Telemedicine

Telemedicine

Rupak ChakravartyRupak Chakravarty

Telemedicine

Telemedicine has been defined as the use of Telemedicine has been defined as the use of telecommunications to provide medical telecommunications to provide medical information and services. It may be as simple as information and services. It may be as simple as two health professionals discussing a case over two health professionals discussing a case over the telephone, or as sophisticated as using the telephone, or as sophisticated as using satellite technology to broadcast a consultation satellite technology to broadcast a consultation between providers at facilities in two countries, between providers at facilities in two countries, using videoconferencing equipment or robotic using videoconferencing equipment or robotic technology.technology.

Telemedicine

Telemedicine generally refers to the use of ICT for Telemedicine generally refers to the use of ICT for the delivery of clinical carethe delivery of clinical care

Telemedicine

Types of telemedicineTypes of telemedicine

Telemedicine is practiced on the basis of two Telemedicine is practiced on the basis of two concepts: concepts:

real time (synchronous) and real time (synchronous) and store-and-forward (asynchronous)store-and-forward (asynchronous)

Real time telemedicine

Real time telemedicine could be as simple as a Real time telemedicine could be as simple as a telephone call or as complex as robotic surgery. It telephone call or as complex as robotic surgery. It requires the presence of both parties at the same requires the presence of both parties at the same time and a communications link between them that time and a communications link between them that allows a real-time interaction to take place. Video-allows a real-time interaction to take place. Video-conferencing equipment is one of the most conferencing equipment is one of the most common forms of technologies used in common forms of technologies used in synchronous telemedicine.synchronous telemedicine.

Real time telemedicine

There are also peripheral devices which can be There are also peripheral devices which can be attached to computers or the video-conferencing attached to computers or the video-conferencing equipment which can aid in an interactive equipment which can aid in an interactive examination. examination.

For instance, a For instance, a tele-otoscopetele-otoscope allows a remote allows a remote physician to 'see' inside a patient's physician to 'see' inside a patient's earear; a ; a tele-tele-stethoscopestethoscope allows the consulting remote allows the consulting remote physician to hear the patient's physician to hear the patient's heartbeatheartbeat. .

Store-and-forward telemedicine

Store-and-forward telemedicine involves Store-and-forward telemedicine involves acquiring medical data (like medical images, acquiring medical data (like medical images, biosignals etc) and then transmitting this data to a biosignals etc) and then transmitting this data to a doctor or medical specialist at a convenient time doctor or medical specialist at a convenient time for assessment offline. It does not require the for assessment offline. It does not require the presence of both parties at the same time.presence of both parties at the same time.

Dermatology, radiology, and pathology are Dermatology, radiology, and pathology are common specialties that are conducive to common specialties that are conducive to asynchronous telemedicine. A properly structured asynchronous telemedicine. A properly structured Medical Record preferably in electronic form Medical Record preferably in electronic form should be a component of this transfer.should be a component of this transfer.

Store-and-forward telemedicine

Teleradiology, the sending of x-rays, CT scans, Teleradiology, the sending of x-rays, CT scans, or MRIs (store-and-forward images) is the most or MRIs (store-and-forward images) is the most common application of telemedicine in use today. common application of telemedicine in use today. There are hundreds of medical centers, clinics, There are hundreds of medical centers, clinics, and individual physicians who use some form of and individual physicians who use some form of teleradiology. Many radiologists are installing teleradiology. Many radiologists are installing appropriate computer technology in their homes, appropriate computer technology in their homes, so they can have images sent directly to them for so they can have images sent directly to them for diagnosis, instead of making an off-hours trip to a diagnosis, instead of making an off-hours trip to a hospital or clinic.hospital or clinic.

