers. etc. Telehealth and telemedicine can be delivered in developing countries by at least three ways -. such as midwives. Another is via installation of a telehealth or telemedicine service in a rural clinic or a small hospital or. thirdly. Norway uses mobile emergency units.37 AR-CRDT-96/23-E value chain work. commercial (or even partly subsidized) telehealth/telemedicine service could look quite different when there are several hundred users or sites compared to when there are only a few. Other. paramedics. medical specialists • other professionals involved in the broader provision of health care (managers. midwife or doctor who travels from village to village with his (or her) satellite phone. in a "telecentre" or community centre (which could be a church. police station.03 11. school. especially in the context of exploring potential export markets? Is the value chain commercially viable or otherwise sustainable? One could depict one configuration of the value chain as follows: equipment supplier hospital system integrator paramedic midwife docotor patient telecom operator This is only one simplified example of a telehealth/telemedicine value chain. to be of interest to all of the participants and to serve as models or "test-beds" for other developing countries. more complex configurations are conceivable. ultra-sound scan and a few other pieces of equipment which enable him to consult with a distant hospital or service provider. post office. practical and pragmatic) need to be validated.

the cost-benefit ratios have improved: projects that could not receive funding in the past have become feasible and were approved later. Texts on these topics are widely available.96 . An important factor to keep in mind when preparing a cost/benefit assessment is that telemedicine is conducted in a complex and ever-changing technological. and cost/benefits assumptions valid a few years ago. operating costs) versus expected benefits or revenues possibly generated.. so here is presented only a review of the most important elements to provide a workable and simple framework for analysis and assessment.38 AR-CRDT-96/23-E • • • • • • • • • • • biomed equipment manufacturers telecom and computer equipment manufacturers professional associations health management organizations individual experts universities or other academic research institutions hospitals insurance companies pharmaceutical companies the Ministry of Health (or equivalent) regulators and licensing authorities 7. procurement costs. they may include specific national policy objectives such as provision of universal care or those simply aimed at reducing the costs of health care provision among specific target population or in a specific target region.3. over time. politicians and health care administrators to seriously address a proposal for a telemedicine project.10. Many countries have experienced that. particularly in the absence of readily available necessary inputs (described below). Costs and priorities can change rapidly. may no longer be valid now. Some concern has been expressed in the past that cost/benefit studies could do more harm than good if not conducted properly. there is usually need to justify expenditures on telemedicine (i.as well as the economic and social benefits. running expenses..03 11. or even last year.WW7 (34900) 11.e. for instance a net present value (NPV) analysis. Overall fundamental objectives of telemedicine should be kept in mind when conducting any economic feasibility study. medical and political environment.05. Various standard techniques for project analysis can be used.3 Cost-benefit analysis 7. TMP_E\ITU-D\CONF-D\CRDT96\AR\000\023E.1 The need for cost/benefit assessment Apart from the most trivial telemedicine applications. While a full-fledged cost/benefit analysis (for assessment or a feasibility study) could itself be costly and time consuming. This argues for properly conducted studies which include all known benefits . which may enable a comparison with the costs of the existing situation and other alternatives. at least a thumb-nail sketch of both the costs and benefits is required to enable the planners.both direct and indirect -.

diagnostics apparatus and computers.05. c.96 . • promoting maximization of scarce central resources (specialists. • reduced waiting time which can in some cases prevent serious complications or death. Indirect benefits These are benefits accruing to various players involved in the provision of telemedicine. Intangible direct benefits Intangible benefits are those that have a definite perceived value but the actual value is somewhat more difficult to determine. such as: • increased revenues to (national) equipment providers.39 AR-CRDT-96/23-E a.WW7 (34900) 11. • enabling specialist and technical personnel to increase their knowledge and qualifications. etc. • improved teaching and learning possibilities and opportunities. both internally and externally. resulting in increased job satisfaction. hospitals.03 11. difference in cost of construction and running of facilities.). 7. • improved overall health care management. • reduced expenses for family members who might otherwise accompany the patient • improved effectiveness of specialists: broader reach. wages differential.e.. • improved availability and reduced cost of training of local medical specialists. more patients seen due to reduced travel. Such intangible benefits include: • better opportunity for second opinion and consultations resulting in avoidance of delays or costly mistakes. • increased collegial support to medical personnel working in remote and isolated areas. • facilitating decentralization of care and distribution of competence.) b.3. TMP_E\ITU-D\CONF-D\CRDT96\AR\000\023E.2 Benefits of telemedicine Tangible direct benefits Tangible benefits are those the monetary value of which can be readily ascertained. etc. although in many instances it can be ascertained or estimated. for example: • savings from reduced travel costs of specialists • savings from reduced travel costs of patients • savings on hospital accommodation of patients that can be treated remotely • savings on hospital processing costs of patients that can be treated remotely • savings due to provision of health care in remote clinics or mobile health units versus expansion of urban or regional hospitals (i. telecom services providers and the like.10. • reduced loss of income for patients who need not travel.

