Telehealth

Store-and-forward telemedicine involves acquiring medical data (like medical images, biosignals etc.) and then transmitting this data to a doctor or medical specialist at a convenient time for assessment offline.[8] It does not require the presence of both parties at the same time.[13] Dermatology (cf: teledermatology), radiology, and pathology are common specialties that are conducive to asynchronous telemedicine. A properly structured medical record preferably in electronic form should be a component of this transfer. The 'store-and-forward' process requires the clinician to rely on a history report and audio/video information in lieu of a physical examination.

Telehealth Blood Pressure Monitor

Remote monitoring, also known as self-monitoring or testing, enables medical professionals to monitor a patient remotely using various technological devices. This method is primarily used for managing chronic diseases or specific conditions, such as heart disease, diabetes mellitus, or asthma. These services can provide comparable health outcomes to traditional in-person patient encounters, supply greater satisfaction to patients, and may be cost-effective.[14] Examples include home-based nocturnal dialysis[15] and improved joint management.[16]

Electronic consultations are possible through interactive telemedicine services which provide real-time interactions between patient and provider.[13] Videoconferencing has been used in a wide range of clinical disciplines and settings for various purposes including management, diagnosis, counseling and monitoring of patients.[17]

Videotelephony comprises the technologies for the reception and transmission of audio-video signals by users at different locations, for communication between people in real-time.[18]

At the dawn of the technology, videotelephony also included image phones which would exchange still images between units every few seconds over conventional POTS-type telephone lines, essentially the same as slow scan TV systems.

Currently videotelephony is particularly useful to the deaf and speech-impaired who can use them with sign language and also with a video relay service, and well as to those with mobility issues or those who are located in distant places and are in need of telemedical or tele-educational services.

U.S. Navy medical staff being trained in the use of handheld telemedical devices (2006).

Common daily emergency telemedicine is performed by SAMU Regulator Physicians in France, Spain, Chile and Brazil. Aircraft and maritime emergencies are also handled by SAMU centres in Paris, Lisbon and Toulouse.[19]

A recent study identified three major barriers to adoption of telemedicine in emergency and critical care units. They include:

• regulatory challenges related to the difficulty and cost of obtaining licensure across multiple states, malpractice protection and privileges at multiple facilities
• Lack of acceptance and reimbursement by government payers and some commercial insurance carriers creating a major financial barrier, which places the investment burden squarely upon the hospital or healthcare system.
• cultural barriers occurring from the lack of desire, or unwillingness, of some physicians to adapt clinical paradigms for telemedicine applications.[20]

Telemedicine system. Federal Center of Neurosurgery in Tyumen, 2013

Emergency Telehealth is also gaining acceptance in the United States. There are several modalities currently being practiced that include but are not limited to TeleTriage, TeleMSE and ePPE.

Medication assisted treatment (MAT) is the treatment of opioid use disorder (OUD) with medications, often in combination with behavioral therapy[21] As a response to the COVID-19 pandemic the use of telemedicine has been granted by the Drug Enforcement Administration to start or maintain people OUD on buprenorphine (trade name Suboxone) via telemedicine without the need for an initial in-person examination.[22] On March 31, 2020 QuickMD became the first national Tele-MAT service in the United States to provide Medication-assisted Treatment with Suboxone online—without the need of an in-person visit; with others announcing to follow soon.[23]

Telenutrition refers to the use of video conferencing/ telephony to provide online consultation by a nutritionist or dietician. Patient or clients upload their vital statistics, diet logs, food pictures etc. on TeleNutrition portal which are then used by nutritionist or dietician to analyze their current health condition. Nutritionist or dietician can then set goals for their respective client/ patients and monitor their progress regularly by follow-up consultations.

Telenutrition portals can help clients/ patients seek remote consultation for themselves and/ or their family from the best nutritionist or dietician available across the globe. This can be extremely helpful for elderly/ bed ridden patients who can consult their dietician from comfort of their homes.

Telenursing refers to the use of telecommunications and information technology in order to provide nursing services in health care whenever a large physical distance exists between patient and nurse, or between any number of nurses. As a field it is part of telehealth, and has many points of contacts with other medical and non-medical applications, such as telediagnosis, teleconsultation, telemonitoring, etc.

Telenursing is achieving significant growth rates in many countries due to several factors: the preoccupation in reducing the costs of health care, an increase in the number of aging and chronically ill population, and the increase in coverage of health care to distant, rural, small or sparsely populated regions. Among its benefits, telenursing may help solve increasing shortages of nurses; to reduce distances and save travel time, and to keep patients out of hospital. A greater degree of job satisfaction has been registered among telenurses.[24]

Baby Eve with Georgia for the Breastfeeding Support Project

In Australia, during January 2014, Melbourne tech startup Small World Social collaborated with the Australian Breastfeeding Association to create the first hands-free breastfeeding Google Glass application for new mothers.[25] The application, named Google Glass Breastfeeding app trial, allows mothers to nurse their baby while viewing instructions about common breastfeeding issues (latching on, posture etc.) or call a lactation consultant via a secure Google Hangout,[26] who can view the issue through the mother's Google Glass camera.[27] The trial was successfully concluded in Melbourne in April 2014, and 100% of participants were breastfeeding confidently.[28][29] Small World Social[30] Breasfteeding Support Project.[31]

Pharmacy personnel deliver medical prescriptions electronically; remote delivery of pharmaceutical care is an example of telemedicine.

