The Freifunk-Initiative installing Wi‑Fi antennas in Berlin-Kreuzberg in 2013.
Wireless community networks or wireless community projects or simply community networks, are non-centralized, self-managed and collaborative networks organized in a grassroots fashion by communities, non-governmental organizations and cooperatives in order to provide a viable alternative to municipal wireless networks for consumers.
Many of these organizations set up wireless mesh networks which rely primarily on sharing of unmetered residential and business DSL and cable Internet. This sort of usage might be non-compliant with the terms of service of local internet service provider (ISPs) that deliver their service via the consumer phone and cable duopoly. Wireless community networks sometimes advocate complete freedom from censorship, and this position may be at odds with the acceptable use policies of some commercial services used. Some ISPs do allow sharing or reselling of bandwidth.
The First Latin American Summit of Community Networks, held in
Argentina in 2018, presented the following definition for the term
"community network": "Community networks are networks collectively owned
and managed by the community for non-profit and community purposes.
They are constituted by collectives, indigenous communities or
non-profit civil society organizations that exercise their right to
communicate, under the principles of democratic participation of their
members, fairness, gender equality, diversity and plurality".
According to the Declaration on Community Connectivity, elaborated through a multistakeholder process organized by the Internet Governance Forum's
Dynamic Coalition on Community Connectivity, community networks are
recognised by a list of characteristics: Collective ownership; Social
management; Open design; Open participation; Promotion of peering and
transit; Promotion of the consideration of security and privacy concerns
while designing and operating the network; and promotion of the
development and circulation of local content in local languages.
Wireless community networks started as projects that evolved from amateur radio using packet radio, and from the free software community which substantially overlapped with the amateur radio community. Wireless neighborhood networks were established by technology enthusiasts in the early 2000s. The Redbricks Intranet Collective (RIC) started 1999 in Manchester, UK, to allow about 30 flats in the Bentley House Estate to share the subscription cost of one leased line from British Telecom (BT). Wi-Fi was quickly adopted by technology enthusiasts and hobbyists, because it was an open standard and consumer Wi-Fi hardware was comparatively cheap.
Wireless community networks started out by turning wireless access points designed for short-range use in homes into multi-kilometre long-range Wi-Fi by building high-gain directional antennas. Rather than buying commercially available units, some of the early groups advocated home-built antennas. Examples include the cantenna and RONJA, an optical link that can be made from a smoke flue and LEDs. The circuitry and instructions for such DIY networking antennas were released under the GNU Free Documentation License (GFDL). Municipal wireless networks, funded by local governments, started being deployed from 2003 onward.
Regarding the international policy scenario, discussions on
Community Networks have gained prominence over the last few years,
especially since the creation of the Internet Governance Forum's Dynamic Coalition on Community Connectivity
in 2016, providing "a much needed platform through which various
individuals and entities interested in the advancement of CNs have the
possibility to associate, organise and develop, in a bottom-up
participatory fashion collective 'principles, rules, decision-making
procedures and shared programs that give shape to the evolution and use
of the Internet.'".
By 2003, a number of wireless community projects had established themselves in urban areas across North America, Europe and Australia. In June 2000, Melbourne Wireless Inc. was established in MelbourneAustralia as a not-for-profit project to establish a metropolitan area wireless network using off-the-shelf 802.11 wireless equipment. By 2003, it had 1,200 hotspots. In 2000 Seattle Wireless was founded with the stated aim of providing free WiFi access and share the cost of Internet connectivity in Seattle, USA. By April 2011, it had 80 free wireless access points all over Seattle and was steadily growing.
In August 2000, Consume was founded in LondonEngland as "collaborative strategy for the self provisioning of a broadband telecommunications infrastructure". Founded by Ben Laurie and others, Consume aimed to build a wireless infrastructure as alternative to the monopoly-held wired metropolitan area network. Besides providing Wi-Fi access in East London, Consume installed a large antenna on the roof of the former Greenwich Town Hall and documented the states of wireless connections in London. Consume created political pressure on municipal authorities,
by staging public events, exhibitions, encouraging consumers to set up
wireless equipment and setting up temporary Wi-Fi hotspots at events in
East London. While Consume generated sustained media attention, it did
not establish a lasting wireless community network.
The Wireless Leiden
hobbyist project was established in September 2001 and constituted as
non-profit foundation in 2003 with more than 300 active users. The
Wireless Leiden foundation aimed to facilitate the cooperation of local
government, businesses and residents to provide wireless networking in LeidenNetherlands. The first wireless community network in Spain was RedLibre, founded in September 2001 in Madrid.
By 2002 RedLibre coordinated the efforts of 15 local wireless groups
and maintained free RedLibre Wi-Fi hotspots in five cities. RedLibre has
been credited for facilitating the widespread availability of WLAN in
the urban areas of Spain.
In Italy, Ninux.org was founded by students and hackers in 2001 to create a grassroots wireless network in Rome,
similar to Seattle Wireless. A turning point for Ninux was the lowering
of prices in 2008 for consumer wireless equipment, such as antennas and
routers. Ninux volunteers installed an increasing number of antennas on
the roofs of Rome. The network served as example for other urban
community wireless networks in Italy. By 2016, similar wireless networks
had been installed in Florence, Bolongna, Pisa and Cosenza. While they
share common technical and organizational frameworks, the working groups
supporting these urban wireless community networks are driven by the
different needs of the city in which they operate.
A Patras Wireless Network (PWN) access point, the first city-wide wireless community network in Greece.
Houston Wireless was founded in summer 2001 as the Houston Wireless
Users Group. The telecommunications providers were slow to roll out
third-generation wireless (3G), so Houston Wireless was established to promote high-speed wireless access across Houston and its suburbs. Houston Wireless experimented with network protocols such as IPsec, mobile IP and IPv6, as well as wireless technologies, including 802.11a, 802.11g and ultra-wideband (UWB). By 2003, it had 30 WLAN hotspots, 100 people on their mailing lists and their monthly meetings were attended by about 25 people.
NYCwirelsss was established in New York City
in May 2001 to provide public hotspots and promote the use of consumer
owned unlicensed low-cost wireless networking equipment. In order to get
more public Wi-Fi hotspots installed, NYCwirelsss contracted with the
for-profit company Cloud Networks, which was staffed by some of the
founding members of the NYCwireless community project. In the aftermath
of the September 11 attacks
in 2001 NYCwirelsss helped to provide emergency communication by
quickly assembling and deploying free Wi-Fi hotspots in areas of New
York City that had no other telecommunications. In summer 2002, the Bryant Park
wireless network became the flagship project of NYCwireless, with about
50 users every day. By 2003 NYCwireless had more than 100 active
hotspots throughout New York City.
Early project in rural areas
A volunteer installing a "supernode" of guifi.net. In July 2018 guifi.net had over 35,000 active nodes and about 63,000 km of wireless links.
In 2000, guifi.net was founded because commercial internet service providers did not build a broadband Internet infrastructure in rural Catalonia. Guifi.net was conceived as a wireless mesh network, where households can become a node in the network by operating a radio transmitter. Not every node needs to be a wireless router,
but the network relies on some volunteers being connected to the
Internet and sharing that access with others. In 2017 guifi.net had
23,000 nodes and was described as the biggest mesh network in the world.
In 2001, BCWireless founded to help communities in British Columbia, Canada, set up local Wi-Fi networks. BCWireless hobbyists experimented with IEEE 802.11b
wireless networks and antennas to extend the range and power of signal,
allow bandwidth sharing among local group members and establish
wireless mesh networks. The Lac Seul First Nation communities set up their Wi-Fi network and constituted the non-profit K-Net to manage a wireless network based on IEEE 802.11g to provide the entire reserve with Wi-Fi using the unlicensed spectrum in combination with licensed spectrum at 3.5 GHz.
Co-operation between community networks
For
the most, early wireless community projects had a local scope, but many
still had a global awareness. In 2003, wireless community networks
initiated the Pico Peering Agreement (PPA) and the Wireless Commons Manifesto. The two initiatives defined attempts to build an infrastructure, so that local wireless mesh networks could become extensive wireless ad hoc networks across local and national boundaries. In 2004, Freifunk released the OpenWrt-based
firmware FFF for Wi-Fi devices that participate in a community network,
which included a PPA, so that the owner of the node agrees to provide
free transit across the network.
Technical approach
A Linksys WRT54GS
There are at least three technical approaches to building a wireless community network:
Cluster: Advocacy groups which simply encourage sharing of unmetered internet bandwidth via Wi-Fi, may also index nodes, suggest uniform SSID (for low-quality roaming), supply equipment, DNS services, etc.
Wireless equipment, like many other consumer electronics, comes with hard-to-alter firmware that is preinstalled by the manufacturer. When the Linksys WRT54G series was launched in 2003 with an open sourceLinux kernel
as firmware, it immediately became the subject of hacks and became the
most popular hardware among community wireless volunteers. In 2005, Linksys
released the WRT54GL version of its firmware, to make it even easier
for customers to modify it. Community network hackers experimented with
increasing the transmission power of the Linksys WRT54G or increasing
the clock speed of the CPU to speed up data transmission.
Hobbyists got another boost when in 2004 the OpenWrt firmware was released as open source alternative to proprietary firmware. The Linux-based embedded operating system
could be used on embedded devices to route network traffic. Through
successive versions, OpenWrt eventually could work on several hundred
types of wireless devices and Wi-Fi routers.
OpenWrt was named in honor of the WRT54G. The OpenWrt developers
provided extensive documentation and the ability to include one's own
code in the OpenWrt source code and compile the firmware.
