Telemedicine

Modern technological advancement has massively increased its influence across the different facets of life as we know it. From the production market, to finance, retail, entertainment, and medicine, labor-intensive manual processes required for repetitive procedures are now replaced with robotics and other latest inventions of technology. In medicine, the narrative is arguably nobler. Advanced two-way audiovisual communications systems have revolutionized the primitives of medical care. This concept, referred to as Telemedicine, involves the delivery of healthcare protocols including surgery, consultation, and counseling across long distances via remote electronic interfaces.

By offering a technology-based virtual platform, telemedicine has been demonstrated to improve the reach of modern medicine by remodeling the processes involved in diagnosis, radiological imaging, consultation, laboratory investigations, psychiatry care, addictions therapy, and disease prevention. Not only does telemedicine provide expert care in rural communities, but it also reduces the frequency of in-person hospital visit, optimize the index of care delivery and provide precision-driven medical care in terminal illnesses. This course is designed to examine the protocols of telemedicine as a healthcare delivery option, with a direct focus on its potential and its role in furthering the objective of modern healthcare delivery. It also provides a succinct view of the operational principles of the telehealth packages while recommending different plans for the implementation of telemedicine as a care protocol across the globe.

Mowat Al-Firsan resides in the suburbs of Andoabat, a relatively busy city in the Southern part of Egypt. As a country man, Mowat, a 75-year-old male, had traveled around the country in his youth, living his life as a Consulting Auditor for top banks, consulting firms, and public financial institutions. Now in his older age, he lives a sedentary life enjoying retirement in his birthplace. Two months until his 63rd birthday, Mowat was diagnosed with coronary artery disease by a cardiologist in Cairo. His diagnostic profile also shows a high risk of multiple cardiovascular diseases. For his routine checks, he travels an approximate distance of 56 kilometers two times a week. Seven months after his first diagnosis, Mowat was rushed to the emergency department of a local clinic in Andoabat after suffering a myocardial infarction.

On stabilization, he was referred on ambulatory support to the cardiology team in Cairo. A month later, under inpatient care, Mowat suffered multiple episodes of myocardial infarction prompting the team to prep him for cardiovascular stent placement. This surgery increased his cardiovascular risk of hypertension and dyslipidemia forcing the cardiology team to keep him under observatory watch for 3 weeks. Two weeks later, he developed infarction-induced ischemic cardiomyopathy leaving him with an ejection fraction of 20% to 25%. He was discharged with an observatory referral to a primary healthcare provider in Andoabat. His primary healthcare provider was to coordinate with the team in Cairo, sending weekly evaluation reports covering medication adherence, frequency of activity per day, diet chart, and vitals. Follow-up visits were scheduled for a month later after his coronary artery bypass surgery.

Back in Andoabat, Mowat lived with his extended family, eating almost the same diet as them but in smaller quantities. The first follow-up visit was smooth as he only complained of frequent body weakness and fatigue associated with traveling the long distance from Andoabat to Cairo. The cardiologist suspected nothing since the updated primary care provider report transmitted to the team showed no anomalies. However, between the first follow-up visit and the next, two months later, Mowat was admitted to the hospital three times on account of congestive heart failure. Historical documentation revealed he had been consuming a high-sodium diet after the first follow-up visit and had significantly reduced his activity-minute-per-day index.

Mowat complained about his frequent admissions and expressed frustrations with his frequent long-distance travels to Cairo. In an attempt to solve these issues and optimize healthcare delivery, the cardiology team drafted him into a remote patient monitoring program and referred him to a telemedicine consultation center situated about 2 kilometers from Andoabat. The Nurse Coordinator at the consolation center worked closely with the cardiology team in Cairo, transmitting real-time clinical reports on outpatient diuresis, fluid intake level, and weight tracking. With this report, the cardiology team performed interventions that lowered Mowat’s cardiovascular risk and prevented episodes of fluid overload. Transmitting his vitals to Cairo over a secured network solved the problem of fatigue and his frustrations on travels. After six months on the remote patient monitoring program, his frequency of readmission was reduced, and his cardiovascular risk was significantly lowered. Mowat now lives a happy life leveraging real-time medical guidance from the cardiology team in Cairo and the telemedicine consultation close to Andoabat.

