What is Telehealth?

What is Telehealth?

Telehealth is the remote provision of healthcare services and health education, mediated by technology. You may hear other similar terms such as telemedicine, e-health, connected health and health telematics – we consider the differences between these terms to be so minor that they are essentially equivalent. The important common thread between all of these terms is that technology is used to break down barriers of geography and access to health care and education.
If you are really interested in pursuing the semantic differences between these terms, we invite you to check out these links:

Wikipedia Definitions:

Operational Modes of Telehealth

There are two primary modes of telehealth: (1) real-time (synchronous) and (2) store-and-forward (asynchronous). Real-time telehealth sessions are live and interactive, and frequently use videoconferencing technologies. Often, special telehealth-enabled instruments (peripherals), such as a video otoscope (to examine the ear) or an electronic stethoscope, are operated by a nurse or technician at the consulting provider’s direction to remotely perform a physical examination. In store-and-forward telehealth, data (such as digital photographs) are captured locally, then temporarily stored (cached) for transfer at a later time, either via a secure web server, encrypted e-mail, specially-designed store-and-forward software, or electronic health record. The consulting provider then reviews the stored data and makes diagnosis, treatment, and planning recommendations that are electronically transferred or faxed back to the referring provider. UM TeleHealth uses both modes in different projects – for example real-time in our CMS applications (hyperlink) and store-and-forward with the Great Plains Regional Medical Command (link).

Recently, a hybrid approach has been developed, that has both real-time and store-and-forward elements. For example, a hybrid teledermatology method may use a digital camera to capture high resolution pictures of the skin that the consulting dermatologist reviews prior to a real-time videoconferencing session.

Benefits of Telehealth

Access — Telehealth extends medical/health expertise across geographic barriers using technology. Telehealth improves access to primary and specialty medical care, which is increasingly important to address current and projected physician and specialist shortages. Specialists can be virtually co-located in primary care and other settings where specialty services are scarce or unavailable.

Convenience – Patient satisfaction with telehealth has been widely demonstrated, as specialty services are provided closer to home. Providers in remote clinics can stay connected with their colleagues at hospitals and academic medical centers and receive continuing education in latest evidence based practices.

Quality – Patients can receive earlier medical intervention by more timely access to specialists’ opinions via telehealth. Technology allows the entire care team – primary care providers, nurses, specialists, and family members – to collaborate. Remote monitoring and home telehealth have been demonstrated to improve disease management and drastically reduce re-hospitalization and emergency department visits.

Cost – Telehealth can reduce the cost of healthcare and increase efficiency through reduced patient and provider travel, better management of chronic diseases, shared health professional staffing, and fewer as well as shorter hospital stays.

Telehealth Technology Basics

Telehealth involves many different technologies, including networking and telecommunications, multimedia collaboration, devices and sensors, and health information technology. It is important to have a general grasp on how these technologies work in order to understand the possibilities and limits of telehealth. All applications of telehealth rely on telecommunications and data networks, so we will begin with an overview of the involved concepts and terminology of networking.

Networking and Telecommunications Concepts

Fundamentally, telehealth involves the capture, management, and transmission of bits of data. The volume of bits that a network can carry is known as bandwidth, which is normally characterized in bits/second (bps). A digital telephone line can carry up to 64 kilobits per second (kbps). Telecommunications providers ordinarily sell aggregates of multiple phone lines (called multiplexing) to provide higher bandwidth services, such as T-1 (DS-1), which is 24 phone lines (1.54 Mbps) and Integrated Services Digital Network (ISDN), which is 3 digital phone lines for a Basic Rate Interface (BRI). ISDN can also be purchased in an aggregate similar to a T-1, known as a Primary Rate Interface (PRI). Both T-1 and ISDN services are leased circuits that logically act as a direct connection from one point to another. As such, these types of services are circuit-switched, in that the connection may have several intermediate telephone company switches in the path, but the connection acts like a dedicated path between two points. The benefit of circuit-switched services is that element of dedication – the user/organization determines what network traffic travels that path – meaning that this circuit can be used only for telehealth if so desired.

Internet Protocol (IP) and Ethernet are packet-switched networks, which means that data are broken into small units (packets) before they are transferred over a network. Individual packets travel through a network and its switches and routers that optimize the best route for that packet. So, in theory, a file that is comprised of 100 packets could be transferred via 100 different paths before it is reassembled at its final destination. Also, since the network is shared by multiple users and applications, the packets are subject to congestion and collisions (just like car traffic on a freeway at rush hour). Therefore, time-sensitive applications like videoconferencing can suffer performance losses over IP networks, and IP telehealth networks must be designed with this in mind. Home broadband networks, such as cable modem and Digital Subscriber Line (DSL) are packet-switched. Also, both of these services are commonly asymmetric (unless you pay extra) in that the bandwidth is higher in one direction than in the other. Usually, the connection to your home or office (download/inbound) is faster than in the upload/outbound direction. The benefit of IP networks is that they can simultaneously support many users and applications – the same connection that a remote clinic uses for telehealth could also be used for Internet access, e-mail, electronic health records, etc.

Videoconferencing and Multimedia Collaboration

Raw (uncompressed) audio and video would require extremely high bandwidth networks that would be prohibitively expensive for telehealth. Fortunately, properties of the human senses of vision and hearing allow for these data to be compressed with little or no perceived difference. A CODer-DECoder (CODEC) is the core technology that accomplishes this compression pre-transmission and decompression post-transmission. A CODEC often refers to a standalone videoconferencing device or appliance; but a CODEC may also refer to the software or algorithm that performs the compression/decompression. Another common term for a videoconferencing system is an endpoint – a hard endpoint (hardware) referring to a videoconferencing device/appliance or a soft endpoint referring to a system that uses software on a personal computer with an attached video camera, microphone, and speakers (or headphones).

Today’s videoconferencing endpoints also have many additional features and options. Two channels can be transmitted and received simultaneously, for example digital sides alongside a presenter. Built-in multipoint conferencing allows three or more sites (up to four, sometimes eight) without needing a dedicated (and expensive) hardware multipoint conferencing unit (MCU).

There are two primary standards for IP videoconferencing systems – International Telecommunications Union (ITU) H.323 [link: http://www.itu.int/rec/T-REC/e] and Session Initiation Protocol (SIP) [IETF RFC 3261; link: http://www.ietf.org/rfc/rfc3261.txt?number=3261]. Traditionally, ITU H.323 has been supported by the hardware endpoint manufacturers, while SIP has soft endpoint developers as its proponents. Currently, there are several efforts underway to bridge the two standards.

Telehealth devices (peripherals)

There are a variety of different devices (peripherals) that can be used to expand the capabilities of a telehealth system. Telehealth-enabled physician’s examination instruments, such as a video otoscope (ear), dermascope (skin) or electronic stethoscope (heart, lung, bowel sounds) can be connected to a digitizer or videoconferencing endpoint for remote examination. Similarly, other medical diagnostic equipment with standard video outputs can be used for telehealth, for example, ultrasound (adult or pediatric echocardiogram, OB/GYN, abdominal, B-scan [eye]), ocular imaging equipment (fundus camera, slit lamp, or optical coherence tomograph), endoscopes (rhinolaryngoscope, culposcope, sigmoidoscope, etc.). There are also many different examples of network-enabled biomedical/physiological monitoring devices that can be used for telehealth (e.g. ECG, EEG, EMG, vital signs monitors, glucometers, weigh scales, spirometers, etc.). Consumer electronics are being increasingly used in telehealth – digital cameras are often used in store-and-forward dermatology