The Audio-Visual Connection: A Brief History of Telemedicine

Telemedicine [tel-uh-med-uh-sin]: the practice of medicine when the doctor and patient are widely separated using two-way voice and visual communication (as by satellite, computer, or closed-circuit television)¹

In an 1879 article published in the Lancet, the authors talk about the transmission of medical knowledge over the telephone and conducting doctor’s appointments through the telephone in lieu of unnecessary office visits.² In today’s health care system, reducing the number of office visits saves patients money and time, and, potentially, spares them the “white coat syndrome” some patients experience with office visits (which researchers are now finding does not limit itself to the adult population).³

Although the history of telemedicine can be traced back into the Middle Ages, when physicians diagnosed and treated patients through the exchange of hand-written notes,⁴ the major developments did not emerge until the growth of technology in the 20th century. Over the past century, telemedicine has proven beneficial in cardiology, psychiatry, surgery, and wound care⁵—but how we arrived at this point deserves some attention.

The Foundation

Willem Einthoven (1860–1927), the inventor of the electrocardiograph, first started experimenting with remote consultations via the telephone in 1906,⁶ which was first developed in 1876.^7,8 In April 1924, the cover of Radio News magazine⁹ featured a “radio doctor” performing a “radio” office visit through a small screen with a young boy (Figure 1). In 1948, at a distance of 24 miles apart in Pennsylvania, two health care professionals transmitted the first radiographic images via telephone.¹⁰ It wouldn’t be until 1959 at the University of Nebraska that doctors used interactive telemedicine to send neurological examinations; this is often credited as the first case of real-time video telemedicine.^6,10,11 Half a decade later, psychiatrists built a closed-circuit television link to allow physicians to provide psychiatric consultants at a staggering distance of 112 miles away at Norfolk State Hospital.¹⁰ From the groundwork laid by these advances, modern telemedicine was built.

Telepsychiatry

Among the various developments that emerged from the field of psychology, the communication networks established in the ‘50s and ‘60s would perpetuate the momentum of modern telemedicine today. In 1955, Cecil Wittson, MD, (1907–1989) at the Nebraska Psychiatric Institute (NPI [also known as University of Nebraska Medical Center]; Omaha, NE; 1948–1985) established a closed-circuit television in conjunction with the Bell Telephone Company to improve psychiatric education through weekly lectures with other mental health hospitals in four states.^12,13

Eight years later, Dr. Wittson, Reba Benschoter, PhD, and Van Lear Johnson developed the first two-way closed-circuit television system in the United States (Figure 2).^4,5,12,13 This circuit first was tested by connecting NPI and the Anatomy Department of the University of Nebraska (located across the street from NPI in Omaha, NE). When this communication proved successful, these doctors expanded into neurology exams via television prior to psychotherapy sessions.⁴ From their positive results, the National Institutes of Health (Bethesda, MD) sponsored a grant to connect NPI with the Norfolk State Mental Hospital (NE) via a microwave link in 1964,^4,5,13 which is credited as arguably the first telemedicine program.⁵

1967: Boston, Massachusetts

In 1967, an interactive network between Logan International Airport and Massachusetts General Hospital, both in Boston, was established to treat patients with a two-way microwave audio and visual connection 24/7 at the airport.^5,12,14 This medical station, Massachusetts General Hospital–Logan Airport Medical Station, was a result of the Massachusetts General Hospital Telemedicine Project in which Robert Scully, MD, was tested on correctly identifying microscopy images, including routine surgical specimens, stained blood smears, radiology images, and white blood cell counts, from remotely projected slides.¹⁴ Dr. Scully identified all 100 black-and-white slides correctly, occasionally requesting additional information (e.g., coloring of subjects) from the technician conducting the test directly.¹⁴ 

NASA & Community-based Medicine

From 1972 to 1975, expanding on the success of the medical station partnered with the Massachusetts General Hospital–Logan Airport Telemedicine Program, the Space Technology Applied to Rural Papago Advanced Health Care (STARPAHC) program was developed and funded by the federal government. The STARPAHC program provided the Papago American Indian reservation (remote area in Arizona) with the same telemedicine technology that was used by the National Aeronautics and Space Administration (NASA) for astronauts.^2,11,14 This NASA-Lockheed Missiles and Space Co. (now Lockheed-Martin, Bethesda, MD) joint program further proved that rural health care via audio-visual communication (aka, telemedicine) was a feasible option for home- and community-based care.^5,11,12

In-home care only expanded from that point, with US Department of Veterans Affairs developing care management programs for personalized education, monitoring, and feedback for remote disease management support teams¹¹ to today’s wearable wireless monitors and Virtual Technology Specialists conducting patient follow-up appointments and check-ins via telephone support networks (KCI, an Acelity Company, San Antonio, TX).¹⁵ During the 1970s, various remote villages in Alaska and Canada were connected with large area hospitals via telemedicine¹²; these types of hospital-owned programs now are available at most urban hospitals with connections to rural areas and patients in the home. 