software. reduction of additional examinations. There is a fourth cost to cost. etc. while. if these factors are used not only for telemedicine. costs of vehicles. facilitates scientific/statistical analysis. Heath. 46 "Economic Aspects of Telemedicine". should be shared in relevant proportions. Director General XIII/C4. following a survey. 7. benefits to clinicians: e. as follows: – Improved quality of treatment/patient care. interfaces. European Commission.96 47 TMP_E\ITU-D\CONF-D\CRDT96\AR\000\023E. broader base for decision making. costs of personnel may be rising. avoidance of inconvenience of travelling to another hospital or physician. improved image quality and the opportunity to manipulate images. improved treatment of coronary diseases. better communication between sites. and indirect costs.g. on the other hand. advice more readily available to junior staff. avoidance of inconvenience of travelling.3 Costs of telemedicine These are usually quite readily identifiable.g.WW7 (34900) . 11... It should be kept in mind that costs of telecommunications are decreasing every year. or the costs of equipment that have already been obtained for a different reason.g. – savings in time and costs for staff and specialists. greater accessibility.40 AR-CRDT-96/23-E Another way of classifying benefits according to the target group:46 benefits to patients: e. according to the degree of significance.. by Thomas Sommer. benefits to hospitals: e. recurring operating costs. R. reduced risk of images getting lost. The same can be said of the costs of computers. benefits to other groups: e.g. provision of an additional teaching resource for students. faster and more precise decision-making ability. quoted in the Sommer article above. Health Telematics.. The costs fall roughly into three categories: capital expenditures. relatives can be closer to patients and service. The United States Army is reported to have allocated some 30 per cent of investments in telemedicine for evaluation of systems.. more efficient use of equipment. Similarly. although care must be taken to avoid including costs that the national or private health service providers would have incurred regardless. – more timely information. telecom equipment and operators. – more available information.. Ranking of benefits Benefits have also been ranked47. transport savings.05. Final Report of the EC supported project TELEMED (1992). Cost/Benefit Analysis.3. faster and more precise diagnosis and treatment.10. which is the cost of evaluating projects. April 1994. faster diagnosis and treatment.03 11. – improved communications compared with existing. new opportunities to consult experts.

It is important that the seemingly large initial. • annual schedule of savings resulting from telemedicine applications. cost of necessary hardware. • • • • • • • c. • annual operating costs for the health centre responsible for running the programme.03 11.WW7 (34900) 11. one-time licence fees and similar. Such analyses will satisfy the requirements of government decision makers. Key among the possible angles of view are: • overall feasibility in a country.41 AR-CRDT-96/23-E a. In fact. if necessary. cost of special diagnostics apparatus or modifications to the existing stock. policy planners and health care administrators. maintenance of computers. vehicles running expenses and maintenance. regional or subregional setting. import duties. training and skill maintenance costs. • • • • • • b. All benefits can be annualized and used for constructing a series of cost/benefit ratios. discounting should be done using appropriate social discount rates as opposed to commercial rates. administrative costs. Indirect costs impact of competition for available funds in times of scarcity. 7. cost of telemedicine specialists and operators (when performing also non-telemedicine duties. if also used for other purposes ): cost of vehicles.3. peripherals. to better reflect the value of a telemedicine programme to the community. It should be noted that not all categories of either benefits or costs are applicable in a particular programme or a country setting. planes for mobile units (unless already available). software. • • Capital expenditures cost of telecom equipment specifically used for telemedicine (or a proportion. In performing net present value (NPV) analysis..10. say 5 or 10 years. boats. balance of payment impact if funds need to be obtained externally. one-time set-up cost of a telemedicine programme is contrasted with all categories of benefits over a suitable period of time. TMP_E\ITU-D\CONF-D\CRDT96\AR\000\023E. most cost/benefit analyses can turn out to be very simple and straightforward. specialized telemedicine apparatus.96 . costs of modifications to remote clinics.05.4 Simple framework for assessment Cost/benefit analysis and economic and financial assessments should be done from several angles to obtain good understanding of all cost and benefits elements as well as their evolution in time. insurance costs. only a relevant portion should be counted). Operating expenses telecom expenses. interfaces.

(Encryption and password security may help. since physicians working in rural areas are often not very young.) TMP_E\ITU-D\CONF-D\CRDT96\AR\000\023E. complexity.96 . 2) There are few insurance providers who will cover risks associated with telemedicine consultations. a physician will find it difficult to provide a telemedicine service outside his own state.42 AR-CRDT-96/23-E Criteria for telemedicine project selection and assessment Telemedicine should be implemented on a scale commensurate with the requirements (needs) of the health care policy and resources available. 5) Confidential medical data regarding patients must be protected from unauthorized access. Here are some typical criteria and factors needed to be considered for a project selection.. 4) Some states in the United States may require that if a physician is to practise his/her profession in that state. • • • • 2. • • • 8 Health care criteria kind of patients and symptoms to be addressed by telemedicine skills needed for telemedicine practitioners what existing health care protocols need to be established or modified? how is the success of telemedicine going to be evaluated? Management criteria operational support needed administrative skills required training needs to be arranged for practitioners at either end of the telemedicine link technical requirements and skills necessary to implement telemedicine what is required to integrate telemedicine into overall health care scheme? Technology criteria equipment required for the initial set-up to achieve at least the minimum of set objectives requirements on the telecommunications side to operate telemedicine applications reliably type of training needed Main trends Acceptance and further development of telemedicine will depend upon a number of factors. Care should be taken that technology (level.WW7 (34900) 11. It is best to start with smaller scale and simple projects or pilots. some physicians may resist use of a new technology which they don't understand. granted to him/her by that particular state.03 11. quantity) and specific applications are appropriate for the objectives selected. among which are the following: 8. 3) Rural consultations are not frequent and it may be difficult to run cost effective systems. • • • • • 3.05. This is especially so.1 TEN potential problems with telemedicine 1) Like many people.10. 1. the physician must be the owner of a licence. and gradually expand as experience is gained. In other words.

