Abstract
In this last issue of 2011 we find ourselves in the northern hemisphere at winter's solstice with leaves gone and the land at rest, awaiting a new spring. It is a time of reflection and the indoor work of the season. Writing, doing, planning, evaluating, hoping are paired perhaps with anxiety for the coming year, regrets for opportunities not realized in the past year and uncertainty in the challenge of ever knowing the next stumbling steps of our community. Indeed this is a time of uncertainly perhaps more than most. The world economy is still failing to give bright promise and human suffering all too often is delayed or put on hold while we wait for more propitious signs. What are the initiatives of governments, business, and institutions that might guide us in our constant seeking to find ways to improve the human situation through telecommunications and information technology? Where are the hot spots that might allow us to use our knowledge and learn new things? What are the barriers to surmount and where does the message of seamless humanity need to be taken?
In many ways telemedicine is in a marvelous time of fulfillment. The research, pilot studies, and grants from so many governments find us in a time of confident application of programs and principles. There is no longer a need to prove the potential of mass information and communication to support healthcare. Governments are ready to embrace telemedicine and telehealth as welcome enablers of the aspirations of ministries. Business recognizes the power and financial potential of telemedicine. Business and governmental programs are generally growing. It is ever more evident that telemedicine by whatever name is the way forward from a model of healthcare that is unsustainable to a workable, effective, and affordable way to meet the expectations of the people. The old model was labor intensive, choking on paper, reliant on a fixed place for care such as hospital or clinic. The new model can be centered on an empowered and connected public, a full partner in their health maintenance and needs to regain health and function. The new model is mobile, ubiquitous, seamless, and is staffed through cyberspace with a virtual medical staff of ultimate richness in skill and information. The new model is seamless, assessable, and the efficiencies of electronic solutions means it is cheaper and therefore more accessible regardless of resources.
A great question for us in the telemedicine community is what to do next? Does our task end when telemedicine is fully integrated into education, public awareness, and medical practice? Does telemedicine merge into the monolith of human endeavor as another grain of sand in the concretion of infrastructure and only have a history with a bureaucratic, regulated, and utilitarian future?
Certainly for many of the legion of telemedicine founders who brought us to this point that would be fine. However, one might remember the prediction at the end of the 19th century that nothing remained to be invented. What a surprise that prognosticator would have if he were awakened in 2011! Well, if more is to be done, what are the driving questions and where is the funding to pay for the research? Who has to be convinced there are new horizons?
With no claims to prescience here are a few of the questions and opportunities. We are at the very beginning of sensing to evaluate the human condition. From the early days of space programs in Russia and the United States, telemetry informed terrestrial managers of the physiologic status of space travelers. Now we have intensive care units and home monitoring that would have amazed early practitioners of space medicine. However, the richness and rapid changes of human physiology invite us to new realms of assessment using body area networks, noninvasive sensors, and implantable sensors. The need for chemical analysis in conditions such as diabetes is crying for solutions based on spectrometry or some new technology. The use of electronics to assess the activity of electronically active tissues such as heart or muscle or central nervous system has only just provided a glimpse at the potential for a full capture of the conditions. The ability to acquire images of light reflection, light penetration, images of heat, and other portions of the electromagnetic spectrum strongly urge us toward discovery to record an event.
The ability to analyze the data of a human sensor network is ever greater with local evaluation and algorithmic consideration, and local response means that the crucial interventions for human crisis can be applied on site without the intervention of a distant telemedicine manager. What are the new technologies that will facilitate the communications with a distant caregiver? We have so many short range technologies in the wireless realm but are there others to come? Zigbee, Bluetooth, and radio are great but not perfect by any stretch. Just how much can we safely automate in analysis of physiological sensing? The Automatic Electronic Defibrillator is trusted to read an electrocardiogram with no human oversight and deliver the right number of joules to the thorax. What else can we do with stroke, falls, chemical imbalance, arrhythmia, and dementia? What are the elements of monitoring that reliably predict crisis and arrange to avoid it? We are at the level of noting the flight of birds and the howling of dogs to predict earthquake when it comes to anticipating plaque buildup in crucial circulatory beds, the movement of tumor cells in metastasis, and growing danger of fall or disorientation. In fact, the vast majority of our attention in clinical management is based upon recognition of a fait accompli and subsequent response.
With regard to telemedicine implementation we have many leagues to go before regulatory matters are resolved and telemedicine is fully represented in curriculum, practice, and planning.
