Uses of Videoconferencing
ViDe Videoconferencing Cookbook
Telemedicine is a growing field made possible by improved, more widely available,
and affordable telecommunications services. Once narrowly defined as direct
provision of medical services using telecommunications technology, the term
telemedicine is now being supplanted by "Telehealth", and covers "use
of electronic information and communications technologies to provide and support
health care when distance separates the participants" (US Veterans Administration)
or "use of electronic information and telecommunications technologies to
support long-distance clinical health care, patient and professional health-related
education, public health and health administration" (Office for the Advancement
of Telehealth, US Health Resources and Services Administration.)
These definitions include activities providing direct and indirect clinical
services such as teledermatology, but also include educational and administrative
uses of these technologies to support health care, such as for continuing education
or administrative videoconferencing. As convergence of video, voice and data
networks occurs in the marketplace, it is not surprising that services previously
offered on multiple media are now migrating to converged Internet, providing
opportunities for convergence of a number of health care activities occurring
at a distance.
- Brief history of Telemedicine/Telehealth
The earliest recorded use of telemedicine was a 1950's Nebraska demonstration
project using closed circuit television to provide mental health services
from a university medical center to a state hospital 100 miles away. Forty
years ago the NASA space flight telemedicine program began so that medical
personnel on the ground could monitor astronauts' biomedical responses
to space flight and to provide any necessary medical care. NASA's "Telemedicine
Space Bridge to Armenia" Project provided medical assistance in response
to a severe earthquake in Armenia in 1988. Using a live, two-way satellite
link medical personnel at hospitals in Salt Lake City, Houston Texas, and
Maryland conducted many sessions with Armenia physicians for a variety
of medical consultations. Due to the enormous expense of these pioneering
efforts it is only within the last ten years that the practice of telemedicine
has begun to move from pilots to public availability.
- Current Practice of Telemedicine
Remote clinical diagnosis via videoconferencing is currently used in some
rural areas. A rural doctor or nurse practitioner consults with a physician
based at a metropolitan or university hospital. Using videoconferencing
technology and specially adapted medical tools, the remote doctor can see
the patient, talk with the local health care practitioner, hear a heartbeat
through a remote stethoscope, see images from ear/nose/throat exams, or
examine skin conditions. This application has typically required leased
T-1 telephone or ISDN lines, which can be quite expensive. Due to a number
of issues (cost effectiveness, patient/physician acceptance of the technology,
licensing and payment issues), the most common use of such facilities has
been to provide health care to prisoner populations. Prisoners have a legal
right to receive needed medical treatment, but the cost of transporting
a prisoner to a medical facility is extremely high since at least two guards
and possibly and ambulance are required for transport during trips requiring
an entire day. This high transport expense has provided cost-justification
for telemedicine in states such as Virginia and Texas.
A notable pioneer in broader acceptance of telemedicine can be found at the
East Carolina University's Telemedicine Center .
Their telemedicine program employs an array of interactive video and audio
technologies to deliver clinical care and education to the rural population
of eastern North Carolina. Since 1992, the Center has supported over 7,500
telemedicine consultations in over 35 different medical specialties, and
over 10,000 distance learning and continuing medical education activities.
ECU's Telemedicine Center includes an operational communications hub providing
connections between points of need and global medical resources utilizing
POTS, ISDN, T-1, Microwave, Satellite, and IP technologies.
The US Veterans' Administration (VA) 
has had a number of
clinical telemedicine programs, including teleradiology/filmless digital
imaging, telepathology, telenuclear medicine (MRI), home telephone monitoring
of cardiac pacemakers, telephone liaison care programs, and more.
Network in Ontario Canada  runs an extensive H.323-based telehealth
service for remote hospitals and clinics in the northern parts of
the province. They use a private IP network (dedicated to health
care applications) to link over 60 sites in the north to large urban
teaching hospitals. They currently facilitate hundreds of videoconference
enabled consultations per week as well as running an extensive educational"broadcasts"using
the same technologies. They've avoided the typical billing problems
for remote consultations by getting a special government grant that
allows them to directly pay consulting physicians.
is a vendor offering systems specifically designed for the healthcare
industry. The HealthCare System III is a turnkey solution that combines
an H.323 videoconferencing station with medical examination tools that
can be read at a distance, thus allowing the doctor to see both the
patient and an auxiliary transmission, including sonograms, store and
forwards, telescopic images, or a computer or graphic image. The Intern
II is a compact system; it has a built-in MCU, provides HIPAA compliant
data encryption and meets UL, CSA and FCC regulations so that it can
be rolled right up to a patient's bedside.