Telemedicine

Telemedicine is most beneficial for populations Telemedicine is most beneficial for populations living in isolated communities and remote regions living in isolated communities and remote regions and is currently being applied in virtually all and is currently being applied in virtually all medical domains. Specialities that use medical domains. Specialities that use telemedicine often use a "tele-" prefix; for telemedicine often use a "tele-" prefix; for example, telemedicine as applied by radiologists is example, telemedicine as applied by radiologists is called Teleradiology. Similarly telemedicine as called Teleradiology. Similarly telemedicine as applied by cardiologists is termed as applied by cardiologists is termed as telecardiology, etc.telecardiology, etc.

Telemedicine

Telemedicine is also useful as a communication Telemedicine is also useful as a communication tool between a general practitioner and a specialist tool between a general practitioner and a specialist available at a remote location.available at a remote location.

Telemedicine

Telepathology is another common use of this Telepathology is another common use of this technology. Images of pathology slides may be technology. Images of pathology slides may be sent from one location to another for diagnostic sent from one location to another for diagnostic consultation. consultation. Dermatology is also a natural for store and Dermatology is also a natural for store and

forward technology (although practitioners are forward technology (although practitioners are increasingly using interactive technology for increasingly using interactive technology for dermatological exams). Digital images may be dermatological exams). Digital images may be taken of skin conditions, and sent to a taken of skin conditions, and sent to a dermatologist for diagnosis.dermatologist for diagnosis.

TelemedicineThe other widely used technology, The other widely used technology, two-way two-way

interactive television (IATV)interactive television (IATV), is used when a , is used when a 'face-to-'face-to-face' consultationface' consultation is necessary. The patient and is necessary. The patient and sometimes their provider, or more commonly a nurse sometimes their provider, or more commonly a nurse practitioner or telemedicine coordinator (or any practitioner or telemedicine coordinator (or any combination of the three), are at the originating site. combination of the three), are at the originating site. The specialist is at the referral site, most often at an The specialist is at the referral site, most often at an urban medical center. urban medical center. Video conferencingVideo conferencing equipment at both locations equipment at both locations

allow a 'real-time' consultation to take place. The allow a 'real-time' consultation to take place. The technology has decreased in price and complexity technology has decreased in price and complexity over the past five years, and many programs now over the past five years, and many programs now use desktop video conferencing systems. use desktop video conferencing systems.

Telemedicine

There are many configurations of an interactive There are many configurations of an interactive consultation, but most typically it is from an consultation, but most typically it is from an urban-to-urban-to-rural locationrural location. It means that the . It means that the patient does not have patient does not have to travel to an urban area to see a specialistto travel to an urban area to see a specialist, and in , and in many cases, provides access to many cases, provides access to speciality carespeciality care when when none has been available previously. none has been available previously. Almost all specialities of medicine have been found Almost all specialities of medicine have been found

to be conducive to this kind of consultation, including to be conducive to this kind of consultation, including psychiatry, internal medicine, rehabilitation, psychiatry, internal medicine, rehabilitation, cardiology, paediatrics, obstetrics and gynaecology cardiology, paediatrics, obstetrics and gynaecology and neurology.and neurology.

Telemedicine

There are also many There are also many peripheral devicesperipheral devices which can which can be attached to computers which can aid in an be attached to computers which can aid in an interactive examination. interactive examination.

For instance, an For instance, an tele-otoscopetele-otoscope allows a physician to 'see' inside a patient's ear; allows a physician to 'see' inside a patient's ear;

a a tele-stethoscopetele-stethoscope allows the consulting physician allows the consulting physician to hear the patient's heartbeat.to hear the patient's heartbeat.

Teleradiology:

Teleradiology is the ability to send radiographic Teleradiology is the ability to send radiographic images (x-rays) from one location to another. For this images (x-rays) from one location to another. For this process to be implemented, three essential process to be implemented, three essential components are required, an image sending station, a components are required, an image sending station, a transmission network, and a receiving / image review transmission network, and a receiving / image review station. station. The most typical implementation are two computers The most typical implementation are two computers

connected via Internet. The computer at the receiving connected via Internet. The computer at the receiving end will need to have a high-quality display screen end will need to have a high-quality display screen that has been tested and cleared for clinical purposes. that has been tested and cleared for clinical purposes. Sometimes the receiving computer will have a printer Sometimes the receiving computer will have a printer

so that images can be printed for convenience.so that images can be printed for convenience.