Europe Assistance. Who pays? In the end. it is the consumer or the taxpayer who can expect to pay (they always do). where no difference is made between a plain consultation and a teleconsultation. Frequently. 9) Telemedicine may not seem cost-effective since it often enhances the service rather than perform a process more efficiently. On a commercial basis. operational costs. Similarly.WW7 (34900) 11. • university or hospital subsidy or grant. TMP_E\ITU-D\CONF-D\CRDT96\AR\000\023E.05. e. etc. secondary consultations cannot easily be reimbursed and investment and telecom costs cannot easily be amortized. the telemedicine service is delivered within the framework of a social establishment. one way or another. users pay for all components of the telemedicine service: remote consultations. amortization of investments.10. the absence of standards in some aspects of telemedicine can also deter the cost-effective implementation of new telemedicine services.. telemedicine service providers must focus on the needs of the medical profession and the patient. telecom expenditures.96 . 10) Systems management and organizational problems may defeat the successful implementation of technologies or services or intentions which all otherwise may be good. 8.g. thereby increasing costs.. This may multiply demand for a previously inaccessible service. maintenance.. among which are: • government subsidy or grant.43 AR-CRDT-96/23-E 6) To be successful. assistance contracts include payment of telemedicine in cases of emergency. telecom operators and hospitals). Public regulation will have to evolve with the generalization of telemedicine in public organizations.2 Issues As yet. but that is a facile answer to a complex problem where there are many diverse players in the telemedicine value chain(s) and where the consumers may be distant from the service providers. Therefore. American Express. there are a number of unresolved issues which need debate and further consideration before telemedicine can truly become widely accepted even in the developed countries.03 11.g. There are many different telemedicine projects taking place around the world and they are funded from a variety of sources. Returns and reimbursement Telemedicine services can be delivered either on a commercial or public basis. and not force fit existing technology on these services. 8) Financing is often complex since telemedicine applications often involve different partners in a single venture (e. 7) Some telemedicine systems and services require that users have compatible hardware at both ends of the communications link. On a public basis. which reduces interoperability and the benefits of access to different sources of telemedicine expertise. Customer focus must not be replaced by a product focus. Definition There is no globally accepted definition of telemedicine.

g."48 Medical laws are based on who has a duty to whom. When a telemedicine consultation crosses state lines. funded in whole or in part by international and regional organizations.WW7 (34900) . which community standard applies? If the telemedicine services are available and a poor outcome results when they are not used. particularly in the United States. patients seem willing to take advantage of telemedicine services. costly or difficult travel to see the doctor. the other. but consultations between specialists who do not require patient contact (e. legal precedents for remote liability and licensing are not yet established. accreditation.. the military. ITU. does this constitute malpractice? Today's patchwork of state regulation. few individuals will be able to pay for telemedicine. What is more dangerous for the patient? Is treatment by telemedicine better than no or delayed treatment? 48 "Legal Issues". As telemedicine services become commercialized. General practitioners and paramedics would like to have a second opinion or consultation or guidance from a specialist who may be many hundreds or thousands of kilometres away. In the next several years.44 AR-CRDT-96/23-E • • • • under-written by a telecom operator directly or undertaken in a joint venture with an equipment manufacturer or other service provider. the doctor or patient in developed countries.03 11. At least one survey of doctors in the United States showed overwhelming support for telemedicine. European Commission. and liability is clearly incompatible with the widespread use of electronic medical services. Medical practices without clinical examinations may be contrary to medical ethics. the introduction of telemedicine (except for the very rich) will most likely require active support by governments. 8 Feb 1995. either as a user of the service or as a taxpayer or through a private medical insurance plan.. has funded a significant amount of telemedicine research and projects. the end user. pathologists. Similarly. SatelLife and other satellite operators have supported telemedicine projects and services. Journal of Telemedicine. etc. Despite the evidence so far.A.05. Allen.D. Legal issues: who is responsible for the patient? If a local doctor or paramedic treating a patient contacts a telemedicine service and sends digital ultra-sound images or X-rays for interpretation. such as the WHO. it is likely that telemedicine projects and services will be funded from a variety of sources. there is still an issue with regard to the willingness of doctors today to make judgements on the basis of transmitted information. Intelsat.96 TMP_E\ITU-D\CONF-D\CRDT96\AR\000\023E. The doctor in direct connection (contract) with the patient is liable. In developing countries. 11. who bears the responsibility toward the patient? Is it the local doctor or the specialist a thousand kilometres away? Although many telemedicine interactions are already crossing state and national boundaries. does the provider have to be licensed in one state. Inmarsat. as the concept of managed health care is more widely implemented. especially if it means they can avoid unnecessary.10. radiologists. Perodania & M. Hence. lab specialists) are partly exempt. can expect to pay for the commercial service. or both? If the community "standard of care" is to be upheld. by D. Diagnosis at a distance Are doctors willing to make judgements on the basis of information transmitted rather than seeing the patient face to face? The answer seems to be yes.

