TELEMEDICINE REPORT -- Revised in March,1997


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Contents at a Glance

1. Summary

2. Definition of Telemedicine

3. Benefits of Telemedicine

4. History of Telemedicine in Japan

5. Issues in Telemedicine
5-1. Legal Issues
5-2. What departments benefit most from telemedicine?
5-3. Patient Issues
5-4. Timing Issues
5-5. Technical Issues

6. How can telemedicine fit into the medical system?

7. Delivery of Telemedicine
7-1. Telemedicine between two medical facilities (with doctors)
7-2. Telemedicine between a medical facility and a home
7-3. Telemedicine between medical facilities and medical-related facilities with no physicians
7-4. Telemedicine between co-medicals and homes
7-5. Telemedicine for TV conferencing

8. Suggestions for the Future
8-1. Suggestions for government organizations
8-2. Suggestions for the medical community
8-3. Suggestions for the industry
8-4. Suggestions for home care support organizations
8-5. Suggestions for the academic society

9. The Future of Telemedicine


1. Summary

In this report, we define telemedicine as: "medical care and health supporting practices based on patient information derived from images transmitted from a remote site." This definition is used to make clear the conditions under which telemedicine can be accepted as a form of medicine. Telemedicine can be practiced in many ways and each has challenges and conditions that must be considered. Telemedicine can vary depending on either the facilities using telemedicine, or the type of data transmitted.

Telemedicine can be practiced between two medical facilities. This type of consultation has no legal problems. However, this form of telemedicine has not prevailed in Japan largely because little consensus has been reached in the medical community over the requirements and limitations of telemedicine. Thus far, the medical community has agreed that: (1) for transmitting x-ray images, diagnosis must be based on CRT, and (2) for digitizing and displaying film, the minimum requirements are 200 µm sampling pitch, 10 bit density sampling resolution, 1000 x 1000 resolution degree, and 8-bit resolution in the density direction.

However, factors such as camera and digitilizer quality, degree of data compression at transmission, CRT quality, and image processing method also influence x-ray transmission. These make it difficult to define the exact requirements for image quality. Physicians who practice telemedicine should be aware of these differences in image quality and practice accordingly. A physician is equally liable for a diagnosis based on transmitted x-rays as he is for normal x-rays.

Pathological data can also be transmitted. However, determining what tissue to sample and determining what part of the sample to transmit are extremely complicated processes on the sending side. Thus, the technology for transmitting pathological data is more complicated than that for x-ray transmission. As a result, pathologists need to decide how sophisticated the equipment needs to be for accurate transmission. Another issue is the fact that Japan has a very small number of pathologists. The use of telemedicine in pathology should be limited to emergency situations and situations where speedy diagnosis has a critical influence on therapeutic decisions. When telemedicine is used in pathology, all records, including paraffin slices of the sample, must be kept by both the sending and receiving (clinical and pathology) sites after the diagnosis is made.

Telemedicine can be used in internal medicine if images by NTSC can be immediately transmitted to a color display and sound can be transmitted simultaneously, allowing for conversation between parties. There is no legal problem with this type of telemedicine. However, the extent to which physicians should introduce telemedicine to their clinical settings should not be regulated by law, but rather, by each physician. Telemedicine also has the potential to be practiced in departments such as dermatology, ophthalmology, and psychiatry.

Telemedicine consultation between a medical facility and a home will be an important part of home health care in the future. However, home health care using telemedicine has not been legally defined. Advice from the Ministry of Health and Welfare should play a major role in defining the range of legally permitted practices. Telemedicine in home health care can be used for patients who are in stable condition and who have received medical care from the same doctor for a long time. For this type of telemedicine home health care to be effective, a color display, moving images by NTSC, and simultaneous sound for discussion are needed. This type of home health care may be expanded to include dermatology care, rehabilitation guidance, home care guidance, and self-management of a pregnancy.

Even after 25 years of trials, telemedicine has not spread in Japan due to an incomplete infrastructure. In the future, it is necessary for political, academic, and business communities to promote a complete infrastructure for telemedicine. Once a favorable environment is established, telemedicine can become a great contributor to Japanese medicine.


