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<title>Telemedicine-Breaking the Distance Barrier in Health Care Delivery</title>
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<p><b><font size="5">Telemedicine-Breaking the Distance Barrier in Health
Care Delivery</font></b></p>
<p><b>V. Garshnek, Ph.D.; L. H. Hasseff, M.D.; and H. Q. Davis, M.D.,
M.P.H.; </b><a href="http://www.tamc.amedd.army.mil/">Tripler Regional
Medical Center, HI</a></p>
<p><b>V. Garshnek, Ph.D., is Project Manager of the </b><a
href="telmed_eval.html">AKAMAI Telemedicine Evaluation Initiative</a><b> at Tripler
Regional Medical Center (TRMC), Hawaii. Dr. Garshnek was formerly an
Aerospace Physiologist with the U.S. Navy at the Naval Aerospace Medical
Institute, Pensacola, Florida; Senior Scientist, Life Sciences Division,
NASA Headquarters, Washington, D.C.; and Principal Scientist for Advanced
Planning with Lockheed Engineering &amp; Sciences Company, under contract
to NASA Ames Research Center, Motfett Field, California.</b></p>
<p><b>Colonel 1. H. Hassell is the Principal Project Director of the AKAMAI
Telemedicine Evaluation Initiative at TRMC. Colonel Hassell is a physician
in the U.S. Army Medical Corps specializing in Nephrology and is Chief
of the Department of Clinical Investigation at TRMC.</b></p>
<p><b>Lieutenant Colonel H.O. Davis is tile U.S. Army Pacific Regional
Medical Command Flight Surgeon located at TRMC. He is a physician in
the U.S. Army Medical Corps and a specialist in Aerospace Medicine.
Dr. Davis was formerly a researcher with the Department of Behavioral
Biology at Walter Reed Army Institute of Research, Washington, D.C.,
where he completed a fellowship in Medical Research.</b></p>
<p>In this century, we have witnessed the rapid emergence of technology
and, with it, the ability to break significant barriers previously hindering
human progress. For example, through advanced aeronautical technology,
we have broken the <i>sound barrier </i>and are now able to fly aircraft
through Mach velocities. Through rocket propulsion technology we have
broken the gravity barrier<i>, </i>enabling humankind to visit the moon,
routinely orbit Earth, and claim space flight as a frontier of human
destiny. Currently we are standing on the edge of another barrier that
is rapidly eroding-the <i>physical distance barrier. </i>Through telecommunications
and <i>computer technologies, </i>such capabilities as telepresence,
real-time or stored multimedia information transfer, and real-time interactive
video enable instantaneous acquisition of knowledge and expertise (whenever
and wherever we need them). We have the means and ability to electronically
transport the &quot;essence&quot; of who we are -mental, visual, and,
in the future, &quot;tactile-to remote destinations without transporting
our physical being!</p>
<p>At the present time, nowhere is this distance barrier eroding more
rapidly than in medicine. Patients traveling miles to see a specialist
for medical consultation, and medical documents and films being physically
stored and physically transported are becoming antiquated modes of operation.
Medicine now has a powerful fuel behind it enabling it to operate in
a more distance-independent manner. This fuel is telemedicine.</p>
<p>Telemedicine has obvious rural applications; however, it can also potentially
unite the world through a global health network making it possible to
reach developing and third world countries and effectively respond to
international disasters. Telemedicine continues to gain importance in
manned space efforts and military operations where distance and time
place heavy restrictions on patient transport to remote medical expertise.
