East Carolina University School of Medicine serves the very rural area of
eastern North Carolina, where there are serious shortages of health care
providers. Telemedicine is helping to overcome this shortage by making
specialty medical consultations available to people in rural communities.
Between August 1992 and September 1996, ECU physicians conducted more than
1,000 clinical consultations via telemedicine. These consultations occurred in
29 different specialties (), with a majority in dermatology (55%). A typical distant
consultation involved a nurse at the “spoke site” (rural hospital,
rural clinic, or prison clinic) presenting the patient to the specialist
physician at the “hub site” (ECU School of Medicine in Greenville,
North Carolina). The physician would interact with the patient much like he or
she would in a face-to-face clinic visit.
Clinical Consultations by Specialty, August 8, 1992-September 3, 1996
The ECU telemedicine network is a scalable, hybrid communications network
that comprises T1, asynchronous transfer mode (ATM), plain old telephone
service (POTS), microwave, and SW56 transmission modes. A variety of
compression engines have been tested, deployed, and integrated into a
multichannel bridge that interconnects all of these technologies. This
multichannel bridge allows cross-platform communication. For example, our
ATM-based telemedicine sites routinely take part in continuing medical
education teleconferences that are primarily T1-based sites. Telemedicine at
ECU is not a “one-size-fits-all” model. Rather, it is a scalable
system designed to conform to the functional and financial constraints of the
hub (ECU School of Medicine) and the spoke sites (four rural hospitals, two
rural clinics, one maximum security prison, and one naval hospital).
A primary component of telemedicine at ECU is an optimized physician
workspace in which specialty physicians at ECU conduct consultations with
patients at the spoke sites. The ECU physicians sit in custom-designed, 6- by
12-feet, sound-proofed booths and have a range of telediagnostic tools
available (stethoscope, otoscope, ophthalmoscope, dermatology camera).
illustrates the basic
The physician workspace at the ECU School of Medicine. (Photo by Richard K.
Another component of the telemedicine system at ECU is an application that
connects a small, rural hospital's emergency department to a tertiary care
center's emergency department. Teleradiology services are included in this
application so that the tertiary care center can receive high-resolution
images of a patient's radiologic studies. This application uses North
Carolina's statewide network for high-speed video, audio, and data
communications over ATM/SONET, a switched broadband network. This network
includes all four medical schools in North Carolina, and ECU is one of the hub
sites. This network has been designed to protect patient privacy by using
dedicated 27 Mbps circuits for each telemedicine link. The links provide full
support for all telemedicine tools and include far-end camera controls and
full-motion, 30-frames-per-second video.
The newest component of telemedicine at ECU, a still-image transfer system
that uses standard telephone lines, illustrates the scalability of the
network. Compared with the emergency medicine application described above,
which uses the highest bandwidth and the most expensive technology available,
this application uses standard telephone service and equipment with a total
cost of less than $10,000. Using a video telephone, a primary care physician
on the Outer Banks of North Carolina can transmit dermatologic or orthopedic
images to specialty physicians at the ECU School of Medicine. The video phone
includes an image storage system, so multiple patient cases can be bulk
transmitted in a store-and-forward manner. Accessories for the system include
a dermatology camera and a document camera.
Two other components of telemedicine at ECU are distance learning and
administrative teleconferencing. Since 1991, over 3,000 educational programs,
conferences, and meetings have been conducted over the telemedicine system at
the ECU School of Medicine. These have included weekly transmission of family
medicine grand rounds to physicians at the rural sites on the Rural Eastern
Carolina Health Network (REACH-TV), administrative teleconferences, and
nursing courses broadcast to hospitals and community colleges in rural areas
of eastern North Carolina.
Along with the application currently in use, the telemedicine program at
ECU is also involved in research to develop the next generation of
telemedicine application and tools. The technologic research at ECU includes
things as diverse as the DOCking station, which explores the optimum physician
interface for next-generation telemedicine systems; hands-free, voice-operated
telediagnostic tools; and virtual reality (VR) simulations for medical
training. Two VR tools are currently in development: a binaural digital
stethoscope to provide spatialized heart and lung sounds, and a stereo
dermatology system that provides three-dimensional displays of skin lesions.
Our telemedicine network is growing and evolving as we learn more about the
potentials of this technology. However, certain design criteria are shaping