Abstract
Telemedicine did not begin with the Internet, and the Internet did not begin with telemedicine. However, the relationship of the two is structural and hugely important. Telemedicine began with analog communications and microwave transmission. In 1965, with the launch and activation of Comsat's Intelsat I satellite named “Early Bird,” Dr. Michael DeBakey conducted an aortic valve replacement in Houston, TX, with live interaction with surgeons in Geneva, Switzerland, and the Director-General of the World Health Organization. 1 Satellite communication was extremely expensive, and most telemedicine work was in the demonstration mode. These demonstrations were powerful, including noteworthy efforts such as NASA's Space Technology Applied to Rural Papago Advanced Health Care (STARPAHC) 2,3 and NASA's outreach to Armenia after the 1988 earthquake. 3,4 However, these demonstrations required acquisition of satellite time at a very high expense. The driver for NASA was the absolute need for telemetry and distant management of health of astronauts during spaceflight.
The Internet was preceded by computer-to-computer connectivity and was digital as opposed to analog signals. Digital allowed for so many possibilities in information science with data management and data mining. The initiative through the U.S. Defense Advanced Research Projects Agency (DARPA) was aimed at secure communications during the Cold War. The need for standardization was paramount. Packet switching was introduced in 1965, and computers were soon networked. 5 Vinton Cerf at Stanford University introduced the transmission control protocol/Internet protocol (TCP/IP) in 1974 and allowed what was called a handshake between computers, a common protocol for otherwise incompatible electronics. 6 The World Wide Web became feasible for massive networking with the work of Tim Berners-Lee in 1992 in Switzerland, and the setting was complete. 7 In 1991, the U.S. High-Performance Computing and Communication Act (often called the Gore Bill) 8 created the National Information Infrastructure and moved connectivity from a defense emphasis to civilian, commercial, and international. The bill funded scientists at the University of Illinois to develop the badly needed browser (Mosaic) in 1993. Netscape followed, and the airways were ready for digital transmission into the Internet cloud via landlines, wireless, satellite, and any kind of computer. 9
In the critical years of that decade, telemedicine was ablaze with possibilities. These were reviewed at the Augusta Conference in 1995. 9 Telemedicine leaders urged research funding, stabilizing regulations, technology infrastructure, capacity improvement, reimbursement, markets, and professional issues. It seems the leaders were very prescient indeed, and the recommendations of this conference have largely been realized. Uldal et al. 10 in 1997 reviewed the advances in teleradiology, noted the advances in workstations, development of standards such as Digital Imaging and Communications in Medicine (DICOM), and transmission fidelity, and called for Internet applications.
Throughout the 1990s, most advanced telemedicine efforts were conducted with the Integrated Services Digital Network (ISDN). This connectivity allowed for privacy and high-quality transmission with multiples of the standard 128 kilobits/second transmission rate. Although that strikes one as pretty small bandwidth, two-way video was possible and very useful. The National Library of Medicine in the United States sponsored much of this excellent work and supported rapid development of standards and potentiality. 11 However, the fruition of Internet telemedicine lagged because of limited access. Peter Yellowlees cogently observed in his review of a cybermedicine text in 1999 that the book was already out of date in 1997 because of the overwhelming implications of Internet connectivity. 12
In 1994, several researchers pushed the limits of the Internet and the emerging World Wide Web to utilize desk top computing to support telemedicine. 13,14 DeBakey was again a co-author of what was newest and best in a case report in our journal in 1998 concerning the use of the Internet for long-term clinical follow-up. 15 In the collaboration between NASA and the Russian space community, the Internet saw its full potential in a publication in 1998. 14 The purpose of that bridge was evaluation of cost-effective methodology with appropriate protocols for consultation using the Internet. In that year, NASA-funded researchers at Yale University established Internet connectivity with satellite connections on Mount Everest with a Web site for students and clinical consultation. In that program live consultation for ocular problems and even gallstones in a Sherpa guide and distant management for a team in a nearly disastrous snowstorm proved the Internet to be robust and highly effective with intuitive properties not previously recognized. 16
There was much speculation that the Internet would become the standard for medical consultation. 17 Certainly the use of digital information has become a standard and is the very foundation of healthcare, governance, and commerce. The Broadband Initiative was generously funded by the American Recovery and Reinvestment Act of 2009, and access is rapidly expanding across the continent. 18 Internet service providers (ISPs) have become competitive and ubiquitous throughout the world with a blend of microwave, undersea cable phone lines, and satellite connectivity to support the Internet. One enormous problem of early Internet connectivity was the limited use of IP addresses by the ISPs.
At one time there were more IP addresses at Stanford University than in the entire People's Republic of China. Often IP addresses were shared and changed from use to use, especially in the international setting. The problems for privacy and dependability were daunting. The protocol of IPv4 allowed only 4.3 billion addresses. IPv6, launched in 2012, allows 2128 or 3.4×1038 addresses. This can accommodate a unique address for each of the 7 billion people on Earth and for every electronic device in existence. The 128-character IP address allows for privacy and uniqueness for every imaginable purpose—every imaginable purpose one can imagine at this point anyway! IPv6 is not a new technology but indeed only a new protocol. This huge advance by a mere technical protocol indicated the power of international cooperation and standardization. 19 International cooperation is through engineering groups and certainly the International Telecommunication Union (ITU), an element of the United Nations. 20
Telemedicine research, as reflected in our journal, has been dynamic and burgeoning. At this date, there are over 900 items in the Journal that are related to the Internet. That is nearly half of all articles issued since publication was begun in 1994, and the first Internet article did not appear for several years after that. It seems clear that the future of telemedicine is entwined with that of the Internet. It has been a partnership of technology, economics, and human need that should encourage the future and make dreams a reality. As we contend with issues of interoperability, open access, privacy, and economics, it is inevitable that more changes and innovations are in store. In this 20th anniversary of the Journal, we may anticipate great changes and great creativity as telemedicine moves forward as it has in the past to assure a global standard of healthcare and health improvement.