Telemedicine is the use of telecommunication and information technologies in order to provide clinical health care at a distance. It helps eliminate distance barriers and can improve access to medical services that would often not be consistently available in distant rural communities. It is also used to save lives in critical care and emergency situations. Although there were distant precursors to telemedicine, it is essentially a product of 20th century telecommunication and information U. S. Navy medical staff being trained in the use technologies.
These technologies permit communications between of handheld telemedical devices (2006). atient and medical staff with both convenience and fidelity, as well as the transmission of medical, imaging and health informatics data from one site to another. Early forms of telemedicine achieved with telephone and radio have been supplemented with videotelephony, advanced diagnostic methods supported by distributed client/server applications, and additionally with telemedical devices to support in-home care.  Disambiguation Other expressions similar to telemedicine are the terms “telehealth” and “eHealth”, which are frequently used to denote broader definitions of remote healthcare not always involving active clinical treatments. 2]
Telehealth and eHealth are at times incorrectly interchanged with telemedicine. Like the terms “medicine” and “health care”, telemedicine often refers only to the provision of clinical services while the term telehealth can refer to clinical and non-clinical services involving medical education, administration, and research.  The term eHealth is often used, particularly in the U. K. and Europe, as an umbrella term that includes telehealth, electronic medical records, and other components of health information technology.
Early precursors In its early manifestations, African villagers used smoke signals to warn people to stay away from the village in case of serious disease.  In the early 1900s, people living in remote areas of Australia used two-way radios, powered by a dynamo driven by a set of bicycle pedals, to communicate with the Royal Flying Doctor Service of Australia. Types of telemedicine Categories Telemedicine can be broken into three main categories: store-and-forward, remote monitoring and (real-time) interactive services. Store-and-forward telemedicine involves acquiring medical data (like medical images, biosignals etc. and then transmitting this data to a doctor or medical specialist at a convenient time for assessment offline. 
It does not require the presence of both parties at the same time.  Dermatology (cf: teledermatology), radiology, and pathology are common specialties that are conducive to asynchronous telemedicine. A properly structured medical record preferably in electronic form should be a component of this transfer. A key difference between traditional in-person patient meetings and telemedicine encounters is the omission of an actual physical examination and history.
The ‘store-and-forward’ process requires the clinician to rely on a history report and audio/video information in lieu of a physical examination. Telemedicine Remote monitoring, also known as self-monitoring or testing, enables medical professionals to monitor a patient remotely using various technological devices. This method is primarily used for managing chronic diseases or specific conditions, such as heart disease, diabetes mellitus, or asthma. These services can provide comparable health outcomes to traditional in-person patient encounters, supply greater satisfaction to patients, and may be cost-effective.
Interactive telemedicine services provide real-time interactions between patient and provider, to include phone conversations, online communication and home visits.  Many activities such as history review, physical examination, psychiatric evaluations and ophthalmology assessments can be conducted comparably to those done in traditional face-to-face visits. In addition, “clinician-interactive” telemedicine services may be less costly than in-person clinical visit Emergency telemedicine Common daily emergency telemedicine is performed by SAMU Regulator Physicians in France, Spain, Chile, Brazil.
Aircraft and maritime emergencies are also handled by SAMU centres in Paris, Lisbon and Toulouse.  A recent study identified three major barriers to adoption of telemedicine in emergency and critical care units. They include: • regulatory challenges related to the difficulty and cost of obtaining licensure across multiple states, malpractice protection and privileges at multiple facilities • Lack of acceptance and reimbursement by government payers and some commercial insurance carriers creating a major financial barrier, which places the investment burden squarely upon the hospital or healthcare system. Cultural barriers occurring from the lack of desire, or unwillingness, of some physicians to adapt clinical paradigms for telemedicine applications. 
General health care delivery Benefits and uses Telemedicine can be extremely beneficial for people living in isolated communities and remote regions and is currently being applied in virtually all medical domains. Patients who live in such areas can be seen by a doctor or specialist, who can provide an accurate and complete examination, while the patient may not have to travel or wait the normal distances or times like those from conventional hospital or GP visits.