2. Definition of Telemedicine

In its broadest sense, telemedicine is the use of any electrical signal to transmit medical information. However, the working definition of telemedicine varies and for the purposes of this report, we define it as: "Medical care and health supporting practices based on patient information derived from images transmitted from a remote site."

This definition needs clarification. First, by our definition, telemedicine must include transmitted images. In other countries, the word telemedicine is defined as electronic transmission of medical information, with or without images. For example, an electronic transmission of any patient information would be considered telemedicine. However, we believe the transmission of images is the essential and forefront aspect of telemedicine. Thus, we limit our definition of telemedicine to those transmissions that include images.

Second, by saying "from a remote site," we do not specify whether communication sites must be medical facilities. Usually, the word telemedicine implies that both transmitting and receiving sites are medical facilities. In some other countries, electronically transmitted home care support is distinguished from telemedicine; it is called tele-care instead. However, for our report, patients receiving such care at home are also included in the definition of telemedicine.

Third, by using the expression "medical care and health supporting practices," we do not limit telemedicine to medical care only. We predict that the application of image-transmission will be extended to home-based care for the elderly. In our growing aged society, home health care will be a big issue. Thus, we need to expand the definition of telemedicine to include such care. In the future, the users of telemedicine will not be limited to physicians, but may include dentists, nurses, medical technicians, pharmacists and other medical care professionals. All of these professionals may give advice from some remote site.

Telemedicine usually means transmission of information followed immediately by medical care. However, we do not require this time concept in our definition of telemedicine. We reason that some situations, such as the examination of X-ray images is not dependent on the amount of time between image transmission and actual medical care. For example, a large number of X-rays could be transmitted during the night, stored at the receiving site, then read by a specialist who sends back the results when time permits. In fact, a time lag between image transmission and examination may even be beneficial if more specialists can be asked to examine the X-ray.

The utilization of image-transmission has been successful in academic meetings and TV conferences. Also, doctors from different hospitals have found image transmission useful when they need to review unique cases together. A TV conferencing system can serve to improve patient amenities by transmitting school lessons to children staying in hospitals or by enabling long-term inpatients to have TV phone conversations with their families. These additional forms of TV conferencing are not further discussed in this report since they are not considered a part of medical care. However, there is much to be learned because telemedicine is a developed form of TV conferencing.


3. Benefits of Telemedicine

The first benefit of telemedicine is the leveling of regional differences. The same information can be accessed from the next room and from a medical facility several thousand kilometers away. The quality of medical care will be largely improved because accessibility to special medical care can be extended to rural areas.

The second benefit of telemedicine is improved efficiency of medical care. For example, the number of times patients had to be transported was halved in the Aomori prefecture after employing a telemedical system. According to calculations, the telemedical system is very economically advantageous. Moreover, telemedicine will bring forth more effective use of the small number of pathologists in our country. In some rural hospitals where few operations are performed, there is not enough work for full-time pathologists. Currently, traveling pathologists visit such hospitals, but further propagation of telemedicine will lead to a more efficient solution.

Improved efficiency is also good news for fields where information transmission does not include images. Though this report deals only with telemedicine with image-transmission, improved efficiency of telemedicine will upgrade the quality of nation-wide medical care. This is because we predict increased cooperative care - a kind of medical care given jointly by more than one medical facility or specialist - in the future.

The third benefit is improved service for patients. It is a large burden for sick patients to physically go to a hospital. Ideally, a patient could receive a doctor's visit in the comfort of his own home. However, it has not been possible to achieve such ideal care efficiently. A patient's psychological comfort would be greatest if they could be monitored constantly by physicians. Telemedicine will bring patients much closer to that ideal situation.

The fourth benefit is that physicians will have greater opportunities to deliver medical care to patients in places where medical care is not otherwise accessible. The most typical case would be to use telemedical communication between a hospital and an ambulance. This sort of usage will be further expanded to ships, planes, and even spacecrafts in the future.

Finally, telemedicine can be a very effective method of international medical cooperation. The technology used in telecommunications is basically the same throughout the world. Thus, it will be possible for Japan to give advice and to support its medical projects stationed in other countries. Though we see numerous applications of this kind in other countries, we seldom find it in Japan. However these will be important applications of telemedicine in the future.