45 AR-CRDT-96/23-E Competition As in so many other sectors of the economy. completeness and correctness and prevention of unauthorized modification) and (3) availability. Alliances are common and undoubtedly will increase. Security of data has three aspects: (1) confidentiality. One of the projects sponsored by the European Commission as part of its Third Framework Programme focused on this issue. Thus. but on the other hand some people have limited or no access to any kind of medical care now.05. given the huge costs of health care now in the industrialized countries. he or she will not need to visit the hospital. the United States and elsewhere towards achieving it. Hospitals today are major cost centres. There are concurrent issues about who should bear which costs.e. it will undoubtedly force some structural changes in the delivery of health care and medical services. As information technology becomes increasingly sophisticated and accessible. As telemedicine's acceptance grows. as telemedicine requires expertise from several distinct disciplines. indeed the use of information technology in general. This would give doctors greater and more complete information on which to base advice. while governments or health care service providers are "containing" some costs. i. they may also be expending greater sums on telemedicine equipment and services. Clearly. accessibility and readiness for immediate use as well as when and where needed in a usable form. private. will depend upon how users -. competition is increasing in telemedicine services. questions may arise about how much information should be given to insurance companies who can fine tune their premiums to higher risk groups. equipment manufacturers and specialized service providers competing for local and global telemedicine markets. currently under development. governments may seek to promote telemedicine as a way of containing health care costs. it is natural that there should be concerns about the security and confidentiality of health care data. Within the next few years.96 . Some countries. The project was titled the Secure Environment for Information Systems in Medicine (SEISMED). It may be that. Privacy and confidentiality of information Medical data are frequently sensitive.patients. There are telecom operators.WW7 (34900) 11. but work is in progress in the United Kingdom.e. hospitals and governments -. In March 1995.3 Technologies Future telemedicine technologies Telesurgery may not be used in practice for another decade.03 11.10.. all European citizens could choose to have their medical histories stored on a database known as Hermes. there was an TMP_E\ITU-D\CONF-D\CRDT96\AR\000\023E.. doctors. especially when it is transmitted electronically from one location to another.accept it. confidential. (2) integrity (i. such as Australia and Singapore. are competing to become regional hubs for telemedicine services.. Acceptance The success of telemedicine. Consequently. it will gradually put pressure on practices that are not networked. much of the equipment used in telemedicine is still expensive (though costs are coming down) and network costs can be significant. On the other hand. a service delivered via telecommunications is not quite so personal as being in the consulting rooms of a doctor. A conference on Virtual Reality in Surgery and Medicine was held in the United Kingdom in 1994. 8. Structural changes in health care delivery If telemedicine is widely accepted. If a patient can be dealt with via telecommunications.

type approvals and other regulatory sanctions. In a few countries. International Federation of Red Cross and Red Crescent Societies (IFRC). standards. the existence of various regulatory and commercial barriers (e.05. TMP_E\ITU-D\CONF-D\CRDT96\AR\000\023E. Pan American Health Organization (PAHO). universities. 8. licensing. liability due to misleading or faulty images during transmission or any other stages. and have contributed to the emergence of interactive technology systems in a growing number of applications. equipment manufacturers. however. regional and/or international levels. If the image is too "coarse". Thus. In the case of mobile satellite services. the value of an image transmitted over a telecom network will increase as its resolution increases. it is conceivable that. information service providers..4 Service Providers As noted elsewhere in this report. Service providers may need operator licences. system integrators. have begun to reduce these costs.10. requirements may emerge for certain minimum standards. etc.96 .1 Policy and regulatory situation Delivery of telemedicine services may require a variety of licences. Global services may require global standards. Recent developments. hospitals. high import duties) inhibits the use of mobile earth stations despite their successful application by various health and relief organizations such as the World Health Organization (WHO). International Committee for the Red Cross (ICRC). telemedicine is delivered by a variety of service providers. especially the section which reviews telemedicine in some countries. Many countries have yet to develop a policy and regulatory framework covering telemedicine issues. Médecins Sans Frontières (MSF) and others. often in alliances or joint ventures. its utility is limited and doctors will hesitate to make a diagnosis. As telemedicine becomes more of a commercial service. one of the mediums of telemedicine delivery. 9 Prospects for development of global standards 9. Telecom operators require licences.WW7 (34900) 11. Users of telecom equipment may require individual licences (there may be "class licences" obviating the need for individual licences). confidentiality of data.46 AR-CRDT-96/23-E international tutorial and conference on Interactive Technology in Medicine and Surgery in Leeds.g. Interactive technologies. such as in regard to tariffs. The cost of using holograms and virtual reality systems is still high.. pharmaceutical companies and suppliers are active. governments. There is thus a need for more favourable regulatory regimes.03 11. a minimum resolution for transmitted images may emerge.. The conference considered the progress and challenges of interactive technology in surgery and medicine. Some new standards for compression algorithms seem likely. may revolutionize the practice and delivery of medicine as well as other scientific and engineering disciplines by providing novel methods of visualising and manipulating complex images. Equipment specifications may need to meet various standards at the national. such as telecom operators. For example. including virtual reality systems. as time goes on.

