Telehealth, also known as telemedicine, is the remote provision of health care services enabled by technology. A continuum of successful telehealth applications have been demonstrated over the last twenty years, ranging from the transmission of digital photographs and patient histories for diagnostic consultation, to remote monitoring of physiologic data for chronic disease management, to interactive patient physical examination using medical video endoscopes and ultrasound over high-definition videoconferencing links. The common tie among these varied applications is that technology is used to improve access to health care services independent of geography.
Telehealth can improve quality, efficiency and customer service in medical tourism applications by better coordination of care between providers in patients’ home and foreign countries, enhanced preoperative and postoperative care, and optimizing patient and family member travel. This article describes the basic principles and applications of telehealth and explores the potential roles and challenges of telehealth in medical tourism.
There are two primary operational modes of telehealth:
(1) real-time or synchronous and
(2) deferred or asynchronous, or store-and-forward.
Real-time telehealth sessions are live and interactive, and frequently use videoconferencing technologies. Often, a nurse presenter operates special telehealth-enabled instruments, such as a video otoscope to examine the ear or an electronic stethoscope, under a remote consultant’s direction to perform a telehealth physical examination.
In deferred telehealth, data (such as digital photographs) are captured locally at the patient’s site, then temporarily stored or 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.
There are several categories of clinical telehealth applications. Teleconsultation is the classical model of remote care that involves a physician or specialist consultant at a center of medical expertise providing a diagnosis, workup and treatment plan based on conducting a remote interactive patient interview and examination and/or reviewing data from a store-and-forward encounter. Occasionally, the encounter may be a physician-to-physician consultation or the rendering of second opinion services.
Telecare is the use of telehealth to directly communicate with a patient and/or care giver in the location where the patient lives for disease management, electronic monitoring of physiologic data, following up on problems related to a known diagnosis, patient education and ascertaining compliance with treatment plans.
Multidisciplinary clinical collaboration includes specialists at multiple locations collaborating on a single case or groups of cases. An example of this application is a virtual tumor board that involves oncology, radiation oncology, hematology, pathology, immunology, among other specialties. Another example would be physician-to-specialist collaboration.
Fundamentally, telehealth involves the capture, management, and transmission of bits of data. The volume of data carried by a network is known as bandwidth and is characterized in bits per second (bps). Raw uncompressed audio and video would require extremely high bandwidth networks that would be prohibitively expensive for telehealth.
Fortunately, properties of the human senses such as 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 refers to a videoconferencing device or appliance and a “soft” endpoint refers 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 slides alongside a presenter. Built-in multipoint conferencing allows three or more sites without the need for a dedicated and expensive hardware multipoint conferencing unit (MCU).
There are a variety of different devices called peripherals that can be used to expand the capabilities of a telehealth system. Telehealth-enabled physician’s examination instruments, such as a video otoscope for the ear, dermascope for the skin or electronic stethoscope for heart, lung, and 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, ultrasounds for adult or pediatric echocardiograms, obstetrical, gynecologic or abdominal evaluations, ocular imaging equipment including a fundus camera, slit lamp, and optical coherence tomograph, and endoscopes including a rhinolaryngoscope, culposcope, and sigmoidoscope.
There are also many different examples of network-enabled biomedical/physiological monitoring devices that can be used for telehealth, including an electrocardiogram, electroencephalogram, electromyogram, vital signs monitor, glucometer, body weight scale and spirometer. Consumer electronics are being increasingly used in telehealth; e.g. digital cameras are often used in store-and-forward dermatology.
Telehealth in Medical Tourism
One of the significant potential benefits of telehealth in medical tourism is in improving the process and quality of pre- and post-operative care. There are several preoperative telehealth applications. Baseline data can be collected remotely, preoperative physical examinations performed and patient education given.
Anesthesiologists can perform tele-consultations, including remote physical assessment of the cardiovascular and respiratory systems, including the airway. Postoperative care can also be provided via telehealth after patients return home with virtual follow-up visits. Wound healing also can be evaluated remotely.
Telehealth would allow surgeons to coordinate follow-up care with patients’ local primary care providers and specialists. Developments in remote monitoring technology make it possible for postoperative home monitoring, potentially mitigating the risk of hospitalization or reducing the length of hospital stays in the immediate postsurgical period.
