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tions technologies to provide and support health care when distance separates the participants. It has recently gained widely in popularity because of dramatic advances in the information and telecommunications technologies, but it has been used since the 1950s in selected fields, such as remote psychiatry. There are still several different levels within telemedicine:
Seeing and hearing through remote real-time audio and video technology;
Transferring data, such as radiology, pathology, etc.;
Remote manipulation, including surgery, through the use of robotics.
The first two levels have been widely implemented, beginning about 1992 at the University of Kansas and a few other places. Now there are over 70 medical services worldwide that routinely make use of telemedicine technology, and there is an explosive growth in linkages and services available. The third level is still in a developmental stage, and today is primarily of interest to the military.
The situation in Kansas in the early 1990s was roughly analogous to that of PEI, although on a somewhat larger scale. There were remote counties with no physicians, and there was a clear demand for equal access to health care. In 1992, the problem was put in the hands of the medical school at the University of Kansas, and a retired general familiar with military telemedicine applications was put in charge. The state telephone company put in a LAN-based structure with a fractional T1 bandwidth, and equipment was purchased for the university and the potential remote sites. But there was an initial error of focusing heavily on technology and not embedding the telemedicine service within the formal health delivery system, and the service was not fully utilized. In 1995, the university began to create a needs-based service, beginning with an assessment of needs in rural areas, and technology services were placed in the context of clinical and educational programs.
In the clinical program, patients now see the physicians in one of three modes:
on an as-needed basis, in an emergency or when a rare subspecialty is required, as they would in the normal practice of medicine;
on fee-for-service contracts for specific services requested by the rural center; and
at regularly scheduled subspecialty clinics. For example, there might be an oncology clinic on a given day of the month, cardiology on a different day; other specialties might be dermatology, psychiatry, and rheumatology.
A scheduler at each rural center arranges appointments for patients. In all cases, the specialist receives x-rays and other data at the patient's appointment time, and he or she can examine and interact with the patient privately through an interactive audio-video (ITV) hookup, assisted by a nurse specially trained on use