Teleradiology:

The teleradiology process begins at the image The teleradiology process begins at the image sending station. The radiographic image and a sending station. The radiographic image and a modem or other connection are required for this first modem or other connection are required for this first step. The image is scanned and then sent via the step. The image is scanned and then sent via the network connection to the receiving computer.network connection to the receiving computer.

Advantages of Telemedicine:

Providing healthcare services via telemedicine Providing healthcare services via telemedicine offers many advantages. It can make specialty care offers many advantages. It can make specialty care more accessible to underserved rural and urban more accessible to underserved rural and urban populations. populations.

Video consultations from a rural clinic to a specialist Video consultations from a rural clinic to a specialist can alleviate prohibitive travel and associated costs can alleviate prohibitive travel and associated costs for patients. for patients.

Advantages of Telemedicine:

Video conferencing also opens up new possibilities Video conferencing also opens up new possibilities for continuing education or training for isolated or for continuing education or training for isolated or rural health practitioners, who may not be able to rural health practitioners, who may not be able to leave a rural practice to take part in professional leave a rural practice to take part in professional meetings or educational opportunities. meetings or educational opportunities.

the use of telemedicine can also cut costs of the use of telemedicine can also cut costs of medical care for those in rural areas.medical care for those in rural areas.

Barriers to Telemedicine

There are still several barriers to the practice of There are still several barriers to the practice of telemedicine. Many states will not allow out-of-state telemedicine. Many states will not allow out-of-state physicians to practice unless licensed in their state. physicians to practice unless licensed in their state. The Centers for Medicare and Medicaid (CMS) still The Centers for Medicare and Medicaid (CMS) still has several restrictions for Medicare telemedicine has several restrictions for Medicare telemedicine reimbursement. Many private insurers also will not reimbursement. Many private insurers also will not reimburse, although some states, such as California reimburse, although some states, such as California and Kentucky, have legislated that they must and Kentucky, have legislated that they must reimburse the same as for face-to-face consultations.reimburse the same as for face-to-face consultations.


Many potential telemedicine projects have been Many potential telemedicine projects have been hampered by the hampered by the lack of appropriate lack of appropriate telecommunications technologytelecommunications technology. Regular telephone . Regular telephone lines do not supply lines do not supply adequate bandwidthadequate bandwidth for most for most telemedical applications. telemedical applications.

Many rural areas still Many rural areas still do not have cable wiringdo not have cable wiring or or other kinds of high bandwidth telecommunications other kinds of high bandwidth telecommunications access required for more sophisticated uses. access required for more sophisticated uses.


Lack of funding for developing state-of-the-art Lack of funding for developing state-of-the-art telemedicine infrastructuretelemedicine infrastructure

Some private corporations and telecommunications Some private corporations and telecommunications companies are stepping in to fill the void, however, companies are stepping in to fill the void, however, pressure on the appropriate government and pressure on the appropriate government and legislative agencies is needed before more funding legislative agencies is needed before more funding will become available.will become available.

Need for Telemedicine in India:

The The health of a nationhealth of a nation is the product of many factors is the product of many factors and forces that combine and interact. Economic and forces that combine and interact. Economic growth, per capita income, literacy, education, age at growth, per capita income, literacy, education, age at marriage, birth rates, information on health care and marriage, birth rates, information on health care and nutrition, access to safe drinking water, public and nutrition, access to safe drinking water, public and private health care infrastructure, access to private health care infrastructure, access to preventive health and medical care and the health preventive health and medical care and the health insurance are among the insurance are among the contributing factorscontributing factors. .

