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Telemedicine, you might be surprised to learn, was practiced in ancient times. The history of telemedicine closely parallels the history of communication and information technologies. The key technical feature of telemedicine is being able to communicate medical data over a distance, and long distance communication methods existed throughout human history.

Some forms of medical information can be communicated over distance just easily as any other verbal information. (Or, depending on your outlook and the age of the technology involved, they can be communicated with the same level of difficulty.) In the past, information that a new sovereign was crowned can be sent over the same long-distance communication medium as a warning about a dangerous disease outbreak. Here are a couple additional telemedicine examples that only require verbal communication:

  •      Identification, or diagnosis, of a specific disease based on a verbal description of the symptoms
  •      Prescription for the patient regarding what to eat and drink

In this article, we walk through telemedicine history until the present time.

Ancient Telemedicine

We’ll start the times of ancient Greece and Rome, around 500 BCE. By this point in human history, humans have mastered agriculture and lived in multiple nearby villages or towns. Communication between towns was common. Human messengers, of course, could still be used to transfer medical advice or medicine. In addition, additional methods of long distance communication became widely adopted.

The major driver for improvements in long distance communication was the military. Cities needed to know as quickly as possible whether a foreign army was approaching, and be able to coordinate their own forces from a distance. Any other communication needs, medical or otherwise, were lower priority. Several widely used communication mediums included:

  •      Fires
  •      Smoke signals
  •      Light reflection beacons
  •      Drums
  •      Horns

Around the same historical time, we have evidence that some of these communication mediums, specifically smoke signals and light reflection, were used to communicate medical information. Specifically, long distance communication methods were used to signal the outbreaks of plagues and to notify about health events such as births or deaths. Similarly, just like in ancient Greece, American Indian tribes also used smoke signals to relay medical calamities and health events.[1]

Early Telemedicine

The history of modern telemedicine, as we know it, was kicked off by the inventions of the electrical telegraph and the telephone. Although other inventions, such as flag semaphores and light telegraph, came onto the scene earlier, they were primarily used for military and naval communication. Before the telegraph and telephone, communication inventions did not expand the scope of telemedicine beyond ancient times. Mail, another popular long-distance communication medium, was used for medical communication. However, from a technological perspective, mail can be considered simply an extension of the human messenger.

The telegraph and telephone brought long distance communication into the mainstream, where almost anyone could send a telegraph message or make a phone call. Telegraph was still a special-use technology — few individuals installed telegraphs in their homes due to the special training required to operate the telegraph, as well as due to the lack of a sufficient network of other telegraph receivers. Nevertheless, thanks to the communication speed of the telegraph, this technology was adopted for telemedicine in military situations. During the U.S. Civil War, telegraph was used for ordering medical supplies as well as communicating deaths and injuries on the battlefield.[2] It seems likely that telegraph was also used for medical consultations.

With the telephone, the era of the connected world arrived. Major city hospitals and doctor offices installed telephones. Within a few years, many city residents also had telephones in their homes. All of a sudden physicians could talk over the telephone to their patients and give medical advice directly. In addition, medical providers could speak over the phone to other physicians in order to consult or exchange information.

All of us, the children of the modern world, take the telephone for granted. We’ve seen and used telephones from our childhood. Many people do not consciously consider the use of telephone as a telemedicine application. Patients don’t consider it out of the ordinary when they discuss their blood test results with a nurse over the phone. In fact, the use of the telephone is on the decline. Many people now prefer other asynchronous communication methods, such as text messages, which are more convenient for them. Still, the fact remains that the telephone was the foundation for many later communication and telemedicine technologies.

Through the 1900s, the overall usage of the telephone grew as the telephone network was enhanced with higher quality signals, telephone numbers, and other features. In 1968, 9-1-1 became the official emergency telephone number in the United States. The number could be used to report a fire, get the police, or a medical emergency. Previously, people using the telephone had to get the operator to forward their call to the right department (police, fire station, or hospital), or to know the specific number to dial. From a telemedicine perspective, 9-1-1 provided a consistent and faster access to emergency medical care.

