Musings on Telemedicine
Thurman L Pedigo Sr, MD
Clinical Professor and Interim Chair
Department of Family Medicine
Vanderbilt University Medical Center
Nashville, Tennessee

accepted for publication in Medical Computing Today October 1997

In April 1995 a student at Peking University posted an e-mail on the Internet requesting help on behalf of a colleague, a young chemistry student. The colleague had inexplicably developed symptoms that rapidly progressed from hair loss to paralysis and had now lapsed into a coma. Many of us who saw this e-mail forwarded it to individuals and e-mail groups with the interest or expertise to respond to this distress signal. Correspondence with the patient's physicians in Beijing provided her history, exam, lab tests, etc., to (what had grown into) an extensive online network of physicians, toxicologists, and other experts. A number of diagnoses were entertained, among them thallium poisoning, which was soon confirmed by independent testing. Treatment was instituted, and over the past two years there has been marked improvement in her condition. The student who wrote the original e-mail reported receiving more than 2,000 replies from 18 countries. The above summary has been reported in a number of medical and general publications, and UCLA maintains a Web site Zhu Ling in celebration of what they regard as the first international telemedicine trial.
Telemedicine is the practice of medicine over a distance; the methodology used is immaterial. It is conducted mostly over land phone lines, although satellite and microwave transmission play an increasing role. Modalities include telephone, facsimile, videoconferencing and -- as in the high profile incident described above -- the Internet. List servers and forums are written communications only. Videoconferencing allows a patient and a physician located from a few to thousands of miles apart to hear and see each other as if they were in the same room. Touch is still the missing ingredient, although research along those lines (on the virtual glove, for example) is progressing. Image quality varies with the power of the transmission medium (bandwidth) and the power of the compression/decompression chip processing the image and voice. Many other factors are involved in the image transfer, but transmission is only as good as the weakest link.
O ne major barrier to the broader application of telemedicine has been the cost of equipment and bandwidth; some unpublished estimates of the costs of early systems range up to $2,500 per consult. As use has increased and cost of technology has declined these numbers have plummeted, although consults still generally cost more than $300.
Another important issue is the need for standards. Many of the first systems could communicate only with products from the same vendor. In 1990, however, the International Telecommunication Union, an international organization within which governments and the private sector coordinate global networks and service, agreed to adopt protocols for communication and image compression. Today most systems can communicate with each other, regardless of manufacturer.
T hese issues and others occupy telemedicine's present, such as funding resources, telementoring (defined by Yale University's Telemedicine at Yale as guiding surgical and other clinical procedures from a remote location), liability, licensing, and new developments.
Telemedicine evangelists tell us this new technology is the cure for limited access to health care and runaway costs. Its detractors see telemedicine as technology at its worst, creating a barrier to personal access and further depersonalizing the physician/patient encounter. In reality, I believe, those who treat telemedicine as a style of practice, not a technological showcase, will be the primary shapers of its future.

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