An Introduction to Telehealth

Dr. Rod Elford, BPE, MD, CCFP, MSc

Introduction

The purpose of this document is to educate the reader about telehealth - what it is, how it works and its benefits. It also presents a model for telehealth (i.e. the Telehealth Pyramid) that incorporates many of the different applications that make up the field. Telehealth is defined as,

"The use of communications and information technology to deliver health services and exchange health information when distance separates the participants." (Elford, 1998)

Basically, telehealth is health care at a distance. Telehealth is a general term that includes many different technologies and telecommunications links applied to many different clinical and health education applications. A telehealth system can be divided into four different components: 1) technology e.g. workstation and peripherals, 2) telecommunications link, 3) users e.g. clinicians and patients, and 4) policies and protocols. Each of these components is important and must be properly integrated with the others for telehealth to be successful.

Technology

The technology component of telehealth is the hardware, software and peripheral devices that are used to perform telehealth activities. It is the component that most people envision when they hear the term telehealth. There are many different technologies used for telehealth including: telephones, videophones, personal computers (PCs), videoconferencing systems, store and forward systems (S&F) and specialized telemedicine workstations. Two higher-end technologies are presented below.

Figure 1. Tandberg Health Care System III	Figure 2. Tandberg Vision5000

Figure 1. shows a telemedicine workstation developed specifically for conducting medical consultations at a distance. A number of peripheral devices can be connected to the workstation allowing images, video, text and sound to be captured and transmitted from one site to another. This type of workstation can be used for a variety of applications such as teledermatology, telecardiology, tele-ENT. Figure 2. Shows a general purpose videoconferencing unit. This technology can be used in the health care environment for applications like telepsychiatry, distance medical education, and administrative videoconferencing.

Peripheral Devices

An important part of many telehealth workstations are the peripheral devices. These are devices that can be plugged into or connected to a workstation and allow the local health professional to capture clinical images, video, sounds and vitals. Some peripheral devices are shown below.

Figures 3a,b,c. AMD peripheral devices (from left to right): a) otoscope, b) electronic stethoscope, c) general exam camera

Figure 3a. shows an otoscope. This device allows images from the ear, nose and throat to be captured and transmitted to a distant site for review. Figure 3b. shows an electronic stethoscope. This device allows heart, lung and bowel sounds to be captured and transmitted to a distant site for review. Figure 3c. shows a general exam camera. This device can be used for multiple purposes such as capturing gross pictures of the ear, throat and skin.

Telecommunications Link

The second component of telehealth is the telecommunications link. This is the electronic connection that links the technology mentioned above. There are many different types of telecommunications links including: the plain old telephone system (POTS), dial-up digital telephone lines such as Integrated Service Digital Networks (ISDN) and Switched – 56 (Sw-56), dedicated digital networks such as Asynchronous Transfer Mode (ATM) and Frame Relay (FR), coaxial cable, microwave, satellite including Geosynchronous and Low Earth Orbit (LEO), the Internet and virtual private networks (VPN). All these telecommunications modalities can be used to transmit information, however each one has specific advantages and disadvantages.

The best telecommunications link for your application depends on a number of factors such as what telecommunications infrastructure is available in your region, what bandwidth is required for the application and the cost. Not all telecommunications modalities are available in all areas. For example, ships at sea do not have access to land lines, making satellite and radiowave links the only telecommunications options. Often the best telecommunications link is the one that can be supported and serviced quickly by a local vendor. The cost of the telecommunications link (installation and on-going fees) is a key factor in the sustainability of a telehealth network.

The amount of bandwidth required for your application is another important factor to take into account when choosing a telecommunication link. Bandwidth is the amount of information that can be transmitted over a telecommunications medium in a specified period of time. It is often measured in the number of bits of data that can be transmitted per second, e.g. kilobits per second (kbps) or megabits per second (Mbps). Different telehealth applications require more bandwidth than others. For example, real-time medical videoconferencing often requires a minimum bandwidth of 384 kbps (provided by 3 ISDN lines,), whereas store and forward telemedicine (asynchronous transmission of still images, sounds or video) can be accomplished using a dial up 56 kbps modem connected on a POTS line. Usually the more bandwidth you require the higher the cost.