This text and the accompanying diagram have been adapted from p. coordination and follow-up of standards development in health care informatics at the European level.05. a Technical Committee for Medical Informatics (TC 251) was established within the European Standardization Committee (CEN. Comité Européen de Normalisation).Medical) which focuses on Open systems Interconnection (OSI) model of the International Standards Organization (ISO) and on functional profiles to be used in health care. Produced by ACOSTA (Accompanying Measure on Consensus Formation & Standardization Promotion) for AIM (Advanced Informatics for Medicine). with MEDIS-DC within MITI (Ministry of Trade and Industry in Japan) and many others. Message Development Group for Health Care) which specifically works on implementation of message standards following EDIFACT syntax-rules and directories. Expert Group . Worldwide. Health Care Informatics Standards Planning Panel)..47 AR-CRDT-96/23-E 9. CEN TC 251 is the only official vehicle for European consensus building and standardization in health care informatics.10. with IT/14 Standards Australia. December 1994. 33. 33 of Telematics for Health Care. due to lack of compatibility in format.03 11.WW7 (34900) . CEN TC 251 coordinates with ANSI-HISPP (American National Standards Institute. In Europe.2 Telemedicine standards One of the technical barriers to interconnect telemedicine centres around the world is the difficulties of exchanging and processing medical data from one site to another.96 TMP_E\ITU-D\CONF-D\CRDT96\AR\000\023E. equipment interfaces. an EC programme. The objectives of CEN TC 251 are the organization. etc.49 The liaisons between standards bodies have been depicted as follows: ISO WEEB CEN EWO TC 251 HISPP Others ANSI 49 p. 11. CEN TC 251 liaises closely with EWOS/EG-MED (European Workshop for Open Systems. CEN TC 251 also liaises with WEEB/MD9 (Western European EDIFACT Board.

November 1993. a model widely used in the communications industry. RadioGraphics. The standard provides a mechanism for manufacturers to claim conformance by clearly specifying which DICOM functions are supported. November 1993. RadioGraphics. 1381.50 In 1983. teleconsultation systems are approved by the Food and Drug Administration (FDA). DICOM is a complex set of documents that provide detailed definition of a rich set of communication services and associated protocols. 1382. medicare and insurance companies. It is based on an object data model.05.03 11. it was renamed DICOM which is a multiple-part document that specifies both an ISO compliant profile and an industry standard protocol stack (TCP/IP [transmission control protocolinternet protocol]). V. To give it a degree of independence from the standards body and to foster international collaboration. 9. p.. The reason was that it did not conform to the seven-layer International Standards Organization (ISO) .42 Recommendation defines two different schemes: LAPM and an alternative procedure known as MNP (Microcom Network Protocol). the American College of Radiology (ACR) and the National Electronic Manufacturer's Association (NEMA) both set up a joint committee to develop a standard for medical imaging communication.10. The model represents an abstraction of certain aspects of the real world. The result of the collaboration resulted in the ACR-NEMA Digital Imaging and Communications Standard 300-1985. The most widely used internal error correction protocol is that offered by ITU-T (formerly CCITT) Recommendation V.3 Modems There are different error correction protocols available today.96 51 TMP_E\ITU-D\CONF-D\CRDT96\AR\000\023E. a Telecommunications standards 50 p. a set of command messages. and a data dictionary for image communications. The main advantage of DICOM is that it is applicable to networked environments. This standard defined a point-to-point communications protocol. Basically a 16-bit parallel electrical interface was specified to permit a direct connection between two pieces of imaging equipment or between an imaging device and a network interface unit. "Specifying DICOM Compliance for Modality Interfaces". However it was not successful. "Specifying DICOM Compliance for Modality Interfaces".48 AR-CRDT-96/23-E In the United States.51 The use of the DICOM standard has made information exchange between PACS and various departmental information systems simpler. DICOM (Digital Imaging and Communications in Medicine)/ACR-NEMA DICOM is a standard that was set up to define a standard network interface and data model for imaging devices that can facilitate information systems integration. 11. A second version of the standard was published in 1988.42 which defines error detection and correction techniques.WW7 (34900) .Open Systems Interconnection (OSI) reference model for communication services.

The modem will switch between compressed and uncompressed mode of transmission. This implies holding seminars.96 TMP_E\ITU-D\CONF-D\CRDT96\AR\000\023E. presentations.42bis uses a string encoding algorithm called Blitz. and correspondence addressed to the health authorities and other bodies.42 claims to provide a 4-to-1 data compression. UNESCO etc. • introduce pilot projects so as to demonstrate the value of telemedicine to the decisionmakers and government departments responsible for organization of health services.42 compliant modems. Two complementary strategies might be suggested: • increase awareness in government circles.49 AR-CRDT-96/23-E secondary option.WW7 (34900) . legislative and quality control aspects which this implies are considered. It replaces frequently occurring strings of characters with code words.42bis and V. numerical data. Telematics for Health Care: Its impact ? Its future? 11. Nevertheless.). MNP-5 does not have this ability. 52 p.52 10 Guidelines and recommendations In developing countries. Error correction and compression The most commonly known compression schemes are V. The lightning fast development of computer-based information systems and medical informatics at present allows simultaneous access us to a variety of different types of documents: texts. The success of such action is linked to the synergy of actions initiated by the various international organizations (ITU. Television needs high decompression rates in real time for smooth movement.42bis and MNP-5. 12. with the adverse effect that transmission time will be longer.42bis can actually detect whether the data send has already been pre-compressed (for example by PKZIP). graphs. never adding any overhead to the data sent. V. WHO. but LAPM is first choice by two V. JPEG (Joint Photographic Expert Group) and MPEG (Motion Picture Expert Group) are the most commonly used standards for still and moving image compression. sound and voice messages.10. The combination of V. It maintains a dictionary of strings during transmission and will add new strings and delete old strings when necessary. Multimedia medical records cannot be far away. This is only possible through small differences with original images. either of which can be configured as the method of error control. symposia. this report is concerned with the implementation of telemedicine developing countries and encouraging developing countries to consider telemedicine applications. V. pictures. Such bodies appear to be much more concerned with primary health care coverage for their populations.03 11. MNP allows to connect with older modems. once the regulatory..05. conferences. It will always try to compress the data. the government department responsible for defining and implementing general policy on health and organising health services is generally the ministry for public health. Telemedicine is still a utopian concept. Computerization of health services management The organization of health services is an important factor for telemedicine. even when it is already compressed.