Telepharmacy is the delivery of pharmaceutical care via telecommunications to patients in locations where they may not have direct contact with a pharmacist. It is an instance of the wider phenomenon of telemedicine, as implemented in the field of pharmacy. Telepharmacy services include drug therapy monitoring, patient counseling, prior authorization and refill authorization for prescription drugs, and monitoring of formulary compliance with the aid of teleconferencing or videoconferencing. Remote dispensing of medications by automated packaging and labeling systems can also be thought of as an instance of telepharmacy. Telepharmacy services can be delivered at retail pharmacy sites or through hospitals, nursing homes, or other medical care facilities.

The term can also refer to the use of videoconferencing in pharmacy for other purposes, such as providing education, training, and management services to pharmacists and pharmacy staff remotely.[32]

Teledentistry is the use of information technology and telecommunications for dental care, consultation, education, and public awareness in the same manner as telehealth and telemedicine.

Tele-audiology is the utilization of telehealth to provide audiological services and may include the full scope of audiological practice. This term was first used by Dr Gregg Givens in 1999 in reference to a system being developed at East Carolina University in North Carolina, USA.

Teleneurology describes the use of mobile technology to provide neurological care remotely, including care for stroke, movement disorders like Parkinson's disease, seizure disorders (e.g., epilepsy), etc. The use of teleneurology gives us the opportunity to improve health care access for billions around the globe, from those living in urban locations to those in remote, rural locations. Evidence shows that individuals with Parkinson's disease prefer personal connection with a remote specialist to their local clinician.Such home care is convenient but requires access to and familiarity with internet.[33][34] A 2017 randomized controlled trial of "virtual house calls" or video visits with individuals diagnosed with Parkinson disease evidences patient preference for the remote specialist vs their local clinician after one year.[34] Teleneurology for patients with Parkison's disease is found to be cheaper than in person visits by reducing transportation and travel time[35][36] A recent systematic review by Ray Dorsey et al.[33] describes both the limitations and potential benefits of teleneurology to improve care for patients with chronic neurological conditions, especially in low-income countries.White, well educated and technologically savvy people are the biggest consumers of telehealth services for Parkinson's disease.[35][36] as compared to ethnic minorities in USA[36]

Teleneuropsychology (Cullum et al., 2014) is the use of telehealth/videoconference technology for the remote administration of neuropsychological tests. Neuropsychological tests are used to evaluate the cognitive status of individuals with known or suspected brain disorders and provide a profile of cognitive strengths and weaknesses. Through a series of studies, there is growing support in the literature showing that remote videoconference-based administration of many standard neuropsychological tests results in test findings that are similar to traditional in-person evaluations, thereby establishing the basis for the reliability and validity of teleneuropsychological assessment.[37][38][39][40][41][42]

Telemedicine in rehabilitation

Telerehabilitation (or e-rehabilitation[43][44]) is the delivery of rehabilitation services over telecommunication networks and the Internet. Most types of services fall into two categories: clinical assessment (the patient's functional abilities in his or her environment), and clinical therapy. Some fields of rehabilitation practice that have explored telerehabilitation are: neuropsychology, speech-language pathology, audiology, occupational therapy, and physical therapy. Telerehabilitation can deliver therapy to people who cannot travel to a clinic because the patient has a disability or because of travel time. Telerehabilitation also allows experts in rehabilitation to engage in a clinical consultation at a distance.

Most telerehabilitation is highly visual. As of 2014, the most commonly used mediums are webcams, videoconferencing, phone lines, videophones and webpages containing rich Internet applications. The visual nature of telerehabilitation technology limits the types of rehabilitation services that can be provided. It is most widely used for neuropsychological rehabilitation; fitting of rehabilitation equipment such as wheelchairs, braces or artificial limbs; and in speech-language pathology. Rich internet applications for neuropsychological rehabilitation (aka cognitive rehabilitation) of cognitive impairment (from many etiologies) were first introduced in 2001. This endeavor has expanded as a teletherapy application for cognitive skills enhancement programs for school children. Tele-audiology (hearing assessments) is a growing application. Currently, telerehabilitation in the practice of occupational therapy and physical therapy is limited, perhaps because these two disciplines are more "hands on".

Two important areas of telerehabilitation research are (1) demonstrating equivalence of assessment and therapy to in-person assessment and therapy, and (2) building new data collection systems to digitize information that a therapist can use in practice. Ground-breaking research in telehaptics (the sense of touch) and virtual reality may broaden the scope of telerehabilitation practice, in the future.