The advances in Medical science, biomedical The advances in Medical science, biomedical engineering on one side and Telecommunication and engineering on one side and Telecommunication and Information Technology on the other side are offering Information Technology on the other side are offering wide opportunities for improved health care.wide opportunities for improved health care.


Despite making huge strides in overall development, Despite making huge strides in overall development, the the health coverage to majority of our population is health coverage to majority of our population is still a distant dreamstill a distant dream..India is a vast country gifted with rich and ancient India is a vast country gifted with rich and ancient

historic background and historic background and geographicallygeographically the nature the nature has provided India with all the has provided India with all the varietiesvarieties like the like the mountain regions like Ladakh, deserts, green planes mountain regions like Ladakh, deserts, green planes and far flung areas in the north east and offshore and far flung areas in the north east and offshore islands of Andaman’s and Lakshadweepislands of Andaman’s and Lakshadweep..


India today has more than India today has more than 1 billion population1 billion population and and there is finite limit of elasticity in providing health care there is finite limit of elasticity in providing health care in terms of infrastructure, facility, the manpower and in terms of infrastructure, facility, the manpower and the funds. Wide disparities persist between different the funds. Wide disparities persist between different income groups, between rural and urban income groups, between rural and urban communities, and between different states and even communities, and between different states and even districts within States.districts within States.

The population is The population is predominantly rural and predominantly rural and distributed in distant geographical locationsdistributed in distant geographical locations apart apart from the high-density urban areas; to provide the from the high-density urban areas; to provide the basic minimum health care has been one of the basic minimum health care has been one of the priorities of the Health administration all along.priorities of the Health administration all along.


Further this is compounded by the following factors Further this is compounded by the following factors like:like:

High cost of health care and lack of investment for High cost of health care and lack of investment for health care in rural areas.health care in rural areas.Inadequate medical facilities in rural & inaccessible Inadequate medical facilities in rural & inaccessible

areas.areas.Problem of retaining doctors in rural areas where Problem of retaining doctors in rural areas where

they are required to serve & propagate widespread they are required to serve & propagate widespread health awareness.health awareness.Specialist doctors cannot be retained at rural areas Specialist doctors cannot be retained at rural areas

as they will be professionally isolated and become as they will be professionally isolated and become obsolete and even monetary incentives also cannot obsolete and even monetary incentives also cannot prevent it.prevent it.


A recent survey by the Indian Medical society has A recent survey by the Indian Medical society has found found 75% of qualified consulting doctors practice in urban 75% of qualified consulting doctors practice in urban

centers and centers and 23% in semi urban areas and 23% in semi urban areas and only 2% from rural areas whereas majority of the only 2% from rural areas whereas majority of the

patients come from rural areas. patients come from rural areas. Hospital beds / 1000 people is 0.19 in rural and Hospital beds / 1000 people is 0.19 in rural and 2.2 in urban areas. 2.2 in urban areas.


This calls for innovative methods of utilization of This calls for innovative methods of utilization of science and technology for the benefit, of our society science and technology for the benefit, of our society and telemedicine assumes a great significance to and telemedicine assumes a great significance to revolutionize the health care system in India. revolutionize the health care system in India. Adaptation of Telemedicine technology offers one of Adaptation of Telemedicine technology offers one of the best options for delivering healthcare for rural & the best options for delivering healthcare for rural & geographically distant population spread across geographically distant population spread across India. Importance of Telemedicine in health care India. Importance of Telemedicine in health care started quite some time ago & more recently the started quite some time ago & more recently the telemedicine has undergone something of telemedicine has undergone something of resurgence as technology began catching up with the resurgence as technology began catching up with the need and aspiration.need and aspiration.

The Potential

Some pilot schemes in telemedicine through the Some pilot schemes in telemedicine through the initiative of Department of Space, Department of initiative of Department of Space, Department of Information Technology, and some other public & Information Technology, and some other public & private organizations have demonstrated the private organizations have demonstrated the successful application of information and successful application of information and Communication technology in extending the reach Communication technology in extending the reach and access for improved health care to all.and access for improved health care to all.

