Chapter 1: History of Telehealth

Since early human history and throughout many cultures, accessing a healer or someone with “expert health knowledge” was considered beneficial in alleviating maladies. Healers such as shamans, priests, and medicine men or women are known to have been part of prehistoric cultures. These healers normally required communication with and ideally visualization of the patient in order to diagnose and treat. ¹ In many cultures, over time, healers became known as physicians; the first acknowledged physician, an Egyptian named Imhotep, lived during the 27th century BCE. ¹ By 420 BCE medicine began to develop standards, with Hippocrates credited for initiating the age of “rational medicine.” That era was characterized by the development of the idea that diseases have natural causes and the origination of the concept of ethics in medicine, perpetuated as the Hippocratic Oath. The Asclepion Temples that the Greeks erected became some of the world's first health centers. ² People (pilgrims) traveled great distances to these temples to seek medical advice, prognosis, and healing. ^2,3 In approximately 300 BCE in India, specific structures were constructed for health care, with basic sanitization standards. ⁴ Around 100 BCE, the Romans erected buildings called valetudinarians for the care of sick slaves, gladiators, and soldiers. ³ With the fall of the Roman, Greek, and Egyptian civilizations came a decline in the formal study and practice of medicine in these cultures. ⁵

Medical care improved in the early Middle Ages (6th to 10th century CE), when an infirmary became an established part of nearly every monastery, under the influence of the Benedictine Order. Also during that time the first medical schools were opened. Quite possibly the earliest, reported to have developed out of a monastery dispensary, was the Schola Medica Salernitana at Salerno in southern Italy. ⁶ During the late Middle Ages (beyond the 10th century) monastic infirmaries continued to expand, and public hospitals were opened, financed by city authorities, the church, and private sources. Specialized institutions, including leper houses, also originated at this time. ⁷

Health care evolved over time, from a largely nonscientific discipline involving home remedies and traveling doctors, to one encompassing vast amounts of scientific knowledge, increasingly reliant on technology, technical expertise, and complex systems of care. The work of Benjamin Franklin and Dr. Thomas Bond led to the establishment of Pennsylvania Hospital, which upon its opening in 1751 became the first hospital in the continental United States. ⁸ This was followed by New York Hospital, which was chartered in 1771. During the 1800s, significant advancements began to occur, including the development of the stethoscope, antiseptic surgery, anesthesia, germ theory, and vaccines. During this time, Johns Hopkins and other academic centers were built. However, despite the development of formal hospitals, physicians generally performed medical care in the homes of their patients, a practice that continued throughout that century. ⁹ As the equipment and treatments became more sophisticated and cumbersome, physicians opened offices or treated patients in hospitals. Only 40% of physician encounters were conducted via house call by 1930. By 1950, house calls decreased to 10% of visits, and to less than 1% by 1980. ^9,10

The shift in site of care delivery from the home to clinics and hospitals was also partially the result of the growth of third-party payers and increasing liability concerns. ¹¹ However, throughout the history of health care, obstacles have impeded consistent access to the right expertise, at the right time, and in the right place for those in need. Hence, a desire emerged to make expertise more widely available through distance communications.

Communication and the exchange of information have been important to humans throughout time. Early forms of communication included runners in mountain villages, fires, beacons, smoke signals, communication drums, horns, and reflective devices. ³ For instance, one form of early communication involved the “heliograph”—sending messages by reflecting the sun with a mirror or other shiny surface toward the intended recipient. The Greeks are believed to have used polished shields to signal their fellow soldiers as far back as 405 BCE. ¹² Later, the Roman emperor Tiberius used light reflection to signal orders to the mainland from his “Villa Jovis” on the Isle of Capri. ¹³ Although often slow and limited to relatively small distances, these forms of communication served a functional purpose within the geographic boundaries of the people of those times.

