Telemedicine is the interactive audiovisual communication between health care providers and their patients. The first use of telemedicine was in 1959 when x-ray images were transmitted across telephone lines. Since that time the technology has advanced, making telemedicine more affordable and clinically useful.

The military has been using telemedicine in Croatia and Somalia to help treat the injured and the sick. They have invested a reported $70 Millon in developing this technology. Private industries such as AT&T and V-TEL are reported to be investing up to $1 billion in developing advanced communication technology. There are 13 federal agencies and 40 states that are involved in setting up the infrastructure to make telemedicine accessible, cost effective, user-friendly and clinically useful. University and hospital systems such as the Mayo Clinic, Massachusetts General Hospital, University of Southern California, Emory University and Northwest Covenant Medical Center are already using this technology for medical consulting, medical education and prehospital care.

Uses for telemedicine vary widely. Industry has begun to use this communication technology on oil rigs and cargo ships. Injured workers can have treatment initiated while waiting for transportation to a hospital. This decreases the delay in their acute medical treatment. Telemedicine has been used to provide medical "consultation" during natural disasters such as earthquakes. University hospitals are providing second opinions and continuing medical education to community hospitals as far away as the Middle East. In the future telemedicine may provide the rural hospitals with the subspecialist expertise of a tertiary hospital thus allowing the patient to receive treatment in their local hospital. This not only decreases the patient's cost of traveling but also decreases the amount of time and anxiety waiting for a subspecialist's input. It also allows the rural hospital to increase their bed census. Nursing homes may be able to treat patients without sending them to an acute care hospital. Prisoners, who can be both costly and dangerous to transport, can receive their treatment at the prison with subspecialty consults via telemedicine. Third world countries and poor rural areas could potentially have subspecialty advice upon request. The possibilities are endless.

There are many problems associated with this new technology. First, it must be realized that this technology does not replace the patient-physician relationship. Rather it is an adjunct to the primary care physician or the Emergency physician providing the direct patient care. The legal questions of who is responsible in the event of mechanical failure as well as the licensing of the health care providers and the technicians using this equipment are still unanswered. In addition, it must be decided who will provide the quality assurance for medical care rendered with this technology. Studies have already begun looking at the patient's reaction to having at least part of their medical treatment performed via communication lines versus direct interaction . There are many more questions. Will it ever come to pass that all patients will require a subspecialist consult if this technology is ubiquitous? How will these consultations be paid for? HCFA has already started investigating ways of financing telemedicine consults while remaining revenue neutral.

The technology available now allows for a spectrum of capabilities. Still pictures over a phone line, augmented by direct verbal communication, is presently user-friendly, economical and has a proven utility in the prehospital care arena. The compressed audio-visual technology allows direct and instantaneous visual and audible interaction with the patient. Auscultation, visualizing tympanic membranes and fundoscopic exams can be performed accurately and in real time.

The potential savings in health care money and resources needed for a patient to travel to a consultant are enormous. The increased accessibility to subspecialists in an expeditious manner improves patient care and saves both time and money. Furthermore, it decreases the patient's anxiety caused when having to wait a long time for a consultant. Telemedicine may become another tool used by the clinician to access patient charts, lab work, EKGs, and x-rays. This will allow him/her to discuss clinical decisions in an interactive way. We will be saving both the expense and risk of repeated tests as well as giving immediate feedback to the patient about their condition. This will make the health care system much more user-friendly and allow for a truly integrated system.

John A. Brennan, M.D., FACEP

Chairperson Emergency Department Northwest Covenant Medical Center

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