In 2004, Freifunk
released the FFF firmware for wireless community projects, which
modified OpenWrt so that the node could be configured via a web
interface and added features to better support a wireless ad hoc network with traffic shaping, statistics, Internet gateway support and an implementation of the Optimized Link State Routing Protocol
(OLSR). A Wi-Fi access point that booting the FFF firmware joined the
network by automatically announcing its Internet gateway capabilities to
other nodes using OLSR HNA4. When a node disappeared, the other nodes
registered the change in the network topology
through the discontinuation of HNA4 announcements. At the time,
Freifunk in Berlin had 500 Wi-Fi access points and about 2,200 Berlin
residents used the network free of charge. The Freifunk FFF firmware is among the oldest approaches to establishing a wireless mesh network
at significant scale. Other early attempts at developing an operating
system for wireless devices that supported large scale wireless
community projects were Open-Mesh and Netsukuku.
In 2006, Meraki Networks Inc was founded. The Meraki hardware and firmware had been developed as part of a PhD research project at the Massachusetts Institute of Technology
to provide wireless access to graduate students. For years, the
low-cost Meraki products fueled the growth of wireless mesh networks in
25 countries.
Early Meraki-based wireless community networks included the
Free-the-Net Meraki mesh in Vancouver, Canada. Constituted in 2006 as
legal co-operative, members of the Vancouver Open Network Initiatives Cooperative paid five Canadian dollars
per month to access the community wireless network provided by
individuals who attached Meraki nodes to their home wireless connection,
sharing bandwidth with any cooperative members nearby and participating
in a meshed wireless network.
Community network software
By
2003, the Sidney Wireless community project had launched the NodeDB
software, to facilitate the work of community networks by mapping the
nodes participating in a wireless mesh network. Nodes needed to be registered in the database,
but the software generated a list of adjacent nodes. When registering a
node that participated in a community network, the maintainer of the
node could leave a note on the hardware, antenna reach and firmware in
operation and so find other network community members who were willing
to participate in a mesh.
Organization
Organizationally,
a wireless community network requires either a set of affordable
commercial technical solutions or a critical mass of hobbyists willing
to tinker to maintain operations. Mesh networks require that a high
level of community participation and commitment be maintained for the
network to be viable. The mesh approach currently requires uniform
equipment. One market-driven aspect of the mesh approach is that users
who receive a weak mesh signal can often convert it to a strong signal
by obtaining and operating a repeater node, thus extending the network.
Such volunteer organizations focusing on technology that is rapidly advancing sometimes have schisms and mergers. The Wi-Fi service provided by such groups is usually free and without the stigma of piggybacking. An alternative to the voluntary model is to use a co-operative structure.
Business models
Wireless
community projects made volunteer bandwidth-sharing technically
feasible and have been credited with contributing to the emergence of
alternative business models in the consumer Wi-Fi market. The commercial
Wi-Fi provider Fon was established in 2006 in Spain. Fon customers were equipped with a Linksys Wi-Fi access point that runs a modified OpenWrt
firmware so that Fon customers shared Wi-Fi access among each other.
Public Wi-Fi provisioning through FON customers was broadened when FON
entered a 50% revenue-sharing agreement with customers who made their
entire unused bandwidth available for resale. In 2009, this business
model gained broader acceptance when British Telecom allowed its own home customers to sell unused bandwidth to BT and FON roamers.
Wireless community projects for the most provide best-effort Wi-Fi coverage. However, since the mid-2000s local authorities started to contract with wireless community networks to provide municipal wireless networks
or stable Wi-Fi access in a defined urban area, such as a park.
Wireless community networks started to participate in a variety of public-private partnerships. The non-profit community network ZAP Sherbrooke has partnered with public and private entities to provide Wi-Fi access and received financial support from the University of Sherbrooke and Bishop's University to extend the coverage of its wireless mesh throughout the city of Sherbrooke, Canada.
Regulation
Certain
countries regulate the selling of internet access, requiring a license
to sell internet access over a wireless network. In South Africa it is regulated by the Independent Communications Authority of South Africa (ICASA).
They require that WISP's apply for a VANS or ECNS/ECS license before
being allowed to resell internet access over a wireless link. The Internet Society's publication "Community Networks in Latin America: Challenges, Regulations and Solutions" brings a summary of regulations regarding Community Networks among Latin American countries, the United States and Canada.
Telehealth is the distribution of health-related services and information via electronic information and telecommunication technologies.
It allows long-distance patient and clinician contact, care, advice,
reminders, education, intervention, monitoring, and remote admissions.
Telemedicine is sometimes used as a synonym,
or is used in a more limited sense to describe remote clinical
services, such as diagnosis and monitoring. When rural settings, lack of
transport, a lack of mobility, conditions due to outbreaks, epidemics
or pandemics, decreased funding, or a lack of staff restrict access to
care, telehealth may bridge the gap and can even improve retention in treatment as well as provide distance-learning; meetings, supervision, and presentations between practitioners; online information and health data management and healthcare system integration. Telehealth could include two clinicians discussing a case over video conference;
a robotic surgery occurring through remote access; physical therapy
done via digital monitoring instruments, live feed and application
combinations; tests being forwarded between facilities for
interpretation by a higher specialist; home monitoring through
continuous sending of patient health data; client to practitioner online
conference; or even videophone interpretation during a consult.
Telehealth versus telemedicine
Telehealth is sometimes discussed interchangeably with telemedicine, the latter being more common than the former. The Health Resources and Services Administration
distinguishes telehealth from telemedicine in its scope, defining
telemedicine only as describing remote clinical services, such as
diagnosis and monitoring, while telehealth includes preventative, promotive, and curative care delivery. This includes the above-mentioned non-clinical applications, like administration and provider education.
The United States Department of Health and Human Services
states that the term telehealth includes "non-clinical services, such
as provider training, administrative meetings, and continuing medical
education", and that the term telemedicine means "remote clinical
services".
The World Health Organization uses telemedicine to describe all aspects of health care including preventive care. The American Telemedicine Association
uses the terms telemedicine and telehealth interchangeably, although it
acknowledges that telehealth is sometimes used more broadly for remote
health not involving active clinical treatments.
Telehealth requires good Internet access by participants, usually in the form of a strong, reliable broadband
connection, and broadband mobile communication technology of at least
the fourth generation (4G) or long-term evolution (LTE) standard to
overcome issues with video stability and bandwidth restrictions. As broadband infrastructure has improved, telehealth usage has become more widely feasible.
Healthcare providers often begin telehealth with a needs assessment which assesses hardships which can be improved by telehealth such as travel time, costs or time off work. Collaborators such as technology companies can ease the transition.
Delivery can come within four distinct domains: live video (synchronous), store-and-forward (asynchronous), remote patient monitoring, and mobile health.
Audio-based telemedicine, primarily through telephone consultations,
has been studied as a tool for managing chronic conditions. A systematic
review of 40 randomized controlled trials found that audio-based care
was generally comparable to in-person or video care, though with low to
very low certainty of evidence.
Store and forward
Store-and-forward telemedicine involves acquiring medical data (like medical images, biosignals etc.) and then transmitting this data to a doctor or medical specialist at a convenient time for assessment offline. It does not require the presence of both parties at the same time. Dermatology (cf: teledermatology), radiology, and pathology are common specialties that are conducive to asynchronous telemedicine. A properly structured medical record, preferably in electronic
form, should be a component of this transfer. The 'store-and-forward'
process requires the clinician to rely on a history report and
audio/video information in lieu of a physical examination.
Remote monitoring
A blood pressure monitor
Remote monitoring,
also known as self-monitoring or testing, enables medical professionals
to monitor a patient remotely using various technological devices. This
method is primarily used for managing chronic diseases or specific
conditions, such as heart disease, diabetes mellitus, or asthma. These
services can provide comparable health outcomes to traditional in-person
patient encounters, supply greater satisfaction to patients, and may be
cost-effective. Examples include home-based nocturnal dialysis and improved joint management.
Real-time interactive
Electronic consultations are possible through interactive telemedicine services which provide real-time interactions between patient and provider. Videoconferencing
has been used in a wide range of clinical disciplines and settings for
various purposes, including management, diagnosis, counseling, and
monitoring of patients.
Videotelephony comprises the technologies for the reception and
transmission of audio-video signals by users at different locations for
communication between people in real time.
At the dawn of the technology, videotelephony also included image phones which would exchange still images between units every few seconds over conventional POTS-type telephone lines, essentially the same as slow scan TV systems.
U.S. Navy medical staff being trained in the use of handheld telemedical devices (2006).
Common daily emergency telemedicine is performed by SAMU Regulator Physicians in France, Spain, Chile, and Brazil. Aircraft and maritime emergencies are also handled by SAMU centres in Paris, Lisbon and Toulouse.
A recent study identified three major barriers to the adoption of
telemedicine in emergency and critical care units. They include:
Regulatory challenges related to the difficulty and cost of
obtaining licensure across multiple states, malpractice protection and
privileges at multiple facilities
Financial barriers including a lack of acceptance and reimbursement
by government payers and some commercial insurance carriers, which
places the investment burden squarely upon the hospital or healthcare
system.
Cultural barriers occurring from the lack of desire, or
unwillingness, of some physicians to adapt clinical paradigms for
telemedicine applications.
Emergency telehealth is also gaining acceptance in the United States. There are several modalities currently being practiced that include but are not limited to TeleTriage, TeleMSE, and ePPE.
An example of telehealth in the field is when EMS arrives on scene of an incident and is able to take an EKG that is then sent directly to a physician at the hospital to be read, allowing for instant care and management.
Telenursing refers to the use of telecommunications and information technology in order to provide nursing
services in health care whenever a large physical distance exists
between patient and nurse, or between any number of nurses. As a field,
it is part of telehealth, and has many points of contact with other
medical and non-medical applications, such as telediagnosis, teleconsultation, telemonitoring, etc.
