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#REDIRECT [[Telehealth]] {{R from merge}}
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{{Short description|Medical care by telecommunication}}
{{merge|Telehealth|discuss=Talk:Telehealth#Merger_proposal|date=October 2017}}
'''Telemedicine''' is the use of [[telecommunication]] and [[information technology]] to provide [[health care|clinical health care]] from a distance. It has been used to overcome distance barriers and to improve access to medical services that would often not be consistently available in distant rural communities. It is also used to save lives in [[Trauma (medicine)|critical care]] and [[Emergency medicine|emergency situations]].

Although there were distant precursors to telemedicine, it is essentially a product of 20th century telecommunication and information technologies. These technologies permit communications between patient and medical staff with both convenience and fidelity, as well as the [[Transmission (telecommunications)|transmission]] of medical, [[medical imaging|imaging]] and [[health informatics]] data from one site to another.

Early forms of telemedicine achieved with telephone and radio have been supplemented with [[videotelephony]], advanced [[Medical diagnosis|diagnostic methods]] supported by [[Client–server model|distributed client/server applications]], and additionally with telemedical devices to support in-home care.<ref name="Sachpazidis">{{cite thesis | url=https://www.consultingradiologists.com/wp-content/uploads/2018/08/Dissertation-final-10Nov2008.pdf| title = Image and Medical Data Communication Protocols for Telemedicine and Teleradiology (dissertation)|publisher = Department of Computer Science, Technical University of Darmstadt | location = Darmstadt, Germany| date=10 Jul 2008|last = Sachpazidis | first = Ilias |access-date=14 Aug 2018}}</ref>

== Disambiguation ==
The definition of ''telemedicine'' is somewhat controversial. Some definitions (such as the definition given by the [[World Health Organization]]<ref name="who">{{cite web|url=http://www.who.int/goe/publications/goe_telemedicine_2010.pdf|date=13 January 2011|title=2010 Opportunities and developments &#124; Report on the second global survey on eHealth &#124; Global Observatory for eHealth series - Volume 2: TELEMEDICINE|accessdate=25 March 2016}}</ref>) include all aspects of healthcare including preventive care. The American Telemedicine Association uses the terms telemedicine and [[telehealth]] interchangeably, although it acknowledges that telehealth is sometimes used more broadly for remote health not involving active clinical treatments.<ref name="ATA" />

[[eHealth]] is another related term, used particularly in the U.K. and Europe, as an umbrella term that includes telehealth, [[electronic medical record]]s, and other components of [[health information technology]].

==Benefits and drawbacks==

Telemedicine can be beneficial to patients in isolated communities and remote regions, who can receive care from doctors or specialists far away without the patient having to travel to visit them.<ref>{{cite journal | last = Berman | first = Matthew | last2 = Fenaughty | first2 = Andrea | title = Technology and managed care: patient benefits of telemedicine in a rural health care network | journal = Health Economics | volume = 14 | issue = 6| pages = 559–573 | date = June 2005 | publisher = [[John Wiley & Sons|Wiley]] | doi = 10.1002/hec.952| pmid = 15497196 }}</ref> Recent developments in [[mobile collaboration]] technology can allow healthcare professionals in multiple locations to share information and discuss patient issues as if they were in the same place.<ref>{{cite news | last = Van't Haaff | first = Corey | title = Virtually On-sight | page = 22 | publisher = Just for Canadian Doctors | date = March–April 2009 | url = http://www.justforcanadiandoctors.com/pastissues/JFCD2009/JFCD-Mar-Apr2009.pdf | deadurl = yes | archiveurl = https://web.archive.org/web/20120324052954/http://www.justforcanadiandoctors.com/pastissues/JFCD2009/JFCD-Mar-Apr2009.pdf | archivedate = 2012-03-24 }}</ref> Remote patient monitoring through [[mobile technology]] can reduce the need for outpatient visits and enable remote prescription verification and drug administration oversight, potentially significantly reducing the overall cost of medical care.<ref name="MobilePatient">{{cite book | title = The Mobile Wave: How Mobile Intelligence Will Change Everything | last = Saylor | first = Michael | year = 2012 | publisher = Perseus Books/Vanguard Press | page=153}}</ref> It may also be preferable for patients with limited mobility, for example, patients with Parkinson's disease.<ref>{{Cite journal|last=Schwamm|first=Lee H.|last2=Birbeck|first2=Gretchen L.|last3=Holloway|first3=Melissa R.|last4=Glidden|first4=Alistair M.|last5=Dorsey|first5=E. Ray|date=May 2018|title=Teleneurology and mobile technologies: the future of neurological care|url=https://www.nature.com/articles/nrneurol.2018.31|journal=Nature Reviews Neurology|volume=14|issue=5|pages=285–297|doi=10.1038/nrneurol.2018.31|issn=1759-4766}}</ref> Telemedicine can also facilitate medical education by allowing workers to observe experts in their fields and share best practices more easily.<ref>{{cite journal | last = Conde | first = Jose G. | last2 = De | first2 = Suvranu | last3 = Hall | first3 = Richard W. | last4 = Johansen | first4 = Edward | last5 = Meglan | first5 = Dwight | last6 = Peng | first6 = Grace C. Y. | title = Telehealth Innovations in Health Education and Training | journal = Telemedicine and e-Health | volume = 16 | number = 1 | pages = 103–106 | date = January–February 2010 | doi = 10.1089/tmj.2009.0152| pmid = 20155874 | pmc=2937346}}</ref>

Telemedicine also can eliminate the possible transmission of [[infectious disease]]s or [[parasite]]s between patients and medical staff. This is particularly an issue where [[MRSA]] is a concern. Additionally, some patients who feel uncomfortable in a doctors office may do better remotely. For example, [[white coat syndrome]] may be avoided. Patients who are home-bound and would otherwise require an ambulance to move them to a clinic are also a consideration.

The downsides of telemedicine include the cost of telecommunication and data management equipment and of technical training for medical personnel who will employ it. Virtual medical treatment also entails potentially decreased human interaction between medical professionals and patients, an increased risk of error when medical services are delivered in the absence of a registered professional, and an increased risk that [[protected health information]] may be compromised through electronic storage and transmission.<ref>{{cite journal | last = Hjelm | first = N. M. | title = Benefits and drawbacks of telemedicine | journal = Journal of Telemedicine and Telecare | date = 1 March 2005 | volume = 11 | issue = 2 | pages = 60–70 | url = http://jtt.sagepub.com/content/11/2/60.full.pdf+html | doi = 10.1258/1357633053499886| pmid = 15829049 }}</ref> There is also a concern that telemedicine may actually decrease time efficiency due to the difficulties of assessing and treating patients through virtual interactions; for example, it has been estimated that a [[teledermatology]] consultation can take up to thirty minutes, whereas fifteen minutes is typical for a traditional consultation.<ref>{{cite web | url = http://www.rrh.org.au/publishedarticles/article_print_1581.pdf | title = Barriers to the up-take of telemedicine in Australia – a view from providers | work = The University of Queensland, School of Medicine | author = JJ Moffatt | date = February 2011}}</ref> Additionally, potentially poor quality of transmitted records, such as images or patient progress reports, and decreased access to relevant clinical information are quality assurance risks that can compromise the quality and continuity of patient care for the reporting doctor.<ref>{{Cite journal| pmc = 2082971 | title = One hundred years of telemedicine: does this new technology have a place in paediatrics? | date = December 2006 | pmid=17119071 | doi=10.1136/adc.2006.099622 | volume=91 | issue=12 |vauthors=Strehle EM, Shabde N | journal=Arch. Dis. Child. | pages=956–9}}</ref> Other obstacles to the implementation of telemedicine include unclear legal regulation for some telemedical practices and difficulty claiming reimbursement from insurers or government programs in some fields.<ref name="Angaran">{{cite journal | last = Angaran | first = DM | title = Telemedicine and Telepharmacy: Current Status and Future Implications | journal = American Journal of Health-System Pharmacy | date = 15 Jul 1999 | volume = 56 | pages = 1405–1426 | url = http://www.ajhp.org/content/56/14/1405.abstract | issue=14}}</ref>

Another disadvantage of telemedicine is the inability to start treatment immediately. For example, a patient suffering from a bacterial infection might be given an [[antibiotic]] [[hypodermic injection]] in the clinic, and observed for any reaction, before that antibiotic is prescribed in pill form.