4. History of Telemedicine in Japan

In Japan, telemedicine dates back to the 1970s. In 1971, the first telemedical experiment took place in the Wakayama prefecture. The experiment involved closed-circuit television (CCTV) and the telephone circuit. CCTV was temporarily installed to provide medical care to rural mountain areas that had limited technology. Direct images and sound were transmitted; documents were also transmitted by facsimile (called copying transmission then). This experiment confirmed that telemedicine was possible even with limited technology.

In 1972, the Nippon Telegraph and Telephone Public Corporation experimented with transmitting x-ray images from Aomori Teishin Hospital to Kanto Teishin Hospital. The purpose of the experiment was for doctors in Tokyo to look at transmitted x-rays, make diagnoses, and talk with patients in Aomori - all through television. The most advanced technology at that time included the TV relay circuit, telephone circuit, and data transmission circuit. Although the technology was excellent, maintenance of the high band zone proved difficult and for that reason, the experiment was not developed further.

In 1974, there were two additional teleconferencing experiments. First, Nagasaki University implemented CCTV. In the Okinawa prefecture, a comprehensive medical information system for remote areas used still image transmission. This was seen as a great accomplishment because the difficulty of transmitting analog x-ray pictures through telephone lines had been well established. The project in Okinawa helped advance both the acceptance and expansion of telemedicine.

Other key telemedicine experiments are described below. Experiments using "New Media" were conducted in the pilot project of a communications satellite called CS-2. This experiment was aimed at medical support in the time of disasters, and was the result of collaboration between Tokai University and the Radio Research Center at the Ministry of Postal Service and Telecommunications. An experiment in Mitaka used the digital communication network (INS64) to explore medical care for patients at home by transmitting images using a videophone. At the Suwa Chuo Hospital in Nagano, a medical support system for patients at home, based on a commercial CATV network, was used for several years. Although there have been many other telemedical experiments, few remain today.


5. Issues in Telemedicine

5-1. Legal Issues

Telemedicine can be used in four circumstances: (1) between medical facilities and doctors, (2) between medical facilities and health facilities without doctors, (3) between medical facilities and individual homes, and (4) between co-medicals and individual homes. In general, the definition of telemedicine encompasses (1) and (2), while (3) and (4) are referred to as tele-care.

Telemedicine practiced between physicians does not have legal problems in Japan [e.g. (1)]. However, because telemedicine is not listed on the fee schedule, it is unclear how doctors could be reimbursed for telemedicine. Items not listed on the official fee schedule are not considered formal medical care. In sum, while telemedicine is technically legal, there are reimbursement problems that need to be solved before telemedicine can be widespread.

In Japan, physicians must be in the presence of a patient to practice formal medical care. However, (2), (3), and (4) refer to situations where this is not the case. This creates legal problems for (2), (3) and (4). On the other hand, current insurance policy covers phone consultation with a physician after an initial visit. Thus, in these situations, medical care without the presence of a doctor has already been included in the medical system. It may be possible to extend that medical care to encompass telemedicine in the future.

With new technology, there are medical situations that fall somewhere between traditional face-to-face meetings and telephone consultations. These situations have not been defined or clarified. This report explores some of these situations.

5-2. What departments benefit most from telemedicine?

Sending images of patients is the primary objective of telemedicine and some departments are naturally more apt to benefit from it. For example, patients needing surgical treatment would receive little benefit. On the other hand, departments that perform less direct handling, such as internal medicine, dermatology, rehabilitation therapy, and psychiatry, can benefit much from telemedicine. However, even in the most suitable departments, the success of telemedicine diagnosis depends most on mutual trust and understanding of each person's actions.

5-3. Patient Issues

A patient's ability to reach a hospital is an important factor to consider when discussing telemedicine. However effective telemedicine may be, it is unacceptable to use telemedicine when direct care is possible. On the other hand, when a patient is physically isolated from physicians, any data transmitted to a remote physician can be very valuable. Some situations where telemedicine will be useful are: (1) when a patient does not have easy access to a hospital, (2) when a physician has limited access to a patient, and (3) when emergency care is needed.

Patient privacy also needs to be considered when transmitting images. Everyone has a right to privacy and access to images should be limited to the appropriate personnel. It is critical to discuss and agree upon access rights before commencing image transmission.