NASA is designing a highly portable Telemedicine Instrumentation Pack
(TIP) to collect medical audio, video and data from the patient in space.
|Another approach is to build your own telemedicine system. By combining
a videoconferencing device, a PC, and medical devices that can interface
into a computer, one can build a videoconferencing system that best
meets the needs of the end users. Georgia
Tech's Biomedical Interactive Technology Center  has developed
such a system for use in Sarov, Russia, a former Nuclear City. The
system combines off the shelf PC's with a PictureTel codec, digital
cameras, medical instruments interfaced to the computer, scanners,
printers, and a video microscope. A system like this can be customized
to meet the exact needs of the users, but it lacks the polished, integrated
interface one can expect in a commercial system. As the new field of
telemedicine grows and evolves, homegrown systems such as these will
help refine the needs of systems, and will influence the product design
of future commercial telemedicine products.
In an effort to push the field of telemedicine forward significantly,
the National Library of Medicine 
in 1996 awarded 19 multi-year telemedicine projects intended to serve as
models for evaluating the impact of telemedicine, assessing various approaches
to confidentiality in telemedicine, and testing emerging health data standards.
A symposium summarizing activities in and results from this program was
held in March 2001, and proceedings are available
An emerging application in telemedicine is home health care delivery using
videoconferencing. Patients being monitored for a number of conditions
might be sent home with a PC-based telemedicine appliance that can be used
to connect them back to a hospital or doctor's office via ISDN, DSL or
cable modem connections. Such systems often combine medical diagnostic
devices such as stethoscope, ECG, otoscope, etc.
American TeleCare 
is a pioneer in this field. Other vendors include
AMD Telemedicine ,
AeroTel Medical Systems ,
Medtronic , and
March Networks .
- Current Issues associated with Telemedicine/Telehealth applications
There are many unresolved questions in the field of telemedicine:
Acceptance: The Veterans Administration states that more specific
evidence of efficacy/therapeutic and diagnostic impact/cost analysis are
needed in many areas of telemedicine; in other words, telemedicine is not
widely accepted as an approved medical practice by doctors or patients.
Security:Security of telemedicine sessions and related information
is a crucial issue. The Health Information Portability and Accountability
Act of 1996 (HIPAA) guarantees privacy of patient medical records by federal
law, and with individual as well as institutional accountability for violators.
HIPAA compliance becomes mandatory in Spring 2003. (http://cms.hhs.gov/hipaa/)
For videoconferencing systems used in telemedicine, an implication is
that reliable session encryption will be mandatory. An excellent white
paper describing the state of H.323 encryption is available from
(United Kingdom Research and Education Networking Association). The report describes
the H.235 security recommendations that are part of the H.323 standard,
but finds little implementation of this standard within H.323 clients.
Some vendors such as VCON have built proprietary encryption schemes into
their products; these proprietary solutions may solve an immediate problem
but prohibit interoperability. The authors conclude that encryption at
the H.323 application level is in its infancy so encryption can presently
only be offered widely via network layer encryption, for example by use
of VPN or IPSec.
Regulation and Reimbursement:In the United States, until the late
1990's, private and public third-party payers generally did not have explicit
policies to pay for telehealth services. The
Office for the Advancement of Telehealth 
in the US Department of Health and Human Services' Health Resources and Services Administration
is an excellent source for information on regulatory and reimbursement
issues. The Balanced Budget Act of 1997 was a significant step forward
for telemedicine because it allowed Medicare payments for patients in rural
communities having no health care services at all; this prohibited payment
to medical specialists such as cardiologists or radiologists whose expertise
might be valuable to a general practice physician. The types of services
covered were required to be "interactive" and thus did not apply
to "Store and Forward" technologies such as when X-rays or laboratory
tests might be forwarded to a specialist for diagnosis. The rules were
expanded by the Benefits Improvement Act of 2000 to allow coverage to include
any type of medicine to any rural area and to any entity that had participated
in a Federal telemedicine demonstration project (for example, Veterans
Administration Hospitals, even in urban areas). The practice of medicine
across state lines is severely restricted by current laws.
Note: This particular description is US-Centric. We welcome comment on these
issues from residents of other countries to post for comparison.
- Standards and Guidelines for Telemedicine/Telehealth Videoconferencing
The Office for the Advancement of Telehealth maintains
guidelines  for
evaluating telemedicine/telehealth systems.
These guidelines are based on goals of interoperability, compatibility,
scalability, accessibility, and reliability. Guidelines are also provided
by area of medical specialization, such as dermatology or psychiatry.
- Additional Resources:
Telemedicine Information Exchange 
was created and is maintained by the Telemedicine Research Center with major support from the
National Library of Medicine .
- The American Telemedicine Association seeks to bring together
diverse groups from traditional medicine, academic medical centers, technology
and telecommunications companies, e-health, medical societies, government
and others to overcome barriers to the advancement of telemedicine through
the professional, ethical and equitable improvement in health care delivery.
ATA was established in 1993 as a non-profit organization and is headquartered
in Washington. Links to telemedicine organizations in other countries
can be found on the
ATA web site .