Telenursing is achieving significant growth rates in many
countries due to several factors: the preoccupation with reducing the
costs of health care, an increase in the aging
and chronically ill population, and the increase in coverage of health
care to distant, rural, small or sparsely populated regions. Among its
benefits, telenursing may help solve increasing shortages of nurses,
reduce distances and travel time, and keep patients out of hospital. A
greater degree of job satisfaction has been registered among telenurses.
In Australia, during January 2014, Melbourne tech startup Small World Social collaborated with the Australian Breastfeeding Association to create the first hands-free breastfeeding Google Glass application for new mothers. The application, named Google Glass Breastfeeding app trial,
allows mothers to nurse their baby while viewing instructions about
common breastfeeding issues (latching on, posture, etc.) or call a
lactation consultant via a secure Google Hangout, who can view the issue through the mother's Google Glass camera. The trial was successfully concluded in Melbourne in April 2014, and 100% of participants were breastfeeding confidently.
Telepalliative care
Palliative care is an interdisciplinary medical caregiving approach aimed at optimizing quality of life and mitigating suffering among people with serious, complex, and often terminalillnesses. In the past, palliative care was a disease specific approach, but today the World Health Organization
(WHO) takes a broader approach suggesting that palliative care should
be applied as early as possible to any chronic and fatal illness. As in
many aspects of health care, telehealth is increasingly being used in palliative care and is often referred to as telepalliative care. The types of technology applied in telepalliative care are typically telecommunication technologies, such as video conferencing or messaging for follow-up, or digital symptom assessments through digital questionnaires generating alerts to health care professionals. Telepalliative care has been shown to be a feasible approach to deliver palliative care among patients, caregivers and health care professionals.
Telepalliative care can provide an added support system that enable
patients to remain at home through self-reporting of symptoms and
tailoring care to specific patients.
Studies have shown that the use of telehealth in palliative care is
mostly well received by patients, and that telepalliative care may
improve access to health care professionals at home and enhance feelings of security and safety among patients receiving palliative care. Further, telepalliative care may enable more efficient utilization of healthcare resources, promotes collaboration between different levels of healthcare, and makes healthcare professionals more responsive to changes in patients' condition.
Challenging aspects of the use of telehealth in palliative care
have also been described. Generally, palliative care is a diverse medical specialty, involving interdisciplinaryprofessionals from different professional traditions and cultures, delivering care to a heterogenouscohort
of patients with diverse diseases, conditions and symptoms. This makes
it a challenge to develop telehealth that is suitable for all patients
and in all contexts of palliative care. Some of the barriers to
telepalliative care relate to inflexible reporting of complex and
fluctuating symptoms and circumstances using electronic questionnaires. Further, palliative care emphasizes a holistic approach that should address existential, spiritual and mental distress related to serious illness. However, few studies have included the self-reporting of existential or spiritual concerns, emotions, and well-being. Healthcare professionals may also be uncomfortable providing emotional or psychological care remotely.
Palliative care has been characterized as high-touch rather than
high-tech, limiting the interest in applying technological advancements
when developing interventions. To optimize the advantages and minimize the challenges with the use of telehealth in home-based palliative care, futureresearch should include users in the design and development process. Understanding the potential of telehealth to support therapeutic
relationships between patients and health care professionals and being
aware of the possible difficulties and tensions it may create are
critical to its successful and acceptable use.
Telepharmacy is the delivery of pharmaceutical care via telecommunications to patients in locations where they may not have direct contact with a pharmacist. It is an instance of the wider phenomenon of telemedicine, as implemented in the field of pharmacy. Telepharmacy services include drug therapy monitoring, patient counseling, prior authorization and refill authorization for prescription drugs, and monitoring of formulary compliance with the aid of teleconferencing or videoconferencing. Remote dispensing
of medications by automated packaging and labeling systems can also be
thought of as an instance of telepharmacy. Telepharmacy services can be
delivered at retail pharmacy sites or through hospitals, nursing homes,
or other medical care facilities. This approach allows patients in
remote or underserved areas to receive pharmacy services that would
otherwise be unavailable to them, enhancing access to care and ensuring
continuity in medication management. Health outcomes appear similar when pharmacy services are delivered by telepharmacy compared to traditional service delivery.
The term can also refer to the use of videoconferencing in
pharmacy for other purposes, such as providing education, training, and
management services to pharmacists and pharmacy staff remotely.
Telepsychiatry can be effective in treating people with mental
health conditions. In the short-term it can be as acceptable and
effective as face-to-face care. Research also suggests comparable therapeutic factors, such as changes in problematic thinking or behaviour.
It can improve access to mental health services for some but
might also represent a barrier for those lacking access to a suitable
device, the internet or the necessary digital skills. Factors such as poverty that are associated with lack of internet access are also associated with greater risk of mental health problems, making digital exclusion an important problem of telemental health services.
During the COVID-19 pandemic mental health services were adapted to telemental health in high-income countries.
It proved effective and acceptable for use in an emergency situation
but there were concerns regarding its long-term implementation.
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.
Tele-audiology (or teleaudiology) is the utilization of telehealth to provide audiological
services and may include the full scope of audiological practice. This
term was first used by Gregg Givens in 1999 in reference to a system
being developed at East Carolina University in North Carolina, US.
Teleneurology
Teleneurology describes the use of mobile technology
to provide neurological care remotely, including care for stroke,
movement disorders like Parkinson's disease, seizure disorders (e.g.,
epilepsy), etc. The use of teleneurology gives us the opportunity to
improve health care access for billions around the globe, from those
living in urban locations to those in remote, rural locations. Evidence
shows that individuals with Parkinson's disease prefer personal
connection with a remote specialist to their local clinician. Such home
care is convenient but requires access to and familiarity with the
Internet.
A 2017 randomized controlled trial of "virtual house calls" or video
visits with individuals diagnosed with Parkinson's disease evidences
patient preference for the remote specialist vs their local clinician
after one year.
Teleneurology for patients with Parkison's disease is found to be
cheaper than in person visits by reducing transportation and travel time A recent systematic review by Ray Dorsey et al.
describes both the limitations and potential benefits of teleneurology
in improving care for patients with chronic neurological conditions,
especially in low-income countries. White, well-educated and
technologically savvy people are the biggest consumers of telehealth
services for Parkinson's disease. as compared to ethnic minorities in the US.
Teleneurosurgery
Telemedicine
in neurosurgery was historically primarily used for follow-up visits by
patients who had to travel far to undergo surgery.
In the last decade, telemedicine was also used for remote ICU rounding
as well as prompt evaluation for acute ischemic stroke and
administration of IV alteplase in conjunction with neurology.
From the onset of the COVID-19 pandemic, there was a rapid surge in the
use of telemedicine across all divisions of neurosurgery: vascular,
oncology, spine, and functional neurosurgery. Not only for follow-up
visits, but it has gained popularity for seeing new patients or
following established patients regardless of whether they underwent
surgery. Telemedicine is not limited to direct patient care only; there are a
number of new research groups and companies focused on using
telemedicine for clinical trials involving patients with neurosurgical
diagnoses.
Teleneuropsychology
Teleneuropsychology is the use of telehealth/videoconference technology for the remote administration of neuropsychological tests. Neuropsychological tests are used to evaluate the cognitive status of individuals with known or suspected brain disorders
and provide a profile of cognitive strengths and weaknesses. Through a
series of studies, there is growing support in the literature showing
that remote videoconference-based administration of many standard
neuropsychological tests results in test findings similar to traditional
in-person evaluations, thereby establishing the basis for the
reliability and validity of teleneuropsychological assessment.
Telenutrition
Telenutrition refers to the use of video conferencing/ telephony to provide online consultation by a nutritionist or dietician.
Patient or clients upload their vital statistics, diet logs, food
pictures, etc., on a telenutrition portal that is then used by the
nutritionist or dietician to analyze their current health condition. The
nutritionist or dietician can then set goals for their respective
clients/patients and monitor their progress regularly by follow-up
consultations.
Telenutrition portals can help people seek remote consultation
for themselves and/or their family. This can be extremely helpful for
elderly or bedridden patients who can consult their dietician from
comfort of their homes.
Telenutrition showed to be feasible, and the majority of patients
trusted the nutritional televisits, in place of the scheduled but not
provided follow-up visits during the lockdown of the COVID-19 pandemic.
Telerehabilitation (or e-rehabilitation) is the delivery of rehabilitation services over telecommunication networks
and the Internet. Most types of services fall into two categories:
clinical assessment (the patient's functional abilities in his or her
environment) and clinical therapy. Some fields of rehabilitation practice that have explored telerehabilitation are: neuropsychology, speech–language pathology, audiology, occupational therapy, and physical therapy. Telerehabilitation can deliver therapy to people who cannot travel to a clinic because the patient has a disability
or because of travel time. Telerehabilitation also allows experts in
rehabilitation to engage in clinical consultation at a distance.
Most telerehabilitation is highly visual. As of 2014, the most commonly used mediums are webcams, videoconferencing, phone lines, videophones, and webpages containing rich web applications.
The visual nature of telerehabilitation technology limits the types of
rehabilitation services that can be provided. It is most widely used for
neuropsychological rehabilitation, fitting of rehabilitation equipment such as wheelchairs, braces, or artificial limbs, and in speech-language pathology. Rich web applications for neuropsychological rehabilitation (cognitive rehabilitation) of cognitive impairment (from many etiologies) were first introduced in 2001. This endeavor has expanded as a teletherapy application for cognitive skills enhancement programs for school children. Tele-audiology
(hearing assessments) is a growing application. Physical therapy and
psychology interventions delivered via telehealth may result in similar
outcomes as those delivered in person for a range of health conditions.
Two important areas of telerehabilitation research are (1)
demonstrating equivalence of assessment and therapy to in-person
assessment and therapy and (2) building new data collection systems to
digitize information that a therapist can use in practice.
Ground-breaking research in telehaptics (the sense of touch) and virtual reality may broaden the scope of telerehabilitation practice in the future.
