Telemedicine*

Additional Information

More details about this topic (e.g., different models, definitions, approaches, etc)

Telemedicine services can be subdivided into the following broad categories, discussed in this section:

GENERAL HEALTH CARE

This consists of Emergency Telemedicine, Tele-Nursing and Tele-Pharmacy.

Emergency Telemedicine: Disaster management utilizes diverse technologies to accomplish a complex set of tasks.

Due to increasing speed in processing data and expanding bandwidth of wireless networks, it is possible to perform telemedicine services on personal digital assistants (PDA). A PDA can be used on wideband mobile networks such as Wi- Fi, HSDPA, and WiBro for high speed bandwidths. This system enables to utilize and exchange variety and reliable patient information of video, biosignals, chatting messages, and triage data.

Tele-Nursing. As a field it is part of telehealth, and has many points of contacts with other medical and non-medical applications, such as telediagnosis, teleconsultation, telemonitoring, etc.

• Home Care: One of the most distinctive telenursing applications is home care. For example, patients who are immobilized, or live in remote or difficult to reach places, citizens who have chronic ailments, such aschronic obstructive pulmonary disease, diabetes, congestive heart disease, or disabilitating diseases, such as neural degenerative diseases (Parkinson's disease, Alzheimer's disease, ALS), etc., may stay at home and be "visited" and assisted regularly by a nurse via videoconferencing, internet, videophone, etc. Still other applications of home care are the care of patients in immediate post-surgical situations, the care of wounds, ostomies, handicapped individuals, etc. In normal home health care, one nurse is able to visit up to 5-7 patients per day. Using telenursing, one nurse can "visit" 12-16 patients in the same amount of time. 
• Call Centers: A common application of telenursing is also used by call centers operated by managed care organizations, which are staffed by registered nurses who act as case managers or perform patient triage, information and counseling as a means of regulating patient access and flow and decrease the use of emergency rooms.
• Telenursing can also involve other activities such as patient education, nursing teleconsultations, examination of results of medical tests and exams, and assistance to physicians in the implementation of medical treatment protocols.

Tele-Pharmacy

Telepharmacy is another growing trend for providing pharmaceutical care to patients at remote locations where they may not have physical contact with pharmacists. It encompasses drug therapymonitoring, patient counseling, prior authorization, refill authorization, monitoring formulary compliance with aid of teleconferencing or videoconferencing. In addition, video-conferencing is vastly utilized in pharmacy for other purposes, such as providing education, training, and performing several management functions.

The remote site dispensing and patient education process was described as follows: once the prescription is sent from the remote clinics to the base pharmacy, the pharmacist verifies the hard copy and enters the order. The label is also generated simultaneously, and the label queue is transmitted to the remote site. When the label queue appears on the medication dispensing cabinet known as ADDS, the authorized person can access the medicine from ADDS followed by medication barcode scanning, and the printing and scanning of labels. Once those steps are done, the remote site personnel are connected to the pharmacist at base pharmacy via videoconferencing for medication verification and patient counseling.

TELECARDIOLOGY

Telecardiology is the process wherein a patient’s electrical activity results such as ECG and other diagnostic results   like Echocardiogram, Cardiac CT scan, Cardiac MRI scan, etc., can be transmitted and interpreted through telephone or over the internet, facilitating proper diagnosis. Modalities such as Echocardiogram, ECG, Cardiac CT, Cardiac MRI, Carotid Doppler, Stress Echocardiogram, Cardiac Nuclear Scans, Stress Test (TMT), Holter Monitor, Event Monitor, and Second Opinion for Coronary Angiograms are included under Telecardiology services.

Telemedicine can play a huge role in care delivered by primary care physicians . One of the oldest known telecardiology systems for teletransmissions of ECGs was established in Gwalior, India. The ECG was converted to sound waves with a frequency varying from 500 Hz to 2500 Hz with 1500 Hz at baseline. This system was also used to monitor patients with pacemakers in remote areas. In Pakistan three pilot projects in telemedicine, initiated by the Ministry of IT & Telecom, were linked via the Pak Sat-I communications satellite, and four districts were linked with another hub. A 312 Kb link was also established with remote sites and 1 Mbit/s bandwidth was provided at each hub. These remote sites were
connected and on average of 1,500 patients being treated per month per hub.

The Telecardiology Framework:

The telemedicine framework consists of three participant sites (see Figure-1 in Overview.) including the physician at the point-of-care, the specialized cardiologist and the remote information server. At the point of care, a physician acquires the ECG and other relevant information during the clinical intervention using a mobile device and sends it to the information server. Then the information is processed and a results report is automatically produced and stored on the server. Finally, the specialist connects to the information server and gets the results to be analyzed and used in the patient diagnosis.

