Introduction

In a remote village in Central America, an otherwise unmanaged child's infection can take a turn for worse if not for the long distance diagnosis capacity brought about by the recently installed telemedicine system between Zacapa, Guatemala, and Houston,Texas, where subspecialists in the field of Pediatric Dermatology viewed the wound and prescribed the critically needed treatment.

Recent developments in the telecommunications and the information technology fields hold the promise of improved access to and the better utilization of health-carerelated resources. In addition to these developments, the deployment of interactive distant training programs offers an opportunity to decrease the knowledge gap between the leading academic medical centers where new medical knowledge is continuously being discovered and the remote health-care practitioners who fmd themselves pressed to deliver quality care that meets the needs of their communities in a competitive environment of limited resources. Telemedicine is creating new opportunities for imagining the possibility of a more efficient and accessible health-care delivery system. Telemedicine is just the tool, not the end, by which to negotiate and overcome barriers on the road to the delivery of quality services that the present system cannot deliver as effectively. The developments of modern telecommunications and information technology tools present a radical opportunity to change the health-care delivery infrastructure from the ground up.

The implementation of TeleHealth programs in such an environment is supported by enthusiastic approaches, but not with enough planning tools. There is a need to understand how to best adopt the advantages offered through intelligent communications that limitlessly extends the boundary of our senses, records, activities, and outreach.At its basic application, telemedicine can take tbe distance out of caring. Clinical needs, including the provision for innovative quality continuing education, is one of the programs' prime focuses. However, once we move beyond the clinic, there are the financial, legal, and engineering implications of telemedicine that challenge the status quo. If telemedicine is going to become a staple of medical practice in our planet, a massive re-engineering of tbe national and international telecommunications infrastructure, reimbursement legislation, and clinical practices will be required.

There are over 150 telemedicine programs in operation today. It is estimated that 60 percent of them are less than six years old, representing a relatively new modality in the health-care delivery system, where the vast majority of the providers are still debating the appropriate entry course and the following regulatory and sustainability issues. This paper reviews the evolution and the major issues to consider before embarking on a telemedicine program.

Same Problems Different Solution

The Center for TeleHealth (CTH), one of the first telemedicine program to focus solely on the extension of Pediatrics subspecialty services, is the result of a collaborative program between theTexas Children's Hospital and the Baylor College of Medicine. While the Center was created for the specific goal of linking the institution's expertise to remote communities in Texas as well as globally, it would not have enjoyed the executive and medical faculty's support if it were not for the success demonstrated during its initial applications, which were the result of using video engineering concepts to solving intra-hospital problems. It required the installation of a video network for the transmission of real-time information transmission of echocardiography to the locations where the experts were available, the cardiology reading area. Soon, other problems were solved with similar measure of success. The subspecialty coverage of a remote clinical area, the newborn nursery, successfully tested the provision of remote video monitoring of babies by neonatalogists.

While new knowledge is being discovered and acquired at an accelerated pace, specifically in the field of diagnostic and therapeutic medicine, within the major cluster of the academic medical centers the care provider who practices in the remote and at times rural area or in the overburdened urban clinics has yet to realize how best to absorb and deploy this new information. TeleHealth is providing a unique opportunity to restructure the dissemination of knowledge methodology used in today's health-care delivery system in a way that will distribute specific competencies to the most needed environment - the best practice at the point of care.This focus will allow our society to move from a reactive mode of delivering care toward a life-long health management where individual accountability, preventive medicine and customized wellness programs are integral components of a new health management methodology.

The Telemedicine Evolution

Telemedicine is not a new entity as most may think. Rather, it enjoys over seventy years of historical evolution. The April 1924 issue of the Radio News Magazine showed a drawing of physician viewing a patient over shortwave radio set that included a television like display. More realistically, the early programs in the 1950s and 1960s were highlighted with some success by the Nebraska Psychiatric Instate and the Massachusetts General Hospital and Boston's Logan International Airport link. However, these programs lack the ability to deliver sustained satisfaction to the healthcare providers or to the patients involved. Following the invention of the color television and launching of satellites in 1965, Dr. Michael Debakey, the cardiovascular surgeon at the Baylor College of Medicine, started to incorporate video tools into the medical training program and was successful that year to broadcast the first live cardiac surgery from the operating rooms at the Methodist Hospital at the Texas Medical Center to Europe utilizing satellite transmission. Colleagues in Amsterdam viewed and heard Dr. DeBakey mentoring the procedure at the time a new technique for teaching cardiac surgical intervention.

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