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Publication Date: 2001
Publication Type: TUTORIAL
Telemedicine, the use of computer and networking technologies
to remotely deliver healthcare services or information, was conceived
as a way to extend care to places where local services were
unavailable, too expensive, or too inconvenient. Today, telemedicine is
also applicable when viable on-site options exist because it enables
institutions to control costs, increase productivity, and improve
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Telemedicine is the remote delivery of patient
services, professional collaboration, education, or administrative
support using any telecommunications technology.
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The attraction is that it gives the healthcare industry a way
to benefit from economies of scale, “just-in-time” capacity, and
optimized resource utilization, which other industries have been taking
advantage of for a long time. And the benefits are not all on the
institutional side of the ledger. Telemedicine can increase
quality of care, yield better medical outcomes, and improve the patient
experience by delivering resources in less time and for a lower cost.
The ability to diagnose and treat patients from a distance means that
patients incur less expense, are less likely to be stressed by being
removed from familiar and comfortable surroundings, and are less likely
to be exposed to endemic pathogens in hospital environments.
Applications include teleradiology, in which x-rays or other diagnostic
images are electronically transmitted off-site for remote diagnosis;
telesurgery and teledentistry, in which a doctor remotely controls a
robotic arm in order to operate on a patient; and telerehabilitation
and telepsychiatry, where specialists conduct sessions using
The initial interest in telemedicine was driven largely by the
need to deliver advanced healthcare services to rural areas. But
telemedicine is now being used for a broader range of patients and for
a variety of reasons. Growth in the field is fueled by the
increased availability of high-bandwidth communications and significant
decreases in the price of hardware and software. Despite these
advances, however, healthcare providers often struggle to pick the
right products and implement them successfully. Providers should
proceed pragmatically and realistically, starting with small-scale
implementations and then expanding their programs in measured steps.
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Telemedicine is the delivery of medical data or services over
a distance. (The terms “telemedicine” and “telehealth” are sometimes
used to refer to different concepts. There is no widespread agreement
on the distinction, however, so the terms will be used interchangeably
in this report.) For years, telemedicine has been successfully
used for a variety of critical services, but the practice is still
maturing. Improvements in telecommunications speeds and
mobile communications have made the technology much more convenient and
reliable. These advancements have pushed telemedicine into more parts
of the healthcare system and have made it feasible to use for an even
wider variety of purposes.1
A key motivator in the development of telemedicine is that
geographic isolation should not be a barrier to people seeking care or
to those wishing to provide it. The benefits of telemedicine are that
patients receive expert care from otherwise inaccessible specialists,
and the delivery system saves money by fully utilizing scarce
resources. For example, telemedicine enables a patient in
rural Iowa to receive an ophthalmic examination from a doctor in
Philadelphia, or it enables a doctor in a hospital to remotely perform
medical screenings for inmates in prison. (The corrections
industry was an early adopter of telemedicine practices because it
created significant savings in transportation costs and allowed inmates
to receive care without creating a security risk.)
Examples of leading telemedicine programs include the
- Arizona Telemedicine Program at the University of Arizona
- Children’s Hospital of Pittsburgh Telemedicine Program
- United States Department of Veterans Affairs
- University of Kansas Center for Telemedicine &
- University of Maryland Greenebaum Cancer Center
- University of Virginia Center for Telehealth
The most common applications of telemedicine include the following:
- Videoconferencing – The most
basic and common
application of videoconferencing in healthcare is to enable doctors to
discuss a patient’s diagnosis or treatment. More advanced applications
allow field devices such as video cameras in ambulances to wirelessly
link paramedics to hospitals before they arrive with a patient. Doctors
use this technology to, for instance, quickly diagnose stroke victims
and in so doing, save brain tissue. In this scenario, physicians read
diagnostic-quality video that is beamed to them and subsequently walk
paramedics through neurological tests.
- Teleradiology – Teleradiology
is the transmission of
x-rays and other medical images from one source to another for
diagnosis. This technology has become fairly common, and it is not
unusual for a doctor in India, for instance, to read the x-rays of a
US-based patient and then provide a diagnosis. This arrangement has two
potential benefits for radiology centers. First, it enables them to
provide patients with a diagnosis when a local radiologist is not
available; this could occur during holidays or off-hours, or when a
small or rural facility does not have a staff radiologist. Second, it
provides an opportunity to control costs by using doctors who charge
lower rates, which usually is the case when a doctor in the US is
replaced by a doctor in another country. Teleradiology has blossomed
because of the growth of broadband networking and advancements in the
digitization of medical images. Also, the Digital Imaging and
Communications in Medicine (DICOM) standard is supported by almost all
imaging devices, making it easier to share diagnostic images in
standardized formats between facilities.