Telemedicine, a widely adopted concept in modern science, is described as a branch of e-health that uses communications networks for the delivery of healthcare protocol, medical monitoring, and medical education from one geographic location to another. The first real-life example of telemedicine technology was used in the 1920s when radio communication was utilized to relay medical information from physicians on land to those at sea (Moore, 1999). The first use case of “Telemedicine” (pre-coded as ‘TLM’) is traced back to the 1970s and is credited to the National Aeronautics and Space Administration (NASA). Faced with the need to provide medical assistance to its team of astronauts in space, NASA deployed a virtual communication system focused on exchanging medical information between experts on the ground and astronauts in space. Since 1920, Telemedicine, as a term and concept, has found its way into the medical glossary, heralding a new wave of healthcare delivery that defy distance and other common barriers to in-person hospital visits.

Historically, the term ‘Telemedicine’ was coined by Thomas Bird in 1970 with a word origin described as “healing at a distance.” It is derived from the Latin word ‘Medicus,’ meaning cure, and the Greek word ‘tele,’ meaning far away (Jafarzadeh et al., 2022). ‘Tele-Medicus’ directly implies using a virtual channel to exchange information usable as protocols for managing diseases in humans.

In 1978, the first satellite setup dedicated to medical coverage was established in rural Queensland, Australia. The satellite project was designed solely to improve remote access to medical information and treatment. The concept grew rapidly after 1978, and in 2001, the first robotic surgery leveraging telemedicine was recorded. A team of surgeons in New York operated on a patient with gallbladder illness in Eastern France at a distance of roughly 8,000 kilometers. Using a network of telemedicine-enabled high-speed fiber optic lines and a robotic surgical system, the team completed the surgical procedures, transmitted real-time care optimizations, and set up a post-surgical monitoring protocol (Jafarzadeh et al., 2022).

Today, ‘Telemedicine’ is considered an umbrella term for telecommunication networks used for establishing, promoting, and accelerating healthcare services around the world (Teixeira et al., 2018). Without the need for a routine doctor-patient encounter, telecommunication primarily advances the reach of modern medicine to the slums of Africa, the mountainous regions of the Himalayas, the scantily populated territories of the Northern Pole, and far into Space. Aided by the wide reach of the internet, this protocol facilitates the two-way transmission of health signals packaged as texts, audio recordings, images, videos, and in-app prompts. Over the past 20 years, modifications of these concepts have been adopted to serve primary functions in health monitoring, distant surgery, terminal disease diagnosis, mental healthcare optimization, and medical education (Mechanic et al., 2021).

In a broad description, the history and use cases of ‘Telemedicine’ can be described as consisting of three different eras: the “telecommunication era,” the “digital era,” and the “internet era.”

In the “telecommunication era” of the 1970s, telemedicine was primarily designated as a secondary alternative, complementing the limited range of in-person medical arrangements (Bashshur et al., 2016). This era was characterized by a one-way transmission of audio and visual data with no integrating interface or storefront for clinical records and patients’ data. With tons of limitations on telecommunication during this era, telemedicine networks only transmitted care packages and lacked the complex clinical applications available today.

The second era spanned into the late 1980s when the telecommunications system had improved greatly through digitalization (Bashshur et al., 2016). The “digital era” was characterized by integrating telecommunications and computer services for delivering medical information and care protocols on limited bandwidths. More specifically, the “digital era” introduced the use of telephone lines and switches designed in various combinations, ranging from partially dedicated telephone lines to a combination of multiple, full ‘T1’ lines. For context, the T1 line has a transmission capacity of 1.544 Mbits per second. These dedicated lines could only connect a few patients to clinicians on three bases (Bashshur et al., 2016):

• Point to point (hospital to hospital)
• Point to multipoint (hospital to remote clinics)
• Multipoint to multipoint (a multicomplex network). 

More prominently, the “digital era” also featured the introduction of the Integrated Service Digital Network Technology (Krittanawong, 2021). This system includes digital two-way audiovisual communications protocols permitting the transmission of voice, video, high-definition images, and texts over a secured universal network at a high speed. Using a full multiplex network, the second era of telemedicine was highly dependent on television techs for image capability.

Although the Internet has been around since 1969, the dedicated use of Internet technology for medical purposes is relatively recent. Heralding the third era of telemedicine, the “internet era,” allowed the integration of telecommunications and computers with standardized protocols and tools for wide accessibility and connectivity (Bashshur et al., 2016). This era features open access to a global communication environment with a heterogeneous set of activities enabling a wide spectrum of personal and professional interactions. In addition, advancements in computer technology also created large data repositories and the integration of multiple medical interfaces operating from a single platform (Bashshur et al., 2016).

The possibilities of this arrangement are limitless. Substantially enhanced visuals, intensive images, large-sized audio files, and patient data can be stored in multiple forms and retrieved on-demand at points of care (Kichloo et al., 2020). The digital protocols opened up by the internet made modern medicine accessible, more ubiquitous, and cheaper. With over 70 million daily web users, there are simply no limitations to the reach of telemedicine. Today, information sources and virtual services on patient care, medical information, monitoring, and reporting are popular on the web.