In fact, the basic telemedicine framework was derived from deliberate
engineering and technology transfer, much of it from the space and aviation
fields.</p>
<p>The aeronautical engineering student of today may well find a future
career in the telemedicine field. Telemedicine has grown to encompass
satellite technology, telemetry, communications, telepresence, virtual
reality, robotics, and creative applications of space/aerospace technologies
to medical problems and procedures. The purpose of this paper is to
present a brief overview of telemedicine, its strong aerospace technology
beginnings, and its emerging future whose success and progress will
depend on teams of individuals skilled in engineering, technology transfer,
and medicine.</p>
<p>&nbsp;</p>
<p><b>Telemedicine Defined</b></p>
<p>Telemedicine is the use of modern telecommunications and information
technologies to provide health care to individuals when the health care
provider and patient are physically separated. Instead of transporting
the patient to the site of the expert caregiver, expert knowledge is
transported to the health care provider closest to the patient (i.e.,
move the information not the patient). Telemedicine includes the diagnosis,
treatment, and monitoring of patients using systems that allow ready
access to expert advice and patient information. It involves a spectrum
of technologies. These technologies can include facsimile, medical data
transmission, audio-only format (telephone and radio), still images,
and full-motion video. Robotics and virtual reality interfaces are being
steadily introduced into experimental applications.</p>
<p>The National Aeronautics and Space Administration (NASA) and the Department
of Defense (DoD) have had an early and long-standing interest in the
development of telemedicine. Transfer of NASA and DoD technology as
well as independent efforts driven by the need for specific telemedicine
solutions have resulted in numerous applications for a variety of population
groups and scenarios:</p>
<ul>
<li>Worldwide, forward deployed U.S. forces.</li>
<li>Monitoring and consultation of astronauts in space.</li>
<li>Triage and emergency health care response during disasters.</li>
<li>Services to institutionalized populations in homes for the disabled,
nursing homes, or jails and penitentiaries.</li>
<li>Monitoring and consultation for hospitalized, ambulatory, and home
care patients.</li>
<li>In addition, the possibility of adding telemedicine capability on
commercial and military aircraft is gaining interest.</li>
</ul>
<p><b>Telemedicine Infrastructure</b></p>
<p>The telecommunications infrastructure provides the technology to move
information electronically between geographically dispersed locations.
Participating sites are linked through electronic networks. The telecommunication
medium utilized by telemedicine programs is determined in large part
by the available local infrastructure. These can include satellite,
microwave link, and terrestrial and submarine lines (either twisted
copper phone lines or fiber optic cable). Tools specifically designed
for ISDN represent an inexpensive, but nevertheless powerful, terrestrial
network that is already available in most industrial regions.</p>
<p>The medical systems infrastructure consists of the equipment and processes
used to acquire, present, store, and retrieve clinical information and
data. Acquisition and presentation technologies include teleconferencing,
data digitizing, and display (e.g., remote X-ray, laboratory tests);
text processors (e.g., scanners, fax); or image processors (e.g., video
cameras, monitors). Data storage and retrieval include storage devices
(disks, tape, CD-ROM), along with technology to compress, transmit,
and store data.</p>
<p><b>Telemedicine and the Space Program</b></p>
<p>NASA has long used telemedicine for its astronauts<sup>2 </sup>and
continues to rely on this mode of in-flight medical consultation. More
recently NASA has established telemedicine links with former Soviet
republics for disaster relief.<sup>3</sup>A Specifically, the Space
Bridge to Armenia/Ufa project provided assistance to persons involved
in the 1989 earthquake in Armenia and a major gas explosion in Ufa.
This project was the longest running telemedicine disaster relief effort
on record. It has technologically and philosophically paved the way
for utilizing satellite uplinks and efficiently planned protocols to
provide medical care regardless of distance.</p>
<p>The Space Bridge project provided medical consultation 10 several Armenian
regional hospitals, linking them via satellite with four American medical
centers. The program utilized two-way interactive audio with one-way
full motion video transmitted from Armenia to the United States. There
were also separate data and fax transmission lines. Consultation was
provided in the areas of neurology, orthopedics, psychiatry, infectious
disease, and general surgery. In a separate link, consultation was also
provided to the Russian town of Ufa, where a gas explosion during this
same period of time caused a large number of casualties. Slow-scan black
and white video was transmitted from Ufa to one of the Space Bridge
sites in Armenia (Yerevan), which provided satellite uplink.<sup>5 </sup>Over
a 12-week period, the Space Bridge program was used to discuss the cases
of 209 patients. According to data reported by Houtchens et al.,<sup>3
</sup>the use of telemedicine was responsible for changes in the management
of a large number of patients. For the 189 Armenian patients discussed,
diagnoses were changed for 54 patients, new diagnostic studies were
recommended for 70 patients, and treatment plans were changed for 47.</p>
<p>Similarly, a Space Bridge to Moscow was used to provide consultations
regarding persons injured in the civil insurrection of October 1993.