5-4. Timing Issues

In general, telemedicine implies transmission of patient information followed immediately by medical care. For example immediate transmission is usually required when handling endoscopic images, supersonic tomographic images and x-ray images of the digestive tract. These images are generally transmitted to seek prompt advice from other professionals. When taking CT or MRI images, professional advice from radio-technicians can play a crucial role in obtaining quality images. For example, such professionals can suggest contrast imaging, determine image area, and choose the appropriate pulse sequence. CT and MRI imaging may benefit considerably from telemedicine.

On the other hand, once images and other data are obtained from patients, the data will exist independently and can be transmitted without the patient's presence. For example, x-ray images may be transmitted overnight, stored at the receiving site, and read by a specialist the next day. It may be controversial to classify this type of practice as telemedicine. However, x-ray reading is not done immediately in many non-telemedicine situations and so, we decided to include this practice in the definition of telemedicine. The interpretation of images by a radiologist does not need to immediately follow transmission from a remote site.

Examples of transmitted information include the following:
(1) Examination data

(2) Immediate patient data

5.5 Technical Issues

There are complex technical concerns that need to be considered. Some of these are listed below.
(1) Types of pictures (2) Transmitting conditions (3) Input Devices (4) Transmission related factors (5) Output Devices

6. How can telemedicine fit into the medical system?

Telemedicine has limitations compared to traditional, face-to face medicine. Clearly, information that can only be acquired by touching cannot be transmitted. If we define information gained through face-to-face interaction as perfect and complete, telemedicine provides imperfect information by comparison. However, despite this limitation, telemedicine has useful applications in medical care. The challenge is to apply telemedicine to the appropriate specialties/fields that will receive benefits from it. Guidelines for using telemedicine need to be prescribed. Such guidelines would fall between the two extremes of (1) contribution to patient care and (2) avoidance of malpractice.

Setting guidelines for telemedicine may be quite complicated because conditions can change according to physician competence, environment, and level of technology. For example, a very experienced physician may be able to make a diagnosis based on limited information while a less experienced physician may not be able to do so. Also, in an emergency environment where there are no physicians present, imperfect information transmitted to a site with physicians may be crucial to getting advice. Finally, telemedicine is heavily dependent on the level of technology available to the physicians. It is important to recognize what is possible with the available technology and to avoid using level of technology as a justification for poor medical judgment.

A physician must be held responsible for the results of telemedicine just as he is held responsible for traditional face-to-face care. Broad guidelines may be set for telemedicine, but individual physicians will set their own limits based on experience and circumstances. In addition, guidelines for the reimbursement of telemedicine need to be established. As a research group, we feel that only certain types of telemedicine will ever be insured in Japan.


7. Delivery of Telemedicine

7-1. Telemedicine between two medical facilities (with doctors)

There are no legal restrictions on telemedical consultation between medical facilities. However, there is no consensus in the medical community on how telemedicine should be applied under various situations. Beyond that, the wide use of telemedicine is impossible because telemedicine is not reimbursed under the present insurance system.

A. Transmitting Examination Data

It will be advantageous if examination data such as X-rays, pathological data, and endoscopic images can be transmitted via telemedicine. In addition, because of Japan's shortage of pathologists, the transmission of pathological data will be particularly useful.

(1). Digital Data

Digitalized data such as CT is the most appropriate for electronic transmission because the information is not changed through transmission. In other words, input data and output data are completely identical, making diagnosis based on transmitted data as accurate as that based on original data, given that the technology on both sides are equal.

There are payment issues that must be discussed regarding telemedicine. For example, when one facility (A) solicits the advice of another facility (B), there are three expenses incurred. First, there is the data transmission expense from A to B. Second, there is the diagnosis fee that B can charge A for its services. Finally, there is a second data transmission expense from B back to A. Currently, data transmission is not listed on the fee schedule, and thus, cannot be reimbursed. This creates problems for both facilities.

(2). X-Ray Images

There are no legal problems in making a diagnosis based on transmitted radiology images. However, there is no consensus in the medical community on what guidelines should be followed regarding these images. First, there is the question of whether or not diagnosis can be made based solely on CRT. Secondly, there is the question of what image quality is appropriate.

