2.

1 Telemedicine taxonomy
Telemedicine is the use of electronic information and communication technologies to provide and support
health care when distance separates the participants [10]. It is a system
that connects primary care physicians, providers, specialists and patients. Telemedicine is
not a new concept. It has existed for a number of years in the form of the telephone and
fax machines. In recent years, with the improvements made in access, technology, and
communications systems, telemedicine has expanded and, in a time of limited resources,
has become a feasible alternative for smaller and rural medical facilities to provide routine
and specialized services. Particularly in rural areas, it offers the potential of both improved
access to care and improved quality of care.
The primary applications of telemedicine are clinical, educational, administrative, and research [24].
• Clinical applications include initial patient evaluations, diagnosis (telediagnosis), and
consultation (teleconsultation). Physician supervision of non- physicians and monitoring of patient status are
possible.
• Continuing education for professionals is available, as is patient and community education (tele-education).
• Administrative uses, such as conferences, scheduling, and utilization and quality review may be provided.
• Research is enhanced by aggregation of data from multiple sources and coordination.
Telemedicine allows access to the wealth of information available on the Internet [25, 26,
27, 28, 29, 30, 31, 20]. This allows information to be obtained at the touch of a finger. The
availability of e-mail allows an efficient mechanism of communication between consulting
and primary physicians[32, 33, 34, 35, 36]. The telecommunication infrastructure provides the technology to
move information in an electronic way between geographical locations. Participating sites are connected via
electronic networks. The telecommunication medium utilized by telemedicine programs is
78 Chapter 2. State-of-the-art determined in large part by the available local infrastructure. The communication
could
include satellite, microwaves link or terrestrial lines (either twisted copper phone lines or fiber optic lines).
For the telemedicine system I have defined a taxonomy architecture that categorizes the telemedicine systems in
terms of communication protocols, telemedicine devices, and telemedicine application in clinical domain, as
shown in table 2.1.
Table 2.1: Taxonomy of telemedicine systems
Telemedicine can be divided into home-care, emergency and radiology telemedicine where user defined
applications can be utilized. Each type of telemedicine makes use of dedicated medical devices for medical data
acquisition. In addition, the transmission of the recorded data and data communication is utilized over various
types of communication networks
and various communication protocols.The applications are based on the variety of networks, ranging from the
ordinary telephone lines to specialized networks. Telemedicine involves a spectrum of technologies including
computer technology, digital imaging, video conferencing, remote monitor, file sharing, networking and
telecommunications. Nowadays, we meet telemedicine applications in home care environments, in emergency
and radiology domains.
2.2 Telemedicine protocols
In this section I will focus on telemedicine protocols used by all types of telemedicine applications in home
care, emergency and radiology domains. Telemedical applications have the need to transmit and receive text,
images, and sounds. Text includes ECG results (heart tracings), laboratory results and patient records. Images
range from still photographs to
full motion imagery. Radiological images, slides and graphics may be transmitted, as well as voice and chest
sounds.
Transmission may be done in one of two methods [37]:
1. Real-time transmission is utilized when immediate feedback is essential. Emergency
triage, interactive treating situations [38] [39] and meetings are a few examples.
2. Store-and-forward When immediate feedback is not required, store-and-forward
may be implemented. Data is stored, forwarded and accessed at the hub at a sched-
2.3. Telemedicine devices 9
Home care Emergency Radiology
Applications TOPCARE,TeLeCare DELTASS,REMSAT Chili, DicomWorks
Medication dispenser, ECG,
Devices ECG, SPO2,BP Ultrasound, MRI, CT, PET
glucose, BP, SPO2
Appropriate P2P, DICOM, HTTPS,
Protocols Appropriate P2P, HTTPS Appropriate P2P
e-mail