- Remote Monitoring of Patients
– Telemedicine has
broadened its reach beyond hospitals and into private doctors’ offices
and even people’s homes. Patients can be monitored for any number of
conditions without being in a hospital. Having patients convalesce at
home reduces costs for them and for hospitals, and it increases a
- Telesurgery – Telesurgery
applications allow surgeons
to remotely control a robotic arm to perform surgery. The US military
has studied and developed this technology for use on the battlefield,
and several American medical centers and research organizations have
also been pioneers. An example of the latter is the Center for Medical
Robotics and Computer Assisted Surgery at Carnegie Mellon University.
- Mental Health Services –
Telemedicine has been
applied to the delivery of mental health services. This is particularly
useful in rural areas where there is a shortage of mental health
professionals. To address this shortage, mental health professionals
set up videoconferencing sessions with rural patients.
- Administration – An increasing
number of medical
offices are relying on telecommunications to exchange information on
patient eligibility, claims processing, scheduling, and medical records.
Roughly 25-percent of doctors use telehealth technology, an increase from
5-percent in 2015, according to a 2019 study by American Well, a telehealth company.2
And the same study predicts that the extent of use will continue
growing, driven in part by doctors expanding their applications of the technology beyond what they practice today.
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The Broadening of Telemedicine’s Applications
Many of the technical barriers that once hampered the
development of telemedicine are gone or disappearing. In
particular, there is now enough bandwidth available to support more
advanced services, and the technology needed is becoming
increasingly affordable. A study published in 2016 found the following:
“Telemedicine continues to evolve from a specialty offering to a
mainstream service. Nearly two-thirds of survey participants noted
telemedicine as their top priority or one of their highest priorities
for their healthcare organizations. This represents a 10% increase from
2015.”3 Respondents said that the main goals of
using telemedicine were “improving patient outcomes, improving patient
convenience and increasing patient engagement and satisfaction,” while
the main problems being encountered relate to “reimbursement and EMR
Historically, telemedicine was primarily used as a fallback
when the delivery of conventional onsite services was difficult or
impossible. For instance, an x-ray might be sent off-site when a
facility did not have a radiologist on call, or a highly-specialized
doctor in a remote city might participate in the treatment of a patient
suffering from a rare condition. Beginning several years ago, however,
remote medical services became feasible even when there were viable
on-site options. “There has been a shift in the belief that
telemedicine can only be used for rural areas to a belief that it can
be used anywhere,” explained American Telemedicine Association board
member Dr. Peter Yellowlees in 2012.5
“Before, you had to make do with poor quality, or buy a very expensive
system. Now, you can buy a $100 webcam and do high-quality
Today, the technology is being leveraged to control costs,
productivity, and improve the quality of services. As part of this
trend, healthcare providers are focusing more on wellness, preventive
medicine, consumer access to self-help information, and doctors’
communication with patients through e-mail. Even cell phone use within
hospitals is becoming more common as a fast and convenient way for
doctors to talk to patients and other healthcare personnel. (This last
development also reflects a slight easing of restrictions on cell phone
use in hospitals.6 Cell phones now create less
electromagnetic interference than they did years ago, and
newer medical devices are less susceptible to interference.)
Researchers have been investigating the effectiveness of
telemedicine for a broader range of treatments, including the following
2019 study by researchers at the Washington University School of
Medicine in St. Louis found that telemedicine had the potential to expand
infectious disease consultations into regions in which they are not
- A wide scale literature review
published in 2019 by a large group of investigators found that results
of telehealth consultations matched or improved upon the results of
But opinions in the industry aren’t unanimous about telemedicine’s
quality in all areas of care. “While I think that there’s a
lot of evidence that telemedicine can be
equal quality in many circumstances, I think people have expanded that
too far, and at least in some work that we have ongoing we’ve
documented that in [direct-to-consumer] telemedicine there are serious
quality gaps in terms of antibiotic prescribing,” says Ateev Mehrotra,
a doctor and professor at Harvard Medical School as well as a
staff member at Beth Israel Deaconess Medical Center.9
WebMD is only one of a growing number of sites that allow
anyone with Internet access to obtain health information. People who go
to these sites are, in essence, receiving information about a medical
condition from a remotely located professional. More people are
researching everything from simple aches and pains to major ailments,
further educating themselves for when they sit down face-to-face with a
Introductions of new drugs and expanding treatment options
have driven consumers to their computers for online purchasing and
physician access. Online businesses like drugstore.com not only offer
easy access to prescriptions, but also to health aids, nutrition and
wellness products, over-the-counter medications, and personal care
products. Furthermore, home-based medical evaluation services – such as
the Partners Online Specialty Consultation site offered by a group of
Boston-area hospitals – provide Web-based, physician-produced second
opinions for people who question a diagnosis or treatment approach.
