Abstract
In the practice of medicine, there are standards of care: standard methodologies, processes, and procedures that are accepted and incorporated into everyday practice. After all, they are backed up by evidence! So what happens when technology provides alternatives? Is there pushback? Does frustration mount? Are there naysayers and obstructionists?
Let us go back in time, say to the beginning decade of the 19th century. A French physician, René-Théophile-Hyacinthe Laennec, while working at the Hôpital Necker Enfants Malade (Necker Hospital for Sick Children) in Paris, was examining a young female patient and needed to listen to her heart and lung sounds. The standard of care in this time period was for the physician to place his head upon the patient's chest. Well, this patient was not interested in this man placing his head on her chest. So Laennec fashioned a quire of paper (perhaps a magazine) into a cylindrical funnel and was able to complete the examination. His discovery is the monaural stethoscope, and it led to a new approach of “mediate auscultation.” Soon, it replaced the standard, which was “immediate auscultation,” whereby the ear is placed directly upon the chest, although it took nearly the entire 19th century for the stethoscope to become commonplace and accepted by all physicians. In this example, the standard of care, the approach that was acceptable by the medical community was now challenged by new technology. Students and practicing physicians had to learn a new way. This was not an easy task!
A similar example is Dr. Ignaz Philipp Semmelweis and his work with puerperal fever. In 1846, Semmelweis was a physician at the First Obstetrical Clinic at the Vienna General Hospital. The rate of mortality of mothers and infants was considerably higher than at other hospitals. This mortality was linked to puerperal fever, which Semmelweis traced backed to the student physicians and cadaver laboratories at the Vienna General Hospital, a teaching hospital. Other Vienna hospitals often used midwives for childbirth and did not see this level of mortality. The midwives did not have contact with cadavers, and, what is more important, they washed their hands. In an era before a greater understanding of bacteria and disease, Semmelweis believed something from the cadavers was causing the fever and ultimately death in both birthing mothers and the newborn. By instituting a new process, handwashing, the mortality dropped significantly. However, Semmelweis was fighting against “standard” medical opinion, and his concept of handwashing was rejected. The physicians of his day felt insulted—they were gentleman, after all, and did not have dirty hands—and he was eventually dismissed from his position. In time, his work was published, the medical standards evolved, and people did not die from incompetence or ignorance.
These two examples highlight how technology or at a minimum innovation changed the very foundation of medical practice. There are many other examples that illustrate this point. However, it is our intent to highlight these in conveying how standards of practice evolve. Of course, it is not all technology and innovation. It is also based on evidence and large numbers. For example, trauma surgery changed not because of technology but because of all-out war and the massive casualties it caused. The Crimean War and the American Civil War come to mind.
So what does this have to do with telemedicine and e-health? Well, lots! Consider how technical advances in cameras (still and video), telecommunications, and information systems have evolved in just the past 10 years. Only two decades ago, a business manager would go toe-to-toe with you about new computer systems, servers, backup systems, printers, uninterruptible power supplies, etc. It was not commonplace for information technology (IT) to be at the budget table. Today, the IT budget should be one key budget item, perhaps not equal to labor costs but very important nevertheless.
When this journal began in 1995, we still used beepers. Cell phones were not commonplace, and laptops were very heavy. In fact, those who had cell phones may also have used a personal digital assistant as well. At one of the first American Telemedicine Association (ATA) meetings in the early 1990s, Kodak was displaying a camera that used a postage-size memory chip for acquiring and storing digital photographs. It held fewer than10 photos. Technology no longer takes decades to become fully integrated into society. However, it often can face insurmountable odds in being adopted. Barriers exist that prevent adoption and integration. These include the obvious like expense, training, capabilities, and technical ability. But those that really impact the delay are attitude and poor leadership. Consider our previous examples of Laennec and Semmelweis.
Let us assume that innovation has made its way into a process or procedure in a healthcare setting. There must be a concomitant change in the workflow and other processes. Innovations that are adopted must somehow be integrated with other systems and devices. This implies that standards should be adopted, adapted, developed, and utilized to ensure efficient operations. Although integration is often not seamless, it can and does have a direct impact.