A Mobile platform:

A sample mobile platform in Telecardiology is essentially a wearable device that would be distributed among patients in order to offer continuous monitoring of the patients’ vital signs It is composed of a customized sensor board providing connections to a 3-Lead ECG monitoring system, which is housed on a commercially available TelosB sensor mote. While the sensor board gathers useful patient ECG data, the sensor mote provides limited processing capabilities and more importantly wireless communication for transmitting the signals back to the workstation for feature extraction.

TELEDENTISTRY

Teledentistry is the use of information technology and telecommunications for dental care, consultation, education, and public awareness in the same manner as telehealth and telemedicine. Teledentistry can also be used to assist general dentists with specialty work and improve services to underserved populations such as in rural or less developed areas.

Teledentistry Services -

Teledentistry can be integrated in general dental practice and specialty practices. Teledentistry services would be part of a larger investment by health care practices, organizations, and institutions in information technology or the delivery of clinical care. Like telemedicine, teledentistry can provide different types of programs and services for the patient. The following teledentistry services could evolve from current telemedicine practices.

• Specialist referral service
• Patient consultation
• Remote patient monitoring
• Professional education
• Consumer medical and health information

Telehealth and telemedicine have used the following delivery mechanisms, which could be developed to support teledentistry services.

• Networked programs link hospitals and clinics with outlying clinics and community health centers in rural or suburban areas. The links may use dedicated high-speed lines or the Internet for telecommunication links between sites.
• Point-to-point connections using private networks. These connections are used by hospitals and clinics that deliver services directly, or contract out specialty services to independent providers, at ambulatory care sites.
• Primary or specialty care to the home connections involves connecting primary care providers, specialists and
  home health nurses with patients using single line phone/video systems for interactive clinical consultations.
• Home to monitoring center links are used for patient monitoring, home care and related services that provide care to patients in the home. Often normal phone lines are used to communicate directly between the patient and the center although some systems use the Internet.
• Web-based e-health patient service sites provide direct consumer outreach and services over the Internet.
  Under telemedicine, these include sites that provide direct patient care.

• Information Technology (IT) Infrastructure
• Networks
• Telecommunication Services
• Data Security
• Real Time Video Conferencing vs. Store and Forward Communication

Teledermatology is a subspecialty in the medical field of dermatology and probably one of the most common applications of telemedicine and e-health. In teledermatology, telecommunication technologies are used to exchange medical information (concerning skin conditions and tumors of the skin) over a distance using audio, visual and data communication. Applications comprise health care management such as diagnoses, consultation and treatment as well as (continuous) education.

Teledermatology (as telemedicine) is practiced on the basis of two concepts: Store and forward (SAF) and real time/live interactive teledermatology. Hybrid modes also exist (combining SAF and real time applications).

The SAF method is most commonly used in teledermatology: It involves sending (forwarding) digital images associated with (anonymous) medical information to the data storage unit of a consulted specialist. It can be as easy as sending an email with a digital image of a lesion to seek advice for a skin condition. Advantages of this method are that it does not demand the presence of both parties at the same time and does not usually require expensive equipment.

• Telediagnosis
• Specialist referral
• Home telehealth/telehomecare

TELEPATHOLOGY

Telepathology is the practice of pathology at a distance. It uses telecommunications technology to facilitate the transfer of image-rich pathology data between distant locations for the purposes of diagnosis, education, and research. Performance of telepathology requires that a pathologist selects the video images for analysis and the rendering of diagnoses. The use of “television microscopy”, the forerunner of telepathology, did not require that a pathologist have physical or virtual “hands-on” involvement in the selection of microscopic fields-of-view for analysis and diagnosis.

Telepathology has been successfully used for many applications, including the rendering of histopathology tissue diagnoses at a distance. Although digital pathology imaging, including virtual microscopy, is the mode of choice for telepathology services in developed countries, analog telepathology imaging is still used for patient services in some developing countries.

Telepathology Services and Uses -

• Diagnosing of frozen section specimens
• Primary histopathology diagnoses
• Competency assessment
   
  Research and Education
• Direct access to subspecialty pathologists such as a neuropathologist for immediate consultation.

In today’s health care system, there are many uses of telepathology. One is to provide urgent services at sites either without a pathologist or with a pathologist requiring back- up. Secondly, telepathology can provide immediate access to subspecialty pathology consultants. For example, if a primary care physician in a rural area needs a pathologist to diagnose a disease, and the nearest pathologist is over an hour away, telemedicine can be an excellent alternative.

Thirdly, and probably the one most often used, is to, generate second opinions. Often times, physicians are not sure if their diagnosis is correct and in order to confirm their decision, they can contact another telepathologist via telemedicine. Additionally, it can, assist pathologists in completing or refining a differential diagnosis. And finally, telepathology can be used to continue medical education, proficiency, testing, and recertification of pathologists as well as other laboratory personnel. This can be extremely beneficial to students in rural areas. This way, they do not have to travel far to receive their education or take exams. Obviously, telepathology has become an important aspect of telemedicine in the past few years and it will even more in the years to come.