== History ==

In the early 1900s, people living in remote areas of [[Australia]] used two-way radios, powered by a [[Electrical generator|dynamo]] driven by a set of bicycle pedals, to communicate with the [[Royal Flying Doctor Service of Australia]].{{citation needed|date=December 2017}}

In 1925 the inventor [[Hugo Gernsback]] wrote an article for the magazine [[Science and Invention]] which included a prediction of a future where patients could be treated remotely by doctors through a device he called a "teledactyl". His descriptions of the device are similar to what would later become possible with new technology.<ref>''[https://www.smithsonianmag.com/history/telemedicine-predicted-in-1925-124140942/]'' Telemedicine Predicted in 1925</ref>
In 1967 one of the first telemedicine clinics was founded by Kenneth Bird at Massachusetts General Hospital. The clinic addressed the fundamental problem of delivering occupational and emergency health services to employees and travellers at Boston's [[Logan International Airport]], located three congested miles from the hospital. Over 1,000 patients are documented as having received remote treatment from doctors at MGH using the clinic's two-way audiovisual microwave circuit.<ref>[http://www.medscape.com/viewarticle/457684 "Highlights from the Eighth Annual Meeting of the American Telemedicine Association"] (Accessed December 10, 2008),Medscape website</ref> The timing of Bird's clinic more or less coincided with [[NASA]]'s foray into telemedicine through the use of physiologic monitors for astronauts.<ref>[http://tie.telemed.org/articles/article.asp?path=articles&article=tmhistory_nb_tie95.xml "A Brief History of Telemedicine" ] {{webarchive|url=https://web.archive.org/web/20071124075453/http://tie.telemed.org/articles/article.asp?path=articles&article=tmhistory_nb_tie95.xml |date=2007-11-24 }}, Telemedicine Information Exchange website, (Accessed December 10, 2008)</ref>
Other pioneering programs in telemedicine were designed to deliver healthcare services to people in rural settings.{{citation needed|date=December 2017}}
The first interactive telemedicine system, operating over standard telephone lines, designed to [[Remote diagnostics|remotely diagnose]] and treat patients requiring cardiac resuscitation ([[defibrillation]]) was developed and launched by an American company, MedPhone Corporation, in 1989. A year later under the leadership of its President/CEO S Eric Wachtel, MedPhone introduced a mobile cellular version, the MDPhone. Twelve hospitals in the U.S. served as receiving and treatment centers.<ref>{{cite book | last = Blyth | first = W. John | title = Telecommunications, Concepts, Development, and Management | edition = Second | publisher = Glencoe/McCgraw-Hill | year = 1990 | pages = 280–282 |isbn=0026808412}}</ref>

== Types ==

=== Categories ===

Telemedicine can be broken into three main categories: [[store-and-forward]], [[remote patient monitoring]] and [[interactive|(real-time) interactive]] services.

==== Store and forward ====
Store-and-forward telemedicine involves acquiring medical data (like [[medical imaging|medical images]], [[biosignal]]s etc.) and then transmitting this data to a doctor or medical specialist at a convenient time for assessment [[offline]].<ref name="ATA">{{cite web | url = http://www.americantelemed.org/learn/what-is-telemedicine | archive-url = https://web.archive.org/web/20130508215350/http://www.americantelemed.org/learn/what-is-telemedicine | dead-url = yes | archive-date = 8 May 2013 | title = What is Telemedicine? | publisher = American Telemedicine Association | location = Washington, D.C. | accessdate = 21 August 2011}}</ref> It does not require the presence of both parties at the same time.<ref name="Sachpazidis" /> [[Dermatology]] (cf: [[teledermatology]]), [[radiology]], and [[pathology]] are common specialties that are conducive to asynchronous telemedicine. A properly structured [[medical record]] preferably in [[Electronic medical record|electronic]] form should be a component of this transfer. A key difference between traditional in-person patient meetings and telemedicine encounters is the omission of an actual physical examination and history. The 'store-and-forward' process requires the clinician to rely on a history report and audio/video information in lieu of a physical examination.

==== Remote monitoring ====
[[File:Telehealth - Blood Pressure Monitor.jpg|thumb|Telehealth Blood Pressure Monitor]]
Remote monitoring, also known as self-monitoring or testing, enables medical professionals to monitor a patient remotely using various technological devices. This method is primarily used for managing chronic diseases or specific conditions, such as heart disease, diabetes mellitus, or asthma. These services can provide comparable health outcomes to traditional in-person patient encounters, supply greater satisfaction to patients, and may be cost-effective.<ref>{{Cite journal|last=Salehahmadi|first=Zeinab|last2=Hajialiasghari|first2=Fatemeh|date=2017-03-02|year=|title=Telemedicine in Iran: Chances and Challenges|journal=World Journal of Plastic Surgery|volume=2|issue=1|pages=18–25|issn=2228-7914|pmc=4238336|pmid=25489500|via=}}</ref> Examples include home-based nocturnal [[dialysis]]<ref>Andreas Pierratos, MD. [http://www.cmaj.ca/cgi/content/full/161/9/1137 Nocturnal hemodialysis: dialysis for the new millennium] ''[[Canadian Medical Association Journal]]'', November 2, 1999; 161 (9), 2 November 1966.</ref> and improved joint management.<ref>{{cite journal|date=17 August 2015|title=Socioeconomic impact of e-Health services in major joint replacement: A scoping review|journal=Technol Health Care.|doi=10.3233/THC-151036|pmid=26409523|vauthors=Koutras C, Bitsaki M, Koutras G, Nikolaou C, Heep H|volume=23|issue=6|pages=809–17}}</ref>

==== Real-time interactive ====
[[Electronic consultation]]s are possible through interactive telemedicine services which provide real-time interactions between patient and provider.<ref name="Sachpazidis" /> Videoconferencing has been used in a wide range of clinical disciplines and settings for various purposes including management, diagnosis, counselling and monitoring of patients.<ref>{{cite journal |doi=10.1177/1357633X14552385 |pmid=25399998 |title=Clinical applications of videoconferencing: A scoping review of the literature for the period 2002–2012 |journal=Journal of Telemedicine and Telecare |volume=20 |issue=7 |pages=377 |year=2014 |last1=Fatehi |first1=Farhad |last2=Armfield |first2=Nigel R |last3=Dimitrijevic |first3=Mila |last4=Gray |first4=Leonard C }}</ref>

=== Emergency ===
[[File:US Navy 060518-N-2832L-013 Senior training specialist with Multi-Services Group International (MSGI), Michael Bedwell, trains Sailors to use Battlefield Medical Information Systems Telemedicine (BMIST) equipped Personal Digital.jpg|thumb|U.S. Navy medical staff being trained in the use of handheld telemedical devices (2006).]]
Common daily emergency telemedicine is performed by SAMU Regulator Physicians in France, Spain, Chile and Brazil. Aircraft and maritime emergencies are also handled by SAMU centres in Paris, Lisbon and Toulouse.<ref>George R. Schwartz, C. Gene Cayten; George R. Schwartz (editor). [https://books.google.com/books?id=NlZ_aST4_hcC Principles and Practice of Emergency Medicine, Volume 2], Lea & Febiger, 1992, pg.3202, {{ISBN|0-8121-1373-X}}, {{ISBN|978-0-8121-1373-0}}.</ref>

A recent study identified three major barriers to adoption of telemedicine in emergency and critical care units. They include:
*'''regulatory''' challenges related to the difficulty and cost of obtaining licensure across multiple states, malpractice protection and privileges at multiple facilities
*Lack of acceptance and reimbursement by government payers and some commercial insurance carriers creating a major '''financial''' barrier, which places the investment burden squarely upon the hospital or healthcare system.
*'''Cultural''' barriers occurring from the lack of desire, or unwillingness, of some physicians to adapt clinical paradigms for telemedicine applications.<ref>{{cite journal | last = Rogove | first = Herbert J. | last2 = McArthur | first2 = David | last3 = Demaerschalk | first3 = Bart M. | last4 = Vespa | first4 = Paul M. | title = Barriers to Telemedicine: Survey of Current Users in Acute Care Units | journal = Telemedicine and e-Health | date = January–February 2012 | volume = 18 | number = 1 | pages = 48–53 | doi = 10.1089/tmj.2011.0071| pmid = 22082107 }}</ref>
[[File:Операционная. ФЦН (Тюмень) 01.JPG|thumb|Telemedicine system. ''[[Federal Center of Neurosurgery (Tyumen)|Federal Center of Neurosurgery in Tyumen]], 2013'']]

=== Telenursing ===
{{main|Telenursing}}

'''Telenursing''' refers to the use of [[telecommunications]] and [[information technology]] in order to provide [[nursing]] services in health care whenever a large physical distance exists between patient and nurse, or between any number of nurses. As a field it is part of telehealth, and has many points of contacts with other medical and non-medical applications, such as [[telediagnosis]], teleconsultation, telemonitoring, etc.

