A Brief History of Telemedicine

I compiled this with my internship report for the World Health Organization Regional Office for Europe, as a part of my work on eHealth and the Global Network of Age-Friendly Cities. Much of this material, I first gathered when I was teaching a Master’s Engineering course on Telemedicine Techniques and Aspects for Aalborg University Department of Electronic Systems in 2010.

1906: ECG Transmission
Einthoven, father of electrocardiography, first investigated ECG transmission over  telephone lines. He wrote an article “Le telecardiogramme” Archives Internationales Physiologie 4:132, 1906

1920s: Help for ships
Radios were used to link physicians at shore stations to assist medical emergencies at sea.

1924: The first exposition of Telecare
The cover of “Radio News” magazine from April 1924.

1955/9: Telepsychiatry The Nebraska Psychiatric Institute was one of the first facilities in the country to have closed-circuit television in 1955. In 1971 the Nebraska Medical Center was linked with the Omaha Veterans Administration Hospital and VA facilities in two other towns.

1964: Telepsychiatry

Nebraska Psychiatric Institute began using a two-way closed-circuit TV link between the Institute itself and Norfolk State Hospital about 112 miles away. The link was used for education and consultations between specialists and general practitioners.

1967: Massachusetts General Hospital

A medical station established at Boston’s Logan International Airport linked Massachusetts General Hospital to patients at the airport 24 hours a day, using a two-way microwave audio/video link.

1970s: Satellite telemedicine
Remote Alaskan and Canadian villages linked with hospitals in distant cities

1972: NASA Space Technology

Rural Papago Advanced Health Care (STARPAHC) program for people living in remote locations, like Arizona’s Papago Indian Reservation. The system, engineered by NASA and Lockheed Missiles and Space Co. (now Lockheed-Martin), used two-way microwave transmissions to link personnel in mobile and fixed stations with experts in Tucson and Phoenix. The program lasted until 1975.

1972: 7 telemedicine projects

The Health Care Technology Division of the U.S. Department of Health, Education and Welfare (HEW) funded seven telemedicine research and demonstration projects:

1. Illinois Mental Health Institutes in Chicago,
2. Ohio’s Case Western Reserve University in Cleveland,
3. Massachusetts’ Cambridge Hospital,
4. Illinois’ Bethany/Garfield Medical Center in Chicago,
5. Minnesota’s Lakeview Clinic in Waconia,
6. Dartmouth Medical School’s INTERACT in Hanover, N.H.,
7. and the Mount Sinai School of Medicine in New York City.

1973: Two more projects

U.S. National Science Foundation (NSF) funded two more telemedicine projects:

1. Boston Nursing Home project for geriatric patients
2. Miami-Dade project between Florida’s Dade County and Miami’s Jackson Memorial Hospital.

1977: Canada’s Memorial University of Newfoundland

Canadian Space Program for distance education and care, using satellite.
1984: North-West Telemedicine

Pilot test Australia’s satellite communications network to provide health care to people in five remote towns south of the Gulf of Carpentaria.
1986:  SHARE

Satellite network for interactive video conferencing b/w Canada, Kenya and Uganda.
1989: After massive earthquake in Soviet Republic of Armenia

U.S./U.S.S.R. Joint Working Group on Space Biology offered the Soviet Union use of one-way international telemedicine network between Yerevan, Armenia, and four medical centers in the U.S. The Space Bridge program waslater extended to Ufa, Russia.
1989: First interactive telemedicine system

MedPhone Corporation operated over standard telephone lines for diagnosing and treating patients requiring cardiac resuscitation (defibrillation). A year later the company introduced a mobile cellular version, the MDphone. Twelve hospitals in the U.S. served as receiving and treatment centers.
1998:  Grand Princess

Cruise ship with virtual-reality center and Telemedicine system linked to Medical Center in LA

1998:  And beyond!

Telemedicine on transoceanic air flights, offshore oil platforms, Mt. Everest, in helium balloons, Antarctica, and outer space.
More recent uses of telemedicine

• Department of Defense began digital dog tags in 1999, including health records, images, video and sound. The new tags will be more durable, stable, and have a larger storage capacity than the smart cards currently used in Hawaii. Some tags in the test store up to 340 megabytes of data, and some are no larger than a dime.
• The British government launched a seven-year, 1 billion pound, integrated patient information system with practitioners in the British NHS already computerized. The program will integrate appointment systems, prescriptions, video consultation, and electronic medical records
• 70 million German citizens and 25 million French citizens carry smart cards with administrative and insurance processing info., paving the way for complete, integrated systems.
• In Singapore, a new home-based telemedicine network will use back-end billing and administration through TV or computer-based linked by ADSL or cable modem at 5–10 mbps transmission. By 2001 all Singapore houses should be connected to the SingaporeOne network.
• The first Ayurvedic telemedicine center established in 2007 by Partap Chauhan, a well-known Indian Ayurvedic doctor.
• In Japan, corporations, schools, homes, and offices should be connected with fiber optics by 2010, according to Nippon Telegraph and Telephone.