Telehealth Network – Integration of Technology and Telecommunications

After you have chosen the appropriate technology and telecommunications link, the two need to be integrated into a technical network. Figure 4. Diagrams a possible telehealth network with Calgary, Ottawa and Toronto as the Hub sites (also called Receive or Primary sites. The three sites can link to each other and can exchange information. In addition, each Hub site has a number of Spoke sites (also called Send or Secondary sites) that link to them. These Spoke sites are often rural / remote health centres that send clinical information to the Hub sites to be reviewed. Note - It is possible for any site to be either Send or Receive site.

Figure 4. Diagram of a Telehealth Technical Network

People

If you build a technical telehealth network, people will not automatically come and use it. The maxim "If you build it, they will come", does not hold true for telehealth. Many unsuccessful or underutilized telehealth programs testify to this fact. The "people network" is just as important, (if not more important) than the technical network. For this reason it is essential that you carefully identify, educate, train and support your users.

Experience indicates that it is essential to have an influential, enthusiastic clinical person e.g. champion, at both the sending and receiving sites of a telehealth network. Telehealth networks do not link sites together, they link people at different sites together. Often, it is easiest to link people who have worked together in the past, e.g. utilize traditional referral patterns. If champions cannot be identified at the sites you want to link together, it is probably best not to link those sites in your initial roll-out.

Education, Training and Support

A critical part of telehealth that is often overlooked is the proper education of potential users, and the training and support of those who have chosen to use the technology. Although some people quickly embrace new technologies, the majority of people do not, rather they have neutral or distrustful feelings towards it. As a result, most individuals need to be educated about telehealth, what it is, how it works and how it is beneficial to them before they will consider using it. If they do choose to use telehealth, they then need to be trained how to use it properly. Failure to do so usually leads to users being intimidated by the technology and frustrated when they cannot get it do what they want. Proper training also increases the probability that the user will be able to take full advantage of what the technology can do. Finally, users need to be supported (ideally 24 hours per day x 7 days a week) so that when they do have problems, they can quickly interact with a knowledgeable person who can help them solve the problem.

Policies and Protocols

Before telehealth (in particular medical consultations conducted at a distance) can continue as an on-going service, a number of policy issues must be resolved. Examples of policy issues include reimbursement, licensing and liability. Questions that need to be answered are: who pays the clinician to perform a teleconsultation? If the patient and clinician are not in the same province, is the clinician electronically going to the patient or is the patient coming to the clinician? (In most jurisdiction, it has been decided the physician goes to the patient). If something goes wrong with the patient due to the advice given during a teleconsultation, who is liable – the clinician, hospital, technology vendor, and / or telecommunications provider? Many of these issues have yet to be decided in many parts of the world.

Protocols must also be put in place and agreed upon by all users in order for a telehealth interaction to occur in the proper manner. Examples of questions that need to be answered before protocols can be implemented include: Who initiates the interaction? (as this site pays for the long distance costs), When is the interaction to be initiated?, Who arranges for all participants to be at the different sites at the proper time?, What documentation is required of the encounter?, What happens when there is a technical problem?

How Telehealth Works

Figure 5. depicts how telehealth works. Audio and video from one site is captured (this can include clinical images or sounds) and processed by the central processing unit (CPU) or by the coder-decoder (codec). Processing involves the digitization and often compression of the images and sound. Next, the information is prepared for transmission (this varies depending upon the telecommunications modality used) and transmitted to the distant site. If a real-time (synchronous) videoconferencing link has been established, information from a distant site is simultaneously received by the CPU or codec and decompressed. The in-coming visual information is displayed on a monitor and the auditory information sent to the speakers.

Figure 5. How Telehealth Works.

Compression

One of the major benefits of using digital information is that it can be compressed. Compression decreases the amount of bandwidth needed to transmit information, thereby decreasing the telecommunications costs. An analogy that may be helpful is that compressing digital information is like taking orange juice and concentrating it. The concentrated orange juice is then sent to another site and reconstituted by adding water. Similarly, digital information is compressed, transmitted and decompressed.

Compression of still images (e.g. picture or x-ray) is also important in telehealth, particularly in teleradiology. Still image compression is often classified as lossless or lossy. Lossless compression produces no perceptible loss of image quality between the transmitting and receiving sites and is preferable for clinical images. Maximum lossless compression ratios are 3:1, although wavelet compression promises 10:1 ratios or better. Lossy compression results in images at the receive site that are inferior in quality to the original. At times a lower quality image is still clinically acceptable, particularly when improved transmission speed is important.