Only a few health insurers in the United States, and about half of Medicaid programs, reimburse
for telerehabilitation services. If the research shows that
teleassessments and teletherapy are equivalent to clinical encounters,
it is more likely that insurers and Medicare will cover telerehabilitation services.
In India,
the Indian Association of Chartered Physiotherapists (IACP) provides
telerehabilitation facilities. With the support and collaboration of
local clinics and private practitioners and the Members IACP, IACP runs
the facility, named Telemedicine. IACP has maintained an internet-based
list of their members on their website, through which patients can make
online appointments.
Teletrauma care
Telemedicine
can be utilized to improve the efficiency and effectiveness of care
delivery in a trauma environment. Examples include:
Telemedicine for trauma triage: using telemedicine, trauma
specialists can interact with personnel on the scene of a mass casualty
or disaster situation via the internet using mobile devices to determine
the severity of injuries. They can provide clinical assessments and
determine whether those injured must be evacuated for necessary care.
Remote trauma specialists can provide the same quality of clinical
assessment and plan of care as a trauma specialist located physically
with the patient.
Telemedicine for intensive care unit
(ICU) rounds: Telemedicine is also being used in some trauma ICUs to
reduce the spread of infections. Rounds are usually conducted at
hospitals across the country by a team of approximately ten or more
people including attending physicians, fellows, residents, and other
clinicians. This group usually moves from bed to bed in a unit,
discussing each patient. This aids in the transition of care for
patients from the night shift to the morning shift but also serves as an
educational experience for new residents to the team. A new approach
features the team conducting rounds from a conference room using a
video-conferencing system. The trauma attending, residents, fellows,
nurses, nurse practitioners, and pharmacists are able to watch a live
video stream from the patient's bedside. They can see the vital signs on
the monitor, view the settings on the respiratory ventilator, and/or
view the patient's wounds. Video-conferencing allows remote viewers to
conduct two-way communication with clinicians at the bedside.
Telemedicine for trauma education: some trauma centers are
delivering trauma education lectures to hospitals and health care
providers worldwide using video conferencing technology. Each lecture
provides fundamental principles, first-hand knowledge, and
evidenced-based methods for critical analysis of established clinical
practice standards, and comparisons to newer advanced alternatives. The
various sites collaborate and share their perspective based on location,
available staff, and available resources.
Telemedicine in the trauma operating room: trauma surgeons are
able to observe and consult on cases from a remote location using video
conferencing. This capability allows the attending to view the residents
in real time. The remote surgeon has the capability to control the
camera (pan, tilt, and zoom) to get the best angle of the procedure
while at the same time providing expertise in order to provide the best
possible care to the patient.
Telecardiology
ECGs, or electrocardiographs, can be transmitted using telephone and wireless. Willem Einthoven,
the inventor of the ECG, actually did tests with the transmission of
ECG via telephone lines. This was because the hospital did not allow him
to move patients outside the hospital to his laboratory for testing of
his new device. In 1906, Einthoven came up with a way to transmit the
data from the hospital directly to his lab.
Transmission of ECGs
One
of the oldest known telecardiology systems for teletransmissions of
ECGs was established in Gwalior, India, in 1975 at GR Medical College by
Ajai Shanker, S. Makhija, P.K. Mantri using an indigenous technique for
the first time in India.
This system enabled wireless transmission of ECG from the moving
ICU van or the patients home to the central station in ICU of the
department of Medicine. Transmission using wireless was done using
frequency modulation which eliminated noise. Transmission was also done
through telephone lines. The ECG output was connected to the telephone
input using a modulator that converted ECG into high-frequency sound. At
the other end a demodulator reconverted the sound into ECG with a good
gain accuracy. 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. The central control unit at the ICU was able to correctly
interpret arrhythmia. This technique helped medical aid reach in remote areas.
In addition, electronic stethoscopes
can be used as recording devices, which is helpful for purposes of
telecardiology. There are many examples of successful telecardiology
services worldwide.
In Pakistan,
three pilot projects in telemedicine were initiated by the Ministry of
IT & Telecom, Government of Pakistan (MoIT) through the Electronic
Government Directorate in collaboration with Oratier Technologies (a
pioneer company within Pakistan dealing with healthcare and HMIS) and
PakDataCom (a bandwidth provider). Three hub stations through 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. Three hubs
were established: the Mayo Hospital (the largest hospital in Asia),
JPMC Karachi, and Holy Family Rawalpindi. These 12 remote sites were
connected and an average of 1,500 patients were treated per month per
hub. The project was still running smoothly after two years.
Wireless ambulatory ECG technology, moving beyond previous ambulatory ECG technology such as the Holter monitor, now includes smartphones and Apple Watches, which can perform at-home cardiac monitoring and send the data to a physician via the Internet.
Teleradiology is the ability to send radiographic images (X-rays, CT, MR, PET/CT, SPECT/CT, MG, US...) from one location to another.
For this process to be implemented, three essential components are
required: an image-sending station, a transmission network, and a
receiving-image review station. The most typical implementation is two
computers connected via the Internet. The computer at the receiving end
will need a high-quality display screen that has been tested and cleared
for clinical purposes. Sometimes the receiving computer will have a
printer for convenience.
The teleradiology process begins at the image-sending station.
The radiographic image and a modem or other connection are required for
this first step. The image is scanned and then sent via the network
connection to the receiving computer.
Today's high-speed broadband-based Internet enables the use of
new technologies for teleradiology: the image reviewer can now have
access to distant servers in order to view an exam. Therefore, they do
not need particular workstations to view the images; a standard personal computer (PC) and digital subscriber line
(DSL) connection is enough to reach Keosys' central server. No
particular software is necessary on the PC, and the images can be
reached from anywhere in the world.
Teleradiology is the most popular use for telemedicine and accounts for at least 50% of all telemedicine usage.
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.The performance of telepathology requires that a pathologist selects the video images for analysis and rendering 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.
A pathologist, Ronald S. Weinstein, M.D., coined the term
"telepathology" in 1986. In an editorial in a medical journal, Weinstein
outlined the actions that would be needed to create remote pathology
diagnostic services. He and his collaborators published the first scientific paper on robotic telepathology. Weinstein was also granted the first U.S. patents for robotic telepathology systems and telepathology diagnostic networks. Weinstein is known to many as the "father of telepathology". In Norway, Eide and Nordrum implemented the first sustainable clinical telepathology service in 1989.
This is still in operation, decades later. A number of clinical
telepathology services have benefited many thousands of patients in
North America, Europe, and Asia.
Telepathology has been successfully used for many applications, including the rendering histopathology tissue diagnoses at a distance, for education and research. 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.
Teledermatology allows dermatology consultations over a distance using audio, visual and data communication, and has been found to improve efficiency, access to specialty care, and patient satisfaction.
Applications comprise health care management such as diagnoses,
consultation and treatment as well as (continuing medical) education. The dermatologists Perednia and Brown were the first to coin the term teledermatology in 1995, where they described the value of a teledermatologic service in a rural area underserved by dermatologists.
Teleophthalmology is a branch of telemedicine that delivers eye care
through digital medical equipment and telecommunications technology.
Today, applications of teleophthalmology encompass access to eye
specialists for patients in remote areas, ophthalmic disease screening,
diagnosis and monitoring; as well as distant learning. Teleophthalmology
may help reduce disparities by providing remote, low-cost screening
tests such as diabetic retinopathy screening to low-income and uninsured
patients.
In Mizoram, India, a hilly area with poor roads, between 2011 and 2015,
teleophthalmology provided care to over 10,000 patients. These patients
were examined by ophthalmic assistants locally but surgery was done on
appointment after the patient images were viewed online by eye surgeons
in the hospital 6–12 hours away. Instead of an average five trips for
say, a cataract procedure, only one was required for surgery alone as
even post-op care like removal of stitches and appointments for glasses
was done locally. There were large cost savings in travel as well.
In the United States, some companies allow patients to complete
an online visual exam and within 24 hours receive a prescription from an
optometrist valid for eyeglasses, contact lenses, or both. Some US
states such as Indiana have attempted to ban these companies from doing
business.
Remote surgery (also known as telesurgery) is the ability for a doctor to perform surgery on a patient even though they are not physically in the same location. It is a form of telepresence. Remote surgery combines elements of robotics, cutting-edge telecommunications such as high-speed data connections, telehaptics and elements of management information systems. While the field of robotic surgery is fairly well established, most of these robots are controlled by surgeons at the location of the surgery.
Remote surgery is remote work
for surgeons, where the physical distance between the surgeon and the
patient is immaterial. It promises to allow the expertise of specialized
surgeons to be available to patients worldwide, without the need for
patients to travel beyond their local hospital.
Remote surgery or telesurgery is performance of surgical
procedures where the surgeon is not physically in the same location as
the patient, using a robotic teleoperator
system controlled by the surgeon. The remote operator may give tactile
feedback to the user. Remote surgery combines elements of robotics and
high-speed data connections. A critical limiting factor is the speed, latency
and reliability of the communication system between the surgeon and the
patient, though trans-Atlantic surgeries have been demonstrated.
Teleabortion
Telemedicine has been used globally to increase access to abortion care, specifically medical abortion,
in environments where few abortion care providers exist or abortion is
legally restricted. Clinicians are able to virtually provide counseling,
review screening tests, observe the administration of an abortion
medication, and directly mail abortion pills to people. In 2004, Women on Web
(WoW), Amsterdam, started offering online consultations, mostly to
people living in areas where abortion was legally restricted, informing
them how to safely use medical abortion drugs to end a pregnancy. People contact the Women on Web service online; physicians review any necessary lab results or ultrasounds, mail mifepristone and misoprostol pills to people, then follow up through online communication. In the United States, medical abortion
was introduced as a telehealth service in Iowa by Planned Parenthood of
the Heartland in 2008 to allow a patient at one health facility to
communicate via secure video with a health provider at another facility.