In the United States, the National Institute on Disability and Rehabilitation Research's (NIDRR)[45] supports research and the development of telerehabilitation. NIDRR's grantees include the "Rehabilitation Engineering and Research Center" (RERC) at the University of Pittsburgh, the Rehabilitation Institute of Chicago, the State University of New York at Buffalo, and the National Rehabilitation Hospital in Washington DC. Other federal funders of research are the Veterans Health Administration, the Health Services Research Administration in the US Department of Health and Human Services, and the Department of Defense.[46] Outside the United States, excellent research is conducted in Australia and Europe.

Only a few health insurers in the United States, and about half of Medicaid programs,[47] reimburse for telerehabilitation services. If the research shows that teleassessments and teletherapy are equivalent to clinical encounters, it is more likely that insurers and Medicare will cover telerehabilitation services.

In India, the Indian Association of Chartered Physiotherapists (IACP) is providing telerehabilitation facility. With support and collaboration of local Clinics and privet practitioners and the Members IACP, IACP they are running this facility which they name Telemedicine. IACP has maintained an internet based list of their members on their website, through which patients can make online appointments.

Telemedicine can be utilized to improve the efficiency and effectiveness of the delivery of care in a trauma environment. Examples include:

Telemedicine for trauma triage: using telemedicine, trauma specialists can interact with personnel on the scene of a mass casualty or disaster situation, via the internet using mobile devices, to determine the severity of injuries. They can provide clinical assessments and determine whether those injured must be evacuated for necessary care. Remote trauma specialists can provide the same quality of clinical assessment and plan of care as a trauma specialist located physically with the patient.[48]

Telemedicine for intensive care unit (ICU) rounds: Telemedicine is also being used in some trauma ICUs to reduce the spread of infections. Rounds are usually conducted at hospitals across the country by a team of approximately ten or more people to include attending physicians, fellows, residents and other clinicians. This group usually moves from bed to bed in a unit discussing each patient. This aids in the transition of care for patients from the night shift to the morning shift, but also serves as an educational experience for new residents to the team. A new approach features the team conducting rounds from a conference room using a video-conferencing system. The trauma attending, residents, fellows, nurses, nurse practitioners, and pharmacists are able to watch a live video stream from the patient's bedside. They can see the vital signs on the monitor, view the settings on the respiratory ventilator, and/or view the patient's wounds. Video-conferencing allows the remote viewers two-way communication with clinicians at the bedside.[49]

Telemedicine for trauma education: some trauma centers are delivering trauma education lectures to hospitals and health care providers worldwide using video conferencing technology. Each lecture provides fundamental principles, firsthand knowledge and evidenced-based methods for critical analysis of established clinical practice standards, and comparisons to newer advanced alternatives. The various sites collaborate and share their perspective based on location, available staff, and available resources.[50]

Telemedicine in the trauma operating room: trauma surgeons are able to observe and consult on cases from a remote location using video conferencing. This capability allows the attending to view the residents in real time. The remote surgeon has the capability to control the camera (pan, tilt and zoom) to get the best angle of the procedure while at the same time providing expertise in order to provide the best possible care to the patient.[51]

ECGs, or electrocardiographs, can be transmitted using telephone and wireless. Willem Einthoven, the inventor of the ECG, actually did tests with transmission of ECG via telephone lines. This was because the hospital did not allow him to move patients outside the hospital to his laboratory for testing of his new device. In 1906 Einthoven came up with a way to transmit the data from the hospital directly to his lab.[52] See above reference-General health care delivery. Remotely treating ventricular fibrillation Medphone Corporation, 1989

One of the oldest known telecardiology systems for teletransmissions of ECGs was established in Gwalior, India in 1975 at GR Medical college by Ajai Shanker, S. Makhija, P.K. Mantri using an indigenous technique for the first time in India.

This system enabled wireless transmission of ECG from the moving ICU van or the patients home to the central station in ICU of the department of Medicine. Transmission using wireless was done using frequency modulation which eliminated noise. Transmission was also done through telephone lines. The ECG output was connected to the telephone input using a modulator which converted ECG into high frequency sound. At the other end a demodulator reconverted the sound into ECG with a good gain accuracy. The ECG was converted to sound waves with a frequency varying from 500 Hz to 2500 Hz with 1500 Hz at baseline.

This system was also used to monitor patients with pacemakers in remote areas. The central control unit at the ICU was able to correctly interpret arrhythmia. This technique helped medical aid reach in remote areas.[53]

In addition, electronic stethoscopes can be used as recording devices, which is helpful for purposes of telecardiology. There are many examples of successful telecardiology services worldwide.

