Telemedicine Lokender Yadav. Telemedicine Telemedicine has been defined as the use of...

Telemedicine

Lokender YadavLokender Yadav

Telemedicine

Telemedicine has been defined as the use of telecommunications to provide Telemedicine has been defined as the use of telecommunications to provide medical information and services. It may be as simple as two health medical information and services. It may be as simple as two health professionals discussing a case over the telephone, or as sophisticated as professionals discussing a case over the telephone, or as sophisticated as using satellite technology to broadcast a consultation between providers at using satellite technology to broadcast a consultation between providers at facilities in two countries, using videoconferencing equipment or robotic facilities in two countries, using videoconferencing equipment or robotic technology.technology.

Telemedicine

Telemedicine generally refers to the use of ICT for the delivery of clinical careTelemedicine generally refers to the use of ICT for the delivery of clinical care

Telemedicine

Types of telemedicineTypes of telemedicine

Telemedicine is practiced on the basis of two concepts: Telemedicine is practiced on the basis of two concepts:

real time (synchronous) and real time (synchronous) and

store-and-forward (asynchronous)store-and-forward (asynchronous)

Real time telemedicine

Real time telemedicine could be as simple as a Real time telemedicine could be as simple as a telephone call or as complex as robotic surgery. It telephone call or as complex as robotic surgery. It requires the presence of both parties at the same requires the presence of both parties at the same time and a communications link between them time and a communications link between them that allows a real-time interaction to take place. that allows a real-time interaction to take place. Video-conferencing equipment is one of the most Video-conferencing equipment is one of the most common forms of technologies used in common forms of technologies used in synchronous telemedicine.synchronous telemedicine.

Real time telemedicine

There are also peripheral devices which can be attached to computers or There are also peripheral devices which can be attached to computers or the video-conferencing equipment which can aid in an interactive the video-conferencing equipment which can aid in an interactive examination. examination.

For instance, a For instance, a tele-otoscopetele-otoscope allows a remote physician to 'see' inside a allows a remote physician to 'see' inside a patient's patient's earear; a ; a tele-stethoscopetele-stethoscope allows the consulting remote physician to allows the consulting remote physician to hear the patient's hear the patient's heartbeatheartbeat. .

Store-and-forward telemedicine

Store-and-forward telemedicine involves acquiring medical data (like Store-and-forward telemedicine involves acquiring medical data (like medical images, biosignals etc) and then transmitting this data to a medical images, biosignals etc) and then transmitting this data to a doctor or medical specialist at a convenient time for assessment doctor or medical specialist at a convenient time for assessment offline. It does not require the presence of both parties at the same offline. It does not require the presence of both parties at the same time.time.

Dermatology, radiology, and pathology are common specialties that Dermatology, radiology, and pathology are common specialties that are conducive to asynchronous telemedicine. A properly structured are conducive to asynchronous telemedicine. A properly structured Medical Record preferably in electronic form should be a component of Medical Record preferably in electronic form should be a component of this transfer.this transfer.

Store-and-forward telemedicine

Teleradiology, the sending of x-rays, CT scans, or MRIs (store-and-Teleradiology, the sending of x-rays, CT scans, or MRIs (store-and-forward images) is the most common application of telemedicine in forward images) is the most common application of telemedicine in use today. There are hundreds of medical centers, clinics, and use today. There are hundreds of medical centers, clinics, and individual physicians who use some form of teleradiology. Many individual physicians who use some form of teleradiology. Many radiologists are installing appropriate computer technology in their radiologists are installing appropriate computer technology in their homes, so they can have images sent directly to them for diagnosis, homes, so they can have images sent directly to them for diagnosis, instead of making an off-hours trip to a hospital or clinic.instead of making an off-hours trip to a hospital or clinic.