In this model a person seeking abortion care must come to a health
facility. An abortion care provider communicates with the person located
at another site using clinic-to-clinic videoconferencing to provide
medical abortion after screening tests and consultation with clinic
staff. In 2018, the website Aid Access was launched by the founder of Women on Web, Rebecca Gomperts.
It offers a similar service as Women on Web in the United States, but
the medications are prescribed to an Indian pharmacy, then mailed to the
United States.
The TelAbortion study conducted by Gynuity Health Projects, with
special approval from the U.S. Food and Drug Administration (FDA), aims
to increase access to medical abortion care without requiring an
in-person visit to a clinic. This models was expanded during the COVID-19 pandemic and as of March 2020 exists in 13 U.S. states and has enrolled over 730 people in the study.
The person receives counseling and instruction from an abortion care
provider via videoconference from a location of their choice. The
medications necessary for the abortion, mifepristone and misoprostol,
are mailed directly to the person and they have a follow-up video
consultation in 7–14 days. A systematic review of telemedicine abortion
has found the practice to be safe, effective, efficient, and
satisfactory.
In the United States, eighteen states require the clinician to be
physically present during the administration of medications for
abortion which effectively bans telehealth of medication abortion: five
states explicitly ban telemedicine for medication abortion, while
thirteen states require the prescriber (usually required to be a
physician) to be physically present with the patient.
In the UK, the Royal College of Obstetricians and Gynecologists
approved a no-test protocol for medication abortion, with mifepristone
available through a minimal-contact pick-up or by mail.
Other specialist care delivery
Telemedicine can facilitate specialty care delivered by primary care physicians according to a controlled study of the treatment of hepatitis C.
Various specialties are contributing to telemedicine, in varying
degrees.Other specialist conditions for which telemedicine has been used
include perinatal mental health.
In light of the COVID-19 pandemic, primary care physicians have
relied on telehealth to continue to provide care in outpatient settings.
The transition to virtual health has been beneficial in providing
patients access to care (especially care that does not require a
physical exam e.g. medication changes, minor health updates) and avoid
putting patients at risk of COVID-19. This included providing services
to pediatric patients during the pandemic, where issues of last minute
cancelation and rescheduling were frequently related to a lack of
technicality and engagement, two factors often understudied in the
literature.
Telemedicine has also been beneficial in facilitating medical
education to students while still allowing for adequate social
distancing during the COVID-19 pandemic. Many medical schools have
shifted to alternate forms of virtual curriculum and are still able to
engage in meaningful telehealth encounters with patients.
Medication assisted treatment (MAT) is the treatment of opioid use disorder (OUD) with medications, often in combination with behavioral therapy As a response to the COVID-19 pandemic the use of telemedicine has been granted by the Drug Enforcement Administration to start or maintain people OUD on buprenorphine (trade name Suboxone) via telemedicine without the need for an initial in-person examination. On March 31, 2020, QuickMD became the first national TeleMAT
service in the United States to provide Medication-assisted Treatment
with Suboxone online – without the need of an in-person visit; with
others announcing to follow soon.
Major developments
In policy
Telehealth
is a modern form of health care delivery. Telehealth breaks away from
traditional health care delivery by using modern telecommunication
systems including wireless communication methods.
Traditional health is legislated through policy to ensure the safety of
medical practitioners and patients. Consequently, since telehealth is a
new form of health care delivery that is now gathering momentum in the
health sector, many organizations have started to legislate the use of
telehealth into policy.
In New Zealand, the Medical Council has a statement about telehealth on
their website. This illustrates that the medical council has foreseen
the importance that telehealth will have on the health system and have
started to introduce telehealth legislation to practitioners along with
government.
Traditional use of telehealth services has been for specialist
treatment. However, there has been a paradigm shift and telehealth is no
longer considered a specialist service.
This development has ensured that many access barriers are eliminated,
as medical professionals and patients are able to use wireless
communication technologies to deliver health care. This is evident in rural communities.
Rural residents typically have to travel to longer distances to access
healthcare than urban counterparts due to physician shortages and
healthcare facility closures in these areas.
Telehealth eliminates this barrier as health professionals are able to
conduct medical consultations through the use of wireless communication
technologies. However, this process is dependent on both parties having
internet access and comfort level with technology, which poses barriers
for many low-income and rural communities.
Telehealth allows the patient to be monitored between physician
office visits which can improve patient health. Telehealth also allows
patients to access expertise which is not available in their local area.
This remote patient monitoring ability enables patients to stay at home
longer and helps avoid unnecessary hospital time. In the long-term,
this could potentially result in less burdening of the healthcare system
and consumption of resources.
During the COVID-19 pandemic, there were large increases in the
use of telemedicine for primary care visits within the United States,
increasing from an average of 1.4 million visits in Q2 of 2018 and 2019
to 35 million visits in Q2 2020, according to data from IQVIA.
The telehealth market is expected to grow at 40% a year in 2021. Use of
telemedicine by General Practitioners in the UK rose from 20 to 30%
pre-COVID to almost 80% by the beginning of 2021. More than 70% of
practitioners and patients were satisfied with this. Boris Johnson
was said to have "piled pressure on GPs to offer more in-person
consultations" supporting a campaign largely orchestrated by the Daily Mail. The Royal College of General Practitioners said that a patient "right" to have face-to-face appointments if they wished was "undeliverable".
The technological advancement of wireless communication devices is a major development in telehealth.
This allows patients to self-monitor their health conditions and to not
rely as much on health care professionals. Furthermore, patients are
more willing to stay on their treatment plans as they are more invested
and included in the process as the decision-making is shared. Technological advancement also means that health care professionals are
able to use better technologies to treat patients for example in
maternal care and surgery. A 2023 study published in the Journal of the American College of Surgeons
showed telemedicine as making a positive impact, with expectations
exceeded for those physicians and patients who had consulted online for
surgeries.
Technological developments in telehealth are essential to improve
health care, especially the delivery of healthcare services, as
resources are finite along with an ageing population that is living
longer.
Licensing
U.S. licensing and regulatory issues
Restrictive
licensure laws in the United States require a practitioner to obtain a
full license to deliver telemedicine care across state lines. Typically,
states with restrictive licensure laws also have several exceptions
(varying from state to state) that may release an out-of-state
practitioner from the additional burden of obtaining such a license. A
number of states require practitioners who seek compensation to
frequently deliver interstate care to acquire a full license.
If a practitioner serves several states, obtaining this license
in each state could be an expensive and time-consuming proposition. Even
if the practitioner never practices medicine face-to-face with a
patient in another state, he/she still must meet a variety of other
individual state requirements, including paying substantial licensure
fees, passing additional oral and written examinations, and traveling
for interviews.
In 2008, the U.S. passed the Ryan Haight Act which required
face-to-face or valid telemedicine consultations prior to receiving a
prescription.
State medical licensing boards
have sometimes opposed telemedicine; for example, in 2012 electronic
consultations were illegal in Idaho, and an Idaho-licensed general
practitioner was punished by the board for prescribing an antibiotic,
triggering reviews of her licensure and board certifications across the
country. Subsequently, in 2015 the state legislature legalized electronic consultations.
In 2015, Teladoc filed suit against the Texas Medical Board
over a rule that required in-person consultations initially; the judge
refused to dismiss the case, noting that antitrust laws apply to state
medical boards.
Major implications and impacts
Telehealth
allows multiple, varying disciplines to merge and deliver a potentially
more uniform level of care, using technology. As telehealth
proliferates mainstream healthcare, it challenges notions of traditional
healthcare delivery. Some populations experience better quality, access
and more personalized health care.
Baby Eve with Georgia for the Breastfeeding Support Project
Telehealth
can also increase health promotion efforts. These efforts can now be
more personalised to the target population and professionals can extend
their help into homes or private and safe environments in which patients
of individuals can practice, ask and gain health information. Health promotion using telehealth has become increasingly popular in underdeveloped countries where there are very poor physical resources available. There has been a particular push toward mHealth applications as many areas, even underdeveloped ones have mobile phone and smartphone coverage.
In a 2015 article reviewing research on the use of a mobile health application in the United Kingdom,
authors describe how a home-based application helped patients manage
and monitor their health and symptoms independently. The mobile health
application allows people to rapidly self-report their symptoms – 95% of
patients were able to report their daily symptoms in less than 100
seconds, which is less than the 5 minutes (plus commuting) taken to
measure vital signs by nurses in hospitals.
Online applications allow patients to remain at home to keep track of
the progression of their chronic illnesses. The downside of using
mHealth applications is that not everyone, especially in developing
countries, has daily access to internet or electronic devices.
In developed countries, health promotion efforts using telehealth have been met with some success. The Australian hands-free breastfeeding Google Glass application
reported promising results in 2014. This application made in
collaboration with the Australian Breastfeeding Association and a tech
startup called Small World Social, helped new mothers learn how to breastfeed. Breastfeeding is beneficial to infant health and maternal health and is recommended by the World Health Organisation and health organisations all over the world.
Widespread breastfeeding can prevent 820,000 infant deaths globally but
the practice is often stopped prematurely or intents to do are
disrupted due to lack of social support, know-how or other factors.
This application gave mother's hands-free information on breastfeeding,
instructions on how to breastfeed and also had an option to call a
lactation consultant over Google Hangout. When the trial ended, all
participants were reported to be confident in breastfeeding.
A scientific review
indicates that, in general, outcomes of telemedicine are or can be as
good as in-person care with health care use staying similar.
Telemedicine as predicted in 1925
Advantages of the nonexclusive adoption of already existing telemedicine technologies such as smartphone videotelephony may include reduced infection risks, increased control of disease during epidemic conditions, improved access to care, reduced stress and exposure to other pathogens during illness for better recovery, reduced time
and labor costs, efficient more accessible matching of patients with
particular symptoms and clinicians who are experts for such, and reduced
travel while disadvantages may include privacy breaches (e.g. due to
software backdoors and vulnerabilities or sale of data), dependability
on Internet access and, depending on various factors, increased health care use.
