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Health Care: Delivery, Education, Communication

An Internet-Based Telemedicine System in Nigeria

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2. The History of Telemedicine

The purpose of this section is to present the history of telemedicine in a way to show how this new discipline, and its body of knowledge and practice, has developed and evolved. In particular, it will be useful in a way to understand some of the key experiences that have propelled the development of this new and challenging form of healthcare. By presenting the key examples that led physicians and other health professionals worldwide to make use of different forms of telemedicine, it also aims at showing what have been some of the key driving forces that have made possible the flourishing of telemedicine. This section follows closely the works of Sosa- Iudicissa, Wootton, and Ferre-Roca (2000) and Mahen, Whitten, and Allen (2001) among others.

Telemedicine technologies can be traced to the pre-electronic era. For example, wealthy families commonly sent urine samples to their doctors, who would use a urine chart to arrive at a diagnosis (Sosa-Iudicissa et al., 2000). This would be an early example of pathology. Teleprescribing was practised before postal services were established and there are well-documented examples (Jurin, 1726). The development of postal services in the mid-nineteenth century facilitated prescription by post: a sick person would write to an eminent physician enclosing his medical history. The physician's reply would include a diagnosis, directions for a regimen and a prescription (Porter & Porter, 1989).

Telephony that became widespread in the late nineteenth century was used for medical work from the beginning. It is still widely used for this purpose. However, the telephone can be used for other purposes than simple voice communication. The first trans-telephonic "electrical stethoscope" was demonstrated in England in 1910 (Brown, 1910), which was used to amplify the sounds from a stethoscope and transmitted them through the telephone network. Similar devices are still in use today to permit a physician to carry out remote auscultation using low-cost equipment. Other medical uses for ordinary telephone network include transmission of images and ultrasound images via a computer modem (Shaint, Cheng, & Greenbaum, 1996) and also the use of fax machines (Rollger, Irving, Broere, & Tranmer, 1997). Internationally, there has also been mounting interest in call centres and their use of modern telecommunications for the purpose of medical triage (Lancet, 2001). These initiatives originated mostly in the US in response to the need to reduce escalating healthcare costs (Fries et al., 1993). However, they became widespread in the early 1990s as part of a broader strategy by many US healthcare organisations to implement demand-management strategies focused on improving consumer health knowledge and preventing unnecessary use of expensive health resources.

These services, staffed largely by registered nurses, often act as gatekeepers for access to emergency healthcare services and provide telephone triage, recommending appropriate levels of care supplemented by advice on self-care and information about provider availability. In countries with large public healthcare systems, such as the UK and Canada, gatekeeper functions are performed mostly with existing primary care services. Thus, potential indirect benefits such as improvement in service access and availability (especially after-hours) have made telephone triage a rational and popular policy initiative. The largest whole-of-population approach to date has been implemented by NHSDirect in the UK. This service began in 1997 and currently about 65% of the England has 24-h access (DOH, 1997). In the US 100 million people are estimated to have access to telephone triage, while in Ontario, Canada, the ministry of health and long-term care has instituted a similar approach for a population of more than 10 million people (Turner et al., 2002). In 1966, Australia followed the US, the UK and other developed countries in promoting the use of nurse-led telephone advice services. The core of these services is very similar: nurses follow computer-driven protocols to give advice about a wide range of problems related to acute minor illness (Roland, 2002).

Turner and colleagues reported the operation of a nurse-led telephone advice service in Australia, HealthDirect in Western Australia (Turner et al., 2002). The service has been widely used, with over 300,000 calls being received during the first 2 years of its operation. It operates from a dedicated call centre with 33 full-time-equivalent operational staff (48 nurses) and is available to the whole state, 24 h a day, 7 days a week. The 10 most frequently used guidelines of the service covered more than half of all the calls to HealthDirect, and more than half of callers were advised to contact their general practitioners. As in other countries, most callers were young adults or parents calling on behalf of children. There is some concern that the increasing use of telephone advice may disadvantage elderly and ethnic people, who found it less easy to use the telephone.

Healthcare planners are clearly interested to know whether these services will reduce the demand for existing healthcare services. Turner and colleagues found that HealthDirect has reduced telephone calls to hospital emergency departments. In the UK, a reduction in the number of calls handled by the emergency department staff coincides with the introduction of NHSDirect (Munro, Nicholl, O'Cathain, & Knowles, 2000).

In the early 1900s, radiocommunications were used for providing medical services to Antarctica (Sullivan & Lugg, 1995). The potential of radio to provide medical advice for seafarers was very quickly recognised, and by the 1920s most of the maritime nations had established services (Goethe, 1984). The Italian service, CIRM, for example, treated over 35,000 ship-borne patients by radio in its first 60 years of existence (CIRM, 1995). The growth in long-distance air travel in the second half of the century brought about a new medical problem: the provision of medical advice to passengers of the aircraft. In-flight medical incidents, which require professional assistance occur at a rate of about 1 in 50,000 passengers carried (Bagshaw, 1996). In cases where there is no doctor on-board, airlines maintain an on-call service by which aircraft captain can obtain radio medical advice from the ground (Sosa-Iudicissa et al., 2000).