The concept was modernized in the early 1800s, when Gauss developed the heliotrope for surveying land. Reflected sunlight continued to be used for communications into the late 1800s, notably by the United States military in Arizona and New Mexico. ¹⁴ In France, also in the 1800s, a more sophisticated optical line-of-sight method of communications was developed using a series of towers that held large horizontal beams with smaller connected pieces that could be configured into various shapes associated with a code. This was referred to as an optical telegraph. ¹⁵ Around 1867, Aldis signal lamps used light to communicate using a code between towns on land and ships at sea, as well as between land and sea. ¹⁶

The electronic age of communication began with the electrical telegraph. Although numerous scientists throughout Europe and Russia experimented with electromagnetic telecommunications in the 1800s, Samuel Morse is credited with bringing the telegraph to scale because of a standard code for communications. He made his first transmission in January 1838, across 2 miles of wire near Morristown, New Jersey. ¹⁷ In 1844, he sent a message from the Capitol in Washington to Baltimore, after which commercial telegraphy began to scale quickly in America. Over the next 10 to 15 years lines linked most of the major cities on the East Coast. The transcontinental telegraph was connected on October 24, 1861. ¹⁸ The golden age of the telegraph was cut short with Alexander Graham Bell's invention of the telephone in 1876, with the direct dial phone patented just 13 years later. ^19,20 Wireless communications, innovated in the late 1800s, began to mature in the early 1900s. By 1912 two-way radio communication was available on ships. Two-way radio transmission expanded to police units, throughout the military, and eventually to outer space in the early 1960s.

In 1927, Philo Farnsworth demonstrated a television transmission in his laboratory in San Francisco. However, it took 20 years for commercial television to begin. ²¹ Although the first color television signals were broadcast in 1954, more than a decade passed before television stations began broadcasting prime-time shows in color.

The mid-1960s also saw the beginnings of broadband technology linking computers. It was then that Massachusetts Institute of Technology (MIT) and Dartmouth College linked up with speeds of up to 50 Kbps. Before the end of the decade, this network was expanded to include institutions on the West Coast with higher bandwidth. In 1969, ARPANET (Advanced Research Project Agency Network) was funded by the Advanced Research Projects Agency (ARPA) of the United States Department of Defense. This was one of the first wide-area packet-switching networks, the first to use Transmission Control Protocol and Internet Protocol (TCP/IP), and represents the beginning of today's Internet. ¹⁴ By the mid-1980s, a network of universities across the country had attained data transfer speeds of up to 1.544 Mbps (T1); however, households and private businesses did not begin Internet use until the 1990s, primarily with dial-up modems with speeds of only 56 Kbps. In 2016, competition for home and small business customers was significant, with service providers advertising speeds of up to 100 Mbps. Despite this, a “digital divide” still places rural and some urban intercity areas at a disadvantage.

One of the most significant changes to communications in the late 20th and early 21st centuries was the rapid development and expansion of wireless communications and cellular-based technologies. Martin Cooper, a Motorola engineer, reportedly made the first cell phone call on April 3, 1973. ²² A decade would pass before mobile phones were sold commercially. In 1983, mobile phones cost $4,000 and used a 1G analog network. The next generation of mobile phones, introduced in the 1990s, communicated on a 2G digital network. At the turn of the 21st century, the advancement to 3G networks enabled support of multimedia and Internet access, which quickly gave way to 4G, allowing for relatively high-quality interactive video from handheld devices. ²³

Communications over distance for health purposes also has a long history. Signal flags flew on ships and over ports to indicate outbreaks of various contagious diseases. Aboriginal peoples of Australia carried “message sticks” to communicate news of death and disease to distant tribal gatherings. ³ Consulting by written correspondence was common from the mid-1600s through the 1700s, sometimes because of the lack of local access to physicians in some areas, or sometimes to obtain an opinion from a famous physician. ²⁴ Also in the 17th century, distance diagnostic medicine occurred with patients sending urine samples to distant physicians who provided diagnoses based on uroscopy ²⁵ and dispatched “prescription-by-post” and thorough instructions on recommended treatment. ²⁶