Theoretically, the whole health system could benefit from
telehealth. There are indications telehealth consumes fewer resources
and requires fewer people to operate it with shorter training periods to
implement initiatives.
Commenters suggested that lawmakers may fear that making telehealth
widely accessible, without any other measures, would lead to patients
using unnecessary health care services. Telemedicine could also be used for connected networks between health care professionals.
Telemedicine also can eliminate the possible transmission of infectious diseases or parasites between patients and medical staff. This is particularly an issue where MRSA is a concern. Additionally, some patients who feel uncomfortable in a doctors office may do better remotely. For example, white coat syndrome
may be avoided. Patients who are home-bound and would otherwise require
an ambulance to move them to a clinic are also a consideration.
However, whether or not the standard of health care quality is
increasing is debatable, with some literature refuting such claims. Research has reported that clinicians find the process difficult and complex to deal with.
Furthermore, there are concerns around informed consent, legality
issues as well as legislative issues. A recent study also highlighted
that the swift and large-scale implementation of telehealth across the
United Kingdom NHS Allied Health Professional (AHP) services might
increase disparities in health care access for vulnerable populations
with limited digital literacy. Although health care may become affordable with the help of technology, whether or not this care will be "good" is the issue. Many studies indicate high satisfaction with telemedicine among patients.
Among the factors associated with a good trust in telemedicine, the use
of known and user-friendly video services and confidence in the data protection policies were the two variables contributing most to trust in telemedicine.
Major problems with increasing adoption include technically challenged staff, resistance to change or habits and age of patient. Focused policy could eliminate several barriers.
A review lists a number of potentially good practices and pitfalls, recommending the use of "virtual handshakes" for confirming identity,
taking consent for conducting remote consultation over a conventional
meeting, and professional standardized norms for protecting patient
privacy and confidentiality. It also found that the COVID-19 pandemic
substantially increased, voluntarily, the adoption of telephone or
video consultation and suggests that telemedicine technology "is a key
factor in delivery of health care in the future".
Geriatric population
Technologies’ growing involvement in health care has led to
continuous improvement in access, efficiency and quality of care, but
numerous challenges lie with addressing the barriers that impair the
geriatric population from benefitting the use of this new technology.
With the COVID-19 pandemic, rapid implementation of telehealth in
geriatric outpatient clinics occurred. Although time efficiency was
greatly improve and increase access to geriatric patients with lack of
transportion to the clinic, there are complications that arised during
and after implementation with many appointments requiring rescheduling
due to language barrier, poor connection, hard of hearing, or inability
to perform assessments.
Studies also show that patients and their family member often show
preference to in-person visits. Although benefits were seen in being
able to see a provider sooner, high-quality audio and video, and
functionality to allow family participation during visits, patients and
family noted preferences for in-person visits even still due to
difficulty in using the service.
Currently new improvements are being made to help ease the
complications of telehealth for geriatric patients. This inlcudes
integrated captions on video calls for the hearing impaired, virtual
interpreters that will attend the calls for language differences,
government assisted internet services, increase training to medical
providers and patients on telehealth use, etc.
Economic evaluations
Due
to its digital nature it is often assumed that telehealth saves the
health system money. However, the evidence to support this is varied.
When conducting economic evaluations of telehealth services, the
individuals evaluating them need to be aware of potential outcomes and
extraclinical benefits of the telehealth service.
Economic viability relies on the funding model within the country being
examined (public vs private), the consumers willingness-to-pay, and the
expected remuneration by the clinicians or commercial entities
providing the services (examples of research on these topics from
teledermoscopy in Australia).
In a UK telehealth trial done in 2011, it was reported that the
cost of health could be dramatically reduced with the use of telehealth
monitoring. The usual cost of in vitro fertilisation (IVF) per cycle would be around $15,000; with telehealth it was reduced to $800 per patient. In Alaska the Federal Health Care Access Network,
which connects 3,000 healthcare providers to communities, engaged in
160,000 telehealth consultations from 2001 and saved the state $8.5
million in travel costs for just Medicaid patients.
Digital interventions for mental health conditions
seem to be cost-effective compared to no intervention or
non-therapeutic responses such as monitoring. However, when compared to
in-person therapy or medication their added value is currently
uncertain.
Beneficial enablements
Telemedicine
can be beneficial to patients in isolated communities and remote
regions, who can receive care from doctors or specialists far away
without the patient having to travel to visit them. Recent developments in mobile collaboration
technology can allow healthcare professionals in multiple locations to
share information and discuss patient issues as if they were in the same
place. Remote patient monitoring through mobile technology
can reduce the need for outpatient visits and enable remote
prescription verification and drug administration oversight, potentially
significantly reducing the overall cost of medical care. It may also be preferable for patients with limited mobility, for example, patients with Parkinson's disease.
Telemedicine can also facilitate medical education by allowing workers
to observe experts in their fields and share best practices more easily.
asset identification, listing, and patient to asset matching, and movement
overall healthcare system management
patient movement and remote admission
Physical distancing to prevent transmission of communicable diseases
Limitations and restrictions
While
many branches of medicine have wanted to fully embrace telehealth for a
long time, there are certain risks and barriers which bar the full
amalgamation of telehealth into best practice. For a start, it is dubious as to whether a practitioner can fully leave the "hands-on" experience behind.
Although it is predicted that telehealth will replace many
consultations and other health interactions, it cannot yet fully replace
a physical examination, this is particularly so in diagnostics, rehabilitation or mental health.
To minimise safety issues, researchers have suggested not offering
remote consultations for some conditions (breathing problems, new
psychosis, or acute chest pain, for example), when a parent is very
concerned about a child, when a condition has not resolved as expected
or has worsened, or to people who might struggle to understand or be
understood (such as those with limited English or learning
difficulties).
The benefits posed by telehealth challenge the normative means of
healthcare delivery set in both legislation and practice. Therefore,
the growing prominence of telehealth is starting to underscore the need
for updated regulations, guidelines and legislation which reflect the
current and future trends of healthcare practices.
Telehealth enables timely and flexible care to patients wherever they
may be; although this is a benefit, it also poses threats to privacy, safety, medical licensing and reimbursement. When a clinician and patient are in different locations, it is difficult to determine which laws apply to the context.
Once healthcare crosses borders different state bodies are involved in
order to regulate and maintain the level of care that is warranted to
the patient or telehealth consumer. As it stands, telehealth is complex
with many grey areas when put into practice especially as it crosses
borders. This effectively limits the potential benefits of telehealth.
An example of these limitations include the current American reimbursement infrastructure, where Medicare
will reimburse for telehealth services only when a patient is living in
an area where specialists are in shortage, or in particular rural
counties. The area is defined by whether it is a medical facility as
opposed to a patient's' home. The site that the practitioner is in,
however, is unrestricted. Medicare will only reimburse live video
(synchronous) type services, not store-and-forward, mhealth or remote
patient monitoring (if it does not involve live-video). Some insurers
currently will reimburse telehealth, but not all yet. So providers and
patients must go to the extra effort of finding the correct insurers
before continuing. Again in America, states generally tend to require
that clinicians are licensed to practice in the surgery' state,
therefore they can only provide their service if licensed in an area
that they do not live in themselves.
More specific and widely reaching laws, legislations and
regulations will have to evolve with the technology. They will have to
be fully agreed upon, for example, will all clinicians need full
licensing in every community they provide telehealth services too, or
could there be a limited use telehealth licence? Would the limited use
licence cover all potential telehealth interventions, or only some? Who
would be responsible if an emergency was occurring and the practitioner
could not provide immediate help – would someone else have to be in the
room with the patient at all consult times? Which state, city or country
would the law apply in when a breach or malpractice occurred?
A major legal action prompt in telehealth thus far has been
issues surrounding online prescribing and whether an appropriate
clinician-patient relationship can be established online to make
prescribing safe, making this an area that requires particular scrutiny.
It may be required that the practitioner and patient involved must meet
in person at least once before online prescribing can occur, or that at
least a live-video conference must occur, not just impersonal
questionnaires or surveys to determine need.
Telehealth has some potential for facilitating self-management
techniques in health care, but for patients to benefit from it, the
appropriate contact with, and relationship, between doctor and patient
must be established first.
This would start with an online consultation, providing patients with
techniques and tools that help them participate in healthy behaviors,
and initiating a collaborative partnership between health care
professionals and patient.
Self-management strategies fall into a broader category called patient
activation, which is defined as a "patients' willingness and ability to
take independent actions to manage their health."
It can be achieved by increasing patients' knowledge and confidence in
coping with and managing their own disease through a "regular assessment
of progress [...] and problem-solving support."
Teaching patients about their conditions and ways to cope with chronic
illnesses will allow them to be knowledgeable about their disease and
willing to manage it, improving their everyday life. Without a focus on
the doctor-patient relationship and on the patient's understanding,
telehealth cannot improve the quality of life of patients, despite the
benefit of allowing them to do their medical check-ups from the comfort
of their home.
The downsides of telemedicine include the cost of
telecommunication and data management equipment and of technical
training for medical personnel who will employ it. Virtual medical
treatment also entails potentially decreased human interaction between
medical professionals and patients, an increased risk of error when
medical services are delivered in the absence of a registered
professional, and an increased risk that protected health information may be compromised through electronic storage and transmission.
There is also a concern that telemedicine may actually decrease time
efficiency due to the difficulties of assessing and treating patients
through virtual interactions; for example, it has been estimated that a teledermatology consultation can take up to thirty minutes, whereas fifteen minutes is typical for a traditional consultation.