Unresolved Legal Questions
The issues involved in telemedicine
law are very broad, spanning how doctors should be licensed across
states, the safety of patients, and mechanisms for ensuring privacy.10
With such issues unsettled, concerns about malpractice and how the
concept might be applied to telemedicine loom over doctors.11
The legal issues surrounding telemedicine are still being
out. In particular, there is a focus on licensing issues in cases in
which a patient in one state receives treatment from a provider in
another state. Laws have not yet caught up with the growth of
so providing services across states is still often forbidden, and
penalties for violating such laws can be as severe as losing one’s
license. 12 One effort to solve this problem is
the Interstate Medical Licensure Compact, which asks states to
agree to allow services to be provided across their borders. To
date, 29 states plus Washington, D.C, have joined the compact.13
The Affordable Care Act
Telemedicine is one way to handle the new
volume of patients that have been generated by the Affordable Care Act
a more efficient and cost-effective way to deliver services. The ACA
also penalizes hospitals for excessive readmissions, which telemedicine
could help to limit.14 Patients will be able to
access doctors remotely without being readmitted to the hospital.
Telehealth monitors can help doctors to remotely address issues before
they become severe enough to require a readmission. Preliminary
evidence suggested that the ACA is succeeding in
increasing the use of telemedicine.15
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A Growing Market
Forecasts predict substantial growth in the
market (although the technologies that are included in the market vary
from study to study, which leads to variances in the estimates):
- According to Transparency Market Research, the worldwide
market for telehealth will grow at a compound annual rate of 13-percent
until 2025, when it will reach $19.5 billion.16
- According to Mordor Intelligence, the worldwide
market for telemedicine will grow at a compound annual
rate of 18.8-percent until 2023, when it will reach $32.8 billion.17
But while there is a strong market for the technology underlying
telemedicine, some evidence suggests that the concept is not being used
for a substantial portion of care. A study published in December 2018
found that telemedicine was
“still the exception rather than the rule.”18
The growing adoption of standards for exchanging
administrative and clinical data is propelling the acceptance of
telemedicine. Health Level 7 (HL7), an all-volunteer, worldwide
coalition of healthcare providers, administrators, and payers, offers a
framework for the exchange, integration, sharing,
and retrieval of medical data. The HL7 framework and its underlying
standards aim to reduce costs, improve the portability of
medical records, and support the extension of health services to rural
areas. Given the consequences – human and financial – of poor medical
practice, telemedicine is increasingly becoming a discipline driven by
standards and best practices. (For a discussion of healthcare IT
standards, see “IT Standards for the Healthcare Industry” in Faulkner’s
Advisory on Computer and
Telemedicine is a popular subject of legislation at both the state and
federal levels. In 2019, more than 100 bills passed across 35 states, with goals varying from defining policies for licensing
doctors across state borders to providing grants and other types of
The US federal government funds
telemedicine, especially deployments in rural areas. For example, in
2019 the US Department of Agriculture approved 133 grants, many in
moderate-sized grants of a few hundred-thousand dollars for a single
provider.21 Apart from legislation and financial
help, the government is supporting
others ways. For instance, the federal government operates telehealth
resource centers that help providers establish telemedicine services.
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Equipment and Infrastructure. A
variety of telecom technologies are needed to transfer, store, and
process electronic medical data such as high-resolution images, audio,
and live video. The rapid growth and diversification of broadband
networking – from cloud computing to streaming video to mobile
communications – has made such technologies more effective, reliable,
and affordable. The choices a provider makes about what
technology to use depend largely on the medical application (e.g.,
dermatology, cardiology, psychiatry, home healthcare, pharmaceuticals)
and on its current and projected needs. Questions about what happens if
equipment (or the network it is running on) fails are becoming
increasingly more important as telemedicine is being applied to more
life-critical areas like telesurgery.
Cost. The equipment and software
used in some telemedicine applications remain expensive, but for most
applications, prices have dropped significantly. This has attracted
medical facilities for which the technology was once unaffordable. Even
so, the markets that could benefit the most from telemedicine, such as
rural areas or developing nations, may still find some telemedicine
technologies to be out of reach.
Telemedicine should be initially adopted on a small scale to
ensure that it supports and accommodates the business processes for
providing distance delivery of healthcare. Also, clinicians should
receive thorough training to develop the technical communications
skills they need before attempting to operate a telemedicine system.