The first use of electronic communication for health purposes in the United States occurred during the American Civil War. The Union Army used the telegraph to communicate casualty reports, coordinate patient transport, and request medical supplies. ¹⁴ Evidence shows that the newly constructed telegraph was used in Australia in 1874 in the care of a wounded person and to connect a dying man with his wife 2,000 kilometers away. ²⁷ Five years later, in 1879, a report in The Lancet described a telephone call between a mother and a physician to determine whether a baby had croup. In that report, the physician listened to the baby's cough through the phone. ²⁸ In 1905, Willem Einthoven demonstrated the transmission of heart sounds from a hospital to his laboratory using the telephone. He called it a “telecardiogram.” ¹⁴ Five years later, two New York cardiologists reported the remote transmission of electrocardiograms (ECGs) for diagnosing “hypertrophy and arrhythmias.” ²⁹

In 1910, Sidney Brown, an engineer in England, made improvements to the telephone that led him to state that it was now possible to accurately listen to the sounds of a stethoscope that a patient held in place miles away and “to arrive at a correct diagnosis.” ³⁰

In the 1920s, Haukeland Hospital (now Haukeland University Hospital) in Norway began using two-way radio communications with ships to consult with physicians and to direct treatment. ¹⁴ Similar services developed in other countries during the next decade. Police reportedly began using mobile two-way radios in 1923 in Victoria, Australia, to communicate. By 1925, the theoretical concept of the “radio doctor” providing distance care using audio and video was described in an often-cited article in Science and Invention magazine (Figure 1-1). ³¹

The five-decade period from 1940 to 1990 was a time during which conceptualization of new ideas and innovative experimentation proliferated. In some cases, the technology had to be developed, and the lack of a telecommunication infrastructure limited the scale of projects. However, some landmark projects were developed by the pioneers of the field. During this time, the vocabulary that we use today was just being invented. In fact, the idea of technology-assisted distance diagnosis was captured with the term telognosis, which appeared in the medical literature in 1950 in reference to the 1948 transmission of radiologic images by telephone between West Chester and Philadelphia, Pennsylvania. ³² This model of “teleradiology” was replicated more formally in Montreal at Jean-Talon Hospital in the 1950s. ^33,34 In 1959, the transmission of fluoroscopy images was reported to also have occurred in Canada. ³⁵ Radiology has been a pioneering specialty in telemedicine, particularly in developing standards of practice, described in a later chapter.

The first widely reported use of interactive video communications for health care in the United States occurred at the University of Nebraska, where clinicians transmitted neurological examinations across campus to medical students in 1959. ^36,37 Several years later, a 112-mile, closed-circuit, two-television link was established between the university and Norfolk State Hospital for psychiatric and neurologic consultations. ³⁸

During the 1960s, numerous accounts of wireless transmission of ECGs, cardiac monitoring, and even X-ray images were reported. ³⁹ Although not normally discussed as telemedicine, the critical ability for first responders to send cardiac monitoring information to responding emergency physicians who were en route was accomplished in Miami in 1967 using voice radio channels. ⁴⁰

In 1968, a seminal telemedicine project was established involving Massachusetts General Hospital (MGH) and Logan Airport. Staffed by nurses, the “medical station” at the airport was linked via microwave relay to MGH as a means of providing primary and emergency services to travelers and airport staff. ⁴¹ The telemedicine efforts at the MGH continued two years later with a telepsychiatry link with the Veterans Administration Hospital in Bedford, Massachusetts, that remained in service into the 1980s. ⁴²

Multiple hospitals in two states, Vermont and New Hampshire, participated in another important project during this time period. This network, called INTERACT, involved a combination of telemedicine, remote education, and administration. ¹⁴ It is important not only because it encompassed multiple states and multiple services, but also because it attracted significant federal funding from multiple agencies. The Health Care Technology Division of the Department of Health, Education and Welfare (now the Department of Health and Human Services) and the National Science Foundation funded several other notable telemedicine demonstration projects during this time period. ¹⁴

