Following the early exploration into telemedicine through notable projects in Nebraska, Massachusetts, and Vermont-New Hampshire, 14 the 1990s came to be regarded as the “developmental years” of telemedicine. This was the decade during which many large state and system projects emerged, telecommunications evolved to the point that it was more available and affordable, and passage of state and federal legislation propelled the field forward by recognizing telemedicine as a reimbursable mode of care provision.
Investment in telehealth from a state and system level began in the early 1990s and rapidly expanded during this decade. What differentiated this time period from the early years of telehealth was the emergence of large hub-and-spoke networks in contrast to the customarily project-based approaches of the prior decade. Programs in the 1990s began to involve dozens of “spokes” (patient sites) linking to one or several large specialty or acute care health care organizations.
Several of the noteworthy programs of the early 1990s were subsidized by legislative appropriations or by funds related to telecommunications mergers. Most programs were launched with a focus on improving specialty access to outpatient services and health professions education. Because of the role of academic health centers in providing safety net access, they were frequently in leadership positions with these systems during this decade; programs in the early part of this decade emerged largely in response to inadequacies in health care access in rural areas.
In the early part of this decade, equipment was extremely expensive; videoconferencing systems enhanced with scopes cost upwards of $100K. Early in this decade there were no dominant technology providers of telehealth units—programs repurposed videoconferencing systems for clinical use. Telecommunications options likewise were limited to using telephone circuit-switched networks. Integrated Services Digital Network (ISDN) lines became the norm for video connectivity because it required high bandwidth. This combined multiple 128 Kbit ISDN Basic Rate Interface (BRI) lines for each video call known as bonding. Where ISDN was not available, programs installed dedicated point-to-point circuits such as T1 (1.544 Mbit) and fractional T1 lines for a hefty price. A defining feature in this decade was the first ratified standard enabling videoconferencing capabilities over packet-switched networks, which are still widely used in business and the Internet today. In November 1996 the International Telecommunications Union (ITU) published H.323, which, after its adoption in the late 1990s and early 2000s, became a crucial milestone for telemedicine and interoperability between providers. That said, adoption of this standard introduced an operational barrier, as firewalls during this decade were not H.323-aware, requiring participating organizations to modify their firewalls to allow videoconferencing to function. Although the H.323 standard offered many benefits over ISDN, such as using the Internet for a fixed cost, which introduced an unlimited amount of connections globally, ISDN remained the more reliable option during this decade.
The launch of telemedicine programs was frequently a result of grant funding during this decade. The federal government was one source of funds, and during this decade the Office for the Advancement of Telehealth (then called the Office for Rural Healthcare) was established and administered a grant program. This office, in the Federal Office of Rural Health Policy (FORHP), was created in 1987 to advise the secretary of the U.S. Department of Health and Human Services on health care issues affecting rural communities. 47 The U.S. Department of Agriculture also distributed grants and loans that supported telehealth and distance education via the Rural Utilities Services program.
In 1993 the American Telemedicine Association was launched with an inaugural meeting of 250 people in Albuquerque, New Mexico. Early programs typically established novel collaborations with the goal of sustaining the field (and thus their individual programs). Health systems that were customary competitors formed telehealth alliances during this decade, typically with the goal of overcoming barriers and advancing a legislative and regulatory agenda necessary to support telehealth. Other alliances formed to share access to telecommunication infrastructure.
Recognizing that reimbursement was a fundamental requirement of sustainability, many of the alliances focused on state legislation. For example, in California a coalition of academic health centers, health systems, technology vendors, and policy staffers developed a policy road map in 1994–1995 that resulted in State Senator Mike Thompson (now U.S. Representative Mike Thompson) sponsoring the Telemedicine Development Act of 1996. This legislation redefined the requirement of “face-to-face” for a health care encounter and required the state's Medicaid system to implement a reimbursement policy. 48 Partner legislation passed that same session required the California Medical Board to address licensure as it related to telehealth. These two statutes became model language that other states adopted to advance telehealth reimbursement. 49 The first organization dedicated to address policy issues was launched in this decade: the Center for Telemedicine Law, now called the Robert J. Waters Center for Telemedicine and eHealth Law.