Additionally, potentially poor quality of transmitted records, such as
images or patient progress reports, and decreased access to relevant
clinical information are quality assurance risks that can compromise the
quality and continuity of patient care for the reporting doctor.
Other obstacles to the implementation of telemedicine include unclear
legal regulation for some telemedical practices and difficulty claiming
reimbursement from insurers or government programs in some fields. Some medical organizations have delivered position statement on the correct use of telemedicine in their field.
Another disadvantage of telemedicine is the inability to start
treatment immediately. For example, a patient with a bacterial infection
might be given an antibiotichypodermic injection in the clinic, and observed for any reaction, before that antibiotic is prescribed in pill form.
Equitability is also a concern. Many families and individuals in
the United States, and other countries, do not have internet access in
their homes or the proper electronic devices to access services such as a
laptop or smartphone.
Informed consent
is another issue. When telehealth includes the possibility for
technical problems such as transmission errors, security breaches, or
storage issues, it can impact the system's ability to communicate. It
may be wise to obtain informed consent in person first, as well as
having backup options for when technical issues occur. In person, a
patient can see who is involved in their care (namely themselves and
their clinician in a consult), but online there will be other involved
such as the technology providers, therefore consent may need to involve
disclosure of anyone involved in the transmission of the information and
the security that will keep their information private, and any legal
malpractice cases may need to involve all of those involved as opposed
to what would usually just be the practitioner.
State of the market
The
rate of adoption of telehealth services in any jurisdiction is
frequently influenced by factors such as the adequacy and cost of
existing conventional health services in meeting patient needs;
the policies of governments and/or insurers with respect to coverage
and payment for telehealth services; and medical licensing requirements
that may inhibit or deter the provision of telehealth second opinions or
primary consultations by physicians.
Projections for the growth of the telehealth market are
optimistic, and much of this optimism is predicated upon the increasing
demand for remote medical care. According to a recent survey, nearly
three-quarters of U.S. consumers say they would use telehealth. At present, several major companies along with a bevvy of startups are working to develop a leading presence in the field.
In the UK, the Government's Care Services minister, Paul Burstow, has stated that telehealth and telecare would be extended over the next five years (2012–2017) to reach three million people.
United States
In
the United States, telemedicine companies are collaborating with health
insurers and other telemedicine providers to expand marketshare and
patient access to telemedicine consultations.
As of 2019, 95% of employers believe their organizations will continue to provide health care benefits over the next five years.
The COVID-19 pandemic drove increased usage of telehealth
services in the U.S. The U.S. Centers for Disease Control and Prevention
reported a 154% increase in telehealth visits during the last week of
March 2020, compared to the same dates in 2019.
Switzerland
From 1999 to 2018, the University Hospital of Zurich
(USZ) offered clinical telemedicine and online medical advice on the
Internet. A team of doctors answered around 2500 anonymous inquiries
annually, usually within 24 to 48 hours. The team consisted of up to six
physicians who are specialists in clinical telemedicine at the USZ and
have many years of experience, particularly in internal and general
medicine. In the entire period, 59360 inquiries were sent and answered.
The majority of the users were female and on average 38 years old.
However, in the course of time, considerably more men and older people
began to use the service. The diversity of medical queries covered all
categories of the International Statistical Classification of Diseases and Related Health Problems
(ICD) and correlated with the statistical frequency of diseases in
hospitals in Switzerland. Most of the inquiries concerned unclassified
symptoms and signs, services related to reproduction, respiratory
diseases, skin diseases, health services, diseases of the eye and
nervous systems, injuries and disorders of the female genital tract. As
with the Swedish online medical advice service, one-sixth of the requests related to often shameful and stigmatised
diseases of the genitals, gastrointestinal tract, sexually transmitted
infections, obesity and mental disorders. By providing an anonymous
space where users can talk about (shameful) diseases, online telemedical
services empower patients and their health literacy is enhanced by
providing individualized health information. The Clinical Telemedicine
and Online Counselling service of the University Hospital of Zurich is
currently being revised and will be offered in a new form in the future.
Developing countries
For developing countries, telemedicine and eHealth
can be the only means of healthcare provision in remote areas. For
example, the difficult financial situation in many African states and
lack of trained health professionals has meant that the majority of the
people in sub-Saharan Africa are badly disadvantaged in medical care,
and in remote areas with low population density, direct healthcare
provision is often very poor
However, provision of telemedicine and eHealth from urban centers or
from other countries is hampered by the lack of communications
infrastructure, with no landline phone or broadband internet connection,
little or no mobile connectivity, and often not even a reliable
electricity supply.
Telemedicine in developing countries
Telemedicine in India
India
has broad rural-urban population and rural India is bereaved from
medical facilities, giving telemedicine a space for growth in India.
Deprived education and medical professionals in rural areas is the
reason behind government's ideology to use technology to bridge this
gap. Remote areas not only present a number of challenges for the
service providers but also for the families who are accessing these
services. Since 2018, telemedicine has expanded in India. It has
undertaken a new way for doctor consultations. On 25 March 2020, in the
wake of COVID-19 pandemic, the Ministry of Health and Family Welfare issued India's Telemedicine Practice Guidelines. The Board of Governors entasked by the Health Ministry published an amendment to the Indian Medical Council
(Professional Conduct, Etiquette and Ethics) Regulations, 2002 that
gave much-needed statutory support for the practice of telemedicine in
India. This sector is at an ever-growing stage with high scope of
development.
In April 2020, the union health ministry launched the eSanjeevani
telemedicine service that operates at two levels: the doctor-to-doctor
telemedicine platform, and the doctor-to-patient platform. This service
crossed five million tele-consultations within a year of its launch
indicating conducive environment for acceptability and growth of
telemedicine in India.
Telemedicine in Sub-Saharan Africa
Travel time to the nearest health-care facility by Sub-Saharan African region, for adults aged 60 years or older.
Sub-Saharan Africa is marked by the massive introduction of new technologies and internet access.
Urban areas are facing a rapid change and development, and access to
internet and health is rapidly improving. Population in remote areas
however, still lack access to healthcare and modern technologies. Some
people in rural regions must travel more between 2 and 6 hours to reach
the closest healthcare facilities of their country, leaving room for telehealth to grow and reach isolated people in the near future.
Internet via satellite in rural areas
The Satellite African eHEalth vaLidation (SAHEL) demonstration project has shown how satellite broadband
technology can be used to establish telemedicine in such areas. SAHEL
was started in 2010 in Kenya and Senegal, providing self-contained,
solar-powered internet terminals to rural villages for use by community
nurses for collaboration with distant health centers for training,
diagnosis and advice on local health issues.
Those methods can have major impact on both health professionals to get
and provide training from remote areas, and on the local population who
can receive care without traveling long distances. Some non-profits
provide internet to rural places around the world using a mobile VSAT
terminal. This VSAT terminal equips remote regions allowing them to
alert the world when there is a medical emergency, resulting in a rapid
deployment or response from developed countries.
Technologies such as the ones used by MAF allows health professionals
in remote clinics to have internet access, making consultations much
easier, both for patients and doctors.
The
development and history of telehealth or telemedicine (terms used
interchangeably in literature) is deeply rooted in the history and
development in not only technology but also society itself. Humans have
long sought to relay important messages through torches, optical telegraphy, electroscopes, and wireless transmission. Early forms of telemedicine achieved with telephone and radio have been supplemented with videotelephony, advanced diagnostic methods supported by distributed client/server applications, and additionally with telemedical devices to support in-home care.
In the 21st century, with the advent of the internet, portable devices and other such digital devices are taking a transformative role in healthcare and its delivery.
Earliest instances
Although, traditional medicine
relies on in-person care, the need and want for remote care has existed
from the Roman and pre-Hippocratic periods in antiquity. The elderly
and infirm who could not visit temples for medical care sent
representatives to convey information on symptoms and bring home a
diagnosis as well as treatment. In Africa, villagers would use smoke signals to warn neighboring villages of disease outbreak. The beginnings of telehealth have existed through primitive forms of communication and technology. The exact date of origin for Telehealth is unknown, but it was known to have been used during the Bubonic Plague. That version of telehealth was far different from how we know it today. During that time, they were communicating by heliograph and bonfire. Those were used to notify other groups of people about famine and war.
Those are not using any form of technology yet but are starting to
spread the idea of connectivity among groups of people who
geographically could not be together.
1800s to early 1900s
As
technology developed and wired communication became increasingly
commonplace, the ideas surrounding telehealth began emerging. The
earliest telehealth encounter can be traced to Alexander Graham Bell
in 1876, when he used his early telephone as a means of getting help
from his assistant Mr. Watson after he spilt acid on his trousers.
Another instance of early telehealth, specifically telemedicine was
reported in The Lancet
in 1879. An anonymous writer described a case where a doctor
successfully diagnosed a child over the telephone in the middle of the
night.
This Lancet issue, also further discussed the potential of Remote
Patient Care in order to avoid unnecessary house visits, which were part
of routine health care during the 1800s. Other instances of telehealth during this period came from the American Civil War, during which telegraphs were used to deliver casualty/mortality lists, medical care to soldiers, and ordering further medical supplies.
As the 1900s started, physicians quickly found a use for the
telephone making it a prime communication channel to contact patients
and other physicians.
Over the next fifty-plus years, the telephone was a staple for medical
communication. As the 1930s came around, radio communication played a
key role, especially during World War I. It was specifically used to
communicate with remote areas such as Alaska and Australia.
They used the radio to communicate medical information. During the
Vietnam War, radio communication had become more advanced and was now
used to send medical teams in helicopters to help. This then brought
together the Aerial Medical Service (AMS) who used telegraphs, radios,
and planes to help care for people who lived in remote areas.
From the late 1800s to the early 1900s the early foundations of wireless communication were laid down. Radios
provided an easier and near instantaneous form of communication. The
use of radio to deliver healthcare became accepted for remote areas.The Royal Flying Doctor Service of Australia is an example of the early adoption of radios in telehealth.