By law, CRT images must be stored on film; the length of storage depends on the particular insurance system and laws associated with it. This issue prevents CRT diagnosis from becoming widespread. If this technical issue is solved, CRT diagnosis should be encouraged.

Regarding image quality, a 200 µm sampling pitch, a 10 bit density sampling resolution, 1000 x 1000 resolution degree, and 8 bit resolution in the density direction are generally considered minimum requirements. However, factors such as the quality of the camera and digitalizer, degree of data compression at transmission, the quality of CRT, and the image processing method all influence x-ray images, making it difficult to define the exact requirements for image quality.

Physicians involved in telemedicine should be aware of the differences in image quality after transmission and practice accordingly. A physician is equally liable for his diagnosis based on transmitted x-rays as normal x-rays.

(3). CT/MRI Images

The issues mentioned in regards to X-ray images are also applicable to CT and MRI images. The one exception is that the image quality can generally be lower than that of X-ray images. This is quite natural because the original image has a 512 x 512 resolution.

(4). Pathological Data

Again, there are no legal issues surrounding transmission of pathological data, but there is no consensus among the medical community. The key distinction of transmitting pathological data is that it is technically more complicated than transmitting radiology images.

First, the pathology samples must be collected and stained under the supervision and responsibility of a doctor at the sending site. In addition, a physician also needs to decide what part of the sample should be transmitted since the samples are, on average, fairly large. It is permissible to have pathology technicians select what parts should be transmitted, but a physician must be accountable for the actions of the technician. After the diagnosis, a paraffin slice of the sample must be made. Both the clinical and pathology sides need to keep records that indicate the first diagnosis.

Someone must also decide if it is necessary to use advanced technology such as videophones, high-resolution color monitors, and remote controlled devices for pathological data. Ideally, telemedicine would include transmission of patient records, use of a video phone for viewing the pathology samples taken from patients, remote controlled microscopes for detailed views of the samples, and HDTV transmission for image clarity. This equipment is currently available, but very expensive. No consensus has been reached on the necessity of such high quality equipment. In some cases, only one image is enough for diagnosis if patient records are available and if physicians at both sites have communicated effectively with each other. Consequently, the equipment used to make diagnoses should be chosen by the physicians who will use it.

Currently, telepathological diagnosis based on the available technology is less accurate than diagnosis based on traditional microscopic images. What is needed for a successful pathology diagnosis by telemedicine is a clear understanding of each party's responsibilities, regular communication, and a mutual trust among all participants. Telepathology should also be limited to cases where it may make a significant impact on therapeutic decisions immediately, considering the small number of pathologists in Japan.

There are two fees associated with telepathology. The sender side carries a technical fee for preparing the samples and transmitting the images. The receiver side carries the diagnostic fees. Currently, insurance coverage divides pathology fees into two categories: making samples and diagnosing samples. Therefore, it is simple to apply the same categorization to telemedicine - the fees associated with making the samples will go to the sender while the fees associated with diagnosing the samples will go to the receiver.

(5). Other examination data

Other data such as endoscopic photographs, funduscopic photographs, ultrasound screens, and images of electrocardiograms/electroencephalograms can also be transmitted. Transmission of electrocardiograms is in practice today. These types of images share the same legal concerns as the types mentioned earlier. However, it is more technologically difficult to transmit these images because they are analog-based instead of digital-based. More research on the transmission and storage of non-radiology images, such as endoscope images and ultrasound images, is needed.

On the other hand, the following examples illustrate the problem associated with rapidly changing technology. Today, the standard endoscope is an analog one, but digitalized output endoscopes are currently being developed. These new endoscopes will allow storage of images electronically, making standard film antiquated. However, today, the cost of film is reimbursed through the insurance system. It raises the question of how these new endoscopic images will be reimbursed.

New ultrasound devices that have digital output (DICOM) are also being developed. Compared to conventional devices that can only display analog NTSC screen images, the new devices will have better screen quality and better screen reproduction. These will be better suited to image transmission and telemedicine. When these devices are put into use, a new reimbursement system will need to be developed as well.