Telemedicine

Telemedicine is most beneficial for populations living in isolated Telemedicine is most beneficial for populations living in isolated communities and remote regions and is currently being applied in communities and remote regions and is currently being applied in virtually all medical domains. Specialities that use telemedicine often virtually all medical domains. Specialities that use telemedicine often use a "tele-" prefix; for example, telemedicine as applied by use a "tele-" prefix; for example, telemedicine as applied by radiologists is called Teleradiology. Similarly telemedicine as applied by radiologists is called Teleradiology. Similarly telemedicine as applied by cardiologists is termed as telecardiology, etc.cardiologists is termed as telecardiology, etc.

Telemedicine

Telemedicine is also useful as a communication tool between a Telemedicine is also useful as a communication tool between a general practitioner and a specialist available at a remote location.general practitioner and a specialist available at a remote location.

Telemedicine

Telepathology is another common use of this technology. Images of Telepathology is another common use of this technology. Images of pathology slides may be sent from one location to another for pathology slides may be sent from one location to another for diagnostic consultation. diagnostic consultation.

Dermatology is also a natural for store and forward technology Dermatology is also a natural for store and forward technology (although practitioners are increasingly using interactive technology (although practitioners are increasingly using interactive technology for dermatological exams). Digital images may be taken of skin for dermatological exams). Digital images may be taken of skin conditions, and sent to a dermatologist for diagnosis.conditions, and sent to a dermatologist for diagnosis.

Telemedicine

The other widely used technology, The other widely used technology, two-way interactive television (IATV)two-way interactive television (IATV), is , is used when a used when a 'face-to-face' consultation'face-to-face' consultation is necessary. The patient and is necessary. The patient and sometimes their provider, or more commonly a nurse practitioner or sometimes their provider, or more commonly a nurse practitioner or telemedicine coordinator (or any combination of the three), are at the telemedicine coordinator (or any combination of the three), are at the originating site. The specialist is at the referral site, most often at an urban originating site. The specialist is at the referral site, most often at an urban medical center. medical center.

Video conferencingVideo conferencing equipment at both locations allow a 'real-time' equipment at both locations allow a 'real-time' consultation to take place. The technology has decreased in price and consultation to take place. The technology has decreased in price and complexity over the past five years, and many programs now use desktop complexity over the past five years, and many programs now use desktop video conferencing systems. video conferencing systems.

Telemedicine

There are many configurations of an interactive consultation, but most There are many configurations of an interactive consultation, but most typically it is from an typically it is from an urban-to-rural locationurban-to-rural location. It means that the . It means that the patient patient does not have to travel to an urban area to see a specialistdoes not have to travel to an urban area to see a specialist, and in many , and in many cases, provides access to cases, provides access to speciality carespeciality care when none has been available when none has been available previously. previously.

Almost all specialities of medicine have been found to be conducive to Almost all specialities of medicine have been found to be conducive to this kind of consultation, including psychiatry, internal medicine, this kind of consultation, including psychiatry, internal medicine, rehabilitation, cardiology, paediatrics, obstetrics and gynaecology and rehabilitation, cardiology, paediatrics, obstetrics and gynaecology and neurology.neurology.

Telemedicine

There are also many There are also many peripheral devicesperipheral devices which can be attached to which can be attached to computers which can aid in an interactive examination. computers which can aid in an interactive examination.

For instance, an For instance, an tele-otoscopetele-otoscope

allows a physician to 'see' inside a patient's ear; allows a physician to 'see' inside a patient's ear;

a a tele-stethoscopetele-stethoscope allows the consulting physician to hear the patient's allows the consulting physician to hear the patient's heartbeat.heartbeat.

Teleradiology:

Teleradiology is the ability to send radiographic images (x-rays) from one Teleradiology is the ability to send radiographic images (x-rays) from one location to another. For this process to be implemented, three essential location to another. For this process to be implemented, three essential components are required, an image sending station, a transmission components are required, an image sending station, a transmission network, and a receiving / image review station. network, and a receiving / image review station.