Telefax, although invented before the telephone (and known as electric printing telegraph), did not gain significant traction until fax devices began to use common telephone lines and telephone numbers for transmissions. To this day, medical professionals use faxes en masse to transmit medical records.

Rise of Telemedicine 1.0

The first idea of telemedicine as we know it today appeared in the April 1924 issue of Radio News magazine. The magazine depicted using television and microphone for a patient to communicate with a doctor, including use of heartbeat and temperature indicators. The concept was an imagination of the future, as U.S. residents did not yet have televisions in their homes, and radio adoption was just gaining steam.

Proposals to transmit stethoscope readings and other instrument data over existing communication channels (telephone, radio, etc.) have been made in the first half of the 1900s. However, none of these one-off experiments picked up any traction.

The first uses of telemedicine to transmit video, images, and complex medical data occurred in the late 1950s and early 1960s. In 1959, the University of Nebraska used interactive telemedicine to transmit neurological examinations, which is widely considered the first case of a real-time video telemedicine consultation.[2] Other programs followed, often implemented in an academic setting, which focused on transmission of medical data such as fluoroscopy images, x-rays, stethoscope sound, and electrocardiograms (ECGs). The main motivations of these early projects were:

  •      Providing access to health care in rural areas
  •      Urban medical emergency situations

A major break for the progress of telemedicine came in the 1960s when several partners, including the National Aeronautics and Space Administration (NASA), Lockheed Corporation, and U.S. Indian Health Service, joined together to work on STARPAHC project. STARPAHC stands for Space Technology Applied to Rural Papago Advanced Health Care. The project provided telemedicine access to an American Indian reservation using the same technologies intended for astronauts on space missions.

Many additional grant and government-supported telemedicine initiatives followed, including:

  •      Providing medical care in a war zone
  •      Providing medical care to remote scientific stations in Arctic and Antarctic
  •      Providing medical care to correctional facilities without transporting inmates to the hospital
  •      Digital transmission of radiology images

Radiology was the first medical specialty to fully embrace telemedicine. With the help from grant-sponsored projects, which proved the reliability and efficiency of telemedicine, the medical community gained confidence in teleradiology. In 1980s some radiologists began to use teleradiology systems to receive images for telemedicine consultations.[2]

In almost all of the early deployments of telemedicine, the telemedicine projects were large undertakings requiring considerable staff and organizational changes. The telemedicine implementations used custom hardware and software equipment, often specifically created for the specific use case. The equipment was bulky and required specially trained personnel to use. This means the average patient did not directly interact with telemedicine technologies. Instead, a telepresenter handled the equipment and interacted with the patient. Due to the advancement of technology and other factors, few early projects survived longer than 20 years in their original forms.

We use the term Telemedicine 1.0 to refer to these early types of telemedicine deployments. Specifically, these projects are characterized by the following:

  •      Custom, bulky hardware specifically created for telemedicine
  •      Designed for specific use cases, such as psychiatry consults in ER
  •      Expensive
  •      Requiring specially trained telepresenters

Telemedicine and the Internet

The rise of the Internet in the 1990s also brought with it the information explosion. The Internet protocols allowed support for practically all information and traffic needed for telemedicine, including:

  •      Patient education (text, images, video)
  •      Medical images such as x-rays and scans (DICOM image standards)
  •      Real-time audio and video consultation
  •      Vital signs and other body measurements (ECG, temperature, etc.)

Globalization, content publishing, consumer demand, and other factors outside of health care drove the Internet growth. This growth meant that considerable funds and engineering efforts went into Internet infrastructure improvements, including:

  •      Communication speeds (bandwidth and latency)
  •      Information storage (databases, object-store for large files such as images and video)
  •      Availability – many web services employ back up servers, and even dynamically start up additional servers if traffic increases
  •      Standard formats for data transmission (MP4, PNG, etc.)
  •      Security (encryption, password protection, access levels, etc.)
  •      Application development — new programming languages (JavaScript), frameworks, and open-source software (Apache)
  •      The Cloud – using virtual servers hosted by an infrastructure provider such as Amazon Web Services (AWS)
  •      Digitizing information (digital cameras, scanners, etc.)