Telenursing is achieving significant growth rates in many countries due to several factors: the preoccupation in reducing the costs of health care, an increase in the number of [[aging]] and chronically ill population, and the increase in coverage of health care to distant, rural, small or sparsely populated regions. Among its benefits, telenursing may help solve increasing shortages of nurses; to reduce distances and save travel time, and to keep patients out of hospital. A greater degree of job satisfaction has been registered among telenurses.<ref>{{cite web | url = http://www.e-health-insider.com/news/item.cfm?ID=1263 | archive-url = https://web.archive.org/web/20060618103208/http://www.e-health-insider.com/news/item.cfm?ID=1263 | dead-url = yes | archive-date = 18 June 2006 | title = Nurses Happier Using Telecare, Says International Survey | publisher = eHealth Insider | date = 15 June 2005 | accessdate = 4 April 2009 }}</ref>

[[File:SmallWorldSocial BreastfeedingSupportProject GeorgiawithBabyEve.jpg|thumb|Baby Eve with Georgia for the Breastfeeding Support Project]]
In [[Australia]], during January 2014, [[Melbourne]] tech startup [[Small World Social]] collaborated with the [[Australian Breastfeeding Association]] to create the first hands-free breastfeeding [[Google Glass]] application for new mothers.<ref name="Lactation Help">{{cite web|title=Google Glass connects breastfeeding moms with lactation help|url=http://www.inquisitr.com/1224638/google-glass-connects-breastfeeding-moms-with-lactation-help/|website=Inquisitr|publisher=Inquisitr|accessdate=12 June 2014}}</ref> The application, named [[Google Glass Breastfeeding app trial]], allows mothers to nurse their baby while viewing instructions about common breastfeeding issues (latching on, posture etc.) or call a lactation consultant via a secure Google Hangout,<ref>{{cite web|url=https://vimeo.com/87625169|title=Breastfeeding Walkthrough for Mothers and Counselors|first=Small World|last=Social|date=25 February 2014|publisher=|via=Vimeo}}</ref> who can view the issue through the mother's Google Glass camera.<ref name="Jumpin Today Show">{{cite web|title=Exclusive Clips Google glasses help breastfeeding mums|url=http://www.jump-in.com.au/show/today/videos/3496995149001/|website=Jumpin Today Show|publisher=Mi9 Pty. Ltd.|accessdate=12 June 2014}}</ref> The trial was successfully concluded in [[Melbourne]] in April 2014, and 100% of participants were breastfeeding confidently.<ref>{{cite news| url=http://www.smh.com.au/technology/technology-news/breastfeeding-mothers-get-help-from-google-glass-and-small-world-20140118-311s3.html | work=The Sydney Morning Herald | title=Breastfeeding mothers get help from Google Glass and Small World}}</ref><ref name="Google Glass">{{cite web|title=Turns Out Google Glass Is Good for Breastfeeding|url=http://motherboard.vice.com/read/turns-out-google-glass-is-good-for-breastfeeding|publisher=Motherboard Vice Media Inc.|accessdate=1 May 2014|date=21 April 2014}}</ref> Small World Social<ref>{{cite web|url=http://www.smallworldsocial.com/|title=SWS Website - We transfer complex and tacit knowledge|website=SWS Website}}</ref> Breasfteeding Support Project.<ref>{{cite web|url=https://web.archive.org/web/20140423100600/http://breastfeeding.smallworldsocial.com/|title=Breastfeeding Support Project - Small World Social|date=23 April 2014|publisher=}}</ref>

=== Telepharmacy ===

[[File:Winn Army Community Hospital Pharmacy Stays Online During Power Outage.jpg|thumb|alt=Pharmacists filling prescriptions at a computer | Pharmacy personnel deliver [[medical prescription]]s electronically; remote delivery of [[pharmaceutical care]] is an example of '''telemedicine'''.]]

{{main|Telepharmacy}}

Telepharmacy is the delivery of [[pharmaceutical care]] via [[telecommunications]] to patients in locations where they may not have direct contact with a [[pharmacist]]. It is an instance of the wider phenomenon of telemedicine, as implemented in the field of [[pharmacy]]. Telepharmacy services include [[drug therapy]] monitoring, patient counseling, prior authorization and refill authorization for [[prescription drugs]], and monitoring of [[Formulary (pharmacy)|formulary]] compliance with the aid of [[teleconferencing]] or [[videoconferencing]]. [[Remote dispensing]] of medications by automated packaging and labeling systems can also be thought of as an instance of telepharmacy. Telepharmacy services can be delivered at retail pharmacy sites or through hospitals, nursing homes, or other medical care facilities.

The term can also refer to the use of videoconferencing in pharmacy for other purposes, such as providing education, training, and management services to pharmacists and pharmacy staff remotely.<ref name="Angaran" />

=== Teleneuropsychology ===
Teleneuropsychology (Cullum et al., 2014) is the use of telehealth/videoconference technology for the remote administration of neuropsychological tests. Neuropsychological tests are used to evaluate the cognitive status of individuals with known or suspected brain disorders and provide a profile of cognitive strengths and weaknesses. Through a series of studies, there is growing support in the literature showing that remote videoconference-based administration of many standard neuropsychological tests results in test findings that are similar to traditional in-person evaluations, thereby establishing the basis for the reliability and validity of teleneuropsychological assessment.<ref>{{cite journal |doi=10.1093/arclin/acx140 |title=Validity of Teleneuropsychological Assessment in Older Patients with Cognitive Disorders |journal=Archives of Clinical Neuropsychology |year=2018 |last1=Wadsworth |first1=Hannah E |last2=Dhima |first2=Kaltra |last3=Womack |first3=Kyle B |last4=Hart |first4=John |last5=Weiner |first5=Myron F |last6=Hynan |first6=Linda S |last7=Cullum |first7=C Munro }}</ref><ref>{{cite journal |doi=10.1093/arclin/acw030 |pmid=27246957 |title=Remote Neuropsychological Assessment in Rural American Indians with and without Cognitive Impairment |journal=Archives of Clinical Neuropsychology |volume=31 |issue=5 |pages=420 |year=2016 |last1=Wadsworth |first1=Hannah E |last2=Galusha-Glasscock |first2=Jeanine M |last3=Womack |first3=Kyle B |last4=Quiceno |first4=Mary |last5=Weiner |first5=Myron F |last6=Hynan |first6=Linda S |last7=Shore |first7=Jay |last8=Cullum |first8=C. Munro }}</ref><ref name="auto">{{cite journal |doi=10.1093/arclin/acv058 |pmid=26446834 |pmc=4718188 |title=Video Teleconference Administration of the Repeatable Battery for the Assessment of Neuropsychological Status |journal=Archives of Clinical Neuropsychology |volume=31 |issue=1 |pages=8–11 |year=2016 |last1=Galusha-Glasscock |first1=Jeanine M |last2=Horton |first2=Daniel K |last3=Weiner |first3=Myron F |last4=Cullum |first4=C. Munro }}</ref><ref name="auto"/><ref>{{cite journal |doi=10.1080/13854046.2013.791723 |pmid=23607729 |pmc=3692573 |title=Consumer Acceptability of Brief Videoconference-based Neuropsychological Assessment in Older Individuals with and without Cognitive Impairment |journal=The Clinical Neuropsychologist |volume=27 |issue=5 |pages=808–17 |year=2013 |last1=Parikh |first1=Mili |last2=Grosch |first2=Maria C |last3=Graham |first3=Lara L |last4=Hynan |first4=Linda S |last5=Weiner |first5=Myron |last6=Shore |first6=James H |last7=Cullum |first7=C. Munro }}</ref><ref>{{cite journal |doi=10.1080/13854046.2011.609840 |pmid=21951075 |title=Initial Practice Recommendations for Teleneuropsychology |journal=The Clinical Neuropsychologist |volume=25 |issue=7 |pages=1119–33 |year=2011 |last1=Grosch |first1=Maria C |last2=Gottlieb |first2=Michael C |last3=Cullum |first3=C. Munro }}</ref><ref>{{cite journal |doi=10.1017/S1355617714000873 |pmid=25343269 |pmc=4410096 |title=Teleneuropsychology: Evidence for Video Teleconference-Based Neuropsychological Assessment |journal=Journal of the International Neuropsychological Society |volume=20 |issue=10 |pages=1028–33 |year=2014 |last1=Munro Cullum |first1=C |last2=Hynan |first2=L.S |last3=Grosch |first3=M |last4=Parikh |first4=M |last5=Weiner |first5=M.F }}</ref>