The most typical implementation are two computers connected via The most typical implementation are two computers connected via Internet. The computer at the receiving end will need to have a high-quality Internet. The computer at the receiving end will need to have a high-quality display screen that has been tested and cleared for clinical purposes. display screen that has been tested and cleared for clinical purposes.

Sometimes the receiving computer will have a printer so that images can Sometimes the receiving computer will have a printer so that images can be printed for convenience.be printed for convenience.

Teleradiology:

The teleradiology process begins at the image sending station. The The teleradiology process begins at the image sending station. The radiographic image and a modem or other connection are required for this 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 first step. The image is scanned and then sent via the network connection to the receiving computer.to the receiving computer.

Advantages of Telemedicine:

Providing healthcare services via telemedicine offers many advantages. It Providing healthcare services via telemedicine offers many advantages. It can make specialty care more accessible to underserved rural and urban can make specialty care more accessible to underserved rural and urban populations. populations.

Video consultations from a rural clinic to a specialist can alleviate Video consultations from a rural clinic to a specialist can alleviate prohibitive travel and associated costs for patients. prohibitive travel and associated costs for patients.

Advantages of Telemedicine:

Video conferencing also opens up new possibilities for continuing Video conferencing also opens up new possibilities for continuing education or training for isolated or rural health practitioners, who may not education or training for isolated or rural health practitioners, who may not be able to leave a rural practice to take part in professional meetings or be able to leave a rural practice to take part in professional meetings or educational opportunities. educational opportunities.

the use of telemedicine can also cut costs of medical care for those in the use of telemedicine can also cut costs of medical care for those in rural areas.rural areas.

Barriers to Telemedicine

There are still several barriers to the practice of telemedicine. Many There are still several barriers to the practice of telemedicine. Many states will not allow out-of-state physicians to practice unless licensed in states will not allow out-of-state physicians to practice unless licensed in their state. The Centers for Medicare and Medicaid (CMS) still has several their state. The Centers for Medicare and Medicaid (CMS) still has several restrictions for Medicare telemedicine reimbursement. Many private restrictions for Medicare telemedicine reimbursement. Many private insurers also will not reimburse, although some states, such as California insurers also will not reimburse, although some states, such as California and Kentucky, have legislated that they must reimburse the same as for and Kentucky, have legislated that they must reimburse the same as for face-to-face consultations.face-to-face consultations.


Many potential telemedicine projects have been hampered by the Many potential telemedicine projects have been hampered by the lack of lack of appropriate telecommunications technologyappropriate telecommunications technology. Regular telephone lines do . Regular telephone lines do not supply not supply adequate bandwidthadequate bandwidth for most telemedical applications. for most telemedical applications.

Many rural areas still Many rural areas still do not have cable wiringdo not have cable wiring or other kinds of high or other kinds of high bandwidth telecommunications access required for more sophisticated bandwidth telecommunications access required for more sophisticated uses. uses.


Lack of funding for developing state-of-the-art telemedicine infrastructureLack of funding for developing state-of-the-art telemedicine infrastructure

Some private corporations and telecommunications companies are Some private corporations and telecommunications companies are stepping in to fill the void, however, pressure on the appropriate stepping in to fill the void, however, pressure on the appropriate government and legislative agencies is needed before more funding will government and legislative agencies is needed before more funding will become available.become available.

Need for Telemedicine in India:

The The health of a nationhealth of a nation is the product of many factors and forces that is the product of many factors and forces that combine and interact. Economic growth, per capita income, literacy, combine and interact. Economic growth, per capita income, literacy, education, age at marriage, birth rates, information on health care and education, age at marriage, birth rates, information on health care and nutrition, access to safe drinking water, public and private health care nutrition, access to safe drinking water, public and private health care infrastructure, access to preventive health and medical care and the infrastructure, access to preventive health and medical care and the health insurance are among the health insurance are among the contributing factorscontributing factors. .

