Telemedicine: lessons remain unheeded

Paul McLaren, C J Ball

United Medical and Dental Schools of Guy's and St Thomas's Hospitals
London SEI 9RT 
Paul McLaren, senior lecturer in psychiatry

Academic Department of Psychiatry 
London Hospital Medical College
London E1 1BS
C J Ball, senior lecturer in old age psychiatry

Correspondence to: Dr McLaren.

Telemedicine, the delivery of health care with the patient and health professional at different locations, has been around for over 30 years. Its driving force has been developments in communications technology, and as new communications systems are developed health applications are proposed such as supporting the delivery of primary health care to geographically remote areas or regions underserved through the maldistribution of professional expertise. Despite rapid technological advances, evaluations of such systems have been largely superficial, and more thorough evaluations have failed to show significant advantages for more advanced and expensive technology over older technology such as the telephone. Methods for evaluating the impact of particular technologies on the health care system need to be developed and clearer benefits shown in terms of improved standards of care.

The development of high speed data transmission links on the information superhighway has stimulated a new burst of activity in the field of telemedicine. The prefix, from the Greek telos, implies only distance, but telemedicine has been defined more recently in terms of advanced communications technology. "Telecommunication.that connects a patient and a health care provider through live two - way audio, two - way video transmission across distances and that permits effective diagnosis, treatment and other health care activities." (ref 1) This preoccupation with the latest technology is a symptom of the malaise that has afflicted the field since its inception, and much of the work presented at the Telemed 94 international conference in London last November revealed that the subject is still dominated by advanced communications technology looking for health applications.

Telemedicine, however defined, is not new; early reports appeared in the 1960s. Each decade since has seen a resurgence of activity as new ways of generating images or transmitting data have been developed. The major studies were funded in North America, where telemedicine has been heralded as the answer to health care provision for geographically remote communities and the endemic maldistribution of medical resources. Such studies showed that clinical tasks such as reading a radiograph, interpreting a pathology slide, examining a skin lesion, or auscultating a chest could be performed live with the patient in one location and the physician in another. In most cases, once the technical feasibility was demonstrated, descriptive reports were written and recommendations made for further research - which rarely materialised.

New technology would be developed, offering faster transmission of higher quality images, and the cycle would be repeated. Even the proponents of advanced technology recognised this pattern.(ref 2) Commenting on the demise after 20 years of the StarPach (space technology applied to rural Papago advanced health care) project, which offered mobile remote medical services to an Indian reservation, Preston et al attributed its failure to systems management and organisational problems.(ref 1) In the United States the reluctance of health insurers to reimburse physicians for technologically mediated consultation has been cited as a major obstacle to its acceptance.(ref 3)

Enduring systems and new projects

The RGIT survival centre in Aberdeen has developed a system called Camnet which allows trans mission of vital signs and video and audio pictures from a remote paramedic to a secondary care centre.(ref 6)

There is much current interest in teleradiology and telepathology and a drive to develop systems that will transmit digitised images of radiographs and slides at higher and higher rates for remote examination. While there are obvious attractions for radiologists in systems that allow remote manipulation of real time images, the benefits to the patient and the impact on delivery of health care are less clear. Economies of scale and quality improvements may be gained by handling rare cases in centralised radiological and pathological ser vices, but these have still to be formally evaluated and weighed against potential disadvantages such as the increased use of high cost diagnostic services, greater distance between the diagnostician and the patient, and job satisfaction. The advantages of service rationalisation should not be confused with advantages for advanced technology. Centralisation does not require expensive, high speed links - communication may take place by transmitting digitised images at lower speeds along the existing telephone network or even by sending conventional images by post.

Means to an end

The telephone, in contrast to interactive video, has been absorbed without fuss into many health care systems,(ref 9) but its uses remain largely administrative. It is an established medium for conducting interviews in public health research,(ref 10) and the absence of visual cues may make it particularly suitable for some forms of psychotherapy.(ref 11) The reasons for the limited clinical use of the telephone, despite its popularity for counselling in the voluntary sector, are unclear, but it has lacked the high profile champions who have advocated more expensive technologies.

Telemedicine has been presented as offering both education and service delivery to isolated practitioners, but these aims may conflict as the provider seeks to sustain or increase demand for remote diagnostic services. Remote practitioners may then have less incentive to develop their own skills and services and match them to the needs of the local population, and there is a danger that services, particularly in develop examining countries, will be driven towards high cost diagnostic practice.

Advanced technology