=== Telerehabilitation ===

{{main|Telerehabilitation}}

'''Telerehabilitation''' (or ''e-rehabilitation''<ref name="dl-2005">{{cite book | year = 2005 | title = E-health care information systems: an introduction for students and professionals | publisher = John Wiley and Sons | isbn = 978-0-7879-6618-8 | page = 219}}</ref><ref>{{cite journal | url = http://ijahsp.nova.edu/articles/vol2num4/pierce-keaton.htm | title = An E-rehabilitation Team Helps Caregivers Deal with Stroke | publisher = Ijahsp.nova.edu | accessdate = 26 March 2011 | journal = The Internet Journal of Allied Health Sciences and Practice | volume = 2.4 | issn = 1540-580X | author1 = Lisa Keaton | author2 = Linda L. Pierce | author3 = Victoria Steiner | author4 = Karen Lance}}</ref>) is the delivery of [[Physical medicine and rehabilitation|rehabilitation]] services over [[telecommunication network]]s and the Internet. Most types of services fall into two categories: clinical assessment (the patient's functional abilities in his or her environment), and [[medical therapy|clinical therapy]]. Some fields of rehabilitation practice that have explored telerehabilitation are: [[neuropsychology]], [[speech-language pathology]], [[audiology]], [[occupational therapy]], and [[physical therapy]]. Telerehabilitation can deliver therapy to people who cannot travel to a [[clinic]] because the patient has a [[disability]] or because of travel time. Telerehabilitation also allows experts in rehabilitation to engage in a clinical consultation at a distance.

Most telerehabilitation is highly visual. As of 2014, the most commonly used mediums are [[webcam]]s, [[videoconferencing]], [[phone line]]s, [[videophone]]s and webpages containing rich Internet applications. The visual nature of telerehabilitation technology limits the types of rehabilitation services that can be provided. It is most widely used for [[neuropsychological rehabilitation]]; fitting of rehabilitation equipment such as [[wheelchair]]s, [[Brace (orthopaedic)|braces]] or [[artificial limb]]s; and in speech-language pathology. [[Rich internet applications]] for neuropsychological rehabilitation (aka [[cognitive rehabilitation]]) of cognitive impairment (from many etiologies) were first introduced in 2001. This endeavor has expanded as a [[teletherapy]] application for cognitive skills enhancement programs for school children. [[Tele-audiology]] (hearing assessments) is a growing application. Currently, telerehabilitation in the practice of occupational therapy and physical therapy is limited, perhaps because these two disciplines are more "hands on".

Two important areas of telerehabilitation research are (1) demonstrating equivalence of assessment and therapy to in-person assessment and therapy, and (2) building new data collection systems to digitize information that a therapist can use in practice. Ground-breaking research in [[telehaptics]] (the sense of touch) and virtual reality may broaden the scope of telerehabilitation practice, in the future.

In the United States, the [[National Institute on Disability and Rehabilitation Research]]'s (NIDRR)<ref>{{cite web|url=https://web.archive.org/web/20031011114426/http://www.ed.gov/about/offices/list/osers/nidrr/index.html?src=mr|title=OSERS|website=www.ed.gov}}</ref> supports research and the development of telerehabilitation. NIDRR's grantees include the "Rehabilitation Engineering and Research Center" (RERC) at the [[University of Pittsburgh]], the [[Rehabilitation Institute of Chicago]], the State University of New York at Buffalo, and the National Rehabilitation Hospital in Washington DC. Other federal funders of research are the [[Veterans Health Administration]], the Health Services Research Administration in the US Department of Health and Human Services, and the Department of Defense.<ref>{{cite web| last = Hiers| first = Mary| title = Everything You Need to Know About Telemedicine| url = http://www.accessrx.com/blog/current-health-news/everything-you-need-to-know-about-telemedicine-m0525/| accessdate = 10 July 2014 }}</ref> Outside the United States, excellent research is conducted in Australia and Europe.

Only a few health insurers in the United States, and about half of Medicaid programs,<ref>{{cite journal |doi=10.1016/j.apmr.2003.09.008 |pmid=15241772 |title=Medicaid payment for telerehabilitation |journal=Archives of Physical Medicine and Rehabilitation |volume=85 |issue=7 |pages=1188–91 |year=2004 |last1=Palsbo |first1=Susan E }}</ref> [[reimburse]] for telerehabilitation services. If the research shows that teleassessments and teletherapy are equivalent to clinical encounters, it is more likely that [[insurer]]s and [[Medicare (United States)|Medicare]] will cover telerehabilitation services.

=== Teletrauma care ===

Telemedicine can be utilized to improve the efficiency and effectiveness of the delivery of care in a trauma environment. Examples include:

Telemedicine for trauma triage: using telemedicine, trauma specialists can interact with personnel on the scene of a mass casualty or disaster situation, via the internet using mobile devices, to determine the severity of injuries. They can provide clinical assessments and determine whether those injured must be evacuated for necessary care. Remote trauma specialists can provide the same quality of clinical assessment and plan of care as a trauma specialist located physically with the patient.<ref>{{cite journal | last = Collins | first = Hilton | title = Advanced First Responder and Medical Capabilities Could Save Lives | journal = Emergency Management | date = 28 August 2008 | url = http://www.emergencymgmt.com/disaster/Advanced-First-Responder-and.html}}</ref>

Telemedicine for [[intensive care unit]] (ICU) rounds: Telemedicine is also being used in some trauma ICUs to reduce the spread of infections. Rounds are usually conducted at hospitals across the country by a team of approximately ten or more people to include attending physicians, fellows, residents and other clinicians. This group usually moves from bed to bed in a unit discussing each patient. This aids in the transition of care for patients from the night shift to the morning shift, but also serves as an educational experience for new residents to the team. A new approach features the team conducting rounds from a conference room using a video-conferencing system. The trauma attending, residents, fellows, nurses, nurse practitioners, and pharmacists are able to watch a live video stream from the patient's bedside. They can see the vital signs on the monitor, view the settings on the respiratory ventilator, and/or view the patient's wounds. Video-conferencing allows the remote viewers two-way communication with clinicians at the bedside.<ref>{{cite web | title = Advanced technologies and wireless telecommunications enhance care and medical training at the Ryder Trauma Center in Miami | publisher = Virtual Medical Worlds | date = 4 December 2008 | url = http://www.hoise.com/vmw/09/articles/vmw/LV-VM-01-09-10.html | accessdate = 23 July 2013}}</ref>

Telemedicine for trauma education: some trauma centers are delivering trauma education lectures to hospitals and health care providers worldwide using video conferencing technology. Each lecture provides fundamental principles, firsthand knowledge and evidenced-based methods for critical analysis of established clinical practice standards, and comparisons to newer advanced alternatives. The various sites collaborate and share their perspective based on location, available staff, and available resources.<ref>{{cite web| title = EMS Trauma Grand Rounds| publisher = Utah Telehealth Network| accessdate = 23 July 2013| url = http://www.utahtelehealth.net/education/ems_trauma.html| archive-url = https://web.archive.org/web/20090916083826/http://www.utahtelehealth.net/education/ems_trauma.html| dead-url = yes| archive-date = 16 September 2009}}</ref>

Telemedicine in the trauma operating room: trauma surgeons are able to observe and consult on cases from a remote location using video conferencing. This capability allows the attending to view the residents in real time. The remote surgeon has the capability to control the camera (pan, tilt and zoom) to get the best angle of the procedure while at the same time providing expertise in order to provide the best possible care to the patient.<ref>{{cite news | last = Gonzalez | first = Diana | title = UM Doctors Use Telemedicine to Continue Care In Iraq | publisher = | date = 10 November 2011 | url = http://www.nbcmiami.com/news/local/UM-Doctors-Use-Tele-133650778.html | accessdate = 23 July 2013}}</ref>

== Specialist care delivery ==

Telemedicine can facilitate specialty care delivered by [[primary care physician]]s according to a controlled study of the treatment of [[hepatitis C]].<ref>{{cite journal |doi=10.1056/NEJMoa1009370 |pmid=21631316 |pmc=3820419 |title=Outcomes of Treatment for Hepatitis C Virus Infection by Primary Care Providers |journal=New England Journal of Medicine |volume=364 |issue=23 |pages=2199–207 |year=2011 |last1=Arora |first1=Sanjeev |last2=Thornton |first2=Karla |last3=Murata |first3=Glen |last4=Deming |first4=Paulina |last5=Kalishman |first5=Summers |last6=Dion |first6=Denise |last7=Parish |first7=Brooke |last8=Burke |first8=Thomas |last9=Pak |first9=Wesley |last10=Dunkelberg |first10=Jeffrey |last11=Kistin |first11=Martin |last12=Brown |first12=John |last13=Jenkusky |first13=Steven |last14=Komaromy |first14=Miriam |last15=Qualls |first15=Clifford }}</ref> Various specialties are contributing to telemedicine, in varying degrees.