In Pakistan three pilot projects in telemedicine was initiated by the Ministry of IT & Telecom, Government of Pakistan (MoIT) through the Electronic Government Directorate in collaboration with Oratier Technologies (a pioneer company within Pakistan dealing with healthcare and HMIS) and PakDataCom (a bandwidth provider). Three hub stations through were linked via the Pak Sat-I communications satellite, and four districts were linked with another hub. A 312 Kb link was also established with remote sites and 1 Mbit/s bandwidth was provided at each hub. Three hubs were established: the Mayo Hospital (the largest hospital in Asia), JPMC Karachi and Holy Family Rawalpindi. These 12 remote sites were connected and on average of 1,500 patients being treated per month per hub. The project was still running smoothly after two years.[54]

Telepsychiatry, another aspect of telemedicine, also utilizes videoconferencing for patients residing in underserved areas to access psychiatric services. It offers wide range of services to the patients and providers, such as consultation between the psychiatrists, educational clinical programs, diagnosis and assessment, medication therapy management, and routine follow-up meetings.[55] Most telepsychiatry is undertaken in real time (synchronous) although in recent years research at UC Davis has developed and validated the process of asynchronous telepsychiatry.[56] Recent reviews of the literature by Hilty et al. in 2013, and by Yellowlees et al. in 2015 confirmed that telepsychiatry is as effective as in-person psychiatric consultations for diagnostic assessment, is at least as good for the treatment of disorders such as depression and post traumatic stress disorder, and may be better than in-person treatment in some groups of patients, notably children, veterans and individuals with agoraphobia.

As of 2011, the following are some of the model programs and projects which are deploying telepsychiatry in rural areas in the United States:

1. University of Colorado Health Sciences Center (UCHSC) supports two programs for American Indian and Alaskan Native populations

a. The Center for Native American Telehealth and Tele-education (CNATT) and

b. Telemental Health Treatment for American Indian Veterans with Post-traumatic Stress Disorder (PTSD)

1. Military Psychiatry, Walter Reed Army Medical Center.
2. In 2009, the South Carolina Department of Mental Health established a partnership with the University of South Carolina School of Medicine and the South Carolina Hospital Association to form a statewide telepsychiatry program that provides access to psychiatrists 16 hours a day, 7 days a week, to treat patients with mental health issues who present at rural emergency departments in the network.[57]
3. Between 2007 and 2012, the University of Virginia Health System hosted a videoconferencing project that allowed child psychiatry fellows to conduct approximately 12,000 sessions with children and adolescents living in rural parts of the State.[58]

There are a growing number of HIPAA compliant technologies for performing telepsychiatry. There is an independent comparison site of current technologies.

Links for several sites related to telemedicine, telepsychiatry policy, guidelines, and networking are available at the website for the American Psychiatric Association.[59][60]

There has also been a recent trend towards Video CBT sites with the recent endorsement and support of CBT by the National Health Service (NHS) in the United Kingdom.[61]

In April 2012, a Manchester-based Video CBT pilot project was launched to provide live video therapy sessions for those with depression, anxiety, and stress related conditions called InstantCBT[62] The site supported at launch a variety of video platforms (including Skype, GChat, Yahoo, MSN as well as bespoke)[63] and was aimed at lowering the waiting times for mental health patients. This is a Commercial, For-Profit business.

In the United States, the American Telemedicine Association and the Center of Telehealth and eHealth are the most respectable places to go for information about telemedicine.

The Health Insurance Portability and Accountability Act (HIPAA), is a United States Federal Law that applies to all modes of electronic information exchange such as video-conferencing mental health services. In the United States, Skype, Gchat, Yahoo, and MSN are not permitted to conduct video-conferencing services unless these companies sign a Business Associate Agreement stating that their employees are HIPAA trained. For this reason, most companies provide their own specialized videotelephony services. Violating HIPAA in the United States can result in penalties of hundreds of thousands of dollars.[64]

The momentum of telemental health and telepsychiatry is growing. In June 2012 the U.S. Veterans Administration announced expansion of the successful telemental health pilot. Their target was for 200,000 cases in 2012.[65]

A growing number of HIPAA compliant technologies are now available. There is an independent comparison site that provides a criteria-based comparison of telemental health technologies.[66]

The SATHI Telemental Health Support project cited above is another example of successful Telemental health support. - Also see SCARF India.[67]

The COVID-19 pandemic has been associated with large increases in telemedicine visits in the United States for various behavioral and psychiatric conditions such as anxiety, bipolar disorder, depression, insomnia, opioid use disorder, and overactivity. During the first two quarters of 2020 (January to June), office-based visits decreased as telemedicine visits increased for these six conditions according to data from IQVIA.[68]

A CT exam displayed through teleradiology

Teleradiology is the ability to send radiographic images (x-rays, CT, MR, PET/CT, SPECT/CT, MG, US...) from one location to another.[69] For this process to be implemented, three essential components are required, an image sending station, a transmission network, and a receiving-image review station. The most typical implementation are two computers connected via the Internet. The computer at the receiving end will need to have a high-quality display screen that has been tested and cleared for clinical purposes. Sometimes the receiving computer will have a printer so that images can be printed for convenience.

The teleradiology process begins at the image sending station. The radiographic image and a modem or other connection are required for this first step. The image is scanned and then sent via the network connection to the receiving computer.

Today's high-speed broadband based Internet enables the use of new technologies for teleradiology: the image reviewer can now have access to distant servers in order to view an exam. Therefore, they do not need particular workstations to view the images; a standard personal computer (PC) and digital subscriber line (DSL) connection is enough to reach keosys central server. No particular software is necessary on the PC and the images can be reached from wherever in the world.

Teleradiology is the most popular use for telemedicine and accounts for at least 50% of all telemedicine usage.