Table 2.2: Taxonomy of telemedicine systems

uled time or at the convenience of the hub personnel. This is less costly as data can be compressed and batched
for transmission [40] [41]. The transmission mode may be transported via satellite [42, 43, 44] or terrestrial [45]
media. Terrestrial modes include microwave, fiber-optic, and conditioned copper cables. Satellite transmission
allows a full motion broadcast quality picture. Satellite transmissions have no boundary restrictions. It allows
transmission of large amounts of information. It is ideal for sending visual information to multiple locations.
The disadvantage is the cost, but it is the only way to provide communication means to isolated areas
Terrestrial transmission is less expensive to operate on an hourly basis but is limited toareas that are linked to
the appropriate line Nowadays, the dominant means of communication is the internet and basically all medical
applications make use or have a gateway over TCP/IP [55]. Most applications in home-care use appropriate P2P
(point-to-point) developments for data transmission or https protocols. However, most of the applications work
in store-andforward mode. Emergency applications need real-time transmission and use appropriate P2P
developed protocols for data exchange that add huge configuration efforts during system installation. In
addition, dedicated ports need to be opened for bi-directional communication.In radiology domains both real-
time and store-and-forward communication can be applied,
although most dominant is the store-and-forward mode, making use of e-mail protocol (SMTP, IMAP and
POP3). Furthermore, DICOM protocol is used in hospital settings providing intercommunication among
different medical departments. When an external access to the medical data is needed, normally the HTTPS
protocol is utilized.
2.5 Data types and volumes
Conducting telemedicine transactions in real-time implies that two parties exchanging information are
simultaneously present and communicating interactively. The simultaneous exchange of information could be
facilitated via a telephone conversation or could involve video including interview and examination of the
patient, imaging of various anatomic
sites, auscultation of heart and lung sounds, review of x-ray (CT, MRI, PER, ultrasound) examinations.The
alternative to real-time transaction is to conduct telemedicine transactions in storeand-forward mode whereby a
package of medical information is compiled (stored) and sent (forwarded) to the intended consultant or expert
medical officer for review and interpretation at his/her convenience.
The medical information compiled and sent may be as simple as a paper ECG or may be a combination of still
frame images (x-rays), audio clips, video clips and patient medical records and other related examinations.
26 Chapter 2. State-of-the-art
Real-time Store-and-forward
 Interactive
Bandwidth requirement
Yes No
Telecommunicaiton costs
Higher Lower
Technology costs
Higher Lower
Provides multimedia transmission
Higher Lower
Response time
Yes Yes
Impact on patient/consultant rela
Immediate Delayed
tionship
High Low
Instructional potential for primary
High Low
care providers
Lower Higher
Convenience of use for both
Difficult Unnecessary
providers
Yes No
Ease of scheduling
Resembles face to face consult

Table 2.5: real-time vs. Store-and-forward communication

2.5.1 Communication pathways
In recent years several telemedicine applications have been implemented over wired communications
technologies (plain telephone lines), ISDN and ADSL. However, nowadays modern technologies such as
UMTS, GRPS, Edge as well as satellite communications and WLAN and Bluetooth, allow the operation of
ambulatory and mobile telemedicine systems
[58, 59]. In table 2.5.1 I summarized the available communication means used in mobile telemedicine
applications. GSM is in the standard mode of operation it provides data rates up to 9.6 kb/s. HSCSD techniques
makes it possible to increase the data transmission up to 43.3 kb/s [60, 61]. The evolutions of mobile
telecommunication systems from 2G to 2.5G (iDEN 64 Kb/s, GRPS 171 KB/s, EDGE 384 KB/s) systems
provides the possibility of faster communication channels supporting the development of telemedicine
applications that have demand for larger bandwidth [60].Universal Mobile Telecommunications System
(UMTS) is one of the third-generation (3G) cell phone technologies, which is also being developed into a 4G
technology. Currently, the most common form of UMTS uses W-CDMA as the underlying air interface. It is
standardized by the 3GPP, and is the European answer to the ITU IMT-2000 requirements for 3G cellular radio
systems. UMTS supports up to 14.0 Mbit/s (1.75Mb/s) data transfer rates in theory, although at the moment
users in deployed networks can expect a transfer rate of up to 384 kbit/s for R99 handsets, and 3.6 Mbit/s for
HSDPA handsets in the downlink connection [62, 63, 64]. In recent years other mobile network technologies
such as WLAN have become popular and hot spots for accessing Internet have been deployed in almost every
public place [60]. WLAN provides users with data rates up to 54Mb/s as long as the user is in the range of the
access point.
2.5. Data types and volumes 27
Frequency
Category Type Data transfer rates
band
5 GHz 54 MB/s
2.4 GHz 11 MB/s
2.4 GHz 54 MB/s
5 GHz 23.5 MB/s
5 GHz 54 MB/s
2.5 GHz 1 MB/s
2.4 GHz 2 MB/s
2.4 GHz 10 MB/s
GSM-900 Emergency
GSM- 900 MHz 9.6-43 KB/s telemedicine
1800 1800 MHz 9.6-43.3 KB/s Patient
GSM- 1900 MHz 9.6-43.3. KB/s telemonitoring in
1900 random locations
900 / 1800
GRPS GRPS 171.2 KB/s
/ 1900 MHz
High bandwidth
3G / mobile
UMTS 2 MB/s
UMTS telemedicine
applications
C,S band
L,S,C 2.4 KB/s
band 7.2 KB/s
L, Ka 2.4 KB/s
band 400 KB/s - 30
Ku, Ka MB/s
band 155 MB/s
Ka band, 16 KB/s - 64
40-50 MB/s
GHz 16 KB/s - 2
Ka band MB/s
Ku band
5-32MB/s
5/6/7/8
DVB-T (downlink)
MHz
DVB-H 10 MB/s DVB
5/6/7/8
DVB-RCS (downlink)
MHz
8 MB/s (uplink)