The National Aeronautics and Space Administration (NASA) played a major role in the development of telemedicine. NASA had an obvious need to assess the health of astronauts while in space, beginning with the Mercury program in the early 1960s. As part of the process to test and refine protocols using satellite-based telemedicine, NASA and Lockheed partnered in a project through which medical services were made available to the Papago Indians in Arizona. The program, named STARPAHC (Space Technology Applied to Rural Papago Advanced Health Care), lasted until the late 1970s. ³⁸ Satellite communication opened up telemedicine opportunities for large rural areas. In 1972, NASA's Applications Technology Satellite (ATS-1) began providing telecommunications access for health care between numerous smaller communities in Alaska and larger hospitals. ⁴³ The success of this program resulted in a significant expansion over the next several years.

In the mid-1970s Memorial University of Newfoundland began working in the area of telehealth, with 30 projects undertaken over 20 years. This Newfoundland program notably has been cited as the only pre-1986 program that survived into the 1990s. ⁴⁴ In 1984, the Australian government set up the Q-network via satellite. A pilot program called the North-West Telemedicine Project delivered health care to five remote towns in the Northern Territory. A 1989 publication on this program described improvement in quality of health care and discussed how it reduced some health care costs. ⁴⁵

Although several university programs began serious planning efforts toward the end of the 1980s, reports of telemedicine consultations were modest during this time, as evidenced by the scarcity of literature on the subject during this decade. However, one noteworthy project quickly developed following the massive Soviet Armenian earthquake that occurred December 7, 1988. Just five days later, NASA, as part of the U.S./USSR working Group on Space Biology, made an offer to the USSR to provide humanitarian aid to the region. The project, designated as the U.S.-USSR Telemedicine Space Bridge to Armenia and Ufa, began in March 1989, with consultations by physicians from four U.S. medical centers: University of Utah/LDS Hospital, University of Texas, Maryland Institute for Emergency Medical Service Systems, and Uniformed Services University of the Health Sciences. According to the final project report, “Intelsat and Comsat donated free access to uplink and satellite transponders, and the Soviet Union donated the downlink channels”. ⁴⁶

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.

Georgia

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

Texas

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

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

Arizona

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

This decade was characterized by a maturation of the field in both outpatient and inpatient telehealth, as well as a renewed interest in and broadening of services to the home. By the end of the first decade of the new millennium, telehealth outpatient services included nearly every conceivable outpatient clinical service. Programs existed in all 50 U.S. states and around the world, and programs were actively expanding services, specialties, and the number of sites being served.

Inpatient and emergency telehealth experienced significant expansion during this decade, driven in part by teleneurology and tele-intensive care (tele-ICU). Neurologists started exploring telehealth strategies in the end of the 1990s, and the field expanded significantly during the first decade of the new millennium. The Food and Drug Administration (FDA) approved the use of intravenous tissue plasminogen activator (tPA) in patients with acute ischemic stroke in 1996; however, initial safety concerns led to low utilization. As the evidence base for the safety and effectiveness of tPA grew, its underutilization became a concern. ⁵⁶ Researchers demonstrated that telestroke services could increase the use of tPA ^57,58 ; that prompted national professional organizations to actively promote telemedicine as a valid response to the disparity in geographic distribution of stroke neurologists and with a goal to increase the appropriate use of tPA. ⁵⁸ For this application telehealth became not just a strategy to expand access or to avoid patient travel, but additionally was regarded as an essential tool enabling hospitals lacking a stroke neurologist to meet standards of care. ^58,59

Another area of telemedicine that expanded significantly during this decade was tele-ICU. Although examples of remote consultations to intensive care units existed in previous decades, a new comprehensive model emerged with a command center staffed by intensivists, critical nurses, and other staff, with capacity for protocol-driven remote monitoring with “smart alarms” combined with interactive video conferencing. ⁶⁰ In 2000, Sentara Healthcare in Virginia became the first to implement this approach. Although the literature was somewhat mixed on mortality outcomes and cost effectiveness, studies generally viewed this approach favorably. ⁶¹ By 2010, more than 5,000 intensive care unit beds in nearly 250 hospitals were being covered via tele-ICU. ⁶²