Recent developments in mobile collaboration technology with the use of hand-held mobile devices allow healthcare professionals in Telemedicine system. Federal Center for Neurosurgery in Tyumen, 2013 multiple locations the ability to view, discuss and assess patient issues as if they were in the same room.  Remote monitoring through mobile technology could reduce annual US drug costs by 15 percent by reducing outpatient visits, verifying prescriptions, and overseeing patient drug administration. ] Barriers to widespread adoption of remote monitoring include equipment costs, technical training and evaluation time. For example it has been estimated that a teledermatology consultation can take up to 30 minutes which contrasts sharply Telemedicine with the 15 minutes allowed for a traditional consultation. 
Additionally, poor quality of transmitted records, such as images or patient progress reports, and lack of access to relevant clinical information are quality assurance risks that can compromise the quality and continuity of patient care for the reporting doctor. 10] Telemedicine can be used as a teaching tool, by which experienced medical staff can observe, show and instruct medical staff in another location, more effective or faster examination techniques. It improved access to healthcare for patients in remote locations. “Telemedicine has been shown to reduce the cost of healthcare and increase efficiency through better management of chronic diseases,shared health professional staffing, reduced travel times, and fewer or shorter hospital stays. “
Several studies have documented increased patient satisfaction of telemedicine over the past fifteen years. 11] The first interactive telemedicine system, operating over standard telephone lines, designed to remotely diagnose and treat patients requiring cardiac resuscitation (defibrillation) was developed and launched by an American company, MedPhone Corporation, in 1989. A year later under the leadership of its President/CEO S Eric Wachtel , MedPhone introduced a mobile cellular version,the MDPhone. Twelve hospitals in the U. S. served as receiving and treatment centers.  Telemonitoring is a medical practice that involves remotely monitoring patients who are not at the same location as the health care provider.
In general, a patient will have a number of monitoring devices at home, and the results of these devices will be transmitted via telephone to the health care provider. Telemonitoring is a convenient way for patients to avoid travel and to perform some of the more basic work of healthcare for themselves. In addition to objective technological monitoring, most telemonitoring programs include subjective questioning regarding the patient’s health and comfort. This questioning can take place automatically over the phone, or telemonitoring software can help keep the patient in touch with the health care provider.
The provider can then make decisions about the patient’s treatment based on a combination of subjective and objective information similar to what would be revealed during an on-site appointment. Some of the more common things that telemonitoring devices keep track of include blood pressure, heart rate, weight, blood glucose, and hemoglobin. Telemonitoring is capable of providing information about any vital signs, as long as the patient has the necessary monitoring equipment at his or her location.
Monitoring a patient at home using known devices like blood pressure monitors and transferring the information to a caregiver is a fast growing emerging service. These remote monitoring solutions have a focus on current high morbidity chronic diseases and are mainly deployed for the First World. In developing countries a new way of practicing telemedicine is emerging better known as Primary Remote Diagnostic Visits, whereby a doctor uses devices to remotely examine and treat a patient.
This new technology and principle of practicing medicine holds significant promise of improving on major health care delivery problems, in for instance, Southern Africa, because Primary Remote Diagnostic Consultations not only monitors an already diagnosed chronic disease, but has the promise to diagnose and manage the diseases patients will typically visit a general practitioner for. Telemedicine Telenursing Telenursing refers to the use of telecommunications and information technology in order to provide nursing services in health care whenever a large physical distance exists between patient and nurse, or between any number of nurses.
As a field it is part of telehealth, and has many points of contacts with other medical and non-medical applications, such as telediagnosis, teleconsultation, telemonitoring, etc. Telenursing is achieving significant growth rates in many countries due to several factors: the preoccupation in reducing the costs of health care, an increase in the number of aging and chronically ill population, and the increase in coverage of health care to distant, rural, small or sparsely populated regions.
Among its benefits, telenursing may help solve increasing shortages of nurses; to reduce distances and save travel time, and to keep patients out of hospital. A greater degree of job satisfaction has been registered among telenurses.  Telepharmacy Telepharmacy is another growing trend for providing pharmaceutical care to patients at remote locations where they may not have physical contact with pharmacists. It encompasses drug therapy monitoring, patient counseling, prior authorization, refill authorization, monitoring formulary compliance with the aid of teleconferencing or videoconferencing.