Telepathology is the practice of pathology at a distance. It uses telecommunications technology to facilitate the transfer of image-rich pathology data between distant locations for the purposes of diagnosis, education, and research.[70][71] Performance of telepathology requires that a pathologist selects the video images for analysis and the rendering diagnoses. The use of "television microscopy", the forerunner of telepathology, did not require that a pathologist have physical or virtual "hands-on" involvement is the selection of microscopic fields-of-view for analysis and diagnosis.

A pathologist, Ronald S. Weinstein, M.D., coined the term "telepathology" in 1986. In an editorial in a medical journal, Weinstein outlined the actions that would be needed to create remote pathology diagnostic services.[72] He, and his collaborators, published the first scientific paper on robotic telepathology.[73] Weinstein was also granted the first U.S. patents for robotic telepathology systems and telepathology diagnostic networks.[74] Weinstein is known to many as the "father of telepathology".[75] In Norway, Eide and Nordrum implemented the first sustainable clinical telepathology service in 1989.[76] This is still in operation, decades later. A number of clinical telepathology services have benefited many thousands of patients in North America, Europe, and Asia.

Telepathology has been successfully used for many applications including the rendering histopathology tissue diagnoses, at a distance, for education, and for research. Although digital pathology imaging, including virtual microscopy, is the mode of choice for telepathology services in developed countries, analog telepathology imaging is still used for patient services in some developing countries.

Teledermatology allows dermatology consultations over a distance using audio, visual and data communication, and has been found to improve efficiency, access to specialty care, and patient satisfaction.[77][78] Applications comprise health care management such as diagnoses, consultation and treatment as well as (continuing medical) education.[79][80][81] The dermatologists Perednia and Brown were the first to coin the term "teledermatology" in 1995, where they described the value of a teledermatologic service in a rural area underserved by dermatologists.[82]

Teleophthalmology is a branch of telemedicine that delivers eye care through digital medical equipment and telecommunications technology. Today, applications of teleophthalmology encompass access to eye specialists for patients in remote areas, ophthalmic disease screening, diagnosis and monitoring; as well as distant learning. Teleophthalmology may help reduce disparities by providing remote, low-cost screening tests such as diabetic retinopathy screening to low-income and uninsured patients.[83][84] In Mizoram, India, a hilly area with poor roads, between 2011 till 2015, Tele-ophthalmology has provided care to over 10000 patients. These patients were examined by ophthalmic assistants locally but surgery was done on appointment after viewing the patient images online by Eye Surgeons in the hospital 6–12 hours away. Instead of an average 5 trips for say, a cataract procedure, only one was required for surgery alone as even post op care like stitch removal and glasses was done locally. There were huge cost savings in travel etc.[85]

In the United States, some companies allow patients to complete an online visual exam and within 24 hours receive a prescription from an optometrist valid for eyeglasses, contact lenses, or both. Some US states such as Indiana have attempted to ban these companies from doing business.[86]

Remote surgery (also known as telesurgery) is the ability for a doctor to perform surgery on a patient even though they are not physically in the same location. It is a form of telepresence. Remote surgery combines elements of robotics, cutting edge communication technology such as high-speed data connections, haptics and elements of management information systems. While the field of robotic surgery is fairly well established, most of these robots are controlled by surgeons at the location of the surgery.

Remote surgery is essentially advanced telecommuting for surgeons, where the physical distance between the surgeon and the patient is immaterial. It promises to allow the expertise of specialized surgeons to be available to patients worldwide, without the need for patients to travel beyond their local hospital.[87]

Remote surgery or telesurgery is performance of surgical procedures where the surgeon is not physically in the same location as the patient, using a robotic teleoperator system controlled by the surgeon. The remote operator may give tactile feedback to the user. Remote surgery combines elements of robotics and high-speed data connections. A critical limiting factor is the speed, latency and reliability of the communication system between the surgeon and the patient, though trans-Atlantic surgeries have been demonstrated.

Telemedicine has been used globally to increase access to abortion care, specifically medical abortion, in environments where few abortion care providers exist or abortion is legally restricted. Clinicians are able to virtually provide counseling, review screening tests, observe the administration of an abortion medication, and directly mail abortion pills to people.[88] In 2004, Women on Web (WoW), Amsterdam started offering on-line consultations, mostly to people living in areas where abortion was legally restricted, informing the how to safely use medical abortion drugs to end a pregnancy.[88] People contact the Women on Web service on-line; physicians review any necessary lab results or ultrasounds, mail mifepristone and misoprostol pills to people, then follow-up through on-line communication.[89] In the United States, medical abortion was introduced as a telehealth service in Iowa by Planned Parenthood of the Heartland in 2008 to allow a patient at one health facility to communicate via secure video with a health provider at another facility.[90] In this model a person seeking abortion care must come to a health facility. An abortion care provider communicates with the person located at another site using clinic-to-clinic videoconferencing to provide medical abortion after screening tests and consultation with clinic staff. In 2018, the website Aid Access was launched by the founder of Women on Web, Dr. Rebecca Gomperts. It offers a similar service as Women on Web in the United States, but the medications are prescribed to an Indian pharmacy, then mailed to the United States.