Pediatrics is another field that led the expansion in emergency care and inpatient telehealth models of care. Given that children's services are largely regionalized and concentrated in urban areas, several notable children's hospitals developed programs in this field supporting various services, including neonatal telemedicine, services to the home for ventilator-dependent children, and emergency consultation for ill and injured children. ⁶³ Notable examples include the University of California Davis pediatric emergency medicine network, comprising 28 remote facilities—research about which has demonstrated improved outcomes, few medication errors, and decreased costs of care. ^63,64,65 The applicability of telehealth technology to neonatal intensive care is demonstrated by the Antenatal and Neonatal Guidelines Education and Learning System (ANGELS) program in Arkansas, developed in 2003. This program, which developed practice-based guidelines and is supported by weekly tele-education conferences and 24/7 telemedicine consultations, has demonstrated more appropriate utilization of neonatal intensive care unit (NICU) services in the state. ⁶⁶

In chronic disease management and home care, the VHA emerged as a leader during this decade. Studying early outcomes in 2005 and 2008, VA researchers showed promising results related to patient satisfaction, quality measures, improved adherence to treatments, and hospital bed day and emergency room use at reasonable costs. ^67,68 Telehealth became a core strategy for the VHA, a system bearing total responsibility for the health of its patients, without the complication of third-party payment.

Those working in telemedicine continued to increase their national voice through participation in various organizations. By 2010, the membership of the American Telemedicine Association had grown to around 3,100 U.S. and international members from diverse organizations: industry, academic organizations, and commercial provider groups.

This was also the decade during which the Internet and e-commerce exploded and changed the world economy and culture. As people began to conduct more of their banking, shopping, and communicating with friends and family online, there was a growing expectation that health care should be as easily accessible. Naturally, telehealth evolved rapidly as well, forever changing how providers and patients would interact and deliver care. Dramatic improvements in Internet service speeds and affordability occurred concurrently with the advent of telecommunications options capable of delivering health care services for many organizations, as well as to the home. That said, extensive regions of the country were bypassed in the broadband revolution. In response, the Federal Communications Commission (FCC) released a call for pilot programs in 2007 to install broadband to advance access to health services in rural areas. This program was a recognition that the subsidy program operated by the FCC for more than a decade was not optimized, because fundamental infrastructure was lacking in much of the United States. Sixty-nine awards totaling $417 million over 3 years were granted to programs that greatly expanded access to broadband in underserved regions of the United States and thereby enabled more widespread use of telehealth and health information exchanges. ⁶⁹

The American Recovery and Reinvestment Act of 2009 (ARRA) had far-reaching implications in a number of fields, including health care. Notably, $19 billion was earmarked for health information technology (HIT) and further implementation of electronic health records (EHR). Although telehealth was not directly included in the adoption incentives related to EHR, the overarching focus on HIT and EHR advanced the thinking and implementation of technology-enabled models of care. The ARRA funding did include a number of options leveraged by telehealth programs for development and expansion. During this decade, as a result of the ARRA funding, the nation saw the implementation of telehealth programs related to disaster preparedness with the National Telecommunications & Information Administration's BroadbandUSA (formerly the Broadband Technology Opportunities Program, BTOP).

The federal government also played a role in this field through the Office for the Advancement of Telehealth (OAT), which oversaw grant programs funding a number of clinical telehealth networks, as well as resource centers located throughout the United States. These regional resource centers, in collaboration with a national resource center focused on policy, served to provide local organizations with much-needed information and technical assistance to launch and sustain programs. OAT funded two national resource centers to support programs throughout the nation with technical assistance and policy issues. In addition to the programs under OAT, the federal government made awards through the National Institutes of Health (NIH) and the National Library of Medicine (NLM) to advance scholarship in the area of telehealth related to efficacy, effectiveness, and quality.