The advances in Medical science, biomedical engineering on one side and The advances in Medical science, biomedical engineering on one side and Telecommunication and Information Technology on the other side are Telecommunication and Information Technology on the other side are offering wide opportunities for improved health care.offering wide opportunities for improved health care.


Despite making huge strides in overall development, the Despite making huge strides in overall development, the health coverage health coverage to majority of our population is still a distant dreamto majority of our population is still a distant dream..

India is a vast country gifted with rich and ancient historic background India is a vast country gifted with rich and ancient historic background and and geographicallygeographically the nature has provided India with all the the nature has provided India with all the varietiesvarieties like like the the mountain regions like Ladakh, deserts, green planes and far flung mountain regions like Ladakh, deserts, green planes and far flung areas in the north east and offshore islands of Andaman’s and areas in the north east and offshore islands of Andaman’s and LakshadweepLakshadweep..


India today has more than India today has more than 1 billion population1 billion population and there is finite limit of and there is finite limit of elasticity in providing health care in terms of infrastructure, facility, the elasticity in providing health care in terms of infrastructure, facility, the manpower and the funds. Wide disparities persist between different manpower and the funds. Wide disparities persist between different income groups, between rural and urban communities, and between income groups, between rural and urban communities, and between different states and even districts within States.different states and even districts within States.

The population is The population is predominantly rural and distributed in distant predominantly rural and distributed in distant geographical locationsgeographical locations apart from the high-density urban areas; to provide apart from the high-density urban areas; to provide the basic minimum health care has been one of the priorities of the Health the basic minimum health care has been one of the priorities of the Health administration all along.administration all along.


Further this is compounded by the following factors like:Further this is compounded by the following factors like:

High cost of health care and lack of investment for health care in rural High cost of health care and lack of investment for health care in rural areas.areas.

Inadequate medical facilities in rural & inaccessible areas.Inadequate medical facilities in rural & inaccessible areas.

Problem of retaining doctors in rural areas where they are required to Problem of retaining doctors in rural areas where they are required to serve & propagate widespread health awareness.serve & propagate widespread health awareness.

Specialist doctors cannot be retained at rural areas as they will be Specialist doctors cannot be retained at rural areas as they will be professionally isolated and become obsolete and even monetary professionally isolated and become obsolete and even monetary incentives also cannot prevent it.incentives also cannot prevent it.


A recent survey by the Indian Medical society has found A recent survey by the Indian Medical society has found

75% of qualified consulting doctors practice in urban centers and 75% of qualified consulting doctors practice in urban centers and

23% in semi urban areas and 23% in semi urban areas and

only 2% from rural areas whereas majority of the patients come from only 2% from rural areas whereas majority of the patients come from rural areas. rural areas.

Hospital beds / 1000 people is 0.19 in rural and Hospital beds / 1000 people is 0.19 in rural and

2.2 in urban areas. 2.2 in urban areas.


This calls for innovative methods of utilization of science and technology This calls for innovative methods of utilization of science and technology for the benefit, of our society and telemedicine assumes a great for the benefit, of our society and telemedicine assumes a great significance to revolutionize the health care system in India. Adaptation of significance to revolutionize the health care system in India. Adaptation of Telemedicine technology offers one of the best options for delivering Telemedicine technology offers one of the best options for delivering healthcare for rural & geographically distant population spread across healthcare for rural & geographically distant population spread across India. Importance of Telemedicine in health care started quite some time India. Importance of Telemedicine in health care started quite some time ago & more recently the telemedicine has undergone something of ago & more recently the telemedicine has undergone something of resurgence as technology began catching up with the need and aspiration.resurgence as technology began catching up with the need and aspiration.

The Potential

Some pilot schemes in telemedicine through the initiative of Department Some pilot schemes in telemedicine through the initiative of Department of Space, Department of Information Technology, and some other public & of Space, Department of Information Technology, and some other public & private organizations have demonstrated the successful application of private organizations have demonstrated the successful application of information and Communication technology in extending the reach and information and Communication technology in extending the reach and access for improved health care to all.access for improved health care to all.