During the attempted coup in the second half of 1993, NASA took advantage
of a videoconferencing link in Moscow that was already in place to provide
consultation regarding several casualties of small arms fire. This link
was part of the U.S./Russian telemedicine Demonstration Project, which
consisted of 18 different sessions dedicated to various medical specialties.</p>
<p>Telemedicine has been utilized on many different occasions; however,
it has never before been deployed and tested on such a large scale as
was demonstrated in the Space Bridge projects. Ferguson, Doarn, and
Scott<sup>6</sup> have surveyed the Space Bridge projects, other NASA
telemedicine activities, and various non-NASA telemedicine applications
throughout the world. Interested readers are encouraged to consult this
particular paper for expanded reading.</p>
<p><b>Astrotelemedicine</b></p>
<p>As mentioned, telemedicine is not a new concept to space flight. Since
its very beginning, space medicine has utilized communications and information
processing technologies. In many aspects the operational boundary conditions
in space medicine, such as remoteness, telediagnostics, and biotelemetry
are characteristic of telemedicine applications on Earth. Since the
1960s, in parallel, the United States and Russia served as pathfinders
in the development of space telemedicine when they developed capabilities
for remote medical monitoring and care for astronauts in their human
space flight programs, beginning with Mercury and Vostok, through the
current Space Shuttle and Mir programs. In general, medical conferences
are held between the crew surgeon and crew members, and during extra-vehicular
activity, astronauts are constantly monitored via telemetry. This type
of medical monitoring has existed for decades. For example, during the
Apollo lunar excursions, EKG, heart rate, oxygen consumption, heat production,
suit carbon dioxide levels, and other physiological and environmental
variables were monitored by a biomedical team at NASA's Mission Control
Center at the Johnson Space Center, Houston, Texas. Flight surgeons
were on alert to catch potentially dangerous physiological events and
intervene at the earliest possible moment.<sup>7</sup></p>
<p>Currently NASA has in place a training program that would enable astronauts
who are not medically trained to be providers of remote telemedicine
services (i.e., able to conduct a basic examination for consulting physicians
on Earth). Complicating the provision of such services is the fact that
the astronauts must learn to perform these tasks in a micro gravity
environment. NASA has recently developed the capacity for private medical
conferencing from orbiting spacecraft to Earth stations. Prior to this,
telemedicine consultations had to be done via radio or video channels
that were potentially open to the public. In the current system, the
transmitted data are encrypted and transmitted to the Johnson Space
Center, via White Sands Missile Base, New Mexico. These one-way (Shuttle
to Earth) video and two-way audio signals are received in unscrambled
form only by the chief medical officer in Houston, protecting the confidentiality
of astronauts and allowing NASA to limit media coverage of medical problems
in space.</p>
<p>Development is continuing for telemedicine to support U.S. astronauts
aboard the Russian Mir Space Station and the International Space Station
at the turn of the century. NASA's first permanent, operational, international
space telemedicine system will be established to support NASA's flight
surgeons and astronauts training in several locations in Russia, including
the Gagarin Cosmonaut Training Center in Star City, the TsUP (Mission
Control) at Kalingrad, several sitC5 in Moscow, and the Baikinor Cosmodrome
in Kazakhstan. Utilizing NASA's Program Support Communications Network
(PSCN), flight surgeons and astronauts in Russia will be able to obtain
telemedicine consultations from the NASA Johnson Space Center.<sup>6</sup></p>
<p>NASA has recently developed and field tested a small and lightweight
prototype telemedicine system called a Telemedicine Instrument Pack
(TIP) for potential applications in space as well as remote Earth applications.<sup>8</sup>
The TIP resembles a small suitcase and is entirely self-contained. It
contains commonly used diagnostic instruments (digital scopes), cameras,
and a small flat video monitor. The unit has completed an 8-week field
trial on Earth and is scheduled for flight testing in space aboard the
Space Shuttle in 1997<sup>9 </sup>.</p>
<p>In the future, telemedicine capability will be an important component
in space crew health care aboard the international Space Station, especially
in the prevention and early intervention aspects of disease and injury.