The first use of close-circuit television, that is, interactive video communication in healthcare occurred in the 1950s, when the Nebraska Psychiatric Institute used a two-way interactive television system for telepsychiatric clinic consultations with Norfolk State Hospital, 112 miles away. This link was developed for educational, specialised treatment, and consultation between specialists and general practitioners (Wittson et al., 1961). Another experimental project became active in 1959, when a Canadian radiologist used images transmitted by coaxial cable for a diagnostic consultation (Jutras, 1959). In the late 1960s, a teledermatology demonstration project linked a polytechnic from Logan International Airport in Boston to Massachusetts General Hospital. Using an interactive audio-video system, physicians were able to deliver services by using gray scale screens to communicate relative degrees of erythematic (Murphy & Bird, 1974). The introduction of low-cost computing and digital communication has led to the development of videoconferencing. This has been used for telemedicine, for example, teleconsulting, initially with room systems and more recently with desktop systems (Grisgsby & Allen, 1997).

The recent development of mobile phones has allowed mobile telemedicine and research includes the transmission of slow-scan video pictures from ambulances (Curry & Harrop, 1998; Harrop & Curry, 1998). Wireless techniques also include the use of satellite communications. One of the uses of telemedicine in the third world was the use of low-cost satellite system to enable Internet access for healthcare workers. It linked urban medical centres to remote clinics and practitioners in nine African nations, the Philippines, and three countries in the Americas. The system provided e-communications and CD-ROM availability via the HealthSat satellites (LEO satellites, for a fraction of the cost of geostationary satellites (Groves, 1996; Ferguson, Doarn, & Scott, 1995; Garshnek, Hassel, & Davis, 1997).

Using off-the-shelf hardware components and a specially developed high-end wavelet-based interactive video communication software system, satellite networks for various applications of interactive telemedicine have been designed and developed. Based on the successful generic advanced low-cost trans-European network over satellite several projects such as medical assistance for ships; disaster emergency logistic telemedicine advanced satellite system; and Euro- Mediterranean Internet-satellite platform for health, medical educational and research are being currently realised (Graschew, Roelofs, Rakowsky, & Schlag, 2002; Saleman, 2002).

The National Aeronautics and Space Administration (NASA) was also central in the early development of telemedicine. Concerned about the effects of zero gravity on the physical conditions of astronauts, NASA had an early need to monitor vital signals during space missions. Fuelled by its successes, NASA supported the establishment of a comprehensive test-bed system known as space technology applied to rural Papago healthcare, this programme was incubated on the Tohono Odham reservation in Arizona. The programme tested satellite-based communications designed to provide both the reservation and astronauts with a wide range of medical services (Fuchs, 1979).

NASA was also a pioneer in distributing advanced telemedicine technology following the devastating earthquake that struck Mexico City in 1985 (Garshnek, Hassell, & Davis, 1997). NASA maintained its interest in disaster assistance through telehealth technology. In 1988, NASA conducted the first international telehealth programme, known as space bridge now called space for Russia, to provide medical consultation to earthquake victims in Armenia. This programme was based on technology originally developed for astronauts (Garshnek, 1991; Llewellyn, 1995). Consultants used satellite-based communication to deliver one-way video, voice, and facsimile medical care from four medical centres in the US to a health centre in Yerevan, Armenia, in the areas of psychiatry orthopaedics, neurology, infections disease, and general surgey (Garshnek & Burkle, 1999; Nicogossian, 1989).

It is observed that the appearance of telemedicine solutions is usually associated with the need of addressing a particular unfulfilled necessity in terms of medical services, in the context of a nation healthcare system. The trend towards telemedicine comes from the rich, developed and industrialised countries. In developing countries, there is also a growing interest in the possibilities that telemedicine and telecare can offer in the context of their particular conditions of scarce human and material resources.

An important number of international initiatives have promoted the development of telemedicine at different levels. In Europe, important efforts have been made at the level of understanding the scenarios for the deployment of telemedicine solutions, and into the research, development, and testing various tools and resources. These efforts date back to the late 80s, under the auspices of the European community initiatives, advanced informatics in medicine and later on health telematics (Sosa-Iudicissa, 1991-1994; Laires, Ladeira, & Christensen, 1995; van Goor & Christensen, 1992).

Also at the international level, WHOand some of its branches analysed the potential of health informatics and telemedicine and provided guidance to member countries (WHO, 1997) and also its health-for-all policy for the 21st century: "health telematics".

A major worldwide initiative in this field has been the creation, under the auspices of the ITUBDT to look into the prospects of telemedicine and developing countries, which has since been adopted in October 1997 (ITU-BDT, 1997).

A technical implementation of Columbia university's informatics for diabetes education and telemedicine (IDEATel) project has been presented (Starren et al., 2002). The focal point of the intervention is the home telemedicine unit (HTU), which provides four functions: synchronous videoconferencing over standard telephone lines, electronic transmission of fingerstick glucose and blood pressure readings, secure web-based messaging and clinical data review, and access to web-based educational materials. Providing these functions through HTU requires tight integration of six components: the HTU itself, case management software, a clinical information system, web-based educational materials, data security, and networking and telecommunications. With more than 400 HTUs installed, IDEATel has demonstrated the feasibility of large-scale home telemedicine.

Finally, nowadays, there are a very large number of patients who need specific health support at home. The deployment of broadband communication networks is making feasible the provision of homecare services with a proper quality of service. Guillen and colleagues presented a telehomecare multimedia platform that runs over integrated digital network and Internet protocol using videoconference standards H.320 and H.323, and standard TV set for patient interaction (Guillen, Arredondo, Traver, Garcia, & Fernandez, 2002). This platform allows online remote monitoring of electrocardiogram, heart sound, and blood pressure. Usability, affordability, and interoperability were considered for the design and development of their hardware and software components. The evaluation of technical and usability aspects were carried forward with 52 patients of a private clinic and 10 students in the university. Their results show a high rate in the global perception of users on the quality of images, voice, and feeling of virtual presence.

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