While we talk about PACS. authenticity. providing diagnoses. developments in this field will allow us to move on from PACS to the WWW (World Wide Web). Medical technologies In a modern health service.4 kbs/s transmissions to wide band subscriber loop transmissions starting from the existing access network (copper wire.96 . treatment and care depends on the quality of both the biomedical equipment and professional expertise. • and/or VSAT networks. Telemedicine demands a high degree of telecommunications network security. The need for advanced technologies is pressing. radio-television systems). from which PACS (Pictures Archiving and Communication System) has derived. Over the next decade. and security. where access to a registered patient's record form will be possible anywhere in the world. For reasons of reliability.05. and which is extensively used in the clinical and radiological environment in developed countries. in developing countries one would have to pass from 2. Need for basic infrastructures: telecommunications and medical technology Telecommunications Telecommunications constitute an essential link in introducing a telemedicine application. • holding distant consultations by real time examination of diagnostic pictures. security and reliability of telecommunications networks is a decisive factor for introducing telemedicine applications.10. TMP_E\ITU-D\CONF-D\CRDT96\AR\000\023E. Introduction of telemedicine services comes up against the almost total absence of computerization in present day health services management. But it is precisely in the developing countries that the existing infrastructures are largely obsolete and the transmission capacity of the arterial routes is inadequate for telemedicine. the risks of breakdown or even of any corruption of links must be zero.03 11. using satellites to relay signals in fixed point to point propagation mode.50 AR-CRDT-96/23-E The development of numerous picture processing techniques has made it possible to improve picture management systems. and • interactive management of patients' medical records. For practical and economic reasons. so as to create a genuine medical network via the Internet. multipoint distribution networks for medical information and the Internet. Developing countries are inevitably short of both equipment and well-trained experts.. Hertzian loop. management of health services in developing countries is still done manually on forms. Even referral hospitals use this archaic method of management.WW7 (34900) 11. As far as transmission support capacities are concerned. Acquisition of communications interfaces and suitable expertise is a need which must be taken into account in any strategy for introducing telemedicine in a developing country. a high efficiency level. and adequate transmission capacity. It is advisable to think in terms of introducing a computer tool and starting up medical information systems and high performance networks in order to promote: • exchange of information and data between scientists and experts. or gain access to the networks of the future by deployment of: • installations on fibre optic cables to allow interactive multimedia flows.

Are telecommunications connections needed inside the country only or also outside the country? What telecom infrastructure is available or what could be made available? Do a cost-benefit analysis. countries should do a careful assessment to determine the most appropriate technologies. WHO. Define telemedicine needs. Factors to consider in the implementation of telemedicine Identify the types of medical services where telemedicine could be useful. and the limited resources of a State which must cope with enormous demand for supply of services and basic infrastructure (roads. Administrations should work together to ensure that policies are in place at the national level to expand and introduce interoperable telemedicine networks that can be used effectively to improve the quality of health care delivery worldwide. electricity. Such finance can be granted in the form of aid from industrialized countries. medical technologies. For example. and involve training in the three sectors which play a part in the provision of telemedicine services: telecommunications.05. credits granted by backers. Any plan to create a health care system utilising telemedicine should address medical practice. in primary health care or emergencies. schools. continuing medical education (CME).03 11.10.. Given the state of economic crisis which developing countries are experiencing. Ambulance services may need some telemedicine equipment. means of communications and services. and health services in the particular case. Thus. UNESCO and others. Do market analysis in your country..g. rural and remote hospitals may have no communications links with urban hospitals. there are many applications currently in use which require only basic infrastructure and resources. Who could benefit and who can pay for such services? Remember that there are different technologies and services available which could meet particular needs. or support for implementation of pilot schemes for operational applications of telemedicine and distance health care by specialist international organizations.96 TMP_E\ITU-D\CONF-D\CRDT96\AR\000\023E. Observing technological barriers. Financial constraints All the constraints and requirements mentioned above imply mobilization of major financial resources. e. 11.).51 AR-CRDT-96/23-E Training requirements The requirements for training in telemedicine and distance health care are enormous in developing countries. There is great potential for telemedicine applications in both the industrialized and the developing countries. While the most advanced services require facilities that may not be widely available in developing countries. telephones etc. such as UNDP53. Some will be more expensive and complicated.WW7 (34900) . 53 United Nations Development Programme. and public wellness. financial support for strategies to introduce telemedicine into developing countries must in essence rely on external finance.