In 1925 the inventor Hugo Gernsback wrote an article for the magazine Science and Invention
which included a prediction of a future where patients could be treated
remotely by doctors through a device he called a "teledactyl". His
descriptions of the device are similar to what would later become
possible with new technology.
Mid-1900s to 1980s
When the American National Aeronautics and Space Administration (NASA)
began plans to send astronauts into space, the need for telemedicine
became clear. In order to monitor their astronauts in space,
telemedicine capabilities were built into the spacecraft as well as the first spacesuits.Additionally, during this period, telehealth and telemedicine were
promoted in different countries especially the United States and Canada. Carrier Sekani Family Services helped pioneer telehealth in British Columbia and Canada, according to its CEO Warner Adam.
After the telegraph and telephone started to successfully help
physicians treat patients from remote areas, telehealth became more
recognized. Technological advancements occurred when NASA sent men to
space. Engineers for NASA created biomedical telemetry and telecommunications systems.
NASA technology monitored vitals such as blood pressure, heart rate,
respiration rate, and temperature. After the technology was created, it
then became the base of telehealth medicine for the public.
Massachusetts General Hospital and Boston's Logan International Airport
had a role in the early use of telemedicine, which more or less
coincided with NASA's foray into telemedicine through the use of
physiologic monitors for astronauts.
On October 26, 1960, a plane struck a flock of birds upon takeoff,
killing many passengers and leaving a number wounded. Due to the extreme
complexity of trying to get all the medical personnel out from the
hospital, the practical solution became telehealth.
This was expanded upon in 1967, when Kenneth Bird at Massachusetts
General founded one of the first telemedicine clinics. The clinic
addressed the fundamental problem of delivering occupational and
emergency health services to employees and travellers at the airport,
located three congested miles from the hospital. Clinicians at the
hospital would provide consultation services to patients who were at the
airport. Consultations were achieved through microwave audio as well as
video links. The airport began seeing over a hundred patients a day at its nurse-run
clinic that cared for victims of plane crashes and other accidents,
taking vital signs, electrocardiograms, and video images that were sent
to Massachusetts General.
Over 1,000 patients are documented as having received remote treatment
from doctors at MGH using the clinic's two-way audiovisual microwave
circuit.
One notable story featured a woman who got off a flight in Boston and
was experiencing chest pain. They performed a workup at the airport,
took her to the telehealth suite where Raymond Murphy appeared on the
television, and had a conversation with her. While this was happening,
another doctor took notes and the nurses took vitals and any test that
Murphy ordered.
At this point, telehealth was becoming more mainstream and was starting
to become more technologically advanced, which created a viable option
for patients.
In 1964, the Nebraska Psychiatric Institute began using
television links to form two-way communication with the Norfolk State
Hospital which was 112 miles away for the education and consultation
purposes between clinicians in the two locations.
In 1972 the Department of Health, Education and Welfare
in the United States approved funding for seven telemedicine projects
across different states. This funding was renewed and two further
projects were funded the following year.
In March 1972, the San Bernardino County Medical Society
officially implemented its Tel-Med program, a system of prerecorded
health-related messages, with a log of 50 tapes. The nonprofit initiative began in 1971 as a local medical project to ease the doctor shortage in the expanding San Bernardino Valley and improve the public's access to sound medical information. It covered subjects ranging from cannabis to vaginitis. In January 1973, in response to the developing "London flu"
epidemic hitting California and the country, a tape providing
information on the disease was on air within a week after news broke of
the flu spreading in the state. That spring, programs were implemented in San Diego and Indianapolis, Indiana, signaling a national acceptance of the concept.
By 1979, its system offered messages on over 300 different subjects,
200 of which were available in Spanish as well as English, and serviced
over 65 million people in 180 cities around the country.
1980s to 1990s – maturation and renaissance
Telehealth projects underway before and during the 1980s would take off but fail to enter mainstream healthcare.As a result, this period of telehealth history is called the "maturation" stage and made way for sustainable growth.
Although state funding in North America was beginning to run low,
different hospitals began to launch their own telehealth initiatives. NASA provided an ATS-3 satellite to enable medical care communications of American Red Cross and Pan American Health Organization response teams, following the 1985 Mexico City earthquake.
The agency then launched its SateLife/HealthNet programme to increase
health service connectivity in developing countries. In 1997, NASA
sponsored Yale's Medical Informatics and Technology Applications Consortium project.
Florida first experimented with "primitive" telehealth in its prisons during the latter 1980s. Working with Doctors Oscar W. Boultinghouse and Michael J. Davis, from the early 1990s to 2007; Glenn G. Hammack led the University of Texas Medical Branch (UTMB) development of a pioneering telehealth program in Texas state prisons. The three UTMB alumni would, in 2007, co-found telehealth provider NuPhysician.
The first interactive telemedicine system, operating over standard telephone lines, designed to remotely diagnose and treat patients requiring cardiac resuscitation (defibrillation)
was developed and launched by an American company, MedPhone
Corporation, in 1989. A year later under the leadership of its
President/CEO S Eric Wachtel, MedPhone introduced a mobile cellular
version, the MDPhone. Twelve hospitals in the U.S. served as receiving
and treatment centers.
At-home virtual care
As
the expansion of telehealth continued in 1990 Maritime Health Services
(MHS) was a big part of the initiation for occupational health services.
They sent a medical officer aboard the Pacific trawler that allowed for
round-the-clock communication with a physician. The system that allows
for this is called the Medical Consultation Network (MedNet). MedNet is a
video chatting system that has live audio and visual so the physician
on the other end of the call can see and hear what is happening. MetNet
can be used from anywhere, not just aboard ships.
Being able to provide onsite visual information allows remote patients
expert emergency help and medical attention that saves money as well as
lives. This has created a demand for at-home monitoring. At-home care
has also become a large part of telehealth. Doctors or nurses will now
give pre-op and post-op phone calls to check-in. There are also
companies such as Lifeline,
which give the elderly a button to press in case of an emergency. That
button will automatically call for emergency help. If someone has
surgery and then is sent home, telehealth allows physicians to see how
the patient is progressing without them having to stay in the hospital.
TeleDiagnostic Systems of San Francisco is a company that has created a
device that monitors sleep patterns, so people with sleep disorders do
not have to stay the night at the hospital.
Another at-home device that was created was the Wanderer, which was
attached to Alzheimer's patients or people who had dementia. It was
attached to them so when they wandered off it notified the staff to
allow them to go after them. All these devices allowed healthcare beyond
hospitals to improve, which means that more people are being helped
efficiently.
2000s to present
The advent of high-speed Internet, and the increasing adoption of ICT in traditional methods of care, spurred advances in telehealth delivery.
Increased access to portable devices, like laptops and mobile phones,
made telehealth more plausible; the industry then expanded into health
promotion, prevention and education.
In 2002, G. Byron Brooks, a former NASA surgeon and engineer who had also helped manage the UTMB Telemedicine program, co-founded Teladoc in Dallas, Texas, which was then launched in 2005 as the first national telehealth provider.
In the 2010s, integration of smart home telehealth technologies, such as health and wellness devices, software, and integrated IoT,
has accelerated the industry. Healthcare organizations are increasingly
adopting the use of self-tracking and cloud-based technologies, and
innovative data analytic approaches to accelerate telehealth delivery.
In 2015, Mercy Health system opened Mercy Virtual, in Chesterfield, Missouri, the world's first medical facility dedicated solely to telemedicine.
COVID-19
Telehealth expanded significantly during the COVID-19 pandemic, becoming a vital means of medical communication. It allows doctors to return to humanizing the patient.
It forces them to listen to what people have to say and from there make
a diagnosis. Studies have demonstrated high trust in telehealth
expressed by patients during the COVID-19 pandemic. Among patients with Inflammatory bowel disease
4 out of 5 considered telemedicine as valuable tool for their
management, and 85%) wanted to have a telemedicine service at their
center. However, only 1 out of 4 believed that it may guarantee the same
level of care as the in-person visit.
Some researchers claim this creates an environment that encourages
greater vulnerability among patients in self disclosure in the practice
of narrative medicine.
Telehealth allows for Zoom calls and video chats from across the world
checking in on patients and speaking to physicians. Universities are now
ensuring that medical students graduate with proficient telehealth
communication skills.
Experts suggest that telehealth has become a vital part of medical
care; with more virtual options becoming available. The pandemic era
also identified the "potential to significantly improve global health
equity" through telehealth and other virtual care technologies.
Telehealth versus in-person on treatment and follow-up visits study
A
retrospective study in 2023 examining 1,589,014 adult primary care
patients within an integrated healthcare system in the U.S. found that
patients who initially had a telehealth visit were less likely to
receive prescriptions, lab tests, or imaging compared to those who had
an in-office visit. However, these same telehealth patients had higher
rates of in-person follow-up visits. The study revealed that, out of the
2,357,598 primary care visits, 49.2% were in-office, 31.3% were
telephone visits, and 19.5% were video visits. Office visits led to
higher rates of prescriptions (46.8%), lab tests (41.4%), and imaging
(20.5%) compared to video (38.4%, 27.4%, and 11.9%, respectively) and
telephone visits (34.6%, 22.8%, and 8.7%, respectively). In contrast,
patients who had telephone or video visits were more likely to have
in-person follow-up visits, with 7.6% of telephone, 6.2% of video, and
only 1.3% of office visit patients returning for primary care follow-up.
Furthermore, rates of emergency department visits and hospitalizations
were higher for those who had telemedicine visits, though these
differences were minimal. The study's limitations include the inability
to generalize findings to healthcare settings without telemedicine
services or to patients without insurance or a primary care provider.
The reasons for increased in-person healthcare utilization were also not
captured, and long-term follow-up was not conducted.
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