=== Telecardiology ===

ECGs, or [[Electrocardiography|electrocardiographs]], can be transmitted using telephone and wireless. [[Willem Einthoven]], the inventor of the ECG, actually did tests with transmission of ECG via telephone lines. This was because the hospital did not allow him to move patients outside the hospital to his laboratory for testing of his new device. In 1906 Einthoven came up with a way to transmit the data from the hospital directly to his lab.<ref>[http://www.medetel.lu/download/2009/parallel_sessions/presentation/day1/telecardiology_and_tele-ecg_network.pdf Telecardiology].</ref>
See above reference-General health care delivery. Remotely treating ventricular fibrillation Medphone Corporation, 1989

==== Teletransmission of ECG using methods indigenous to Asia ====

One of the oldest known telecardiology systems for teletransmissions of ECGs was established in Gwalior, India in 1975 at GR Medical college by Ajai Shanker, S. Makhija, P.K. Mantri using an indigenous technique for the first time in India.

This system enabled wireless transmission of ECG from the moving ICU van or the patients home to the central station in ICU of the department of Medicine. Transmission using wireless was done using frequency modulation which eliminated noise. Transmission was also done through telephone lines. The ECG output was connected to the telephone input using a modulator which converted ECG into high frequency sound. At the other end a demodulator reconverted the sound into ECG with a good gain accuracy. The ECG was converted to sound waves with a frequency varying from 500&nbsp;Hz to 2500&nbsp;Hz with 1500&nbsp;Hz at baseline.

This system was also used to monitor patients with pacemakers in remote areas. The central control unit at the ICU was able to correctly interpret arrhythmia. This technique helped medical aid reach in remote areas.<ref>{{cite journal | title= = Teletransmission of ECG Waveform: An Ingenious Low Priced Technique | journal = Indian Heart Journal | year = 1982 | volume = 34 | number = 6}}</ref>

In addition, [[Stethoscope#Electronic|electronic stethoscopes]] can be used as recording devices, which is helpful for purposes of telecardiology. There are many examples of successful telecardiology services worldwide.

In [[Pakistan]] three pilot projects in telemedicine was initiated by the Ministry of IT & Telecom, Government of Pakistan (MoIT) through the Electronic Government Directorate in collaboration with Oratier Technologies (a pioneer company within Pakistan dealing with healthcare and HMIS) and PakDataCom (a bandwidth provider). Three hub stations through were linked via the Pak Sat-I communications satellite, and four districts were linked with another hub. A 312 Kb link was also established with remote sites and 1 Mbit/s bandwidth was provided at each hub. Three hubs were established: the Mayo Hospital (the largest hospital in Asia), JPMC Karachi and Holy Family Rawalpindi. These 12 remote sites were connected and on average of 1,500 patients being treated per month per hub. The project was still running smoothly after two years.<ref name="83a">{{cite web|url=http://202.83.164.29/egdsite04/?p=projimpu |archive-url=https://web.archive.org/web/20110704102514/http://202.83.164.29/egdsite04/?p=projimpu |archive-date=2011-07-04 |dead-url=yes |title=Electronic Government Directorate &#124; Pakistan telemedicine |accessdate=25 March 2016}}</ref>

=== Telepsychiatry ===
{{main|Telepsychiatry}}

Telepsychiatry, another aspect of telemedicine, also utilizes [[videoconferencing]] for patients residing in underserved areas to access psychiatric services. It offers wide range of services to the patients and providers, such as consultation between the psychiatrists, educational clinical programs, diagnosis and assessment, medication therapy management, and routine follow-up meetings.<ref>{{cite news | last = Hoffman | first = Jan | url = https://www.nytimes.com/2011/09/25/fashion/therapists-are-seeing-patients-online.html?_r=1 | title = When Your Therapist Is Only a Click Away | newspaper = [[New York Times]] | date = 25 September 2011 | page = ST1}}</ref> Most telepsychiatry is undertaken in real time (synchronous) although in recent years research at UC Davis has developed and validated the process of asynchronous telepsychiatry.<ref>{{Citation|url = https://www.youtube.com/watch?v=g8_5hCF2q6I|accessdate = 2015-11-14|title= Telepsychiatry Research by Peter Yellowlees}}</ref> Recent reviews of the literature by Hilty et al. in 2013, and by Yellowlees et al. in 2015 confirmed that telepsychiatry is as effective as in-person psychiatric consultations for diagnostic assessment, is at least as good for the treatment of disorders such as depression and post traumatic stress disorder, and may be better than in-person treatment in some groups of patients, notably children, veterans and individuals with agoraphobia.

As of 2011, the following are some of the model programs and projects which are deploying telepsychiatry in rural areas in the United States:
# [[University of Colorado Denver#University of Colorado Health Sciences Center|University of Colorado Health Sciences Center]] (UCHSC) supports two programs for American Indian and Alaskan Native populations
::a. The Center for Native American Telehealth and Tele-education (CNATT) and
::b. Telemental Health Treatment for American Indian Veterans with Post-traumatic Stress Disorder (PTSD)
# Military Psychiatry, [[Walter Reed Army Medical Center]].
# In 2009, the South Carolina Department of Mental Health established a partnership with the [[University of South Carolina School of Medicine]] and the South Carolina Hospital Association to form a statewide telepsychiatry program that provides access to psychiatrists 16 hours a day, 7 days a week, to treat patients with mental health issues who present at rural emergency departments in the network.<ref>{{cite web |publisher=Agency for Healthcare Research and Quality| url=https://innovations.ahrq.gov/profiles/statewide-partnership-provides-mental-health-assessments-telemedicine-patients-rural |title=Statewide Partnership Provides Mental Health Assessments via Telemedicine to Patients in Rural Emergency Departments, Reducing Wait Times, Hospitalizations, and Costs |date=2013-12-04 }}</ref>
# Between 2007 and 2012, the [[University of Virginia Health System]] hosted a videoconferencing project that allowed child psychiatry fellows to conduct approximately 12,000 sessions with children and adolescents living in rural parts of the State.<ref>{{cite web |publisher=Agency for Healthcare Research and Quality |url=https://innovations.ahrq.gov/profiles/videoconferencing-enhances-access-psychiatric-care-children-and-adults-mental-illness-rural |title=Videoconferencing Enhances Access to Psychiatric Care for Children and Adults With Mental Illness in Rural Settings |date=2013-12-04 }}</ref>

There are a growing number of HIPAA compliant technologies for performing telepsychiatry. There is an independent comparison site of current technologies.

Links for several sites related to telemedicine, telepsychiatry policy, guidelines, and networking are available at the website for the [[American Psychiatric Association]].<ref>{{cite web | url = http://www.psychiatry.org/practice/professional-interests/underserved-communities/telepsychiatry | title = Telepsychiatry | publisher = American Psychiatric Association | accessdate = 24 July 2013}}</ref><ref name="telementalhealthcomparisons">{{cite web|url=http://www.telementalhealthcomparisons.com|title=Telemental Health Technologies Compared|publisher=telementalhealthcomparisons.com|accessdate=25 March 2016}}</ref>

There has also been a recent trend towards Video CBT sites with the recent endorsement and support of CBT by the [[National Health Service (England)|National Health Service]] (NHS) in the United Kingdom.<ref>{{cite web | url = http://www.nhs.uk/Conditions/Cognitive-behavioural-therapy/Pages/Introduction.aspx | publisher = NHS Choices | title = Cognitive behavioural therapy | accessdate = 24 July 2013}}</ref>

In April 2012, a Manchester-based Video CBT pilot project was launched to provide live video therapy sessions for those with depression, anxiety, and stress related conditions called InstantCBT<ref name="instantcbt">{{cite web|url=http://www.instantcbt.com/ |title=Instant Change Center |publisher=instantcbt.com|accessdate=25 March 2016}}</ref> The site supported at launch a variety of video platforms (including Skype, GChat, Yahoo, MSN as well as bespoke)<ref name="instantcbt2">{{cite web|url=http://www.instantcbt.com/requirements/ |title=Instant Change Center &#124; InstantCBT Requirements Page |publisher=instantcbt.com|accessdate=25 March 2016}}</ref> and was aimed at lowering the waiting times for mental health patients. This is a Commercial, For-Profit business.

