Journal of Medical Systems, Vol. 19, No, 2.

1995

Telemedicine Infrastructure Development

Dena S. Puskin and Jay H. Sanders

While there are sign~cant technical and regulatory barriers to developing an adequate infra-
structure for telemedicine, even more fundamental organizational and financial infrastructure
issues must be addressed if this technology is to realize its potential. The lack of good evaluative
data on telemedicine consultations has been a further major stumbling block to its acceptance by
both practitioners and policy-makers. This paper discusses these issues and suggests approaches
for overcoming many of the impediments to telemedicine.

INTRODUCTION

Telemedicine is not new. Beginning with the telephone, medical applications of telecom-
munications technology have been with us for a long time. Current interest and activity
in telemedicine, however, is exploding as its potential for improving access to health care
is increasingly recognized. Despite this recent activity, telemedicine applications that go
beyond the telephone or the use of telecommunications for the simple transfer of clinical
data have not found their way into mainstream medicine.
Over the past twenty years, there have been numerous demonstrations of more
advanced uses of telemedicine. Even so, they have typically been of short duration and
without sufficient validation to overcome the skepticism of the health care community.
As is often the case in any diffusion of new technology, the barriers to telemedicine
are multi-faceted. For ease of presentation, they may be broadly categorized as problems
related to: (1) technology or telecommunications infrastructure, (2) human or organiza-
tional infrastructure, and (3) health care financing infrastructure.

TECHNOLOGY OR TELECOMMUNICATIONS INFRASTRUCTURE

System Design
Despite a great deal of rhetoric, much of current telemedicine technology is propri-
etary and not built on open architecture models, thereby severely limiting development of

From the Federal Office of Rural Health Policy, Health Resources and Services Administration, Department of
Health and Human Services; and Telemedicine Center, Medical College of Georgia.

125

0148-5598/95/0400-0125507.50/0 9 1995 Plenum Publishing Corporation

126 Puskinand Sanders

"seamless" systems that are open, scalable, and interoperable. Another impediment to
system integration is the lack of widely accepted standards for health information. And
while standards are necessary, it is equally important to establish mechanisms for their
efficient and appropriate modification with advances in technology. Finally, the lack of
agreed upon standards also slow any impetus for connecting systems across national
boundaries, inhibiting international telemedicine applications.

Outdated Equipment
Outmoded telephone lines and switching equipment are themselves a key barrier to
the diffusion of telemedicine in many areas of this nation.

Telecommunications Industry Regulations

Current telecommunications regulations are among the greatest obstacles to bringing
telemedicine to many parts of the United States, especially to rural communities. The
establishment of local telephone service areas with the breakup of the Bell system has
been a major deterrent to telemedicine. Different and often idiosyncratic regulations, as
well as different telephone carriers, can operate between service areas, making coordi-
nation and integration difficult when telemedicine services cross such areas. In some
instances, the price of long distance telephone services that cross local service area
boundaries is less than that within a local service area where monopoly pricing may
prevail.
In addition, basing transmission prices on distance has posed a significant financial
barrier to telemedicine in rural communities where distances between consulting facilities
are great. Moreover, certain pricing structures, which do not provide for the purchase of
bandwidth-on-demand or which require the purchase of whole T1 lines to obtain any
advanced service, place telemedicine services out of the financial reach of many small
communities.
To overcome certain of these barriers, some states have allowed special discount
rates for public service applications, such as health. They also have provided companies
with greater flexibility in establishing their own rates in exchange for commitments from
the telephone companies to upgrade the quality of service available in underserved areas.
Regulations have also hampered opportunities for communities to take advantage of
the existing fiber optic capacity that state lotteries, electric and gas utilities, cable com-
panies, and some businesses have available. This capacity is virtually unknown to other
users. Even when this capacity has been identified, local telephone companies do not
know how to offer access to this "dark fiber" and still comply with state tariff regula-
tions. It is very important, therefore, that states inventory this fiber and modify their
regulations to facilitate its use.

HUMAN OR ORGANIZATIONAL INFRASTRUCTURE

Developing an adequate technology infrastructure is not enough. If telemedicine

systems are to be successful, they must be perceived as useful and of value to the patients
and practitioners who would use them.