Framework in defining the guidelines and standards:

InteroperabilityInteroperability: Develop telemedicine networks that : Develop telemedicine networks that interface together and create an open environment interface together and create an open environment sharing the application on different participating sharing the application on different participating systems in real-time or seamless interface between systems in real-time or seamless interface between several applicationsseveral applications

CompatibilityCompatibility: Equipment/systems of different : Equipment/systems of different vendors and different versions of the same system, vendors and different versions of the same system, to be able to be interconnectedto be able to be interconnected

Framework in defining the guidelines and standards:

ScalabilityScalability: Equipment/systems inducted for : Equipment/systems inducted for telemedicine to be able to be telemedicine to be able to be augmented with augmented with additional featuresadditional features and functions as modular add-on and functions as modular add-on options.options.PortabilityPortability: The data generated by an application : The data generated by an application

that runs on one system to be able to be that runs on one system to be able to be ported to ported to different platforms with a minimum effortdifferent platforms with a minimum effort..

ReliabilityReliability: Telemedicine systems to follow relevant : Telemedicine systems to follow relevant reliability standards of equipment/systems of similar reliability standards of equipment/systems of similar category to ensure availability of service with category to ensure availability of service with minimum system downtime.minimum system downtime.

The above framework has been so adopted to ensure:

Inclusion of all the stakeholdersInclusion of all the stakeholders: Making the : Making the recommendation with due consideration of the rights recommendation with due consideration of the rights and responsibilities of patient/community, health care and responsibilities of patient/community, health care service provider, the technology provider, the service provider, the technology provider, the government etc.government etc.

Making recommendations vendor neutralMaking recommendations vendor neutral: Ensuring : Ensuring that the recommendations are not biased against any that the recommendations are not biased against any specific vendor/manufacturer of telemedicine specific vendor/manufacturer of telemedicine systemssystems

The above framework has been so adopted to ensure:

Making standards technology neutralMaking standards technology neutral: Ensuring that : Ensuring that the recommendations will not favour any specific the recommendations will not favour any specific technology leaving scope for present/future technology leaving scope for present/future alternatives.alternatives.

Telemedicine Infrastructure:

This will include minimum standards for all the This will include minimum standards for all the hardware and software used in a telemedicine hardware and software used in a telemedicine system. system.

Under Under hardwarehardware it will include standards and it will include standards and guidelines for basic telemedicine platform, servers, guidelines for basic telemedicine platform, servers, clinical devices, video conferencing system, clinical devices, video conferencing system, communication hardware and power support. communication hardware and power support.

The The softwaresoftware standards address operating system, standards address operating system, telemedicine software, and server software.telemedicine software, and server software.

Telemedicine Infrastructure: Hardware Hardware o o Telemedicine platformTelemedicine platform: :

This will include minimum standards for type of This will include minimum standards for type of platform to be used, processor/minimum speed, platform to be used, processor/minimum speed, memory requirements, interfaces, and peripherals.memory requirements, interfaces, and peripherals. o o Clinical devices Clinical devices

This will include minimum standards for all the This will include minimum standards for all the clinical devices to be interfaced or integrated with the clinical devices to be interfaced or integrated with the telemedicine system, including performance telemedicine system, including performance specifications for devices measuring diagnostic specifications for devices measuring diagnostic parameters, imaging devices, compression, and their parameters, imaging devices, compression, and their safety requirements. safety requirements.


Hardware Hardware o Video conferencing units o Video conferencing units o This will include minimum standards for video o This will include minimum standards for video conferencing system, including data rate, picture conferencing system, including data rate, picture resolution, frame rate, type of camera, audio quality resolution, frame rate, type of camera, audio quality etc. etc. o Communication hardware o Communication hardware o This will include minimum standards for various o This will include minimum standards for various hardware used for interfacing the telemedicine hardware used for interfacing the telemedicine system with the communication network, including all system with the communication network, including all types of terrestrial and satellite based networks. types of terrestrial and satellite based networks.


