|Year : 2015 | Volume
| Issue : 1 | Page : 64-67
Telemedicine in education: Bridging the gap
Jesse O'Shea1, Ryan Berger2, Cynthia Samra3, Daniel Van Durme4
1 Medical Student, Florida State University College of Medicine, Florida, USA
2 Orthopedic Surgery Resident, Cleveland Clinic Foundation, Florida, USA
3 Clerkship Director for Pediatrics, Curriculum, Sarasota Campus, Florida State University College of Medicine, Florida, USA
4 Chair of Department of Family Medicine and Rural Health, Director of the Center on Global Health, Florida State University College of Medicine, Florida, USA
|Date of Web Publication||31-Jul-2015|
MS4 Florida State University College of Medicine 1115 West Call Street, Tallahassee, FL 32306-4300
Source of Support: None, Conflict of Interest: None
Background: The increasing cost and inequitable access to quality healthcare, coupled with the merger of the information technology and health service sectors, has given rise to the modern field of telemedicine. Telemedicine, meaning medicine at a distance, allows us to transcend geographic and socioeconomic boundaries to deliver high quality care to remote and/or in-need patients. As technology becomes more affordable and a physician shortage looms, telemedicine is gaining attention as a possible solution to healthcare delivery. Simultaneously, telemedicine holds great promise with regard to medical education. Several studies integrating telemedicine in medical education have shown positive outcomes, demonstrating similar or greater efficacy compared with traditional educational methods with high student-reported enthusiasm. Other domestic and international telemedicine projects, largely spearheaded by universities, have also achieved great success. Discussion: In a novel approach, by pairing medical schools with in-need partner communities, utilizing similar faculty resources as traditional learning methods with standardized patients, students can gain valuable experience and skills while serving actual patients. This progressive approach to medical education fosters collaboration, communication, longitudinal care and teaches students needed skills for their future practices as 21 st Century healthcare providers.
Keywords: Access to care, health, medical education, telehealth, telemedicine
|How to cite this article:|
O'Shea J, Berger R, Samra C, Van Durme D. Telemedicine in education: Bridging the gap. Educ Health 2015;28:64-7
| Background|| |
The increasing cost and inequitable access to quality healthcare, coupled with the merger of the information technology and health service sectors, has given rise to the modern field of telemedicine.  Telemedicine means medicine at a distance, and involves the exchange of medical information across various telecommunication modalities to improve health.  However, the concept is not all that new. In the 1930s, Italy used telemedicine to communicate with ships at sea, while the US National Aeronautical Space Administration (NASA) has utilized it since its earliest space missions. , The United States military also adopted telemedicine early, and now, the Army has now utilized over USD $43 billion serving 9.8 million beneficiaries. 
Telemedicine has been receiving even greater attention given growing clinician shortages. In the U.S., the Affordable Care Act is slated to provide health insurance to approximately 32 million Americans who will then add to an already overwhelmed healthcare system.  Concurrently, U.S. Graduate Medical Education funding and residency slots have remained largely unchanged.  Meanwhile, it is estimated that 57 countries have a combined shortage of over 4.3 million health workers. Health workers are now found predominantly in more affluent areas where health needs are less severe.  Telemedicine is a partial solution to meeting the demand for high quality healthcare in the US and abroad, perhaps even in developing nations and underserved communities. Telemedicine advocates believe it can be part of the economic solution to access to care for large segments in the population and ameliorate geographic obstacles to quality care. A variety of studies have already shown that telemedicine is safe and cost effective, and as technology continues to add tools such as digital stethoscopes and portable ultrasound equipment, the possibilities are expanding. , Analysts valued the global telemedicine market at USD $14.3 billion in 2013 and expect it to grow upwards to USD $36.3 billion by 2020. 
Since its inception, telemedicine has steadily grown and is increasingly utilized by patients, clinicians, and institutions. The U.S. Agency for Healthcare Research and Quality reported that there are 455 telemedicine-based programs, which include consultation, diagnostic, triage and similar services run by academic centers, hospitals and private entities.  In January of 2013, the U.S. Federal Communications Commission promised up to $400 million in annual funding to develop the broadband infrastructure required to link medical hubs to rural and underserved areas.  One healthcare company, Avera, established eCARE, which links 675 rural clinicians with urban providers through telemedicine. Since 2009, eCARE is estimated to have saved over $6.8 million by avoiding patient transfers in 850 urgent care encounters.  Comparable companies and services have sprung up around the U.S. with similar success stories, linking patients in underserved and understaffed regions to medical providers and specialists that may be lacking in those communities, or simply providing patients hospital-quality care from home.