In addition, during a medical emergency, telemedical capability can
play an <i>im</i>portant 'lifeline&quot; role in the rapid exchange
of patient information and access to special medical expertise and crucial
instruction. However, if an emergency is life threatening and requires
medical treatment, the combined resources of telemedicine and existing
onboard medical capability may he limited, requiring medical evacuation
to Earth. For missions beyond Earth or-bit, evacuation to Earth may
not be an option, and the overall onboard medical capability (including
expert computer systems and telemedicine capability in the &quot;store
and forward&quot; mode) as well as crew medical expertise will need
to be greatly enhanced.</p>
<p><b>Telemedicine and the Military</b></p>
<p>The United States armed services have long had an interest and involvement
in both mobile health and telemedicine services. In fact, some of the
most ambitious global applications of telemedicine and utilization of
satellite technology can be found in the military. Recent developments
in data compression, fiber optics, satellite communications, computer
inter-networking, information technology, advanced medical imaging and
diagnostics have combined to provide the U.S. military with the ability
to establish a world wide integrated health care delivery network. Various
combinations of these technologies have been tested in joint exercises,
U.S. Army Advanced Warfighting Experiments (AWEs), aboard deployed naval
vessels, in the peacetime Military Health System (MHS), and as part
of the support for operations in Saudi Arabia, Kuwait, Somalia, Haiti,
Cuba, Panama, Croatia, Macedonia, and Bosnia.</p>
<p>Advanced telecommunications technology was used in conjunction with
mobile health units during the war in the Persian Guif,'<sup>0 </sup>demonstrating
that these two technologies can be integrated, even under difficult
geographic and climatologic circumstances, with beneficial effect.''
Computerized tomography (CT) scanners were installed in transportable
modular military hospital units and deployed in the Saudi desert just
south of the Iraqi and Kuwaiti borders.<sup>10</sup></p>
<p>Recently, the U.S. Department of Defense established a medicine network
that serves U.S. troops in Bosnia and other countries. The telemedicine
segment of this project, known as Operation Primetime Ill, is designed
to help Army physicians communicate with each other using real-time
voice and video for consultation and diagnosis. The communications network
in Bosnia is being supported by an Orion-built communications satellite
orbiting over the area, thereby providing direct broadcast capability.
Using commercially available technology, front-line physicians can transmit
x-rays and other medical images to field hospitals for diagnostic support.
These same links, which extend to deployed units and small clinics at
forward areas in Bosnia, connect Army physicians in Bosnia with physicians
at five regional military medical centers in the U.S. The network also
offers online medical information, patient administration systems, and
information systems.</p>
<p>Operation Primetime was first established in 1993 to provide telemedicine
support to medical units in Macedonia and Croatia. The operation was
upgraded to Primetime II in <i>1995 </i>with a 30-fold increase in communications
bandwidth that substantially improved the transmission of medical images
for diagnostic consultations. The telecommunications, advanced medical
diagnostics, and medical informatics provided by Primetime III have
resulted in an integrated, worldwide system of telemedicine enabled
healthcare delivery. This system extends from operating bases of Bosnia
to the major military centers in Washington, D.C., Texas, California,
and Hawaii. U.S.-based MHS Medical Centers are responsible for providing
local telecommunications, video teleconferencing, teleradiology, and
clinical staff support necessary to provide continuous specialty and
sub-specialty real-time interactive and &quot;store and forward&quot;
teleconsultation support. The selection of medical centers positioned
in varying time zones around the globe facilitate 24-hour, 7-days per
week support without requiring additional medical staffing. This is
a very exciting global telemedicine concept in that telemedical consultations
can literally &quot;follow the sun&quot; around the Earth.</p>
<p>Another wide-area telemedicine project is AKAMAI (a Hawaiian word meaning
&quot;clever&quot;), an in-service project for electronic diagnosis
and consultation, led by Tripler Regional Medical Center in Hawaii.