Framework in defining the guidelines and standards:

InteroperabilityInteroperability: Develop telemedicine networks that interface together : Develop telemedicine networks that interface together and create an open environment sharing the application on different and create an open environment sharing the application on different participating systems in real-time or seamless interface between several participating systems in real-time or seamless interface between several applicationsapplications

CompatibilityCompatibility: Equipment/systems of different vendors and different : Equipment/systems of different vendors and different versions of the same system, to be able to be interconnectedversions of the same system, to be able to be interconnected

Framework in defining the guidelines and standards:

ScalabilityScalability: Equipment/systems inducted for telemedicine to be able to be : Equipment/systems inducted for telemedicine to be able to be augmented with additional featuresaugmented with additional features and functions as modular add-on and functions as modular add-on options.options.

PortabilityPortability: The data generated by an application that runs on one system : The data generated by an application that runs on one system to be able to be to be able to be ported to different platforms with a minimum effortported to different platforms with a minimum effort..

ReliabilityReliability: Telemedicine systems to follow relevant reliability standards of : Telemedicine systems to follow relevant reliability standards of equipment/systems of similar category to ensure availability of service equipment/systems of similar category to ensure availability of service with minimum system downtime.with minimum system downtime.

The above framework has been so adopted to ensure:

Inclusion of all the stakeholdersInclusion of all the stakeholders: Making the recommendation with due : Making the recommendation with due consideration of the rights and responsibilities of patient/community, consideration of the rights and responsibilities of patient/community, health care service provider, the technology provider, the government etc.health care service provider, the technology provider, the government etc.

Making recommendations vendor neutralMaking recommendations vendor neutral: Ensuring that the : Ensuring that the recommendations are not biased against any specific recommendations are not biased against any specific vendor/manufacturer of telemedicine systemsvendor/manufacturer of telemedicine systems

The above framework has been so adopted to ensure:

Making standards technology neutralMaking standards technology neutral: Ensuring that the : Ensuring that the recommendations will not favour any specific technology leaving scope for recommendations will not favour any specific technology leaving scope for present/future alternatives.present/future alternatives.

Telemedicine Infrastructure:

This will include minimum standards for all the hardware and software This will include minimum standards for all the hardware and software used in a telemedicine system. used in a telemedicine system.

Under Under hardwarehardware it will include standards and guidelines for basic it will include standards and guidelines for basic telemedicine platform, servers, clinical devices, video conferencing telemedicine platform, servers, clinical devices, video conferencing system, communication hardware and power support. system, communication hardware and power support.

The The softwaresoftware standards address operating system, telemedicine software, standards address operating system, telemedicine software, and server software.and server software.


Hardware Hardware

o o Telemedicine platformTelemedicine platform: :

This will include minimum standards for type of platform to be used, This will include minimum standards for type of platform to be used, processor/minimum speed, memory requirements, interfaces, and processor/minimum speed, memory requirements, interfaces, and peripherals.peripherals.

o o Clinical devices Clinical devices

This will include minimum standards for all the clinical devices to be This will include minimum standards for all the clinical devices to be interfaced or integrated with the telemedicine system, including interfaced or integrated with the telemedicine system, including performance specifications for devices measuring diagnostic parameters, performance specifications for devices measuring diagnostic parameters, imaging devices, compression, and their safety requirements. imaging devices, compression, and their safety requirements.


Hardware Hardware

o Video conferencing units o Video conferencing units

o This will include minimum standards for video conferencing system, o This will include minimum standards for video conferencing system, including data rate, picture resolution, frame rate, type of camera, audio including data rate, picture resolution, frame rate, type of camera, audio quality etc. quality etc.

o Communication hardware o Communication hardware

o This will include minimum standards for various hardware used for o This will include minimum standards for various hardware used for interfacing the telemedicine system with the communication network, interfacing the telemedicine system with the communication network, including all types of terrestrial and satellite based networks. including all types of terrestrial and satellite based networks.