In the United States, the American Telemedicine Association and the Center of Telehealth and eHealth are the most respectable places to go for information about telemedicine.

The [[Health Insurance Portability and Accountability Act]] (HIPAA), is a United States Federal Law that applies to all modes of electronic information exchange such as video-conferencing mental health services. In the United States, Skype, Gchat, Yahoo, and MSN are not permitted to conduct video-conferencing services unless these companies sign a Business Associate Agreement stating that their employees are HIPAA trained. For this reason, most companies provide their own specialized videotelephony services. Violating HIPAA in the United States can result in penalties of hundreds of thousands of dollars.<ref>{{Cite news|url=http://www.hipaajournal.com/what-are-the-penalties-for-hipaa-violations-7096/|title=What are the Penalties for HIPAA Violations?|date=2015-06-24|work=HIPAA Journal|access-date=2017-03-02}}</ref>

The momentum of telemental health and telepsychiatry is growing. In June 2012 the [[United States Department of Veterans Affairs|U.S. Veterans Administration]] announced expansion of the successful telemental health pilot. Their target was for 200,000 cases in 2012.<ref>{{cite web|url=https://www.va.gov/opa/pressrel/pressrelease.cfm?id=2335|title=News Releases - Office of Public and Intergovernmental Affairs|first=Office of Public and Intergovernmental|last=Affairs|website=www.va.gov}}</ref>

A growing number of HIPAA compliant technologies are now available. There is an independent comparison site that provides a criteria-based comparison of telemental health technologies.<ref name="telementalhealthcomparisons2">{{cite web|url=http://telementalhealthcomparisons.com|title=Telemental Health Technologies Compared|publisher=telementalhealthcomparisons.com|accessdate=25 March 2016}}</ref>

The SATHI Telemental Health Support project cited above is another example of successful Telemental health support. - Also see SCARF India.<ref>{{cite web|url=http://www.scarfindia.org/tele-medicine|title=Tele Medicine - Scarf India|publisher=}}</ref>

=== Teleradiology ===

{{main|Teleradiology}}
[[File:CT viewer Chest Keosys.JPG|right|thumb|A CT exam displayed through teleradiology]]

Teleradiology is the ability to send [[Radiography|radiographic]] images ([[x-ray]]s, CT, MR, PET/CT, SPECT/CT, MG, US...) from one location to another.<ref>{{cite journal |doi=10.3892/or.15.4.1091 |title=Integrated telemedicine applications and services for oncological positron emission tomography |journal=Oncology Reports |year=2006 |last1=Kontaxakis |first1=George |last2=Visvikis |first2=Dimitris |last3=Ohl |first3=Roland |last4=Sachpazidis |first4=Ilias |last5=Suarez |first5=Juan |last6=Selby |first6=Peter |last7=Cheze-Le Rest |first7=Catherine |last8=Santos |first8=Andres |last9=Ortega |first9=Fernando |last10=Diaz |first10=Javier |last11=Pan |first11=Leyun |last12=Strauss |first12=Ludwig |last13=Dimitrakopoulou-Strauss |first13=Antonia |last14=Sakas |first14=Georgios |last15=Pozo |first15=Miguel }}</ref> For this process to be implemented, three essential components are required, an image sending station, a transmission network, and a receiving-image review station. The most typical implementation are two computers connected via the 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. Sometimes the receiving computer will have a printer so that images can be printed for convenience.

The teleradiology process begins at the image sending station. The 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 to the receiving computer.

Today's high-speed broadband based Internet enables the use of new technologies for teleradiology: the image reviewer can now have access to distant servers in order to view an exam. Therefore, they do not need particular workstations to view the images; a standard [[personal computer]] (PC) and [[digital subscriber line]] (DSL) connection is enough to reach keosys central server. No particular software is necessary on the PC and the images can be reached from wherever in the world.

Teleradiology is the most popular use for telemedicine and accounts for at least 50% of all telemedicine usage.

=== Telepathology ===

{{main|Telepathology}}

Telepathology is the practice of [[pathology]] at a distance. It uses [[telecommunications|telecommunications technology]] to facilitate the transfer of image-rich pathology data between distant locations for the purposes of [[Medical diagnosis|diagnosis]], [[Medical education|education]], and [[Medical research|research]].<ref>{{cite journal | last = Weinstein | first = RS | last2 = Graham | first2 = AM | last3 = Richter | first3 = LC | last4 = Barker | first4 = GP | last5 = Krupinski | first5 = EA | last6 = Lopez | first6 = AM | last7 = Yagi | first7 = Y | last8 = Gilbertson | first8 = JR | last9 = Bhattacharyya | first9 = AK | last10 = Gilbertson | first10 = J. R. | title = Overview of telepathology, virtual microscopy and whole slide imagining: Prospects for the future | journal = Hum Pathol | volume = 40 | issue = 8 | pages = 1057–1069 | year = 2009| display-authors = 9 | pmid = 19552937 | doi = 10.1016/j.humpath.2009.04.006 }}</ref><ref>{{cite journal | last = Kumar | first = S | title = Telepathology: An Audit | journal = Telepathology | editor = Kumar S, Dunn BE | publisher = Springer-Verlag Berlin Heidelberg | year = 2009 | pages = 225–229}}</ref> Performance of telepathology requires that a pathologist selects the [[video]] images for analysis and the rendering diagnoses. The use of "[[microscopy|television microscopy]]", the forerunner of telepathology, did not require that a pathologist have physical or virtual "hands-on" involvement is the selection of microscopic fields-of-view for analysis and diagnosis.

A pathologist, Ronald S. Weinstein, M.D., coined the term "telepathology" in 1986. In an editorial in a medical journal, Weinstein outlined the actions that would be needed to create remote pathology diagnostic services.<ref>{{cite journal | last = Weinstein | first = RS | title = Prospect for telepathology (Editorial) | journal = Hum Pathol | year = 1986 | volume = 17 | issue = 5 | pages = 433–434|doi=10.1016/s0046-8177(86)80028-4}}</ref> He, and his collaborators, published the first scientific paper on robotic telepathology.<ref>{{cite journal | last = Weinstein | first = RS | last2 = Bloom | first2 = KJ | last3 = Rozek | first3 = LS | title = Telepathology and the networking of pathology diagnostic services | journal = Arch Pathol Lab Med | volume = 111 | issue = 7 | year = 1987 | pages = 646–652| pmid = 3606341 }}</ref> Weinstein was also granted the first U.S. [[patents]] for [[robotics|robotic]] telepathology systems and telepathology diagnostic networks.<ref>{{cite book | last = Kayser | first = K | last2 = Szymas | first2 = J | last3 = Weinstein | first3 = RS | title = Telepathology: Telecommunications, Electronic Education and Publication in Pathology | year = 1999 | pages = 1–186 | publisher = Springer, NY }}</ref> Weinstein is known to many as the "father of telepathology".<ref>{{cite web | title = ReUnion '10 award winners | publisher = Union College | url = http://www.union.edu/N/DS/s.php?s=8942 | archive-url = https://archive.is/20120805232102/http://www.union.edu/N/DS/s.php?s=8942 | dead-url = yes | archive-date = 5 August 2012 | accessdate = 25 July 2013}}</ref> In Norway, Eide and Nordrum implemented the first sustainable clinical telepathology service in 1989.<ref>{{cite journal |doi=10.1016/0046-8177(91)90226-F |pmid=1864583 |title=Remote frozen section service: A telepathology project in northern Norway |journal=Human Pathology |volume=22 |issue=6 |pages=514–8 |year=1991 |last1=Nordrum |first1=Ivar |last2=Engum |first2=Bjørn |last3=Rinde |first3=Eivind |last4=Finseth |first4=Asgeir |last5=Ericsson |first5=Hans |last6=Kearney |first6=Michael |last7=Stalsberg |first7=Helge |last8=Eide |first8=Tor J }}</ref> This is still in operation, decades later. A number of clinical telepathology services have benefited many thousands of patients in North America, Europe, and Asia.

Telepathology has been successfully used for many applications including the rendering [[histopathology]] tissue diagnoses, at a distance, for education, and for research. Although [[digital pathology]] imaging, including [[virtual microscopy]], is the mode of choice for telepathology services in developed countries, [[Analog signal|analog]] telepathology imaging is still used for patient services in some developing countries.