In addition, video-conferencing is vastly utilized in pharmacy for other purposes, such as providing education, training, and performing several management functions.  A notable telepharmacy program is in the United States, conducted at a federally qualified community health center, Community Health Association of Spokane (CHAS) in 2001, which allowed the low cost medication dispensing under federal government’s program. This program utilized videotelephony for dispensing medication and patient counseling at six urban and rural clinics.
There were one base pharmacy and five remote clinics in several areas of Spokane, Washington under the telepharmacy program at CHAS. “The base pharmacy provided traditional pharmacy study to the clients at Valley clinic and served as the hub pharmacy for the other remote clinics. ” The remote site dispensing and patient education process was described as follows: once the prescription is sent from the remote clinics to the base pharmacy, the pharmacist verifies the hard copy and enters the order. The label is also generated simultaneously, and the label queue is transmitted to the remote site.
When the label queue appears on the medication dispensing cabinet known as ADDS, the authorized person can access the medicine from ADDS followed by medication barcode scanning, and the printing and scanning of labels. Once those steps are done, the remote site personnel are connected to the pharmacist at base pharmacy via videoconferencing for medication verification and patient counseling.  In recent time, the U. S. Navy Bureau of Medicine took a significant step in advancing telepharmacy worldwide.
The telepharmacy program was piloted in 2006 “in the regions served by Naval Hospital Pensacola, Florida, and Naval Hospital Bremerton, Washington. ” Starting from March 2010, the Navy expanded its telepharmacy system to more sites throughout the world. According to Navy Lieutenant Justin Eubanks at Navy Hospital Pensacola, Florida, telepharmacy would be initiated at more than 100 Navy sites covering four continents by the end of 2010.  Telerehabilitation Telerehabilitation (or e-rehabilitation) is the delivery of rehabilitation services over telecommunication networks and the Internet.
Most types of services fall into two categories: clinical assessment (the patient’s functional abilities in his or her environment), and clinical therapy. Some fields of rehabilitation practice that have explored telerehabilitation are: neuropsychology, speech-language pathology, audiology, occupational therapy, and physical therapy. Telerehabilitation can deliver therapy to people who cannot travel to a clinic because the patient has a disability or because of travel time. Telerehabilitation also allows experts in rehabilitation to engage in a clinical consultation at a distance. Telemedicine Most telerehabilitation is highly visual.
As of 2006 the most commonly used modalities are via webcams, videoconferencing, phone lines, videophones and webpages containing rich Internet applications. The visual nature of telerehabilitation technology limits the types of rehabilitation services that can be provided. It is most widely used for neuropsychological rehabilitation; fitting of rehabilitation equipment such as wheelchairs, braces or artificial limbs; and in speech-language pathology. Rich internet applications for neuropsychological rehabilitation (aka cognitive rehabilitation) of cognitive impairment (from many etiologies) was first introduced in 2001.
This endeavor has recently (2006) expanded as a teletherapy application for cognitive skills enhancement programs for school children. Tele-audiology (hearing assessments) is a growing application. As of 2006, telerehabilitation in the practice of occupational therapy and physical therapy are very limited, perhaps because these two disciplines are more “hands on”. Two important areas of telerehabilitation research are (1) demonstrating equivalence of assessment and therapy to in-person assessment and therapy, and (2) building new data collection systems to digitize information that a therapist can use in practice.
Ground-breaking research in telehaptics (the sense of touch) and virtual reality may broaden the scope of telerehabilitation practice, in the future. In the United States, the National Institute on Disability and Rehabilitation Research’s (NIDRR)  supports research and the development of telerehabilitation. NIDRR’s grantees include the “Rehabilitation Engineering and Research Center” (RERC) at the University of Pittsburgh, the Rehabilitation Institute of Chicago, the State University of New York at Buffalo, and the National Rehabilitation Hospital in Washington DC.
Other federal funders of research are the Veterans Administration, the Health Services Research Administration in the US Department of Health and Human Services, and the Department of Defense. Outside the United States, excellent research is conducted in Australia and Europe. As of 2006, only a few health insurers in the United States will reimburse for telerehabilitation services. If the research shows that teleassessments and teletherapy are equivalent to clinical encounters, it is more likely that insurers and Medicare will cover telerehabilitation services.