ATM: Asynchronous Transfer Mode. Each rule is precisely and unambiguously defined so that in principle it can be carried out by machine. telemedicine equipment manufacturers. Japan. 11 Glossary ACR: American College of Radiology AIM: Advanced Informatics in Medicine (EU) Algorithm: A set of rules which specify a sequence of actions to be taken to solve a problem. If the country is seeking a telemedicine service provider outside the country.WW7 (34900) 11. Check out what other countries have been doing. TMP_E\ITU-D\CONF-D\CRDT96\AR\000\023E. but it needs to be introduced in a balanced way so that it is not at the expense of higher priorities.05. including the Ministry of Health or other health care professionals. service providers. September 1994.. Try to get some training in the use of the equipment and services.10. Angiography: The study of the cardio-vascular system by means of radio-opaque media.03 11. ITU. The resolution urges administrations to take all practical steps to reduce and where possible to remove regulatory barriers and to strengthen transborder cooperation between states.96 . European Commission. AT&T: American Telephone and Telegraph Company. National administrations should take steps to implement Resolution 36 (relating to telecommunications for disaster mitigation and disaster relief operations) of the ITU Plenipotentiary Conference. Angiocardiography: The radiological examination of the heart and great vessels after injection of a contrast medium. Kyoto. preferably including visits to some of those countries with relevant telemedicine experience.52 AR-CRDT-96/23-E Ensure a diversity of players are involved in the implementation of telemedicine services. Telemedicine should be a part of the overall health infrastructure. nutrition. sanitation. Ensure adequate organizational and administrative arrangements are established and sustainable. Follow a gradual. regional and international organizations from whom some funding for telemedicine projects can be sought. Get some limited experience via pilot projects or demonstrations before implementing a large scale service. Seek advice from international organizations. then seek competitive bids and establish appropriate contracts. countries should not be enamoured of high technology to the extent that they introduce such services to sectors or areas where other needs should be met first. still the country should ensure the telemedicine services are self-sustaining in the medium to long term to avoid raising false expectations. such as clean water. telecom operators. Raise awareness about potential telemedicine applications among health care professionals and telecom operators. There are various national. At the same time. etc. step-by-step approach to the introduction of telemedicine services. Although it is worthwhile contacting these funding bodies. such as the WHO.

In medicine this technique is used to study patient physiology. Contrast Medium: Substance (widely used in diagnostic radiology) injected into the bloodstream to increase the contrast in X-ray procedures.10. Endoscopy: Any technique for visual inspection of internal organs. diet or toxic substances and examining appropriate preventative or curative measures. Epidemiology: It is the study of disease in the population. DICOM: Digital Image Communications In Medicine.53 AR-CRDT-96/23-E BT: British Telecom.c. DSA: Digital Subtraction Angiography is a radiological technique where an initial X-ray image is digitized and subtracted from another taken after the injection of contrast medium. a project funded under the European Commission's Fourth Framework Programme (1994-98) as a contribution to sub-project 4 of the G-7 Global Information Society theme on global health care. A record of the electrical activity of the heart. Cardiology: The section of medical science concerned with the function and diseases of the heart.WW7 (34900) 11.03 11. Instrument for study of voltage waves associated with the brain. Endoscope: An instrument for inspecting and photographing internal cavities of the body in medicine. GETS: Global Emergency Telemedicine Service. Fluoroscopy: Examination of objects by observing their X-ray shadow on a fluorescent screen. effectively comprises a sensitive detector (voltage or current). defining its incidence and prevalence.05. examining the role of external influences such as infection. CT: Computed Tomography. FEST: Framework for European Services in Telemedicine. As only the contrast in the blood vessels is added. ECG: electrocardiogram. a d. such as heart beat and respiration.96 . a project funded by the European Commission under its Third Framework Programme. usually contains iodine. in the manner of a shift register. amplifier of very good stability and an electronic recording system. It is a semiconductor device which relies on the short-term storage of minority carriers in spatially defined depletion zones on its surface. CCD: Charge-coupled device.. Echocardiography: Echocardiography is the examination of the structure and function of the heart using reflected pulsed ultrasound. EEG: ElectroEncephaloGraph. TMP_E\ITU-D\CONF-D\CRDT96\AR\000\023E. which can be transmitted at higher data rates and with lower error rates. high quality images of these blood vessels can be obtained after a small intravenous injection. Fibre-optics are normally used to both illuminate and inspect the inside of the human body from outside. Dermatology: The branch of medical science which deals with the skin and its diseases. A camera can be connected to the echocardiogram unit camera by means of an ordinary video cable. Codec: Codecs are used in telephone systems to convert analog voice signals into digital signals. The charges thus stored can be moved about by the application of control voltages via metallic conductors to the storage points. reconstruction of cross-sectional images of the body made by a rotating X-ray source and detector which move around the body and records the X-ray transmissions throughout the 360º rotation.

