Telemedicine is the use of information and communications technologies to provide and support health care when distance separates the participants. Clinicians have been practicing telemedicine over the telephone since the telephone was invented. The first video telemedicine application was tested in the 1960s by neurologists and psychiatrists in Nebraska.

Telemedicine applications of the past 20 years have focused on interactive video to connect patients and referring clinicians in remote locations with specialists in urban tertiary care centers. Visual and audio information was at first conveyed by physically transporting recorded media but now is streamed over secured channels on the Internet.

The current generation of telemedicine applications expands the remote clinician’s capabilities beyond diagnosis to therapeutic interventions. Telesurgery, remote psychotherapy, and virtual home visits to manage chronic medical problems have all been demonstrated, although deployment remains limited. Remote monitoring of chronic medical conditions using networked medical devices such as blood pressure cuffs or blood glucose monitors is increasingly popular. Multiple websites describe these and other innovative uses of telemedicine for interested clinicians to explore (Table e4–4).

Table e4–4. Examples of current telemedicine applications.

Although information transfer ignores geographic boundaries, medical licensure does not—especially in the United States, where several states have explicitly limited the interstate practice of telemedicine. Liability and malpractice are thorny issues, as the practice of telemedicine presents a new form of the patient-caregiver relationship and associated hazards, such as technical failures leading to altered or suboptimal data.

The practices of the health care payers are lagging behind the technology. Medicare and other insurers will reimburse telemedicine visits that meet a restrictive set of criteria. Consultative teleradiology is usually reimbursed, as are certain consultations, office visits, individual psychotherapy, and pharmacologic management sessions when they involve interactive audio and video. Triage, diagnosis, and advice are rarely covered by video, just as they are largely excluded from coverage when performed by telephone.