The TelAbortion study conducted by Gynuity Health Projects, with special approval from the U.S. Food and Drug Administration (FDA), aims to increase access to medical abortion care without requiring an in-person visit to a clinic.[91][92][90] This models was expanded during the COVID-19 pandemic and as of March 2020 exists in 13 U.S. states and has enrolled over 730 people in the study.[93][92] The person receives counseling and instruction from an abortion care provider via videoconference from a location of their choice. The medications necessary for the abortion, mifepristone and misoprostol, are mailed directly to the person and they have a follow-up video consultation in 7–14 days. A systematic review of telemedicine abortion has found the practice to be safe, effective, efficient, and satisfactory.[88]

In the United States, eighteen states require the clinician to be physically present during the administration of medications for abortion which effectively bans telehealth of medication abortion: 5 states explicitly ban telemedicine for medication abortion, while 13 states require the prescriber (usually required to be a physician) to be physically present with the patient[94][95] In the UK, the Royal College of Obstetricians and Gynecologists approved a no-test protocol for medication abortion, with mifepristone available through a minimal-contact pick-up or by mail.[96]

Telemedicine can facilitate specialty care delivered by primary care physicians according to a controlled study of the treatment of hepatitis C.[97] Various specialties are contributing to telemedicine, in varying degrees.

In light of the ongoing COVID-19 pandemic, primary care physicians have relied on telehealth to continue to provide care in outpatient settings.[98] The transition to virtual health has been beneficial in providing patients access to care (especially care that does not require a physical exam e.g. medication changes, minor health updates) and avoid putting patients at risk of COVID-19.

Telemedicine has also been beneficial in facilitating medical education to students while still allowing for adequate social distancing during the COVID-19 pandemic. Many medical schools have shifted to alternate forms of virtual curriculum and are still able to engage in meaningful telehealth encounters with patients.[99][100]

Telehealth is a modern form of health care delivery. Telehealth breaks away from traditional health care delivery by using modern telecommunication systems including wireless communication methods.[101][102] Traditional health is legislated through policy to ensure the safety of medical practitioners and patients. Consequently, since telehealth is a new form of health care delivery that is now gathering momentum in the health sector, many organizations have started to legislate the use of telehealth into policy.[102] In New Zealand, the Medical Council has a statement about telehealth on their website. This illustrates that the medical council has foreseen the importance that telehealth will have on the health system and have started to introduce telehealth legislation to practitioners along with government.[103]

Traditional use of telehealth services has been for specialist treatment. However, there has been a paradigm shift and telehealth is no longer considered a specialist service.[104] This development has ensured that many access barriers are eliminated, as medical professionals are able to use wireless communication technologies to deliver health care.[105] This is evident in rural communities. For individuals living in rural communities, specialist care can be some distance away, particularly in the next major city. Telehealth eliminates this barrier as health professionals are able to conduct medical consultations through the use of wireless communication technologies. However, this process is dependent on both parties having Internet access.[105][106][107]

Telehealth allows the patient to be monitored between physician office visits which can improve patient health. Telehealth also allows patients to access expertise which is not available in their local area. This remote patient monitoring ability enables patients to stay at home longer and helps avoid unnecessary hospital time. In the long-term, this could potentially result in less burdening of the healthcare system and consumption of resources.[1][108]

During the COVID-19 pandemic, there have been large increases in the use of telemedicine for primary care visits within the United States, increasing from an average of 1.4 million visits in Q2 of 2018 and 2019 to 35 million visits in Q2 2020, according to data from IQVIA.[109]

The technological advancement of wireless communication devices is a major development in telehealth.[110] This allows patients to self-monitor their health conditions and to not rely as much on health care professionals. Furthermore, patients are more willing to stay on their treatment plans as they are more invested and included in the process as the decision-making is shared.[111][112] Technological advancement also means that health care professionals are able to use better technologies to treat patients for example in surgery. Technological developments in telehealth are essential to improve health care, especially the delivery of healthcare services, as resources are finite along with an ageing population that is living longer.[110][111][112]

Restrictive licensure laws in the United States require a practitioner to obtain a full license to deliver telemedicine care across state lines. Typically, states with restrictive licensure laws also have several exceptions (varying from state to state) that may release an out-of-state practitioner from the additional burden of obtaining such a license. A number of states require practitioners who seek compensation to frequently deliver interstate care to acquire a full license.

If a practitioner serves several states, obtaining this license in each state could be an expensive and time-consuming proposition. Even if the practitioner never practices medicine face-to-face with a patient in another state, he/she still must meet a variety of other individual state requirements, including paying substantial licensure fees, passing additional oral and written examinations, and traveling for interviews.