=== Teledermatology ===
{{main|Teledermatology}}

Teledermatology allows [[dermatology]] consultations over a distance using audio, visual and data communication, and has been found to improve efficiency.<ref>{{cite web |publisher=Agency for Healthcare Research and Quality | url=https://innovations.ahrq.gov/profiles/online-visits-dermatologists-enhance-access-care-patients-minor-and-serious-skin-conditions |title=Online Visits With Dermatologists Enhance Access to Care for Patients With Minor and Serious Skin Conditions, Boost Physician Productivity |date=2013-11-06 | accessdate=6 November 2013}}</ref> Applications comprise health care management such as diagnoses, consultation and treatment as well as (continuing medical) education.<ref>{{cite book |last1=Wootton |first1=Richard |last2=Batch |first2=Jennifer |year=2005 |title=Telepediatrics: telemedicine and child health |publisher=Royal Society of Medicine |isbn=978-1-85315-645-8 }}{{page needed|date=June 2018}}</ref><ref>{{cite journal |doi=10.1111/j.1610-0387.2007.06440.x |pmid=18005076 |title=Telemedicine and teledermatology: Past, present and future |journal=JDDG |volume=6 |issue=2 |pages=106–12 |year=2008 |last1=Wurm |first1=Elisabeth M.T |last2=Hofmann-Wellenhof |first2=Rainer |last3=Wurm |first3=Robert |last4=Soyer |first4=Hans Peter }}</ref><ref>{{cite journal |doi=10.1159/000082573 |pmid=15724100 |title=Teledermatology: Just Cool or a Real Tool? |journal=Dermatology |volume=210 |issue=2 |pages=169–73 |year=2005 |last1=Burg |first1=Günter |last2=Hasse |first2=Urs |last3=Cipolat |first3=Claudio |last4=Kropf |first4=Roger |last5=Djamei |first5=Vahid |last6=Soyer |first6=H. Peter |last7=Chimenti |first7=Sergio }}</ref> The dermatologists Perednia and Brown were the first to coin the term "teledermatology" in 1995. In a scientific publication, they described the value of a teledermatologic service in a rural area underserved by dermatologists.<ref>{{cite journal |pmid=7703938 |pmc=225996 |year=1995 |author1=Perednia |first1=D. A |title=Teledermatology: One application of telemedicine |journal=Bulletin of the Medical Library Association |volume=83 |issue=1 |pages=42–7 |last2=Brown |first2=N. A }}</ref>

=== Teledentistry ===
{{main|Teledentistry}}

Teledentistry is the use of [[information technology]] and [[telecommunications]] for dental care, consultation, education, and public awareness in the same manner as [[telehealth]] and telemedicine.

=== Teleaudiology ===
{{main|Tele-audiology}}

Tele-audiology is the utilization of [[telehealth]] to provide [[audiological]] services and may include the full scope of audiological practice. This term was first used by Dr Gregg Givens in 1999 in reference to a system being developed at [[East Carolina University]] in North Carolina, USA.{{citation needed|date=July 2013}}

=== Teleophthalmology ===
{{main|Teleophthalmology}}

Teleophthalmology is a branch of telemedicine that delivers eye care through digital medical equipment and telecommunications technology. Today, applications of teleophthalmology encompass access to eye specialists for patients in remote areas, ophthalmic disease screening, diagnosis and monitoring; as well as distant learning. Teleophthalmology may help reduce disparities by providing remote, low-cost screening tests such as diabetic retinopathy screening to low-income and uninsured patients.<ref>{{cite web |publisher=Agency for Healthcare Research and Quality |url=https://innovations.ahrq.gov/profiles/telemedicine-based-eye-examinations-enhance-access-reduce-costs-and-increase-satisfaction |title=Telemedicine-Based Eye Examinations Enhance Access, Reduce Costs, and Increase Satisfaction for Low-Income and Minority Patients with Diabetes |date=2013-07-17 |accessdate=24 July 2013}}</ref><ref>{{cite web |publisher=Agency for Healthcare Research and Quality |url=https://innovations.ahrq.gov/profiles/remote-retinal-screening-facilitates-diagnosis-and-treatment-retinopathy-poor-andor |title=Remote Retinal Screening Facilitates Diagnosis and Treatment of Retinopathy for Poor and/or Uninsured Patients With Diabetes in Rural California |date=2012-10-03 |accessdate=24 July 2013}}</ref> In Mizoram, India, a hilly area with poor roads, between 2011 till 2015, Tele-ophthalmology has provided care to over 10000 patients. These patients were examined by ophthalmic assistants locally but surgery was done on appointment after viewing the patient images online by Eye Surgeons in the hospital 6–12 hours away. Instead of an average 5 trips for say, a cataract procedure, only one was required for surgery alone as even post op care like stitch removal and glasses was done locally. There were huge cost savings in travel etc.<ref>{{cite journal|last=Phukan|first=Riki|last2=Mehta|first2=Manoj Rai|last3=Gogia|first3=Shashi|date=2014-11-02|title=Results and Problems in Executing Teleophthalmology|url=http://ijmi.org/index.php/ijmi/article/view/260|journal=Indian Journal of Medical Informatics|volume=8|issue=2|pages=32–33|issn=0973-9254}}</ref>

== Licensure ==

=== U.S. licensing and regulatory issues ===

Restrictive licensure laws in the United States require a practitioner to obtain a full license to deliver telemedicine care across state lines. Typically, states with restrictive licensure laws also have several exceptions (varying from state to state) that may release an out-of-state practitioner from the additional burden of obtaining such a license. A number of states require practitioners who seek compensation to frequently deliver interstate care to acquire a full license.

If a practitioner serves several states, obtaining this license in each state could be an expensive and time-consuming proposition. Even if the practitioner never practices medicine face-to-face with a patient in another state, he/she still must meet a variety of other individual state requirements, including paying substantial licensure fees, passing additional oral and written examinations, and traveling for interviews.

In 2008, the U.S. passed the Ryan Haight Act which required face-to-face or valid telemedicine consultations prior to receiving a prescription.<ref>{{cite web|url=http://www.govtech.com/health/Ryan-Haight-Act-will.html|title=Ryan Haight Act will Require Tighter Restrictions on Internet Pharmacies|website=www.govtech.com|accessdate=7 March 2016}}</ref>

[[:Category:Medical licensing boards in the United States|State medical licensing boards]] have sometimes opposed telemedicine; for example, in 2012 electronic consultations were illegal in Idaho, and an Idaho-licensed general practitioner was punished by the board for prescribing an antibiotic, triggering reviews of her licensure and board certifications across the country.<ref name=":0">{{cite web|url=http://www.spokesman.com/stories/2015/aug/22/telemedicine-sanction-in-idaho-clouds-doctors/|title=Telemedicine sanction in Idaho clouds doctor’s future|website=Spokesman.com|accessdate=7 March 2016}}</ref> Subsequently, in 2015 the state legislature legalized electronic consultations.<ref name=":0" />

In 2015, Teladoc filed suit against the [[Texas Medical Board]] over a rule that required in-person consultations initially; the judge refused to dismiss the case, noting that antitrust laws apply to state medical boards.<ref>{{cite web|url=http://www.modernhealthcare.com/article/20151214/NEWS/151219924|title=Teladoc case against Texas Medical Board will move forward, judge rules|website=Modern Healthcare|accessdate=7 March 2016}}</ref>

== Companies ==
In the United States, the major companies offering primary care for non-acute illnesses include [[Teladoc]], [[American Well]], and PlushCare.<ref name="scsent">{{Cite news| url=http://www.santacruzsentinel.com/article/NE/20180123/NEWS/180129931 |title= Santa Cruz County’s flu death toll rises to three, telemedicine market grows |newspaper= [[Santa Cruz Sentinel]] |access-date= |date= January 23, 2018 }}</ref> Companies such as [[Grand Rounds, Inc.|Grand Rounds]] offer remote access to specialty care.<ref>{{cite news|last1=Rogers|first1=Bruce|title=Owen Tripp's Grand Rounds Is On A Mission To Revolutionize Healthcare|url=https://www.forbes.com/sites/brucerogers/2016/07/20/owen-tripps-grand-rounds-is-on-a-mission-to-revolutionize-health-care/|work=Forbes}}</ref> Additionally, telemedicine companies are collaborating with health insurers and other telemedicine providers to expand marketshare and patient access to telemedicine consultations. For example, In 2015, UnitedHealthcare announced that it would cover a range of video visits from Doctor On Demand, American Well's AmWell, and its own Optum's NowClinic, which is a [[White-label product|white-labeled]] American Well offering.<ref>{{cite web|url=http://mobihealthnews.com/content/independence-blue-cross-offer-members-mdlive-also-reimburse-remote-visits-their-own-pcps|title=Independence Blue Cross to offer members MDLive, also reimburse remote visits with their own PCPs|date=15 March 2016|publisher=}}</ref><ref>{{cite web|url=http://mobihealthnews.com/content/independence-blue-cross-offer-members-mdlive-also-reimburse-remote-visits-their-own-pcps|title=Independence Blue Cross to offer members MDLive, also reimburse remote visits with their own PCPs|date=2016-03-15|access-date=2016-08-03}}</ref> On November 30, 2017, PlushCare launched in some U.S. states, the Pre-Exposure Prophylaxis (PrEP) therapy for prevention of HIV. In this PrEP initiative, PlushCare does not require an initial check-up and provides consistent online doctor visits, regular local laboratory testing and prescriptions filled at partner pharmacies.<ref name="sfgn">{{Cite news|url= http://southfloridagaynews.com/Health/app-allows-patients-to-accessprep-through-their-phones.html |title= App Allows Patients to Access PrEP Through Their Phones |newspaper= [[South Florida Gay News]] |access-date= |date= January 3, 2018 }}</ref><ref>{{cite web|url=https://thepridela.com/2017/08/plushcare-app-brings-prep-masses/ | title= PlushCare App Brings PrEP to the Masses |newspaper=The Pride L.A. |date= August 2, 2017 | access-date= }}</ref><ref>{{cite web|url= http://www.ebar.com/news/article.php?sec=news&article=73192 |title= App allows PrEP access via phones |newspaper= [[Bay Area Reporter]] |date=2017-12-14|access-date= }}</ref>