SoftwareSoftware

o An operating system o An operating system

o Licensed telemedicine S/W with appropriate User Interface(UI) o Licensed telemedicine S/W with appropriate User Interface(UI)

o Back-end Data Base with the mandatory tables/ fields (if applicable) o Back-end Data Base with the mandatory tables/ fields (if applicable)


Connectivity: Connectivity:

options for telemedicine services options for telemedicine services

o VSAT o VSAT

o PSTN o PSTN

o ISDN o ISDN

o Leased Line o Leased Line

o Wireless LAN /WAN o Wireless LAN /WAN

Video conferencing boosts telemedicine

Video conferencing is becoming quite popular among hospitals. Video conferencing is becoming quite popular among hospitals. By using this technology, doctors can help patients who are By using this technology, doctors can help patients who are unable to come to the hospital. It especially benefits the rural unable to come to the hospital. It especially benefits the rural populace since one cannot always get good doctors there. populace since one cannot always get good doctors there. Telemedicine has turned out to be a blessing for patients who Telemedicine has turned out to be a blessing for patients who were otherwise deprived of the best treatment. Polycom is one were otherwise deprived of the best treatment. Polycom is one company that’s providing video conferencing equipment to company that’s providing video conferencing equipment to hospitals for tele-medicine.hospitals for tele-medicine.


A telemedicine system consists of customised hardware and A telemedicine system consists of customised hardware and software at two locations—the patient’s as well as the doctor’s software at two locations—the patient’s as well as the doctor’s end. These locations are usually connected by means of an end. These locations are usually connected by means of an Integrated Service Digital Network (ISDN), Public Switch Integrated Service Digital Network (ISDN), Public Switch Telephone Network (PSTN) or Very Small Aperture Terminal (VSAT) Telephone Network (PSTN) or Very Small Aperture Terminal (VSAT) link, and the system is controlled by the network hub station of link, and the system is controlled by the network hub station of the Indian Space Research Organisation (ISRO).the Indian Space Research Organisation (ISRO).


Polycom IndiaPolycom India provides video conferencing equipment for tele-medicine. provides video conferencing equipment for tele-medicine. Apollo and EscortsApollo and Escorts are their principal clients in this area.” The company’s are their principal clients in this area.” The company’s video conferencing solution is called Unified Collaborative video conferencing solution is called Unified Collaborative Communications (UCC). It helps to provide converged voice, video, web Communications (UCC). It helps to provide converged voice, video, web and data solutions for emerging broadband networks, and is designed to and data solutions for emerging broadband networks, and is designed to integrate with standard video-based medical end-points.integrate with standard video-based medical end-points.

http://www.onlinetelemedicine.com/

Broadband

Broadband has come as a big boost to telemedicine. “With the availability Broadband has come as a big boost to telemedicine. “With the availability of broadband, India is now becoming a hot destination for tele-medicine as of broadband, India is now becoming a hot destination for tele-medicine as it is a win-win situation for both the patients as well as hospitals. it is a win-win situation for both the patients as well as hospitals.

The goal

Telemedicine tools help deliver healthcare in medical disciplines like Telemedicine tools help deliver healthcare in medical disciplines like emergency medicine, behavioural science, dermatology, cardiology, emergency medicine, behavioural science, dermatology, cardiology, radiology, paediatrics, obstetrics, oncology, dentistry, gastro-enterology, radiology, paediatrics, obstetrics, oncology, dentistry, gastro-enterology, neurology, pathology, psychiatry, orthopaedics, family practice, neurology, pathology, psychiatry, orthopaedics, family practice, ophthalmology and rheumatology. As Lavanian puts it, “The primary ophthalmology and rheumatology. As Lavanian puts it, “The primary objective of tele-medicine is to provide quality healthcare assistance to objective of tele-medicine is to provide quality healthcare assistance to every patient.every patient.