AKAMAI allows for Tripler (a tertiary medical center) to support a referral
area of more than one million square miles and a diverse military and
civilian user group throughout the Pacific. The tong-term goal of this
project is to expand telemedicine into the Pacific Basin by establishing
a Pacific-wide telecommunications system for medical information, including
Picture Archiving and Communication System (PACS), telemedicine consultation,
teleradiology imaging, digital patient records, and new technologies
as they develop (e.g., telesurgery and telepathology).'<sup>2</sup></p>
<p>The U.S. armed forces are also engaged in a large-scale program of
telemedicine research and development. For example, the U.S. Army has
experimented with telemedicine to provide care to persons living on
remote islands in the Pacific Ocean.'<sup>3</sup> The armed forces also
have in place projects to develop capabilities for the distant physiological
monitoring of deployed troops and investigation of such technologies
as telepresence and virtual reality.'<sup>4 </sup>Thus, the military
is poised and ready to take telemedicine to new heights into the new
millenium.</p>
<p><b>Telemedicine Applied to Aviation</b></p>
<p>The aviation world has always been keenly interested in communications.
Since the first balloon flight, communication has been a concern for
an aircraft to maintain contact with ground facilities and other aircraft
in the vicinity. The goal has always been to maintain a safe operating
environment. Today an elaborate array of systems using multiple radio
frequency bands, microwaves, satellites, and ground stations' are used
to communicate and navigate the airways. Telemedicine represents a natural
extension of this ability to transfer information to and from an aircraft
while in flight or on the ground. With the increased use of aircraft
to transport patients and the increase in the number of people flying
in commercial aircraft, telemedicine is surely to become a tool that
can be used in many different aviation settings.</p>
<p>The possibility that a health crisis might strike an airline passenger
during flight has prompted discussion and investigation into adopting
telemedicine capabilities aboard passenger aircraft. For example, United
Airlines is evaluating a remote mobile device to monitor potential patients'
vital signs. The monitor was installed on a Boeing 767 and tested for
three months. Medical emergencies were simulated and procedures established
for monitoring a stricken passenger's vital signs, then respond as needed.
The device consists of a brief case-sized laptop computer and monitor
that can electronically measure a passenger's EKG, blood pressure, heart
rate, blood oxygen saturation, and respiration. The vital signs are
transmitted via modem to a United Airlines flight surgeon on the ground
who interprets them and offers medical advice.</p>
<p>In addition to commercial application, other aircraft where telemedicine
capability could be useful include military and civilian aircraft for
medical evacuation (MEDEVAC). In MEDEVAC aircraft where medical personnel,
nurses and, at times, physicians are flown with the patients, the possibility
of being able to effectively act upon a telemedicine consultation and
intervene in an in-flight medical crisis is an attractive scenario.</p>
<p>The increasing use of the military in operations other than war in
remote regions of the world also increases the likelihood that medical
care may have to be rendered to patients within aircraft configured
to provide the needed health care. This need is especially true in rapid
deployment operations that may preclude the deployment of ground based
medical facilities to the site. In these circumstances patients will
not be &quot;stable&quot; during transport, as is the case in most flights
over long distances. The ability to obtain expert consultation while
treating patients in remote areas, whether aboard an aircraft or on
the ground in a third world country, may be crucial to providing the
care needed to save a critically ill patient.</p>
<p>As with any new technology used aboard aircraft, there are multiple
questions that must be answered in order to provide the capability that
is needed in a manner that is safe for the aircraft and provides accurate
information. Some of the issues and questions that will need to be addressed
for these and other applications of telemedicine use in aviation are:</p>
<ul>
<li>What is the medical requirement? What clinical problem aboard the
aircraft are we trying to solve?</li>
<li>What level of technology fulfills the requirement?</li>
<li>What amount of bandwidth is needed to support the technology selected?