Around the world today, telemedicine is becoming increasingly popular as a care protocol for non-emergency services and conditions requiring no hospitalization. Primarily, it lifts the burden of a physical visit for the patient and helps clinics optimize the use of medical resources. The experience around the world only differs in the level of technological advancement and level of reception, however, the primary purpose remains largely similar.

On the surface, a ‘telemedicine workflow’ moves the patient-care provider interface to a digital server. The complete module of a patient-centered telemedicine network primarily includes three interacting parties –the patient, a telemedicine provider, and a digital network provider.

Depending on the care offered and local regulations on telemedicine, each party may be housed in a different unit, hundreds of miles apart. The telemedicine specialty center houses the care providers, and in a ‘store and forward’ module, patients may be housed in the telemedicine consultation centers. Telemedicine network software provides the virtual connection needed and a secure channel for a two-way exchange of data packets. In many cases, this software is cloud-hosted, providing unlimited storage space.

Care providers may require patients to register and supply a series of preliminary personal data needed to document a medical history on the doctor’s end. Each package of data collected from all patients is encoded and marked with a unique digital identifying system. AI algorithms complete the detailed process of data marking, archival, and analysis. Depending on the setup, this digital databank of patient medical records may be accessible to the patient at all times or available only on request. Based on data collected and sorted, customized medical information may be sent to patients belonging to particular categories (Pego-Regiosa et al., 2022).

Online consultations are arranged as a two-way digital interface between care providers and the patient. Audio-visual prompts provided by the algorithms allow the care providers to conduct patient examinations, interviews, and surveys. Patients can send in pictorial depictions of skin defects, glucometer measurements, and vital signs recorded. Online prescriptions are generated remotely by the doctor and sent over the secure network.

A telemedicine network requires a lot of organization at the provider's end of the workflow. Although virtual clinics hosted on a secure server can replace conventional in-person visits, they are only perfect for conditions requiring no hospitalization or emergency interventions.

Most telemedicine providers operate two modules of care delivery:

1. In-person appointments
2. Facilitated Virtual Visits

Networks using the ‘store and forward’ protocol may provide a mechanism to help patients troubleshoot the virtual technology on their end to ensure the integrity of data generated, stored, and forwarded. To this end, telemedicine consultation centers are usually equipped with Automatic Logic Flows (bots) to help patients and contact persons through the setup and troubleshooting process. Experts also recommend the installation of a secondary data flow network in these centers. Providing an alternative route of data transfer may help during technical breakdowns. Ideal secondary options include physical mailings, electronic medical records, and website-based information and links (Singh, 2022). Overall, a telemedicine technical workflow depends on the care plans offered by the provider.

As telemedicine expanded and hospitals adopted at least one of its protocols, the need to develop improved communications technology became important.

The Bell System was the first of many engineering companies to promise an ultimate two-way communications system by 1970. In 1959, Nebraska Psychiatric Institution (NPI) started using the first two-way television to transmit demonstrations and other data forms to medical students after a 12-year trial with the tech. Data packet transfer included motion picture images with accompanying sound. In 1961, a grant-supported trial examining the potential of two-way television in psychiatric treatment started. In addition to assessing the potential of telemedicine in mental healthcare, this trial also tested the reliability of the new technology in telepsychiatry. The trial provided valuable insights, and in 1964, the National Institute of Mental Health sponsored the installation of a two-way closed-circuit television system between NPI and the Norfolk State Memorial Hospital. At a distance of 112 miles away, the new technology was charged with transmitting data packs on in-service training opportunities and providing teleconsultation services remotely.

Since the first use case in the 1960s, two-way interactive technologies have become a huge part of telemedicine. Today, the modifications available to this technology make it possible to exchange medical information remotely over a secured network in real-time.

Closed-circuit televisions enable healthcare professionals to establish a patient-care provider connection with patients or underserved patient groups in remote locations.

Data packs are shared as texts, high-resolution images, and quality sound useful for gauging patient’s response, physical examination (teledermatology), adherence monitoring (telepharmacy), and patient monitoring (telepsychiatry).

Biomedical telemetry, in senior care, measures a patient’s vital signs and transmits the same using standard medical biometric sensors. Geriatric specialists on the receiving end, using a two-way interactive television, may better assess a patient’s health using real-time images, audio responses, and biometric signals transmitted through the closed-circuit television.