Telemedicine has been designed to project human caring and competence to places in need. What can we put in place in the way of assists, robots, smart homes, product safety that would make that kind of vigilance from afar unnecessary on a minute to minute basis. The potential is huge and research is waiting. Our environment can be so much safer, instructive as to health, and assistive for those with physical or mental impairment.
How secure is all the information gathered? Are the records of today the eight track music recording of tomorrow unreadable in five hundred years? Now there is an end to be avoided. Information integrity and its storage is a fertile area of investigation and steady improvement. Security without intrusion includes high priorities but absolute certainty as to the proper password is elusive. Biometrics is a field that should be of great interest to telemedicine to be certain that we are dealing with the proper individual in a telecommunications construct. Passwords are not popular!! They are an annoyance! The entire area of human machine interface is ripe for improvement. Tell a patient with no use of hands to type or use a touch screen. It is very frustrating. We are not there with voice recognition and it is a time of great readiness to make this work.
Let us not forget the problem of power in telemedicine. Research in batteries, power storage, and consumption is sorely needed. Of course the batteries are better and we are in much better condition than a decade ago. However, the charge wires are as ludicrous as the old wired telemetry in terms of human lifestyle. We are ready for a great change in power in terms of generation and storage. Solutions that involve rare metals and 19th century electronics are suspect and the use of kinetic devices, potential energy storage, long life, low power consumption, and small size have not been properly explored.
Perhaps telemedicine is awaiting some disruptive technology that will change the world. That would be nice. Perhaps we are awaiting a request for proposals from a large governmental agency to allow us to engage an army of graduate students and fellows to address problems recognized for their potential contribution to community. This could be a like a war on cancer. That would be interesting. However, funding for basic research is not abundant and graduate students cannot be maintained on start-up funds. Funding from governmental largesse seems inconsistent with a strong sense that we should do less until we as a world have our basic government missions funded without debt. Spend what you have and then get creative. We should await a new funding climate. Perhaps we could find vast pools of funding in disguise such as answering our problems with funded solutions to national security or military needs.
There is enough anxiety and mischief in the world to keep that source of monies fairly secure. That would be fine of course. However, one can only stretch the real questions we ask so far and still honor the intent of the agency that is our support. Perhaps we should wait for new indicators of governmental will. Maybe a great foundation would find the basic questions for quantum advancement suitable places for their largesse. That would be wonderful. However, the world economy is stressed by donor fatigue and immediate problems of disaster relief and urgent health delivery in even the older models. Perhaps we should wait until asked or given guidance by the great foundations. Indeed the early application of new technology could draw great resources from industry, which might be a wonderful driver of innovation. That has a good history. Cellular telephony, wireless in general, software, personal computing and communication, fun, games, and miracles are in evidence. There are fortunes to be made. However, this seems a rather slow time for investment. Initial Public Offerings are being delayed and business seems to be holding on to capital waiting for something. Perhaps we just have to wait until the business climate is more robust and ready for innovation.
Waiting is inconsistent with the inquiring mind. Waiting is boring and uninspiring. No matter the climate that seems to bring so many pressing issues to the fore, the future demands more than the grinding details of the present. Here are a few suggestions. Question the adequacy of the extant. What is wrong with what we are doing and how can we make the outcomes better? Look for new technology that could be translated into a telemedicine breakthrough. If the technology is just not there, have the courage to demand it and create it. Encourage the young to ask the hard questions and find ways innovative or traditional to get them funded. Encourage government and business with incentives for improvement, service, and profit to engage in the great opportunities to make medicine seamless, effective, and more humane. If there is no funding, then at least think and dream.
Your editors strongly encourage your creativity, your motives for discovery and service, and will continue to look for the best in work that might complement your efforts in telemedicine. This has been a wonderful year for publishing new technology, processes, and a fuller understanding of the state of our species revealed in its monitoring and care. From time to time many readers will wonder why some topic is pertinent to telemedicine in current definitions. The pertinence is grounded in our belief that telemedicine is not old, not established, and not perfected. Human care through telecommunications and information technology is no longer an infant. However, it is not ripe or anywhere near senility. Let us say telemedicine is a robust and energetic adolescent with a great future. Now is not the time to wait for a weather report. Put on your foul weather gear and let us venture forth. Beethoven brought out Fidelio during the occupation of his beloved Vienna in 1805. He was so angry during the 1809 bombardment that he covered his ears in his brother's cellar and when he encountered a French officer he opined “If I were a general and knew as much about strategy as I do about counterpoint, I'd give you fellows something to think about.” National finances were in disarray and his stipend cut. However, in all the time when one could have just waited for a more salubrious time for creativity, he wrote the Emperor Concerto. Bombs away! Do not wait!