</li>
<li>How will the bandwidth be provided? (e.g., existing llF radio, satellite
capability, etc.)</li>
<li>What aerodynamic considerations need to be taken into account for
externally mounting additional antennas?</li>
<li>What are the legal issues? With greater information and connectivity,
will patients have unrealistic expectations concerning what can be
done for them? What are the flight safety issues and impacts of any
proposed new technology aboard the aircraft? Could the workstations
negatively impact navigation equipment tactical or non-tactical radios,
or any other onboard electronic systems through electromagnetic interference?</li>
</ul>
<p>The aviation community is taking notice of the advantages that telemedicine
can bring to a flight environment. However, there is still much to be
defined and addressed before the first approved system becomes a useful
part of an in-flight emergency capability.</p>
<p><b>New Horizons for the Future</b></p>
<p>The application of &quot;tele&quot; technologies can be taken beyond
the medical consultation and monitoring applications described thus
far. The potential is great and the possibilities are only limited to
our imagination and ingenuity. The following section presents robotic
and virtual reality manifestations of telemedicine technologies currently
being developed or planned. And as exciting and futuristic as the following
examples may seem, the most awesome aspect is that we have barely begun
to scratch the surface of what lies ahead.</p>
<p><b><i>Telepresence Surgery and Virtual Reality</i></b></p>
<p>Telepresence surgery is the name coined by Satatva, Green, and Simon
<sup>16,17</sup> to describe the application of existing and developing
technologies in remote manipulation as applied to surgical procedures.
The fundamental principle of a telepresence sLiq2ery system is to extend
a surgeon's psychomotor skills and problem-solving abilities to t remote
environment. The goal is to project a surgeons manual<b> </b>dexterity'
to a remote location while providing real-time tactile and visual feedback
from the location to the surgeon. In other words, we are dissolving
time and space, allowing the physician to <i>be </i>at a distant place
at the same time as another person without needing to travel there.
Unlike telerobotic surgery, in which a robotic manipulator is directed
by preprogrammed computer instructions, or surgical virtual reality,
<sup>19</sup> in which manipulations are performed in a simulated environment,
telepresence is a unique human-machine technology that directly' and
transparently projects hit-man motion to a remote location.<sup>20</sup>
It would be possible to operate at a place that is too distant or dangerous,
such as the space station or a battlefield.</p>
<p>An exciting effort in the area of remote surgery is the current work
conducted by Philip Green<sup>21 </sup>of SRI International, the inventor
of the Green Telepresence Surgery System. This is a prototype system
that permits precise, accurate surgery remotely with all the illusion
of being at the actual site. It consists of a remote work site and a
surgeon's console, similar to a computer workstation. This system brings
together 3-D vision, enhanced dexterity, and the sense of touch (through
forcefeedback sensory information). These components provide the realism
of actually operating at the remote site. The surgeon is operating on
a virtual image in front of him/her. The surgeon's abilities are enhanced
and surgery can be performed with greater skill and precision than teleoperations
procedures using a conventional control interface. The current version
is a one-handed 5-degree-of-freedom system with paired CCD cameras for
stereo vision; the next generation will have two 6-DOF surgical hands
and a stereoscopic laparoscope to replace the fixed cameras. The first
prototype had the surgical console directly wired to the remote workstation
and is being updated to a wireless system for remote operations. A military
application of this system is to mount it in an armored mobile vehicle
and posit ion it at the fir forward battlefield. When a soldier is wounded,
the vehicle will drive to the site where the soldier is located allowing
the surgeon at the hospital to operate immediately upon the casualty
on the front lines. Once the system is perfected, it can be transitioned
to civilian LI SC for disaster relief and emergency care.<sup>2~</sup></p>
<p>To enhance their work, physicians will also be able to bring in many
different digital images, such as the patients CT or MRI scan, and fuse
them with real-time video images giving the surgeon a type of &quot;x-ray
vision.&quot; In addition, virtual environments can satisfy the need
for training in medical and surgical procedures. For decades, pilots
have been training on flight simulators that have become so realistic
that a myriad of perfect take-off and landings can be safely performed
before the first actual flight takes place. So too will the surgeon
of the future be able to perfect surgical skills and rehearse the surgical
procedure before operating on the first patient. For example before
doing a surgical procedure, the surgeon could sit at the workstation
and practice on a virtual patient to simulate the operation and then
flip a switch and begin operating on the real patient with precisely
the same workstation.</p>
<p>Hon<sup>24</sup> has developed virtual reality laparoscopic surgery
simulators consisting of a plasitic torso into which handles of instruments
are mounted (to provide force feedback). The virtual abdomen (liver
and gall bladder) is graphically displayed on a video monitor and surgeons
and students can practice specific procedures. Satava<sup>2</sup> has
taken a different approach with a virtual abdomen created for an immersive
experience utilizing helmet-mounted display and Dataglove<sup>TM</sup>.