B. Consultation between medical facilities

In Japan, though efforts to seek consensus on medical practicality of telemedicine has not been pursued by the medical community, the doctors who have experienced telemedicine agree that it would be useful to have a color-video phone, especially in the department of internal medicine. For telemedicine to be effective, they required moving images by NTSC to be immediately transmitted to a color display and simultaneous sound transmission so that discussion between parties would be possible. Still images were sufficient for some diagnosis in dermatology.

There are some complicated questions about standards in telemedicine technology which need to be clarified. For example, what colors in the color CRT band should be available, what should be the frame rate per second, and what should be the transmitting bandwidth are all questions which should be specified in general standards. Nonetheless, participating physicians must assume responsibility for their consultations even if there are standards.

Under the current insurance system, telemedical consultations cannot be reimbursed. In the future, consultations from specialists will be desirable for ensuring quality medical care and such consultations should be covered. Currently, when one receives medical care from several different departments in a general hospital, each department can be reimbursed. The same logic should be applied to departments in different hospitals when they are consulted via telemedicine.

Besides internal medicine, the departments of dermatology and ophthalmology have also been shown to derive practical benefits from telemedicine in Japan. Applications of telemedicine in the field of psychiatry have been used in other countries but have not been attempted in Japan. Officials in Japan are waiting for further research in this area.

7-2. Telemedicine between a medical facility and a home

This area of telemedicine has the potential to be a very important part of home health care in the future. However, telemedicine should not be the primary form of home health care; it should remain a support system for traditional medicine. In addition, telemedicine for home health care must be based on informed consent between physicians and patients. Telemedicine should not be employed if a patient does not want it.

This form of telemedicine (between a medical facility and a home) has not been legally clarified yet. Medical law defines diagnosis only in the form of a face-to-face encounter, but does not directly prohibit any other forms of diagnosis. The legal boundaries should be clarified by the Ministry of Health and Welfare. Practitioners must assume the same responsibilities for diagnosis via telemedicine as for normal medical care.

Internal medicine researchers who experimented with telemedicine using a video phone system reported that it was medically practical under certain circumstances. Yet, there have been a surprisingly small number of studies that have compared physicians' opinion on using a video phone system against performing a regular clinical visit. It has been reported that it is difficult to form an opinion regarding edema in some cases using a video phone system. However, this also correlated with the quality of employed devices, making it difficult to generalize the results.

The use of telemedicine should be limited to patients who have been seen by the same physicians for a long period of time and are in stable condition. For these long-term patients, psychological support may be important and telemedicine may also serve this need.

The minimum technical requirements for this system should be a color videophone with moving images in NTSC and a capacity for simultaneous sound transmission. Standards for color range, frames per second, and bandwidth also need to be established.

Considering the reasons above, insurance coverage for telemedicine between a medical facility and a home should be limited to supplementary care of a chronic patient by a visiting physician. Two telemedical sessions should not be given in succession (a revised opinion: face-to-face medical care should be given every two weeks unless a patient is in stable condition, in which case, face-to-face medical care should be given at least once a month). Under such conditions, these telemedical sessions should be treated as normal return visits to a physician.

Telemedicine between a home and a medical facility also has applications in the fields of dermatology, rehabilitation therapy, home care, and supervision of pregnancy. The legal issues are common among all specialties, revolving around the fact that diagnosis has only been defined as a face-to-face encounter. In dermatology, it has been reported that giving advice via telemedicine is effective if the physician can see the affected part, especially in treating bedsores. Insurance guidelines for dermatology should be similar to those for internal medicine.

In rehabilitation therapy, telemedicine is effective for patients recovering from chronic illness and who have been guided through face-to-face care. In terms of the technology needed, the requirements are more stringent for rehabilitation therapy than those for internal medicine or dermatology because rehabilitation therapy involves movement. Therefore, the frame rate must be able to take moving pictures. The quality of the videophone is critical; a frame speed of 15/second and simultaneous sound transmission are necessary. Insurance should cover this type of care if certain requirements are met. For example, once a month, the patient must meet with a physician face-to-face because telemedical guidance through rehabilitation therapy should be used between direct clinical visits.