Economic evaluation

• There is a lack of concrete evidence with which to fully assess the economic impact of telemedicine.

• Limited information on the efficacy and costs of telemedicine is a key obstacle for the coverage and reimbursement of telemedicine services by most insurance providers.

• Multidimensionality of telemedicine, the lack of funding for large-scale programs, experimental problems (e.g., multi-outcome interventions, delayed and unintended effects), and technological issues related to rapid improvement in technologies and their application to telemedicine.

• In addition, it can be difficult to build a cohesive body of evidence when some of the lessons and conclusions derived from economic evaluations of telemedicine programs can lose validity in a relatively short period of time (e.g., due to the rapid and continuous decline in equipment prices).

• Three of the most common economic evaluation methods are costanalysis, cost-effectiveness analysis, and benefit–cost analysis.

Cost-analysis

This type of economic evaluation identifies the resources used to deliver the services of a specific program and then values the associated opportunity costs.

• Economic or opportunity costs refer to the value of the next best alternative foregone for the use of the resources.

• A common type of cost analysis is cost minimization, whereby the costs of a program are compared to the costs of alternative methods of service delivery under the assumption that both approaches result in similar outcomes.

• Although cost analyses are a good starting point common to all economic evaluation methods, they exclude program outcomes from the analysis, thus limiting the information available to decision makers when deciding which programs should be implemented or expanded.

• Cost Analysis is also significantly limited because it does not incorporate the outcomes or economic benefits of the telemedicine program.

• A review of 600 articles addressing the costs and effectiveness of telemedicine and find that fewer than 4%contain a legitimate economic evaluation and that the vast majority of those carry out a simple cost analysis without linking costs to program outcomes.

Cost-effectiveness analysis

Cost-effectiveness analysis (CEA) is a more inclusive economic evaluation method in that it considers both costs and outcomes of a program.

• Specifically, it compares the economic costs of a program with a nonmonetary outcome such as years of life gained or avoided illnesses, and the findings are generally expressed as cost per unit of outcome.

• Even though CEA is superior to a simple cost analysis, it poses an important drawback in that it limits the evaluation to a single outcome.

• When both costs and outcomes of telemedicine are considered, CEA is the most common, although not widely used, type of full economic evaluation.

• Since multi-outcome interventions are more common in telemedicine, CEA is informative yet somewhat limited.

Benefit-cost analysis

Benefit–cost analysis (BCA) is the most comprehensive type of economic evaluation and allows the study of interventions with multiple outcomes.

• It compares the economic costs and monetized economic benefits of a program to determine whether a program is economically justified and better than alternative uses of the same resources.

• Since the costs and benefits of a program are expressed in a common monetary unit (e.g., dollars), BCA makes possible the direct comparison of programs with disparate outcomes.

• To conduct a BCA, a first step is to clearly identify all of the relevant economic costs and outcomes of a program.

• Second, the economic benefits of a program are calculated by converting the outcomes into monetary values using reliable monetary conversion factors.

Once the economic costs and benefits have been estimated (in constant dollars and discounted to account for the present value of future costs and benefits), the net benefit (total economic benefit minus total economic cost) and the benefit–cost ratio (total economic benefit=total economic cost) are calculated.

A positive net benefit and a benefit–cost ratio larger than indicate that the economic benefits are larger than the economic costs, which suggests that the program is worth implementing from a societal perspective.

BCA is a particularly useful approach in telemedicine, where costs and outcomes can vary widely among specialties due to the fact that each specialty area addresses unique illnesses, follows specific clinical guidelines, employs different telemedicine equipment, and confronts different barriers to access.

• Few telemedicine evaluations have conducted BCAs, perhaps because this type of evaluation is data intensive and technically sophisticated.

• Another possible explanation for the shortage of BCAs in telemedicine studies could be the reluctance to assign monetary values to outcomes such as health improvements.

• Moreover, no established guidelines or systematic procedures have been published on how to undertake BCAs of telemedicine.

• Although some authors claim to have implemented BCA as part of their economic evaluations, their analyses actually constitute simple cost analysis or CEA