Benefits of Telehealth

There are many potential benefits to telehealth. These can be divided into benefits for the patient, remote (sending) health care provider, central (receiving) health care provider and the health care payer (insurer).

Benefits - Patient

• Improved access to medical specialists
  
• Quicker , more accurate diagnosis and treatment ---> improved patient outcomes
  
• Reduced travel
  
• Decreased stress
  
• Decreased cost (travel, meals, accommodation, lost work)

Benefits – Remote Health Care Provider

• Improved access to medical specialists
  
• Increased confidence in management
  
• Increased opportunities for education (CME at a distance, students can attend classes virtually, can attend
• conferences virtually)
  
• Decreased professional isolation
  
• Collaborative research
  
• "Electronic housecalls"

Benefits – Central Health Care Provider

• Decreased need to travel - "see patients, not the road"
  
• Improved screening of patients
  
• Improved follow-up
  
• Increased educational opportunities
  
• Collaborative research

Benefits - Health Care Payer

• Decreased overall health care costs (per patient)
  
• Reduced patient travel costs
  
• Reduced physician travel costs
  
• Improved patient outcomes
  
• Less admissions to hospital
  
• More patients treated at remote site or at home
  
• More specialists can visit region, more often, at less expense
  
• Human resources are used more efficiently, "Do more with less"
  
• Health professionals are attracted to and kept in the region
  
• Back-up nurse practitioners
  

Model for Telehealth – the Telehealth Pyramid

Telehealth is a general term that encompasses many different activities. Figure 6. depicts the Telehealth Pyramid, a model that integrates many of the different components of telehealth. Although it is possible that each section of the pyramid could exist independently, it would be ideal to have all sections coordinated. Note - the different sections could be located in one physical location or could exist at a number of different sites and be connected electronically, e.g. virtual site.

Past experience from successful telehealth programs suggests that a number of the components should initially be located at a single physical centre. This promotes the development of a unified vision and the critical mass of people and resources. The different sections of the pyramid will be described from the base upwards. The size of each section roughly represents the relative number of individuals potentially effected.

Figure 6. A Model for Telehealth – the Telehealth Pyramid

The base layer of the Telehealth Pyramid is a 1-800 Health Call Centre. This centre would operate 24 hours a day x 7 days a week and would be staffed by health professionals, primarily nurses. Clients would phone in and the staff would answer basic health questions, help patients with minor health problems, and if necessary direct the client to the most appropriate health care resource.

The Medical Data Transmission and Telemetry Call Centre would be set up similar to the 1-800 Call Centre but in addition to receiving voice calls would receive medical data and telemetry. Examples of information that could be transmitted includes blood pressure, EKG, blood sugar and other blood chemistry, weight (for patients with congestive heart failure) and pulmonary function tests. This information could be transmitted routinely e.g. on a daily basis, or urgently when required.

The next layer, Internet Health Information and Education, represents health information web sites for patients and health care professionals. The patient web site would have information on a variety of topics, answers to frequently asked health questions, the option to email a health professional on a specific health problem (to get an email response back), and chat groups for patients interested or afflicted with specific conditions. The health professional web site would have more detailed information about different health conditions and provide access to continuing health education activities.

Tele-education includes all potential uses of information and telecommunications technologies to deliver health education to health professionals and patients. Some of the web-based activities in the previous level could be included in this section.

The next level in the pyramid includes teleconsultation, telenursing and telehome care. (Teleconsultation is defined as the provision of any medical service occurring between a physician and a patient e.g. telepsychiatry, teledermatology, tele-ENT). All these activities involve a health professional delivering a health service to a patient.

The final level of the telehealth pyramid includes a number of key components that are vital for the proper functioning and long term sustainability of telehealth. The administrative centre would coordinate/manage the activities listed below (especially those interactions that involve multiple sites). A research unit would assist in the design, implementation and evaluation of telehealth projects and could also do technical testing / evaluation. Finally, a training centre would provide students with a curriculum in telehealth and a place for "hands-on" training (At the Medical College of Georgia this was call the telehealth "petting zoo"). Non-credit courses for education and/or training could also be developed for professionals already practicing in their respective fields (physicians, nurses, technicians). Specific organizations e.g. Department of National Defense could contract the training centre to provide telehealth training to their personnel.