== Advanced and experimental services ==

=== Telesurgery ===
{{main|Remote surgery}}Remote surgery (also known as telesurgery) is the ability for a doctor to perform [[surgery]] on a patient even though they are not physically in the same location. It is a form of [[telepresence]]. Remote surgery combines elements of [[robot]]ics, cutting edge [[telecommunication|communication technology]] such as high-speed data connections, [[telehaptics|haptics]] and elements of [[management information system]]s. While the field of [[robotic surgery]] is fairly well established, most of these robots are controlled by surgeons at the location of the surgery.

Remote surgery is essentially advanced [[telecommuting]] for surgeons, where the physical distance between the surgeon and the patient is immaterial. It promises to allow the expertise of specialized surgeons to be available to patients worldwide, without the need for patients to travel beyond their local hospital.<ref>[http://www.intersurgtech.com/media.html IST's Media Collection], Interface Surgical Technologies website. Retrieved 21 August 2011.</ref>

[[Remote surgery]] or telesurgery is performance of surgical procedures where the surgeon is not physically in the same location as the patient, using a robotic [[teleoperator]] system controlled by the surgeon. The remote operator may give tactile feedback to the user. Remote surgery combines elements of robotics and high-speed data connections. A critical limiting factor is the speed, [[Latency (engineering)|latency]] and reliability of the communication system between the surgeon and the patient, though trans-Atlantic surgeries have been demonstrated.

== Enabling technologies ==
{{further|List of video telecommunication services and product brands}}

=== Videotelephony ===
{{main|Videotelephony}}

Videotelephony comprises the technologies for the reception and transmission of audio-video signals by users at different locations, for communication between people in real-time.<ref name=McGrawHill>McGraw-Hill Concise Encyclopedia of Engineering. [http://encyclopedia2.thefreedictionary.com/Videotelephony Videotelephony], McGraw-Hill, 2002. Retrieved from the FreeDictionary.com website, January 9, 2010</ref>

At the dawn of the technology, videotelephony also included ''image phones'' which would exchange still images between units every few seconds over conventional [[Plain old telephone service|POTS]]-type telephone lines, essentially the same as [[Slow-scan television|slow scan TV]] systems.

Currently videotelephony is particularly useful to the [[deaf]] and [[Speech disorder|speech-impaired]] who can use them with [[sign language]] and also with a [[Video Relay Service|video relay service]], and well as to those with [[disability|mobility issues]] or those who are located in distant places and are in need of [[telerehabilitation|telemedical]] or [[distance education|tele-educational]] services.

==Developing countries==
For developing countries, telemedicine and [[eHealth]] can be the only means of healthcare provision in remote areas. For example, the difficult financial situation in many African states and lack of trained health professionals has meant that the majority of the people in sub-Saharan Africa are badly disadvantaged in medical care, and in remote areas with low population density, direct healthcare provision is often very poor<ref>[https://web.archive.org/web/20160205083116/http://euroafrica-ict.org.sigma-orionis.com/downloads/Coop_Forum/SessionC/Adesina_Iluyemi.pdf ''Refocusing Europe-Africa Strategy: Strategic Importance of eHealth''] NEPAD. Accessed 28 January 2016.</ref> However, provision of telemedicine and eHealth from urban centres or from other countries is hampered by the lack of communications infrastructure, with no landline phone or broadband internet connection, little or no mobile connectivity, and often not even a reliable electricity supply.<ref>Gerhard Bethscheider [http://www.worldteleport.org/news/249029/Satellite-Is-Vital-For-A-Unified-Global-e-Health-System...-An-SES-Techcom-Services-Perspective-.htm ''Satellite is vital for a unified, global, E-Health system''] September 2015 World Teleport Association. Accessed 28 January 2016.</ref>

The Satellite African eHEalth vaLidation (SAHEL) demonstration project has shown how [[Satellite Internet access|satellite broadband]] technology can be used to establish telemedicine in such areas. SAHEL was started in 2010 in Kenya and Senegal, providing self-contained, solar-powered internet terminals to rural villages for use by community nurses for collaboration with distant health centres for training, diagnosis and advice on local health issues<ref>[https://web.archive.org/web/20160203143432/http://www.ses.com/14444955/SES_Broadband_SAHEL_case_study_EN.pdf ''Helping to build sustainable eHealth services in Africa''] SES Broadband. Company brochure. Accessed 28 January 2016.</ref>

In 2014, the government of Luxembourg, along with satellite operator, [[SES S.A.|SES]] and NGOs, Archemed, Fondation Follereau, Friendship Luxembourg, [[German Doctors for Developing Countries|German Doctors]] and [[Médecins Sans Frontières]], established [[Satmed|SATMED]], a multilayer eHealth platform to improve public health in remote areas of emerging and developing countries, using the [[Emergency.lu]] disaster relief satellite platform and the [[Astra 2G]] TV satellite.<ref>Caleb Henry [http://www.satellitetoday.com/telecom/2014/09/25/ses-joins-clinton-global-initiative-announces-satmed-project/ ''SES Joins Clinton Global Initiative, Announces SATMED Project''] September 25, 2014 Satellite Today. Accessed 28 January 2016.</ref> SATMED was first deployed in response to a report in 2014 by German Doctors of poor communications in Sierra Leone hampering the fight against Ebola, and SATMED equipment arrived in the Serabu clinic in Sierra Leone in December 2014.<ref>[http://www.cooperation.lu/2014/en/613/SATMED Satmed] Luxembourg's Development Cooperation. Accessed February 26, 2016</ref> In June 2015 SATMED was deployed at Maternité Hospital in Ahozonnoude, Benin to provide remote consultation and monitoring, and is the only effective communication link between Ahozonnoude, the capital and a third hospital in Allada, since land routes are often inaccessible due to flooding during the rainy season.<ref>[https://www.reuters.com/article/idUSFWN0YP03O20150604 SES SATMED ehealth platform deployed in hospital in Benin] Reuters June 4, 2015. Accessed February 26, 20166</ref><ref>[http://www.satmagazine.com/story.php?number=993564177 Executive Spotlight: Gerhard Bethscheider] SatMagazine November 2015. Accessed February 26, 20166</ref>

== See also ==
{{Portal|Medicine|Health and fitness|Disability|Nursing|Technology|Telecommunication}}
{{colbegin|colwidth=30em}}
* [[American Telemedicine Association]]
* [[Connected health]]
* [[eHealth]]
* [[In absentia health care|''In absentia'' health care]]
* [[mHealth]]
* [[National Rural Health Association]]
* [[Ontario Telemedicine Network]]
* [[Remote therapy]]
* [[Ronald S. Weinstein]]
* [[Tele-epidemiology]]
* [[Telecare]]
* [[Teledermatology]]
* [[Telehealth]]
* [[Telemental health]]
* [[Teleneuropsychology]]
* [[Telenursing]]
* [[Telepathology]]
* [[UNESCO Chair in Telemedicine]]
{{colend}}

== References ==
{{Reflist|colwidth=30em}}

==External links==
{{Commonscatinline}}

{{Medicine}}
{{Telecommunications}}

{{Authority control}}


[[Category:Telecommunication services]]
[[Category:Telecommunication services]]

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