A conversation with Dr. Jane Preston, the ATA's first president over 20 years ago, revealed that when she first started using telemedicine in her practice, the fax machine she was using to transmit electrocardiogram strip recordings from North Texas could not send a facsimile to another fax machine unless it was the same kind of machine (same manufacturer). When fax machines were made available in the early 1970s, they could not interact with one another. There were no standard protocols. Similarly, when the desktop computers became an integral part of our work routine in the late 1980s and earlier 1990s, PCs and Macintosh computers could not work together seamlessly. Files could not easily be transferred from one machine to another. This may have been more of a manufacture-driven anomaly. It nevertheless was challenging. If you have ever traveled internationally, you know that electric plugs are different. Even VCRs worked differently. There were different standards for video—National Television System Committee (NTSC), Phase Alternating Line (PAL), and Séquentiel Couleur à Mémoire (Sequential Color with Memory [SECAM]). Although today, this doesn't seem to be an issue with YouTube and other Web-based video tools.
From the beginning of the current telemedicine era (1990–present), technology has not crept into what we do; it has often come to us like a tsunami. Although each innovation takes the place of a previous device or procedure, the time for acceptance is now measured in months, not years or decades. So there must be standards as well as guidelines that are accommodating to rapid change and provide the practitioner with tools to be successful. It can't take years to develop standards. The technology will be obsolete, as Moore's law states.
Standards are established in wide and diverse discipline—in industry to support manufacturing and in healthcare to support good practice. They include good principles, practices, and guidelines that enable collaboration. When organizations adhere to standards, products and services can be utilized across the entire world. Even if electrical plugs are different.
There are organizations that develop standards like the National Institute for Standards and Technology, other organizations, and professional associations. Standards help us do our jobs better. In a global economy, this is of vital importance. It aids in collaboration and makes good business sense.
Within the telemedicine community, standards and guidelines have been developed by the collective work of subject matter experts. They meet regularly to address the challenges their discipline or subdiscipline is experiencing, and they develop standards to make it work better. The ATA Special Interest Groups have been key to developing a series of documents. However, the early development in the telemedicine field began nearly 20 years ago before the ATA and this journal came into existence.
In 1994, during a National Aeronautics and Space Administration/Uniformed Services University of the Health Sciences international conference, the concept of standards was discussed by several speakers. Houtchens et al. 1 recognized firsthand the importance of standards in conducting international telemedicine during the Spacebridge to Armenia effort in 1989. In 1995, Sanders and Bashshur 2 discussed challenges in implementing telemedicine in the second issue of the Journal. As the ATA and the Journal were developing and telemedicine technologies were emerging in the early 1990s, there were concomitant activities being conducted around the world.
As the world's major economies in the late 1990s and early 2000s held various meetings to discuss a wide variety of initiatives, one project underway in the G8 (G7 [United States, Great Britain, France, Germany, Canada, Italy, and Japan] plus Russia and representatives from Australia) was the International Concerted Action on Collaboration in Telemedicine: Recommendations of the G-8 Global Healthcare Applications Subproject-4. This report and the subsequent article by Lacroix et al. 3 discussed the development of standards. In 2002, Nerlich et al. 4 discussed this further in Subproject-4 “Teleconsultation Practice Guidelines” as part of the G8's Global Health Applications.
Others were also discussing standards as well, including Loane and Wootton. 5 MacDonald-Rencz et al. 6 discussed a national initiative in the Journal in 2004. As the ATA began to grow in stature, it has become an association that has developed tools for practitioners, managers, IT professionals, and industry leaders to use for conducting telemedicine. Through the ATA's Special Interest Groups, standards and guidelines have been developed in clinical areas as teledermatology, 7 telerehabilitation, telemental health, 8 –10 diabetic retinopathy, 11 and many others. 12 Brennan et al. 13 developed a blueprint for standards in telerehabilitation. Greene and Yellowlees 14 have developed standards and guidelines for electronic and remote prescribing.
Krupinski et al. 15 have done a great job summarizing the utilization of the ATA's clinical practice guidelines. The various guidelines, developed by subject matter experts over the past 20 years, continue to be refined to meet growing needs and every changing technology. The Journal has been a platform for sharing this hard work. As you reflect on your telemedicine initiatives, use these standards and guidelines in helping you collaborate effectively and successfully.