Telemedicine is also effective for psychological support and supervision of bedridden aged people in homes. In the future, it may be practical to link the patient, a medical facility, and a support care center/visiting nurses' station. The question of patient privacy must be resolved before this application of telemedicine can be enacted.

Finally, telemedicine may be useful in the supervision of a pregnancy. Research on this application of telemedicine has been done overseas, but there have only been a few cases in Japan. Telemedicine has been effective in enhancing care and reducing the number of hospital visits during pregnancy in other countries. A videophone would not be sufficient in this application. Ideally, blood pressure, protein content in urine, and fetal heart beat could also be monitored from a remote site. Further research is needed in this field.

7-3. Telemedicine between medical facilities and medical-related facilities with no physicians

This type of telemedicine is between a medical facility and a rural medical center or ambulance not staffed by physicians. In this case, there is medical staff at the "other" site, making the situation more favorable than in the case of home health care. However, even so, medical law prohibits these staff from performing many of the practices done by physicians.

The requirements for this form of telemedicine are the same as those for home health care. However, application of telemedicine should be flexible enough to adapt to the environment. It is also important to pursue the range of medical care that the non-physician medical staff can participate in.

7-4. Telemedicine between co-medicals and homes

Telemedicine between co-medicals and homes are especially suited to long term care or handicapped care. These applications of telemedicine are expected to increase in the future. For example, a videophone may be used by nurses at a home care support center to guide patients at home in how to use medical equipment or how to take medicine. They can also give the patients nutritional advice. It can be especially practical in guiding oxygen treatment or injections at home.

7-5. Telemedicine for TV conferencing

Though we did not include TV conferencing in our definition of telemedicine, TV conferencing is one application of telemedicine. Thus, medical personnel must become aware of TV conferencing and its standardization.

A. Current status of TV conferencing

Standardization of the TV conferencing system must be considered on three levels: the protocol level, functional level, and human interface level. On the protocol level, the system has been standardized to a great extent. The International Telecommunications Union (ITU) establishes standards for the digital video phone and conferencing system. These standards are the foundation for every country's TV conferencing system. On a protocol level, standardization has been achieved. In Japan, HATS, an extra-governmental organization of the Ministry of Postal Service and Telecommunications, guarantees the interoperability of different firms' systems by linking them. This procedure is called the "conference test." Although HATS is a domestic organization, large organizations based abroad, such as Picture Tel, are also participating in this "conference test." While ITU establishes the basic (protocol) standards, HATS ensures the functional standards.

B. Problems of the TV conferencing system in telemedicine

While standardization at the protocol level has been promoted by a governmental and industrial effort, standardization at the functional and human interface level has not come very far. We will consider three elements: the pointer function, marker function, and quality of still pictures, which play an important role in applying TV conferencing to medical care.

The ITU recommends a standard for pointing (pointing to one spot on the screen) and marking (marking one spot on the screen). In their recommendation, the screen's coordinate system is defined by number of pixels. Since the number of pixels can be specified by the sender, we can interchange an image that has an arbitrary number of pixels. Therefore, in principle, we can transfer even a hi-vision image (1920 x 1035). However, the TV conferencing system sold on the market has not followed the ITU recommendations. The medical information development center (MEDIS) plans to standardize the image transfer system used in the TV conferencing system, especially in the medical field.

ITU recommendations do not regular the quality of still images. ITU only regulates the transfer protocol; displaying images is a human interface issue. The standardization of still image quality may be on MEDIS's agenda because high-resolution images (high definition) will be required for medical consultation and diagnosis. The standardization of still image quality is left for future inquiry.

C. Future adaptation of TV conferencing for telemedicine

As we have seen, standardization at the function and human interface level is not sufficient. It is difficult for industry to lead the efforts in human interface / user's handling because this is the domain where each firm can express its own uniqueness. However, today, the basic TV conferencing system cannot be used in telemedicine. Many functions specifically adapted to telemedicine are needed. Most of these functions are on the functional or human interface level. To make good standards for these functions, users must provide feedback and the specifications will be achieved with a collaboration of users and the industry.


8. Suggestions for the Future

8-1. Suggestions for government organizations

The main reason why telemedicine has not spread in Japan, even though it has been widespread in other countries, is because telemedicine has not been clearly defined in medical terms. There are ambiguities regarding what can be considered a diagnosis. In order for telemedicine to expand, this definition must first be set.

