Most historical reviews of telemedicine, such as one on a Stanford Web site, credit NASA's efforts during the 1960s to transmit physiologic signals from astronauts via satellite as the first efforts in telemedicine or telehealth. NASA also funded a range of research and demonstration projects in the late 1960's and 1970's, and according to Basher et al (1975) there were 15 active projects by the mid-1970's. These included study of use of video of varying quality for telediagnosis. Thus some of these went beyond evaluation of pysiologic parameters in healthy astronauts to actual medical applications.

By the 1980s the military was more formally engaged in telemedicine activities, including both store and forward exchange of medical images and videoconferencing. Most of these applications centered on the needs of military physicians, and in particular access to specialists.

In the early 1990's, several federal agencies initiated important telemidicine activities. One was the Office for Rural Healthcare, later to be renamed the Office for the Advancement of Telehealth (OAT), which initiated a large grants program that established telemedcine networks over half of all states. This included support for technical infrastructure, such as T1 lines and videoconferencing systems. A typical network used the hub-stoke model, and had about 15 or 20 sites. Because many of these awards were made before the H.320 videoconferening standard hit in the mid-1990's, many of these hub-spoke networks were very expensive, and used proprietary equipment from a one of several vendors in the videoconferencing market. OAT also coordianted the Joint Working Group on Telehealth, a collection of about a dozen federal agencies that were involved in either funding or implementing telemedicine programs. These included the National Library of Medicine (NLM), which funded a large grants program targeting infrastructure for accessing information and services, and both the VA Medical Center and Department of Defense (DOD). The tri-services telemedicine operation was centered in Fredrick Maryland.

In addition to high-tech hub-spoke infrastructure, the 1990s produced many lower-tech grass roots efforts that took advantage of the high penetration (~95%) of standard POTS phone lines within our society. Many of these were ad hoc efforts by nurses working in a rural environment, often taking advantage of the H.324 standard for POTS-based videophones to augment phone calls. Several integrated home telehealth products also reached the marketplace, although the costs for such systems tended to be an order of magnitude higher than the roughly $400 price tag for a standard videophone. Such telehealth systems transmitted vital signs or exercise parameters, signals with low sampling rates that can be easily transmitted to a central nursing station. Signals with higher sampling rates, such as ECGs, also started to be transmitted. By 1998 this instructor had evaluated nearly every H.324 videophone, and a good number of integrated home telehealth products. In this class you will have the opportunity to try several H.324 videophones.

An important byproduct of these home telehealth applications was that the concept of "telehealth" emerged as the appropriate term for the field, with terms such as "telemedicine" and "telehomecare" viewed as subsets of telehealth.

Within this context, the hub-spoke hospital networks normally target telemedicine, for example specialized teleconsultations between clinicians. Such a "clinician-as-client" telemedicine model is loosely analogous to the "medical model" approach to rehabilitation. OAT studies showed that many of these hub-spoke networks ended up being underutilized.

Home teleheatlth applications, in contrast, focused on "access to health" and thus a patient-as-client model, and were often seen as an replacement for, or aumentation of, home health visits by nurses and other professions. Various studies have suggested that the cost of a typical televisit was about one-quarter of the cost of a physical visit (e.g., $25 vs $100). There are, of course, tradeoffs with the lower bandwidth, as will be evident when you have the opportunity to experience these various technologies.

By 1997, potential applications of telehealth approaches were being explored in many fields of healthcare, including rehabilitation. Telerehabilitation is a remarkably new field, essentially "created" in 1997 when the National Institute on Disability and Rehabilitation Research (US Department of Education) issued a set of proposed priorities for a new Rehabilitation Engineering Research Center (RERC) in the area of what was called tele-rehabilitation. The scientific and technical objectives of the RERC on Telerehabilitation were embodied in the four "priorities" originally defined in the request for applications published in the Federal Register (7). Mildly paraphrased, these are:

1. develop and evaluate telecommunication techniques for delivering training, education and counseling rehabilitation services at a distance;
2. develop and evaluate technologies for assessment and monitoring of progress and outcome of rehabilitation at a distance;
3. develop and evaluate technologies for therapeutic intervention at a distance; and
4. conduct research on applications of virtual reality technologies to rehabilitation. 

Notice the technology- and process-oriented nature of these objectives, the first three of which can be procedurally viewed as, respectively, as teleconsultation, telemonitoring/teleassessment, and teletherapy.  Notice also the emphasis on the delivery of conventional clinical services, with a special focus on research that will yield access to services in underserved (e.g., rural) geographic areas.

Not yet mentioned is IP-based teleconferencing. It didn't really surface until the late 1990's, when a number of producted surfaced. The most notable product of this type was Microsoft's Netmeeting package. Because this package was free, it quickly emerged as the de-facto gold-standard for minimal H.323 interoperability. Various third packages added value, such as multipoint conferencing. In 1998 this instructor, along with Donal Lauderdale, evaluated 9 such products. While there was generally good interoperability and functional systems, and the value-added of shared whiteboards and applications, the time delays of nearly one-half second and the varying quality of service associated with the Internet limited the utility of these products. Netmeeting was also integrated into packages such as MSN Messenger. You will have the opportunity to experience IP-based videoconferening, wich started to take off in the late 1990's with the H.323 standard. Many, including your instructor, see this as the future, and later this semester we will compare this standard with a fascinating alternative call SIP (Session Initiation Protocol).

Of note is that in recent years, implementation of IP-conferencing protocols, especially for voice over Internet (VoIP) are now getting to the point where the quality rivals conventional POTS telephones. And as you will experience first-hand, videoconferencing is also possible using devices such as PocketPCs. Thus the technical barriers to the dream -- universal access to voice, video and data -- is gradually becoming a reality.

In this class we will explore the opportunities.

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