Policy advancements supported the evolution of telehealth. By 2010, California and 10 other states had enacted some form of health insurance coverage mandate for telemedicine. Five states (Colorado, Hawaii, Kentucky, Oklahoma, and Texas) have since adopted telemedicine statutes similar to California's that in some way prohibit the requirement of face-to-face contact for reimbursement. Five states (Georgia, Louisiana, Maine, New Hampshire, and Oregon) have stronger requirements; among them, three (Louisiana, New Hampshire, and Oregon) mandate coverage for telemedicine for any service that would be covered in person. Thirty-six states had adopted telemedicine statutes or policies for coverage of telemedicine in Medicaid, five other states are considering doing so, and Florida covers telemedicine under the terms of a federal Medicaid waiver. ⁷⁰

This decade marked a movement in the field signaling that telehealth plays a role in the delivery of health care services in this nation. The models of care that were observed during this time frame were predominantly services that emulated traditional in-person care translated over technology. Examples revealed an emerging shift to new models of care that didn’t “look” like in-person care. But much of that innovation was yet to come in the most recent decade.

Development and innovation in telehealth continues at an exponential rate. The pioneers in this field likely would be amazed at the state of telehealth in the current decade. Telehealth has truly become mainstream in many areas of health care and has been increasingly accepted as a legitimate and, in some cases, the preferred method of care delivery. This is reflected in the growing evidence base in the peer-reviewed literature. A search of PubMed from 2010 to 2016 using the keywords “telemedicine” and “telehealth” reveals more than 11,000 papers published. In 2016, Time magazine, in its issue on “240 reasons to celebrate America,” cited telemedicine as one of those reasons. That article noted that health care organizations are investing heavily in digital health, exemplified by the VHA and the 700,000 vets who were treated in 2015 using a technology-enabled modality of care. ⁷¹ In addition, 46% of health care providers answering a Healthcare Information and Management Systems Society (HIMSS) survey stated that in their practice they used multiple telemedicine technologies, by far the most popular of which is two-way video messaging. ⁷²

State and federal policy changes, although slow, are removing barriers to a seamlessly functioning technology-enabled health care system. One of the barriers that telemedicine providers encounter is the requirement for them to undergo the privileging process at every health care organization for which they hope to provide services. To resolve this problem, CMS, the federal agency that administers Medicare, Medicaid, and the state Children's Health Insurance Program, in July 2011 issued a rule authorizing the proxy credentialing of providers: “Hospitals and CAHs (Critical Access Hospitals) may rely, when granting telemedicine privileges, upon the privileging decisions of a distant-site hospital or telemedicine entity with which they have a written agreement that meets Medicare requirements.” Policy issues related to reimbursement have also moved forward significantly. This has historically been one of the most cumbersome barriers to the advancement of telemedicine. As of August 2016, 48 state Medicaid programs and the District of Columbia were reimbursing for live video telehealth, with 12 state Medicaid programs offering some reimbursement for store-and-forward, not counting states that reimbursed only for teleradiology. Remote patient monitoring was reimbursed by 19 state Medicaid programs by late 2016. ⁷³

The telecommunications infrastructure, once an unwieldy barrier, is rapidly improving as well, with Internet access speeds of 10 Mbps or greater available in 99% of the United States. In addition, 98% of Americans live in areas with 4G LTE service for mobile devices that support video. As the processing speeds of computers and mobile devices have increased to the point where they now support high-quality video, and with increasing cloud-based video conferencing options, the threshold for doing telehealth is much lower than in years past.

The incoming generation of health care providers has grown up in a digital world in which the difference between in-person and distance communication is less significant. They are willing and expect that some of the care they provide can be conducted via telecommunication technology. Although their world and the world of the sick are radically different from the early healers and patients, the benefit of facilitating a connection between them is not. Those early visionaries in the many fields that contributed to the current state of telehealth have already clearly improved the lives of many people. We are only just beginning to realize the full potential of this growing area of health science.