SoftwareSoftware

o An operating system o An operating system

o Licensed telemedicine S/W with appropriate User o Licensed telemedicine S/W with appropriate User Interface(UI) Interface(UI)

o Back-end Data Base with the mandatory tables/ o Back-end Data Base with the mandatory tables/ fields (if applicable) fields (if applicable)


Connectivity: Connectivity:

options for telemedicine services options for telemedicine services o VSAT o VSAT o PSTN o PSTN o ISDN o ISDN o Leased Line o Leased Line o Wireless LAN /WAN o Wireless LAN /WAN

Video conferencing boosts telemedicine

Video conferencing is becoming quite popular Video conferencing is becoming quite popular among hospitals. By using this technology, among hospitals. By using this technology, doctors can help patients who are unable to doctors can help patients who are unable to come to the hospital. It especially benefits the come to the hospital. It especially benefits the rural populace since one cannot always get good rural populace since one cannot always get good doctors there. Telemedicine has turned out to be doctors there. Telemedicine has turned out to be a blessing for patients who were otherwise a blessing for patients who were otherwise deprived of the best treatment. Polycom is one deprived of the best treatment. Polycom is one company that’s providing video conferencing company that’s providing video conferencing equipment to hospitals for tele-medicine.equipment to hospitals for tele-medicine.


A telemedicine system consists of customised A telemedicine system consists of customised hardware and software at two locations—the hardware and software at two locations—the patient’s as well as the doctor’s end. These patient’s as well as the doctor’s end. These locations are usually connected by means of an locations are usually connected by means of an Integrated Service Digital Network (ISDN), Public Integrated Service Digital Network (ISDN), Public Switch Telephone Network (PSTN) or Very Small Switch Telephone Network (PSTN) or Very Small Aperture Terminal (VSAT) link, and the system is Aperture Terminal (VSAT) link, and the system is controlled by the network hub station of the controlled by the network hub station of the Indian Space Research Organisation (ISRO).Indian Space Research Organisation (ISRO).


Polycom IndiaPolycom India provides video conferencing provides video conferencing equipment for tele-medicine. equipment for tele-medicine. Apollo and EscortsApollo and Escorts are are their principal clients in this area.” The company’s their principal clients in this area.” The company’s video conferencing solution is called Unified video conferencing solution is called Unified Collaborative Communications (UCC). It helps to Collaborative Communications (UCC). It helps to provide converged voice, video, web and data provide converged voice, video, web and data solutions for emerging broadband networks, and is solutions for emerging broadband networks, and is designed to integrate with standard video-based designed to integrate with standard video-based medical end-points.medical end-points.

http://www.onlinetelemedicine.com/

Broadband

Broadband has come as a big boost to telemedicine. Broadband has come as a big boost to telemedicine. “With the availability of broadband, India is now “With the availability of broadband, India is now becoming a hot destination for tele-medicine as it is a becoming a hot destination for tele-medicine as it is a win-win situation for both the patients as well as win-win situation for both the patients as well as hospitals. hospitals.

The goal

Telemedicine tools help deliver healthcare in medical Telemedicine tools help deliver healthcare in medical disciplines like emergency medicine, behavioural disciplines like emergency medicine, behavioural science, dermatology, cardiology, radiology, science, dermatology, cardiology, radiology, paediatrics, obstetrics, oncology, dentistry, gastro-paediatrics, obstetrics, oncology, dentistry, gastro-enterology, neurology, pathology, psychiatry, enterology, neurology, pathology, psychiatry, orthopaedics, family practice, ophthalmology and orthopaedics, family practice, ophthalmology and rheumatology. As Lavanian puts it, “The primary rheumatology. As Lavanian puts it, “The primary objective of tele-medicine is to provide quality objective of tele-medicine is to provide quality healthcare assistance to every patient.healthcare assistance to every patient.