Finally, telehealth offers the potential to improve the level of customer service provided to medical tourists. For example, preoperative videoconferencing would allow patients, family members, surgeons and other key members of surgical staff to virtually meet face-to-face.
Similarly, concerned family members who did not accompany the patient could stay in touch with the patient or traveling family members and receive briefings or updates from the surgeon or other key staff. This level of connectedness could also be used to improve continuity of care, by keeping the patient’s care providers in his or her home country involved throughout the perioperative period.
Although telehealth offers great promise in improving medical tourism, several challenges must be addressed. Legal and regulatory factors complicate the telehealth landscape. In the United States, a telehealth physician is considered to be virtually transported to the patient’s state.
Therefore physicians are required to possess a medical license in each state where their patients reside. Similarly, the Joint Commission requires that the consulting physician be credentialed at the facility where the patient is located.
Since telehealth is relatively new, policies regarding inter-country telehealth practice are not well developed and the legal environment must be assessed on a country-by country basis. Many malpractice insurance providers will extend their coverage to care provided via telehealth, sometimes with a telehealth rider. Separate telehealth malpractice policies are commercially available.
Privacy and security issues must also be considered. For example, the Health Insurance Portability and Accountability Act (HIPAA) applies to telehealth in the U.S. However, such risks can be avoided via proper patient consent/authorization. In addition, technical means are available to ensure privacy, including virtual private network connections, file encryption and encrypted videoconferencing.
Telehealth technologies have vastly improved over the last decade; however some technical challenges still remain. Although most of the contemporary videoconferencing CODEC appliance manufacturers’ systems readily interoperate, personal computer-based videoconferencing systems often do not interoperate between manufacturers or with CODEC appliances.
Currently, interoperability is most limited between electronic health record systems and biomedical monitoring devices. Standards development organizations and industry consortia are slowly improving system and device interoperability. Also, network security measures can complicate inter-organizational videoconferencing, although this can be managed via several technical solutions and the willingness to collaborate between different organizations’ information technology departments.
Finally, several human and organizational factors may be barriers to telehealth in medical tourism. Physicians and health care organizations may be unwilling to provide their services or facilities to support patients that travel to foreign countries for medical procedures. Health insurance companies may be reluctant to pay for services rendered via telehealth and health providers may be hesitant to adopt this method of delivering care.
Telehealth applications have rapidly expanded over the last five years and offer the potential to make a major impact on the improving quality, efficiency and customer service in medical tourism. Advanced technologies enable the remote provision of health care services at locations most convenient for the patient and minimize travel for patients and family members. Telehealth can lead to improvements quality and efficiency of pre- and postoperative care as well as continuity of care.
Although there are several legal, regulatory, technical, and organizational barriers to telehealth, they are surmountable. Telehealth will play a significant role in the continued expansion and improvement of medical tourism.
Scott C. Simmons, MS has a proven track record in systems engineering and management of complex research and development projects. He was the project manager for development of the Telemedicine Instrumentation Pack (TIP; U.S. Patent #5,701,904), NASA’s first space-certified telemedicine system and the co-PI for the TIP’s evaluation aboard Shuttle Endeavour mission, STS-89. In July 2007, Scott moved to join the University of Miami Miller School of Medicine where he is currently the Director of TeleHealth. He has presented and published extensively on various aspects of telemedicine and is a member of the editorial board of the Telemedicine and e-Health Journal. Since joining the University of Miami, Scott has developed many new telehealth product and service offerings and was elected as Secretary of the ATA Latin American and Caribbean Chapter.
Anne E. Burdick, MD is the Associate Dean for Telemedicine and Clinical Outreach and Professor of Dermatology at the University of Miami (UM) Miller School of Medicine. Prior to her arrival at UM she served as Chief of Dermatology at Kaiser Permanente Medical Center in Martinez, California. She was Jackson Memorial Hospital Dermatology Clinic Director for 14 years and currently is Medical Director of the UM/JMH Hansen’s Disease (leprosy) Program. Dr. Burdick has over 16 years’ experience in telehealth. As Associate Dean for Telemedicine and Clinical Outreach, Dr. Burdick is leading UM’s expansion of its telemedicine services and infrastructure to extend its reach and clinical service offerings in the US and internationally.