International Telemedicine

On December 7, 1988, a 6.8-magnitude earthquake killed more than 25,000 people in Soviet-occupied Armenia.¹⁶ Disaster relief (including medical professionals) was sent to the affected area by the Union of Soviet Socialist Republics, but more aid was needed. Weeks later, a telemedicine consultation would be established between NASA and the USSR under the existing bilateral space agreement (Space Act; 1958–1991) and referred to as the Telemedicine Spacebridge Project.¹⁷ With the goal of providing high-quality medical consultation to the USSR–Armenian area, health care professionals in the fields of plastic and reconstructive surgery, physical rehabilitation, psychiatry, public health, and epidemiology from four US hospitals were brought into the fold.^16,17 

During the establishment of this system, both sides visited the other’s facilities involved in their operation to familiarize themselves with the communications and medical professionals, established a translation protocol to relay information from English to Russian and vice versa, and developed an encrypted network to protect patient data, which predates the Health Insurance Portability and Accountability Act of 1996 (HIPAA).¹⁷ However, on June 4, 1989, an explosion caused a railway accident during this time of this network near the city of Ufa, Bashkortostain (Russia), killing more than 600 people and injuring an additional 800.^17,18 The Telemedicine Spacebridge provided additional support to this disaster with 400+ health care professionals from both countries working together.¹⁷ This was the first large-scale telecommunication network.¹⁷ Although it was only in existence for about three months, the program demonstrated the value in telemedicine as well as provided results of successful transcontinental communication of medical care consultation. 

Wound Care Telemedicine

Recent studies show benefits of lower costs,^19,20 reduced healing times,^19,21 alternative options to standard follow-up care,^22,23 and increased access to expertise in rural areas²⁰ resulting from the use of telemedicine in wound care.

Sood et al¹⁹ reviewed the current status of wound care and telemedicine of a database of 5,795 patients from a French mobile wound care center. In this 2016 publication,¹⁹ the authors reviewed literature published between January 2005 and October 2015 for relevance to wound healing and discussions on potential applications, benefits, and limitations involved in wound care telemedicine. They¹⁹ found the benefits of telemedicine in wound care resulted in an increase of patient care in rural and remote settings and lower costs. In addition, telemedicine showed improved wound closure rates of 75% and reductions in hospitalizations (72%) and ambulance transfers to wound care centers (56%). These results were further supported in a 2018 comparison evaluation between video consultations with in-person assessments in Sweden.²¹

Wickström et al²¹ sought to investigate ulcer healing and wait times between video consultation and in-person assessments for patients with hard-to-heal ulcers. From October 2014 to September 2016, 100 patients were diagnosed via video consultation (study group) and 1,888 patients through in-person assessments (control group). The study group patients had a median healing time of 59 days compared with 82 days in the control group. The median wait time was 25 days and 32 days for the study and control groups, respectively.²¹ Even with the limitations of a limited sample size (N = 100) and difficulty of obtaining follow-up data, the authors²¹ found reduced healing and wait times for patients diagnosed via video consultation compared with in-person assessment, which shows a lower cost of care for wound care patients.

From these published studies,^19-23 there is promise in the use of telemedicine for wound care patients in terms of follow-up care supplementary to in-person care²³ or as an alternative care.²¹ However, research does suggest the need for more study in relation to conclusive evidence in the benefit of routine clinical care.²²

Conclusions

The 1879 article published in Lancet² predicted a future widespread use of audio-visually transmitting radiology imaging and test results, conducting remote initial and follow-up appointments, and diagnosing health care ailments with only the data received through telemedicine means. Considering the developments in psychiatric care, NASA, and joint international operations with the USSR, it seems the foresight published in 1879² came to fruition. Although published evidence of the use of telemedicine in wound care has only been in existence for about the last decade, there are positive results showcasing a promising future for clinical decision making and patient outcomes. n

Jaclyn Gaydos is Managing Editor of Wounds: A Compendium of Clinical Research and Practice. 

1. https://www.merriam-webster.com/dictionary/telemedicine#medicalDictionary

2. Nesbitt TS. The evolution of telehealth: where have we been and where are we going? In: The Role of Telehealth in an Evolving Health Care Environment: Workshop Summary. Washington, DC: The National Academic Press; 2012: 11–15.  https://www.nap.edu/read/13466/chapter/4

3. Hanevold CD. White coat hypertension in children and adolescents. Hypertension. 2019;73(1):24–30.

4. Greene JA. When television was a medical device. Humanities. 2017;28(2). https://www.neh.gov/humanities/2017/spring/feature/when-television-was-medical-device.

5. Grigsby J, Kaehny MM, Sandberg EJ, Schlenker RE, Shaughnessy PW. Effects and effectiveness of telemedicine. Health Care Financ Rev. 1995;17(1):115–131.

6. Rinde E, Balteskard L. Is there a future for telemedicine? Lancet. 2002;259(9322):1957–1958.

7. Alexander Graham Bell. HISTORY. August 21, 2018. https://www.history.com/topics/inventions/alexander-graham-bell

8. Hochfelder D. Alexander Graham Bell: American inventor. Encyclopedia Britannica. March 7, 2019.  https://www.britannica.com/biography/Alexander-Graham-Bell

9. Gernsback H. The radio doctor—maybe! Radio News. 1924;5(10). https://www.americanradiohistory.com/Archive-Radio-News/20s/Radio-News-1924-04-R.pdf

10. The history of telemedicine. Iris Telehealth. February 2, 2017. https://iristelehealth.com/blog/the-history-of-telemedicine/

11. History of telemedicine. mdPortal. September 2015. http://mdportal.com/education/history-of-telemedicine/

12. Peterson C. A brief history of telemedicine. Gerontechnology Resource: Technologies to Benefit Aging. February 9, 2014. http://gerontechnologyresource.blogspot.com/2014/02/a-brief-history-of-telemedicine.html

13. Schleincher J. UNMC a pioneer in telemedicine. UNMC Newsroom: University of Nebraska Medical Center. February 10, 2015. https://www.unmc.edu/news.cfm?match=16468

14. Weinstein RS. Telemedicine: back to the future—a 50 year perspective. Tucson, AZ: Arizona Telemedicine Program; 2013. https://www.nrtrc.org/content/presentation-files/Telemedicine%20Back%20to%20the%20Future%20-%20a%2050%20Year%20Perspective.pdf