The goal

Video conferencing also ensures that the patients are treated irrespective Video conferencing also ensures that the patients are treated irrespective of their financial condition, and this makes it popular in most countries. It of their financial condition, and this makes it popular in most countries. It is expected that home-based patient monitoring is also going to become is expected that home-based patient monitoring is also going to become popular, as will remote surgery, which will involve surgery via robotics, popular, as will remote surgery, which will involve surgery via robotics, with the surgeon in one location and the patient in another.with the surgeon in one location and the patient in another.

Possibilities of Telemedicine

Transmission of digitized audio, video, and still images Transmission of digitized audio, video, and still images

Improvements in quality of care in rural and underserved communities Improvements in quality of care in rural and underserved communities

Overcoming isolation of rural practitioners by linking them to urban Overcoming isolation of rural practitioners by linking them to urban medical centers medical centers

Delivery of information and services into the home Delivery of information and services into the home

Monitoring patients at home Monitoring patients at home

Possibilities of Telemedicine

Keeping patients in the community and maintaining continuity of care Keeping patients in the community and maintaining continuity of care

Reduction of travel time and expense for physicians and patients Reduction of travel time and expense for physicians and patients

Increased mobility as people move from urban to rural areas with Increased mobility as people move from urban to rural areas with continued access to specialists continued access to specialists

New business and marketing opportunities New business and marketing opportunities

Barriers to Implementation

Ambiguity of multiple definitions and visions Ambiguity of multiple definitions and visions

Belief among some that implementing telemedicine is the goal rather Belief among some that implementing telemedicine is the goal rather than the means to a goal than the means to a goal

High cost of infrastructure and hardware High cost of infrastructure and hardware

Poorly designed systems Poorly designed systems

Incompatibility of systems Incompatibility of systems

Limited bandwidth Limited bandwidth

Outmoded regulations Outmoded regulations


Lack of standards Lack of standards

Confidentiality concerns Confidentiality concerns

Complex liability issues (for example, where would a law suit be filed?) Complex liability issues (for example, where would a law suit be filed?)

State-based licensor laws that pose obstacles to practising telemedicine State-based licensor laws that pose obstacles to practising telemedicine across state lines across state lines

Lack of guidelines for credential physicians Lack of guidelines for credential physicians

Potential strain on physician-patient relationship Potential strain on physician-patient relationship

Questions about image fidelity and context Questions about image fidelity and context


Distrust and fear of new technologies Distrust and fear of new technologies

Disruption of normal office routine Disruption of normal office routine

Time required to train providers and support personnel Time required to train providers and support personnel

Resistance to responsibility for increased number of patients Resistance to responsibility for increased number of patients

Increased time required for patient referral Increased time required for patient referral

Increased practice and capitalization costs Increased practice and capitalization costs

Difficulty in evaluating cost and quality of care Difficulty in evaluating cost and quality of care

Difficulty in determining value, and added value, of telemedicine Difficulty in determining value, and added value, of telemedicine


Compartmentalization of costs, which reduces incentive to optimize Compartmentalization of costs, which reduces incentive to optimize whole system whole system

Federal, state, local, and private-sector budget constraints Federal, state, local, and private-sector budget constraints

Concerns about overuse--and inappropriate use--of telemedicine Concerns about overuse--and inappropriate use--of telemedicine

Inconsistent reimbursement practices (for example, Medicare reimburses Inconsistent reimbursement practices (for example, Medicare reimburses image transmission but not consultation) image transmission but not consultation)

Political agendas that can derail progress in health-system and Political agendas that can derail progress in health-system and telecommunication-system reform telecommunication-system reform

Uncertainty on all sides about which elements of telemedicine will work Uncertainty on all sides about which elements of telemedicine will work

Telemedicine Lokender Yadav. Telemedicine Telemedicine has been defined as the use of...

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