The above Internet improvements had a positive impact on health care and telemedicine. All of a sudden it was easier and cheaper than ever to build a health care software application for exchanging and storing clinical data, using the existing tools and frameworks for web applications.

The e-health floodgates opened with the transition to electronic medical records (EMRs), led by U.S. government incentives (and future penalties). Most of today’s modern EMR vendors employ the Internet in order to provide access to medical information for medical providers and patients. In addition, patient portals have become more common, where patients can look up their lab results, refill prescriptions, or send a secure message to their physician.

Both medical providers and patients are becoming more and more technology savvy.  The use of the Internet is now commonplace in health care — it is surprising to hear of a private practice without a web site. Many practices are trying to leverage the Internet further by engaging existing and potential new patients through social media outlets like Twitter and Facebook. Also, they reach out to their patients and encourage them to post reviews on Yelp and other web sites.

Patients, meanwhile, have access to tons of medical information online.Many patients research their symptoms using “doctor Google” before coming to see their physician. Of course, one issue with getting information from public sources on the Internet is reliability – some online articles may mislead or confuse patients.

Today, the Internet is firmly established in day-to-day life. The majority of U.S. adults own a mobile device capable of accessing the Internet, such as a smart-phone or tablet. Many rely on these devices as their primary entry point for the online world.

The ubiquity of the Internet, the ready access to Internet-enabled computing devices, and the technical savvy of the U.S. population are important factors in the ongoing Telemedicine 2.0 transition. The “2.0” suffix typically refers to applications running on Web 2.0 technologies, and characterized by their collaboration, usability, interoperation, and openness features. This moniker is commonly used in health care in terms such as Health 2.0 or Medicine 2.0. Telemedicine 2.0 is characterized as:

  •      Using existing computing device belonging to patient or physician
  •      Communicating over the Internet and using standard web infrastructure
  •      Using inexpensive off-the shelf equipment for gathering clinical data
  •      Easy to use — can be used directly by patient or physician without special training

Some of the affordable measurement devices that are commonly used with telemedicine include:

  •      Smartphone cameras
  •      Digital stethoscopes
  •      Ophthalmoscopes (for eye exams)
  •      Otoscopes (for ear exams)
  •      Vital sign monitoring devices
  •      Wearable biosensors

Telemedicine has now fully embraced the Internet communication medium. Many private practices and health care systems are in the process of becoming hybrid health care providers – allowing patients to see their medical provider either through telemedicine or in-person. We take a deeper look at the categories and types of Telemedicine 2.0 use cases in the Categories of Telemedicine article.

References:

  1. Rashid Bashshur, PhD and Gary W. Shannon, History of Telemedicine: Evolution, Context, and Transformation. New Rochelle, NY: Mary Ann Liebert, 2009.
  2. Marilyn J. Field, Telemedicine: A Guide to Assessing Telecommunications in Health Care. Washington, D.C.: National Academy, 1996.
  3. John Plunkett. (2012, July) Decline of the phone call: Ofcom shows growing trend for text communication. [Online]. http://www.theguardian.com/technology/2012/jul/18/ofcom-report-phone-calls-decline
  4. Erin McCann. (2012, Aug) Getting the fax straight. [Online]. http://www.healthcareitnews.com/news/getting-fax-straight?single-page=true
  5. FIPS, “The Radio Doctor–Maybe,” Radio News, p. 1406+, Apr 1924, http://www.americanradiohistory.com/Archive-Radio-News/20s/Radio-News-1924-04-R.pdf
  6. Gunther Eysenbach, “Medicine 2.0: Social Networking, Collaboration, Participation, Apomediation, and Openness,” J Med Internet Res, vol. 10, no. 3, p. e22, Aug. 2008, http://www.jmir.org/2008/3/e22/

 

Last modified: 9/23/2015