A standard for still and moving image compression. Ophthalmology: The study of the eye and its diseases. MDIS: Medical Diagnostic Imaging Support. which provides satellites for maritime. both research and development.03 11. IFRC: International Federation of Red Cross and Red Crescent Societies. NASA: National Aeronautics and Space Administration. TMP_E\ITU-D\CONF-D\CRDT96\AR\000\023E. United States. ISDN: Integrated Services Digital Network. nose and throat. In the United Kingdom GP's are the non-specialists physicians who provide primary care to the community. JPEG: Joint Photographic Experts Group. aeronautical and land mobile communications. Their surgeries are usually the first point of contact for the patient regarding anything other than a medical emergency. HERMES: Telematic HEalth care Remotenes and Mobility Factors In Common European Scenarios.96 . MEDLARS: Medical Literature Analysis and Retrieval System.WW7 (34900) 11. Oncology: That part of medical science dealing with new growths (tumours) of body tissue.. ISO: International Standards Organization. data and still pictures in digital form. the United Nations agency responsible for telecommunications. Gynaecology: The branch of medicine concerned with diseases in women.05. A standard for still and moving image compression. It is mainly those diseases of the genito-urinary tract. Inmarsat: International Mobile Satellite Organization. NM: Nuclear Medicine is the application of radionuclides in the diagnosis or treatment of disease. ICRC: International Committee for the Red Cross. MPEG: Motion Picture Expert Group.54 AR-CRDT-96/23-E GP: General Practitioner. IMIA: International Medical Informatics Association. MRI: Magnetic Resonance Imaging is the use of nuclear magnetic resonance of protons to produce proton density maps or images of the human body. Otorhinolaryngology: That part of surgical science which deals with diseases of the ear. MERMAID: Medical Emergency Aid Through Telematics. NREN: National Research and Educational Network. It is a set of standards defined by the International Telecommunication Union and the International Telegraph and Telephone Consultative Committee of the ITU that defines a type of digital telecommunication service allowing the integrated transmission of voice. It is a collection of more than 25 databases in the biomedical field produced by the National Library of Medicine which is located in Bethesda.10. a project funded under the European Commission's Fourth Framework Programme. It is responsible for civil space activities in the United States. NEMA: National Electrical Manufacturers Association. ITU: International Telecommunication Union.

05.).03 11. Psychiatry: The study of mental disorders. Pharmacology: The scientific study of the action of chemical substances on living systems. PEACESAT: Pan-Pacific Education and Communication Experiments by Satellite.e. heart rate or blood pressure etc. (i. PET: Positron Emission Tomography. Tele-obstetrics: Tele-oncology: Tele-ophthalmology: Telepathology: Telepathology is the transmission of images of cell or tissue samples for microscopic examination and evaluation. SEISMED: Secure Environment for Information Systems in Medicine (EU).96 . Telepharmacology: TMP_E\ITU-D\CONF-D\CRDT96\AR\000\023E. PC: Personal Computer. Distant consultations based on microscopic examinations of cell and tissue section by using distant microscope control is for transferring video. Radiology: Radiology is the scientific study of X-rays and other high energy radiation which is used in the medical profession.55 AR-CRDT-96/23-E PACS: Picture Archival and Communications System. PAHO: Pan American Health Organization. from a remote site. and with the bodily changes wrought by disease. Pathology: Pathology is the area of medical science which deals with the causes of disease. especially of the ear.WW7 (34900) 11. SPECT: Single Photon Emission Computed Tomography. Today's modern instruments are usually flexible fibre-optic devices and additional facilities for biopsy. Telefluoroscopy: Telegynaecology: Telehaematology: Telemetry: It is a way of monitoring and studying physiological functions of a human being or animal. TAMC: Tripler Army Medical Centre (Hawaii).. TEACH: Training Education Applied to Community Health (Hawaii). nose. SuperJanet: Super Joint Academic Network.10. speech and data for controlling the microscope and different cameras. Tele-endoscopy is the transmission of digital images. RCCS: Remote Clinical Communications Systems. throat and nasal passages. Telecardiology: Teledermatology: Tele-endoscopy: Endoscopy is any technique for visual inspection of the internal organs.

file data and then review and discuss them.10. Electronic film distribution and archiving can give physicians instant access to patient images without the film leaving the hospital's radiology department. mammograms and similar images can be transmitted over ordinary telephone lines. TETRA: Telemedicine and Educational Technology Resources Agency. an agency of the United Nations. nurses and other health care providers to transmit images generated by magnetic resonance imaging (MRI) or computed tomography (CT) scans to each other. WHO: World Health Organization. It is a trademark of AT&T laboratories.03 11. Telepsychiatry: Can be delivered via telephone help lines or videoconferencing equipment. labs. based in Geneva. allowing personnel to view images.05. The reflected waves are then recorded and an image is formed. Images are digitized and stored in a computer database. MRIs. and to discuss diagnosis and treatment.WW7 (34900) 11. Teletherapy: Counselling. between the patient and the specialist. X-rays. pharmacies and other facilities. Thermography: The use of radiant heat emitted by the body to construct images of increased heat emission which can indicate tumours or inflammation.56 AR-CRDT-96/23-E Telepresence: A technique in which a person has the virtual feeling of being at a chosen site even though he/she is not physically at the site.. usually by telephone. UNIX: TN for a well known operating system not tied to a particular computer manufacturer. transport and storage can be eliminated. Problems of image availability. lab results. ___________________ TMP_E\ITU-D\CONF-D\CRDT96\AR\000\023E. Widely used mail network connecting machines running UNIX operating system. Ultrasound: It involves passing a high frequency sound wave (2-4 MHz) into the patients body. In addition. nursing homes. teleradiology enables interaction among hospitals. Teleradiology: Teleradiology allows doctors. CAT scans.96 . often over ordinary telephone dial-up lines. UUCP: UNIX to UNIX copy.

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