On the national level, organizations began to coordinate demands for Medicare reimbursement, without which programs would struggle financially. The expansion of Medicare reimbursement began when Congress passed the Balanced Budget Act of 1997 (BBA), which mandated Medicare reimbursements for telehealth care and funding for telehealth demonstration projects. Even though this first federal law had significant restrictions, its enactment was important because it recognized telemedicine as a mechanism to provide care to geographically isolated people. Reimbursement was limited to enrollees living in medically underserved rural regions, to specific providers, and to billing codes selected by the Centers for Medicare and Medicaid Services (CMS). The first version of this reimbursement also required splitting fees between specialists and primary care providers, which was unprecedented given overarching policies that strictly prohibit referral arrangements with any perceived or real collusion between providers. Despite the imperfections in the legislation, the telemedicine community celebrated this important milestone in the emergence of the field as the result of a broad, grassroots coalition of telehealth providers. 50
The Veterans Health Administration (VHA) was in a period of internal reorganization during this decade, with a significant emphasis on the electronic health record and on local innovation, with the goal of providing access to entitled veterans. During this decade, telehealth pilots emerged in a number of clinical areas around the country in a “grassroots” model. Between 1994 and 2004 VHA staff members published about 80 peer-reviewed journal articles, contributing to the evidence base for telehealth. The positive findings of a Kaiser Permanente home telehealth (HT) study corroborated the VHA's strategy of piloting HT and developing an associated care coordination model. 51
Correctional health organizations began to explore telehealth as a delivery strategy during this decade. Although Florida was the first to experiment with telemedicine in prison, introducing it in state penitentiaries in the late 1980s, Texas became best known for the use of telehealth in penal institutions and began using telehealth to care for its prison population in the early 1990s. Given that transporting inmates for health care is expensive—the cost of security personnel—and presents a community safety risk, telemedicine became a strategy of interest by county, state, and federal correctional organizations.
Recognized for its pioneering program in the field of telehealth, Georgia enacted legislation in 1992 to establish a statewide network led by the Medical College of Georgia and the state's Department of Administrative Services. Funding for the launch of the program came from a settlement with the Southern Bell telecommunications company related to an “overearnings” program was proposed as a means to help counteract escalating health care expenses and disparities in access. Starting with a pilot program in 1991 at Dodge County Hospital (which predated the legislation), the network grew to include an academic hub, “secondary” specialty services hubs, correctional sites, and ambulatory care sites. Georgia's operational and clinical training and consultation influenced the design and implementation of many programs in the 1990s. 52
In 1993, the Texas legislature established a correctional managed care plan that incorporated telemedicine and an operational strategy to respond to escalating health care costs and to obstacles that impeded services for remote prisons, despite the constitutional requirement to provide health care to inmates. The University of Texas Medical Branch (UTMB) in Galveston, which together with Texas Tech Health Sciences, was capitated for inmate health services, implemented a hub-and-spoke telemedicine model providing a broad spectrum of specialty services. 53 As an early adopter of telemedicine, UTMB overcame the challenges of the 1990s, including expensive equipment and installation of telecommunications infrastructure, and remains a leader in correctional/prison telemedicine. Texas continues to have the nation's largest prison population, currently 153,000 inmates. However, per-prisoner medical care expenditures in Texas are approximately 60% of the national average; a UTMB correctional-managed care administrator attributes those cost savings to efficiencies achieved through telemedicine. 54
Alaska's significant barriers in terms of geography, weather, and isolation stimulated early adoption of telecommunications to overcome health care access barriers. Dating back to the 1920s, when telephone and telegraph were used to direct the distribution and administration of diphtheria antitoxin to the most remote regions of the state, the state has been an innovator in the use of telemedicine. In 1996, the National Library of Medicine funded a test project using telemedicine to address the high prevalence of otitis media. Two years later, an unprecedented coalition of federal agencies (Department of Defense, Office for the Advancement of Telehealth, the Department of Health and Human Services, the Indian Health Services, and the Department of Veterans Affairs) appropriated funds to establish a broad telehealth network called the Alaska Federal Health Care Access Network (AFHCAN). The 235 AFHCAN sites are associated with diverse partners, including Alaska Native organizations, public health offices, and military and Veterans Affairs sites. 14
Leveraging early experience in telemedicine (as described earlier in this chapter, including STARPAHC, NASA, and experience at Massachusetts General Hospital), leaders in the state of Arizona engaged in the early 1990s in establishment of the Arizona Rural Telemedicine Network, subsequently renamed the Arizona Telemedicine Network. Launched as a project encompassing rural sites, a correctional facility, and a hospital on an Indian reservation, the program now has status as a statewide enterprise. Utilizing a membership model that offers organizations flexible options for engagement, the network provides telecommunications infrastructure, training, distance education programming, research and program assessment, and “open forum” telemedicine consultations. This notable program from the early days of telehealth, developed through a collaboration of public and private organizations, has integrated research with education and practice, and has solidified diverse funding sources consisting of membership fees, state and university support, and grants. 55