In 2008, the U.S. passed the Ryan Haight Act which required face-to-face or valid telemedicine consultations prior to receiving a prescription.[113]

State medical licensing boards have sometimes opposed telemedicine; for example, in 2012 electronic consultations were illegal in Idaho, and an Idaho-licensed general practitioner was punished by the board for prescribing an antibiotic, triggering reviews of her licensure and board certifications across the country.[114] Subsequently, in 2015 the state legislature legalized electronic consultations.[114]

In 2015, Teladoc filed suit against the Texas Medical Board over a rule that required in-person consultations initially; the judge refused to dismiss the case, noting that antitrust laws apply to state medical boards.[115]

Baby Eve with Georgia for the Breastfeeding Support Project

Telehealth can also increase health promotion efforts. These efforts can now be more personalised to the target population and professionals can extend their help into homes or private and safe environments in which patients of individuals can practice, ask and gain health information.[108][112][118] Health promotion using telehealth has become increasingly popular in underdeveloped countries where there are very poor physical resources available. There has been a particular push toward mHealth applications as many areas, even underdeveloped ones have mobile phone and smartphone coverage.[119][120][121]

In developed countries, health promotion efforts using telehealth have been met with some success. The Australian hands-free breastfeeding Google Glass application reported promising results in 2014. This application made in collaboration with the Australian Breastfeeding Association and a tech startup called Small World Social, helped new mothers learn how to breastfeed.[122][123][124] Breastfeeding is beneficial to infant health and maternal health and is recommended by the World Health Organisation and health organisations all over the world.[125][126] Widespread breastfeeding can prevent 820,000 infant deaths globally but the practice is often stopped prematurely or intents to do are disrupted due to lack of social support, know-how or other factors.[126] This application gave mother's hands-free information on breastfeeding, instructions on how to breastfeed and also had an option to call a lactation consultant over Google Hangout. When the trial ended, all participants were reported to be confident in breastfeeding.[124]

Theoretically, the whole health system stands to benefit from telehealth. In a UK telehealth trial done in 2011, it was reported that the cost of health could be dramatically reduced with the use of telehealth monitoring. The usual cost of in vitro fertilisation (IVF) per cycle would be around $15,000, with telehealth it was reduced to $800 per patient.[127] In Alaska the Federal Health Care Access Network which connects 3,000 healthcare providers to communities, engaged in 160,000 telehealth consultations from 2001 and saved the state $8.5 million in travel costs for just Medicaid patients.[128] There are indications telehealth consumes fewer resources and requires fewer people to operate it with shorter training periods to implement initiatives.[12]

However, whether or not the standard of health care quality is increasing is quite debatable, with literature refuting such claims.[117][129][130] Research is increasingly reporting that clinicians find the process difficult and complex to deal with.[129][131] Furthermore, there are concerns around informed consent, legality issues as well as legislative issues. Although health care may become affordable with the help of technology, whether or not this care will be "good" is the issue.[117]

In the United States, telemedicine companies are collaborating with health insurers and other telemedicine providers to expand marketshare and patient access to telemedicine consultations. For example, In 2015, UnitedHealthcare announced that it would cover a range of video visits from Doctor On Demand, American Well's AmWell, and its own Optum's NowClinic, which is a white-labeled American Well offering.[150][151] On November 30, 2017, PlushCare launched in some U.S. states, the Pre-Exposure Prophylaxis (PrEP) therapy for prevention of HIV.[152][153][154] June 2019: OakBend Medical Center based in Texas has launched telemedicine cart for patients afflicted with cardiac disorder. The system helps cardiologist to virtually examine the patient and decide if hospitalization is needed.[155]

From 1999 to 2018, the University Hospital of Zurich (USZ) offered clinical telemedicine and online medical advice on the Internet. A team of doctors answered around 2500 anonymous inquiries annually, usually within 24 to 48 hours. The team consisted of up to six physicians who are specialists in clinical telemedicine at the USZ and have many years of experience, particularly in internal and general medicine. In the entire period, 59360 inquiries were sent and answered.[156] The majority of the users were female and on average 38 years old. However, in the course of time, considerably more men and older people began to use the service. The diversity of medical queries covered all categories of the International Statistical Classification of Diseases and Related Health Problems (ICD) and correlated with the statistical frequency of diseases in hospitals in Switzerland. Most of the inquiries concerned unclassified symptoms and signs, services related to reproduction, respiratory diseases, skin diseases, health services, diseases of the eye and nervous systems, injuries and disorders of the female genital tract. As with the Swedish online medical advice service,[157] one-sixth of the requests related to often shameful and stigmatised diseases of the genitals, gastrointestinal tract, sexually transmitted diseases, obesity and mental disorders. By providing an anonymous space where users can talk about (shameful) diseases, online telemedical services empower patients and their health literacy is enhanced by providing individualized health information. The Clinical Telemedicine and Online Counselling service of the University Hospital of Zurich is currently being revised and will be offered in a new form in the future.[158]

Although, traditional medicine relies on in-person care, the need and want for remote care has existed from the Roman and pre-Hippocratic periods in antiquity. The elderly and infirm who could not visit temples for medical care sent representatives to convey information on symptoms and bring home a diagnosis as well as treatment.[167] In Africa, villagers would use smoke signals to warn neighboring villages of disease outbreak.[168] The beginnings of telehealth have existed through primitive forms of communication and technology.[167]