The basic stages of implementation for a telemedicine project
include the following:
- Pilot Project – A trial run
set up for limited use
between two locations can test the viability of the technologies and
services that will support telemedicine. The idea is to measure the
impact on healthcare delivery in a narrowly defined environment and
clear up any system bugs before committing additional resources and
- Internal Integration –
Involving more commitment than
a pilot project, internal integration presumes a high comfort level
the technologies and services involved. It entails the systematic
implementation of telemedicine in the normal course of healthcare
delivery and, as the benefits become apparent to additional geographic
locations, usage can be expanded accordingly.
- Process Redesign – This stage
existing healthcare operations to make the most advantageous use of the
various technologies and services. Although this can produce noteworthy
improvements in efficiency and productivity, its success hinges on the
participation of every department within a healthcare organization.
- Network Engineering –
Extending process redesign to
all participants, network engineering can produce the most efficiencies
and economies of scale, but it is also more difficult to implement and
manage because all participants must be willing to change their
Telemedicine Is Transforming Health Care.” The Wall Street
Journal. June 26, 2016.
“How Has Telemedicine Technology Changed
in Recent Years?” AMD Global Medicine. May 23,
2 Heather Landi. “1 in 5 Physicians Use
Telehealth. Burnout May Drive More Adoption, Survey Says.” FierceHealthcare.
April 15, 2019.
3 REACH Health. “2016 U.S. Telemedicine
Industry Benchmark Survey.” REACH Health. 2016.
5 Pam Belluck. “With Telemedicine as
Bridge, No Hospital Is an Island.” The New York Times.
October 8, 2012.
6 See, for instance:
The McGill University Health Centre. “MUHC Lifts Restrictions on Cell Phone Use in Hospitals.”
The McGill University Health Centre. November 1, 2012.
The Japan Times. “New Guidelines Ease Restrictions on Cellphone Use at Hospitals.” The
Japan Times. August 19, 2014.
7 Rachel Lutz. “How Effective
is Telemedicine for Infectious Disease Consultations?” Contagion. December
Northwest Evidence-based Practice Center. “Telehealth for Acute and
Chronic Care Consultations.” Comparative
Effectiveness Review (Number 216).
9 Jonah Comstock. “Experts Debate
Telemedicine Merits and Myths.” MobiHealthNews.
October 12, 2018.
10 Patrick Connelly. “Legal Questions
Exist in Telehealth’s Promising Future.” Buffalo Law Journal.
July 15, 2019.
11 Bonnie G. Ackerman. “Is the Doctor In?
Medical Malpractice Issues in the Age of Telemedicine.” National Law Review.
April 17, 2019..
Marcie M. Damisch.
“Telemedicine Licensure and Related Challenges for Physicians. Medical Economics.
April 10, 2018
Office of the National
Coordinator for Health Information Technology. “Are There State
Licensing Issues Related to Telehealth?” ONC. April 15, 2019.
13 Andis Robeznieks.
“Interstate Medical Licensure by the Numbers. American Medical Association.
October 11, 2019.
14 Elena Malykhina. “Home Is Where the
Health Is: Obamacare Positions ‘Telehealth’ Tech as a Remedy for
Chronic Hospital Readmissions.” Scientific American.
April 9, 2013.
15 Michelle Rosenfeld. “The ACA and
Telehealth: Mutually Beneficial?” California Healthline.
June 3, 2015.
16 Heather Landi. “Report:
Telehealth Market Estimated to Reach $19.5B by 2025.” Healthcare
Informatics. April 2, 2018
17 Mordor Intelligence.”Telemedicine Market Share,
Analysis, Size.” Mordor Intelligence.
K. Kane and Kurt Gillis. “The Use of Telemedicine by Physicians: Still
the Exception Rather Than the Rule.” Health Affairs.
19 Geoff Keston. “IT Standards for the
Healthcare Industry.” Faulkner’s
Advisory on Computer and Communications Technologies.
20 Center for Connected Health Policy.
“2019 in Review: State and Federal Telehealth Policy — Legislative
21 Dave Muoio. “USDA Announces
Dozens of Grants to Support Rural Telehealth Rollouts.” MobiHealthNews.
December 3, 2019.
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About the Author
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Geoff Keston is the author of
more than 250 articles that help organizations find opportunities in
business trends and technology. He also works directly with clients to
develop communications strategies that improve processes and customer
relationships. Mr. Keston has worked as a project manager for a major
technology consulting and services company and is a Microsoft Certified
Systems Engineer and a Certified Novell Administrator.
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