Using a virtual scalpel and clamps, the abdominal organs can be operated
upon and explored. These examples are but the first of many potential
applications of virtual reality for medical and surgical simulation
and education.</p>
<p><b>Conclusion</b></p>
<p>We are standing at the edge of a new frontier that is maturing with
the help of a multi disciplinary team of scientists, engineers, and
others. The vista before us shows an unfolding story of advances in
telemedicine. Embedded within this story are key events and observations:
</p>
<ul>
<li>Aviation and space technologies have provided significant technology
&quot;roots&quot;<b> </b>for telemedicine development and will continue
to play major roles in its future.</li>
<li>The Military and Space programs as well as independent rural and
health community efforts have provided an historical experience base
from which we can judge the value of telemedicine and plan for its
future.</li>
<li>Telepresence surgery and virtual reality are making possible the
transport of movement skill. Medical experts will not only consult
and advise but also &quot;do.&quot;</li>
<li>Fertile ground exists for creative individuals planning future careers
in telemedicine related 10 its use in aviation and space flight, military
battlefield needs, simulator development, telepresence technology
development, virtual reality applications, disaster management, and
medical outreach to underdeveloped and third world countries.</li>
<li>Telemedicine has the potential to medically unite the world and
make possible the sharing of much needed expertise in times of great
need.</li>
</ul>
<p>In the future, a new framework for the modern medical scenario will
emerge enabled by the digital communication infrastructure. The physician
of the future will be a &quot;digital physician.&quot; Today, almost
any information needed about a patient can be acquired electronically.
Tomorrow, medical expertise in the form of transmittable psychomotor
skills (teleoperation, telemanipulation, and telesurgery) will complete
the loop, and medical distance independence will arrive.</p>
<p>As medicine continues to accelerate technologically, a major question
to ask is, &quot;Where does it leave the human?&quot; Intuitively, we
know that technology will never totally replace the human health care
provider. The potential is high that a significant and positive enhancement
of the medical process will result. But are we de-humanizing medicine?
How far can technology take us in the healing art? What will be the
impact and acceptance of an electronically-generated healing touch?
Who knows? We may discover that in machine systems where humans are
truly in the loop, our human presence and essence will always be felt.
And, for a finite moment, we will become that object which extends our
reach.</p>
<p><b>References</b></p>
<p>1. Grigsby, J., Kaehny, M.M., Schlenker. RE., et al. &quot;Analysis
of expansion of access to care through use of telemedicine and mobile
health services.&quot; <i>Report I: Literature Review and Analytic Framework.
</i>Denver, CO: Center for Health Policy Research, 1993.</p>
<p>2. Pool, S.L., Stonsifer, J.C., and Belasco, N. &quot;Application of
telemedicine systems in future manned space flight.&quot; Paper presented
at Second Telemedicine Workshop, Tucson, AZ, Dec., 1975.</p>
<p>3. Houtchens, B.A., Clemmer, T.P.. Holloway, H.C., et al. &quot;Telemedicine
and international disaster response: Medical consultation to Armenia
and Russia via a telemedicine spacebridge.&quot; <i>Prehospital and
Disaster Medicine, </i>8: 57-66. 1993.</p>
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<p>&nbsp;</p>
<p><i>Note: The opinions or assertions contained herein are the private
views of the authors and are not to be construed as official or as reflecting
the views of the Department of the Army or the Department of Defense.</i></p>
</td>
</tr>
</table>
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