The goal

Video conferencing also ensures that the patients are Video conferencing also ensures that the patients are treated irrespective of their financial condition, and treated irrespective of their financial condition, and this makes it popular in most countries. It is expected this makes it popular in most countries. It is expected that home-based patient monitoring is also going to that home-based patient monitoring is also going to become popular, as will remote surgery, which will become popular, as will remote surgery, which will involve surgery via robotics, with the surgeon in one involve surgery via robotics, with the surgeon in one location and the patient in another.location and the patient in another.

Possibilities of Telemedicine

Transmission of digitized audio, video, and still Transmission of digitized audio, video, and still images images Improvements in quality of care in rural and Improvements in quality of care in rural and

underserved communities underserved communities Overcoming isolation of rural practitioners by linking Overcoming isolation of rural practitioners by linking

them to urban medical centers them to urban medical centers Delivery of information and services into the home Delivery of information and services into the home Monitoring patients at home Monitoring patients at home

Possibilities of Telemedicine

Keeping patients in the community and maintaining Keeping patients in the community and maintaining continuity of care continuity of care Reduction of travel time and expense for physicians Reduction of travel time and expense for physicians

and patients and patients Increased mobility as people move from urban to Increased mobility as people move from urban to

rural areas with continued access to specialists rural areas with continued access to specialists New business and marketing opportunities New business and marketing opportunities

Barriers to Implementation

Ambiguity of multiple definitions and visions Ambiguity of multiple definitions and visions Belief among some that implementing telemedicine Belief among some that implementing telemedicine

is the goal rather than the means to a goal is the goal rather than the means to a goal High cost of infrastructure and hardware High cost of infrastructure and hardware Poorly designed systems Poorly designed systems Incompatibility of systems Incompatibility of systems Limited bandwidth Limited bandwidth Outmoded regulations Outmoded regulations


Lack of standards Lack of standards Confidentiality concerns Confidentiality concerns Complex liability issues (for example, where would a Complex liability issues (for example, where would a

law suit be filed?) law suit be filed?) State-based licensor laws that pose obstacles to State-based licensor laws that pose obstacles to

practising telemedicine across state lines practising telemedicine across state lines Lack of guidelines for credential physicians Lack of guidelines for credential physicians Potential strain on physician-patient relationship Potential strain on physician-patient relationship Questions about image fidelity and context Questions about image fidelity and context


Distrust and fear of new technologies Distrust and fear of new technologies Disruption of normal office routine Disruption of normal office routine Time required to train providers and support Time required to train providers and support

personnel personnel Resistance to responsibility for increased number of Resistance to responsibility for increased number of

patients patients Increased time required for patient referral Increased time required for patient referral Increased practice and capitalization costs Increased practice and capitalization costs Difficulty in evaluating cost and quality of care Difficulty in evaluating cost and quality of care Difficulty in determining value, and added value, of Difficulty in determining value, and added value, of

telemedicine telemedicine

Barriers to ImplementationCompartmentalization of costs, which reduces Compartmentalization of costs, which reduces

incentive to optimize whole system incentive to optimize whole system Federal, state, local, and private-sector budget Federal, state, local, and private-sector budget

constraints constraints Concerns about overuse--and inappropriate use--of Concerns about overuse--and inappropriate use--of

telemedicine telemedicine Inconsistent reimbursement practices (for example, Inconsistent reimbursement practices (for example,

Medicare reimburses image transmission but not Medicare reimburses image transmission but not consultation) consultation) Political agendas that can derail progress in health-Political agendas that can derail progress in health-

system and telecommunication-system reform system and telecommunication-system reform Uncertainty on all sides about which elements of Uncertainty on all sides about which elements of

telemedicine will work telemedicine will work