The quality and format of images transmitted using a two-way interactive television may depend largely on the type of healthcare delivery it is used for. For instance, with the exemption of teledermatology (dermatology telemedicine services), the black-and-white, high-resolution view is considered preferable for diagnostics purposes. Other critical factors such as lightning effect, depth illusion, and magnification are also important when using a two-way interactive television. In essence, this technology has significantly expanded the frontiers of telemedicine by adding the personal touch considered absent in non-visual telemedicine. Patients can relate better with their care providers as audio-visual tech of the two-way television better mimic the conventional in-person hospital appointment.

Recently, the possibilities of a three-dimensional (3D) visualization fusing AI-aided technology with the audio-visual tech of two-way television have received wide publicity. This new proposal seeks to improve the data packs sent using two-way televisions. 3D visualizations provide a real-time, true-form high-definition image of the internal organs. This is particularly useful in tumor care, teledermatology, and maternal care.

At the Radiological Society of North America’s Scientific Assembly Meeting in 2009, telecommunication giants, Siemens and NVIDIA, demonstrated a new 3D ultrasonic imaging technology that can be hooked to a two-way interactive television. This new technology provided incredible insight into the internal organs in different magnification and resolution. There are also possibilities of deploying this technology for maternal healthcare, especially in fetal imaging. 3D imaging in telemedicine opens a new era of medical imaging, helping healthcare stakeholders improve the reach of modern medicine.

Primarily, the clinical applications of telemedicine are designed to optimize patient care and solve the common barriers to healthcare delivery. Early reports evaluating the clinical roles of telemedicine in healthcare largely recognized six classifications. These include:

1. Consultation, including a second opinion
2. Remote monitoring and tracking of vital signs, medication adherence, and therapy effectiveness
3. Remote supervision of primary care by caregivers in underserved populations
4. Initial evaluation of patients for stabilization, triage, and referral
5. Provision and supervision of primary care by a specialist or primary care provider in underserved populations
6. Real-time assessment and analysis of vital medical data for the modification of ongoing therapy

These broad classifications describe the primary challenges of healthcare delivery by offering an alternative method of care delivery.

Today, telemedicine plays a direct role in how medical personnel delivers care and how patients receive care. These roles include:

• Public health
• Disease prevention
• Addiction care
• Patient monitoring and counselling

Interactive healthcare communication takes a principal role in patient management. People with chronic disease conditions have multiple medical needs. This includes information about their illness and the treatment options available. Interactive health communication tools hosted on telemedicine networks may help the exchange of this vital information between the healthcare team and the patients. Generally, interactive healthcare tools improve patients’ knowledge about their disease condition, provide social support from the health community, and help the clinical team better control the clinical outcomes of therapy, especially in telepsychiatry (Calvache-Mateo et al., 2021).

Interprofessional communications across healthcare teams have been identified as a contributing factor to the effectiveness of therapy. In a patient with chronic medical conditions requiring long-term hospitalization, the therapy regimen may require interventions from different members of the medical team.

Many times, these interventions are communicated on a secured channel to provide a real-time update on the course of therapy and modifications proposed. As a team, developing an effective channel of communication can be quite challenging in the medical setting. In addition, members of the healthcare team may be required to make real-time inputs on the medical regimen implemented for different patients. A telemedicine network helps solve the common barriers to communication in healthcare settings. Interactive Health Communication protocols on these networks use in-app chat features, question prompts, and image-sharing features to facilitate the easy flow of information among team members. The importance of these internal communication systems cannot be overemphasized in patient management.

The COVID-19 pandemic championed a global awareness of the use of telemedicine protocols. Nationwide lockdowns forced medical professionals to initiate remote patient monitoring plans using texts, in-app prompts, and two-way interactive platforms. Online appointments also replaced in-person hospital visits, cutting off travel time and waiting time at the clinic. The usefulness of remote healthcare delivery is becoming obvious to a large population of patients and caregivers.

Telemedicine specifically relies on electronic transmission, artificial intelligence, cloud computing, virtual storage, and telematics technology for the generation and transmission of medical data. Arguably, using the technology of the future is a welcome development in modern medicine. These technological inputs primarily enhance the reach of medical care and provide a reliable care option for at-risk populations in remote parts of the world.

Although this mode of care delivery opens a bright future for the medical profession, it is important to understand that the human factor in care delivery holds a significant position in telemedicine workflow. In essence, telehealth services should be considered a complementary approach to in-person medical care and not a replacement. Regional regulatory agencies are expected to develop guidelines and standards moderating the technological input and the professional quality of telemedicine providers. Telemedicine holds massive breakthroughs for the global medical community in the future. Well-guided research and policies are required to shape the future of remote healthcare delivery and address its multiple sociocultural and technical challenges.

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