Data size of typical

Data type examina
tion
Digital blood pressure 1 Kb
Digital thermometer < 2 Kb
Oxygen saturation meter < 21 Kb
Electrocardiogram < 141 Kb
Ultrasound 100 Kb - 2 Mb
Dermatology (high resolution and 24-50MB
colour) 2 - 4 MB
Scanned x-ray 24 - 50 MB
Mammogram 58 - 164 MB
 CT (whole body) 58 - 164 MB
MR (whole body) 12 MB
PET (whole body) < 600 MB
Video conference < 100 KB
Patient’s medical records

Table 2.7: Required bandwidth for real-time transmission of medical data

In the US WLAN operates in two unlicensed bands:
• 802.11b and 802.11g operate in the 2.4 GHz band together with many other devices
including Bluetooth [65, 66]
• 802.11a (Wi-Fi 5.2 GHz) operates in the 5.2 GHz which is relatively free of interference from other electrical
devices operating in this band[67].
2.5.2 Size of medical data
The table 2.7 provides a rough estimation of the size of the medical data that may beinvolved in a telemedicine
application. Here, I give typical data volumes. The figures would be higher or lower depending on the duration
of the data acquisition as well as on the compression methods used for storage.
2.5.3 Bandwidth requirements
The range and complexity of telecommunication technology requirements vary with specific telemedicine
application. Regarding the transmission of medical data there are no
theoretical bandwidth requirements. Lack of bandwidth is interpreted as longer transmission time.
However, in table 2.8, I have depicted the bandwidth needed for real time transmission.
 2 3 Adoption of mHealth
initiatives by WHO region
Due to the diversity within WHO
regions it is often difcult to
identify common trends between
based on
commonalities in countries and
this applies to data gathered on
mHealth adoption. However, the
report
attempts to identify regional
fndings where possible.
Figure 4 shows health call
centres/health care telephone help
lines are one of the two most
common mHealth
initiatives across all WHO
regions; the other is emergency toll-free telephone services – with the exception
of the African Region. The use of mobile devices for emergency and disaster situations was reported by over
48% of Member States across all regions except the African and Eastern Mediterranean Regions.
The low frequency of emergency toll-free telephone services reported in the African Region (28%)
compared to other regions (42–75%) could be due to insufcient infrastructure to respond efciently and
effectively to emergency calls in some countries (e.g. lack of paved roads, dispatch systems connecting
ambulances to hospitals).
Health call centres, globally the most frequently reported initiative, show consistently high levels of
adoption across all regions except the African Region where it is just over 40% compared to all other
regions which are approximately 60%. With the ongoing development of infrastructure and increasing
level of acceptance of these services it is likely that they will expand in the African Region.
The use of mHealth for emergency situations is also frequently reported globally (approximately 50%).
The Regions of the Americas and South-East Asia show higher than average adoption (around 70%) and
the African and Eastern Mediterranean Regions are lower (approximately 40%).
Treatment compliance shows a global uptake of almost 40% and fve regions show little variation
above or below this fgure. The Western Pacifc Region is the exception, with an uptake of only 20%.
This is most likely due to the fact that mobile technologies have not yet been accepted or integrated
into this particular process.