The second reason why telemedicine has not spread is because telemedicine has not been reimbursed under current insurance coverage. In Japan, most medical care is covered; nothing can expand without insurance coverage. Some, if not all, of telemedicine must be covered by insurance immediately. New fees for such things as telephone line usage and maintenance must also be set.

Third, wide band transmission must be ensured for telemedicine to become popular. Image quality is very important for medical applications. Creating and completing an infrastructure for wide band transmission will be very important for that reason.

Transmission fees in Japan are higher than those in other countries. For telemedicine to become economically feasible, a policy to reduce or waive the cost of medical transmission is necessary.

Finally, the payment system at public medical facilities should be better organized to accommodate smooth payment between medical facilities. In the future, more patients will be seen/treated/diagnosed at more than one medical facility, in part due to telemedicine. The current, rigid system makes it virtually impossible to make and receive payments on many cases. This should be revised quickly; the current system would hamper the growth of telemedicine.

8-2. Suggestions for the medical community

The medical community is also responsible for the slow spread of telemedicine. Although telemedicine has been legal and has been shown to be medically beneficial, physicians were reluctant to try new diagnostic methods, preferring to stay with their old ones. In the future, physicians need to analyze the practicality of new technology more objectively.

Some reorganization in medical facilities will be necessary for telemedicine to root itself as a legitimate form of medicine. Until now, telemedicine has been supported and practiced by physicians on an informal basis. For legitimate status in medicine, it may be necessary to establish a telemedicine department staffed by regular employees.

8-3. Suggestions for the industry

Looking from a mechanical perspective, telemedicine is a complex system of devices including screening devices, transmission devices, and medical devices. These devices have been developed in separate departments of one firm. The Japanese industry does a poor job of integrating these devices into one product. There are few, perhaps no, products which can been called a "telemedical system."

8-4. Suggestions for home care support organizations

Buying a whole system of equipment for telemedical care would not be economical for a family because the devices may only be used for a short period of time. Therefore, supporting organizations that lend out devices will be necessary. Such supporting organizations are well developed in the United States; some are even affiliated with medical facilities. In Japan, such organizations have not been developed, but there are some welfare volunteer organizations which provide similar types of support. It is clear that this type of organization will be needed as telemedicine spreads. The issue of how to develop such organizations needs to be considered.

8-5. Suggestions for the academic society

Though academic societies have discussed telemedicine, there have been few opportunities for systematic discussion. Academic societies need to be involved with all the activities mentioned above, as well as provide discussion opportunities for people from various disciplines.


9. The Future of Telemedicine

Currently, telemedicine is limited because physicians cannot touch patients or provide hand-on medical care, such as giving injections. Although these speculations may seem to belong in the realm of science fiction, the most advanced technology may make these speculations a reality in the future. Such technology is currently being explored and is called "virtual reality." Someday, this technology may make remote surgery a reality.



The number of pathologists

In Japan, the current number of certified pathologists (who have been certified as diagnostic pathologists by the Japan Pathology Association) is about 1,600. According to a report by the Ministry of Health and Welfare, in 1986, there were 5.5 pathologists per 100,000 people in the USA while there is 1.0 pathologist per the same population in Japan. Also, the ratio of pathologists to all doctors is 2.6% in the USA and 0.7 % in Japan.

As we can see, the number of pathologists in our country is smaller than that of the USA. However, when we make a simple comparison of our ratio to those of some European countries, we do not find much difference: 2.0 in England, 1.3 in West Germany, and 1.4 in France.

The problem in our country is uneven distribution of diagnostic pathologists. For example, in 1992, the Ministry of Health and Welfare reported that there were 40 pathologists in 100 hospitals in the Tokyo area while there were only 14 pathologists per 100 hospitals in Tohoku. The difference becomes bigger if we consider the fact that the Tohoku area is much larger than the Tokyo area. Also, in the Miyagi prefecture, which is the center of the Tohoku area and includes in the city of Sendai, all 21 pathologists are concentrated in either Sendai or its commuter towns of Shiogama and Natori. The hospitals in other areas, regardless of how large they are, do not have full-time pathologists.


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