As technology developed and wired communication became increasingly commonplace, the ideas surrounding telehealth began emerging. The earliest telehealth encounter can be traced to Alexander Graham Bell in 1876, when he used his early telephone as a means of getting help from his assistant Mr. Watson after he spilt acid on his trousers. Another instance of early telehealth, specifically telemedicine was reported in The Lancet in 1879. An anonymous writer described a case where a doctor successfully diagnosed a child over the telephone in the middle of the night.[167] This Lancet issue, also further discussed the potential of Remote Patient Care in order to avoid unnecessary house visits, which were part of routine health care during the 1800s.[167][169] Other instances of telehealth during this period came from the American Civil War, during which telegraphs were used to deliver mortality lists and medical care to soldiers.[169]

From the late 1800s to the early 1900s the early foundations of wireless communication were laid down.[167] Radios provided an easier and near instantaneous form of communication. The use of radio to deliver healthcare became accepted for remote areas.[167][108] The Royal Flying Doctor Service of Australia is an example of the early adoption of radios in telehealth.[168]

In 1925 the inventor Hugo Gernsback wrote an article for the magazine Science and Invention which included a prediction of a future where patients could be treated remotely by doctors through a device he called a "teledactyl". His descriptions of the device are similar to what would later become possible with new technology.[170]

When the American National Aeronautics and Space Administration (NASA), began plans to send astronauts into space, the need for Telemedicine became clear. In order to monitor their astronauts in space, telemedicine capabilities were built into the spacecraft as well as the first spacesuits.[167][108] Additionally, during this period, telehealth and Telemedicine were promoted in different countries especially the United States and Canada.[167]

In 1964, the Nebraska Psychiatric Institute began using television links to form two-way communication with the Norfolk State Hospital which was 112 miles away for the education and consultation purposes between clinicians in the two locations.[171] The Logan International Airport in Boston established in-house medical stations in 1967. These stations were linked to Massachusetts General Hospital. Clinicians at the hospital would provide consultation services to patients who were at the airport. Consultations were achieved through microwave audio as well as video links.[167][171]

In 1967 one of the first telemedicine clinics was founded by Kenneth Bird at Massachusetts General Hospital. The clinic addressed the fundamental problem of delivering occupational and emergency health services to employees and travellers at Boston's Logan International Airport, located three congested miles from the hospital. Over 1,000 patients are documented as having received remote treatment from doctors at MGH using the clinic's two-way audiovisual microwave circuit.[172] The timing of Bird's clinic more or less coincided with NASA's foray into telemedicine through the use of physiologic monitors for astronauts.[173]

In 1972 the Department of Health, Education and Welfare in the United States approved funding for seven telemedicine projects across different states. This funding was renewed and two further projects were funded the following year.[167][171]

Telehealth projects underway before and during the 1980s would take off but fail to enter mainstream healthcare.[168][108] As a result, this period of telehealth history is called the "maturation" stage and made way for sustainable growth.[167] Although State funding in North America was beginning to run low, different hospitals began to launch their own telehealth initiatives.[167] NASA provided an ATS-3 satellite, to enable medical care communications of American Red Cross and Pan American Health Organization response teams, following the 1985 Mexico City earthquake. The agency then launched its SateLife/HealthNet programme to increase health service connectivity in developing countries. In 1997, NASA sponsored Yale's Medical Informatics and Technology Applications Consortium project.[108][174]

Florida first experimented with "primitive" telehealth in its prisons during the latter 1980s.[175] Working with Doctors Oscar W. Boultinghouse and Michael J. Davis, from the early 1990s to 2007; Glenn G. Hammack led the University of Texas Medical Branch (UTMB) development of a pioneering telehealth program in Texas state prisons. The three UTMB alumni would, in 2007, co-found telemhealth provider NuPhysician.[176]

The first interactive telemedicine system, operating over standard telephone lines, designed to remotely diagnose and treat patients requiring cardiac resuscitation (defibrillation) was developed and launched by an American company, MedPhone Corporation, in 1989. A year later under the leadership of its President/CEO S Eric Wachtel, MedPhone introduced a mobile cellular version, the MDPhone. Twelve hospitals in the U.S. served as receiving and treatment centers.[177]

The advent of high-speed Internet, and the increasing adoption of ICT in traditional methods of care, spurred advances in telehealth delivery.[12] Increased access to portable devices, like laptops and mobile phones, made telehealth more plausible; the industry then expanded into health promotion, prevention and education.[1][3][108]

In 2002, Dr. G. Byron Brooks, a former NASA surgeon and engineer who had also helped manage the UTMB Telemedicine program, co-founded Teladoc in Dallas, Texas, which was then launched in 2005 as the first national telehealth provider.[178]

In the 2010s, integration of smart home telehealth technologies, such as health and wellness devices, software, and integrated IoT, has accelerated the industry. Healthcare organizations are increasingly adopting the use of self-tracking and cloud-based technologies, and innovative data analytic approaches to accelerate telehealth delivery.

In 2015, Mercy Health system opened in Mercy Virtual, in Chesterfield, Missouri, as the world's first medical facility dedicated solely to telemedicine.[179]