In medical education, the apprenticeship model is particularly strong in surgical training through telementoring, where trainees "learn by doing" under the guidance of experienced mentors. Using this approach, remote clinicians learn about surgical devices, procedures, and techniques. Deaton et al. described how telementoring was used during endovascular aortic grafting to provide support for surgeons performing the technique.  No differences were observed in clinical outcomes between the remote patients and those operated on by traditional methods. In 2001, the capabilities of telesurgery were further demonstrated when surgeons in New York removed a woman's gallbladder in France. 
However, to date medical education has not taken full advantage of advances in telehealth. Despite its impressive growth, information about this mode of healthcare delivery remains noticeably absent from the medical school curriculum. Traditional medical education consists of two components: Basic science and clinical education. Most medical students receive most of their first two years of training in classrooms, laboratories, with standardized patients (SPs), and through clinical encounters. Yet, telemedicine has the potential to transform professional health education at all levels. While the merger of telemedicine and medical education is in its infancy, there have been several experimental applications demonstrating a wide range of effects in terms of promoting the learner's knowledge, attitudes, skills and behaviors, as well as advancing patient care.
Seibert et al. conducted a study in which a group of nursing students interviewed and examined patients within an examination room with a telemedicine set-up.  Utilizing SPs, each student gathered a portion of the history. Another student remotely conducted the physical examination by verbally directing an onsite examiner. Finally, the encounter was summarized and students presented an oral report to faculty. This study demonstrated that when selected engagement elements are carefully chosen and thoughtfully integrated into a technology-mediated course, student learning can be effective.
Alternatively, the student can be with the patient physically and have an attending watching or consulting via telemedicine in a distant site. A trial telemedicine system was established between the Gizo Hospital in the Solomon Islands and Emory University Hospital in the continental U.S.  A visiting British medical student at Gizo Hospital received approximately one hour of technologic training and was equipped with a commercially available digital camera and a personal computer, with a modem providing low-bandwidth internet access. The student relayed photographs and results of relevant laboratory and imaging studies to the Emory University Hospital to successfully complete eight referrals with specialists. In another case, Morse et al. demonstrated that during a psychiatry rotation undertaken by a Harvard Medical School student in Bethlehem, Palestine, physician case-supervision could be successfully provided through voice-over internet technology and E-mail.  The student learned comparably to other students at traditional psychiatry rotations within mental health clinics.
A leading example of a university pairing with an international community to improve access to care through telemedicine is the Botswana-University of Pennsylvania Partnership.  Through this program, clinicians in Botswana are armed with smart phones capable of relaying patient information to in-country specialists for consultation, with the option of out-of-country collaboration by sending data to outside specialists. This links underserved areas with expert-level care. The program also provides Botswana medical residents with smartphones loaded with mobile medical applications, with a future goal of allowing them to collaborate on cases. In a similar setup, the University of Arizona, partnering with the U.S. Army and the Panamanian government, developed a "top-down" national telemedicine program in Panama. The program is now self-sufficient, providing services that include telepediatrics, teleobstetrics, telepulmonology, teledermatology and teleemergency medicine. 
| Discussion|| |
A Recipe for Success
We believe that there is an opportunity whereby underserved patients and medical students can equally benefit from utilizing telemedicine-while providing low cost care and increasing standards for medical education in the 21 st Century. We propose here a way to integrate elements of existing applications to mainstream telemedicine within medical education.
In our vision, a medical school would partner with an underserved or in-need community, either domestically or internationally. Working together, they would purchase the telemedicine hardware and establish the infrastructure necessary to effectively communicate (e.g., laptop, microphone, camera, internet connection and onsite staff trained in physical examination techniques and IT support). Patient appointments could then be coordinated with the medical school and the community health center. Medical students, overseen by faculty, would play a direct role in patient care. Utilizing the same patient care principles and faculty resources as traditional SP encounters, students' care would benefit patients in actual need of consultation.
Consultation schedules would be paired down to the level of the student's training. For example, first and second year students would be responsible for gathering a thorough history. Performance of selected elements of the physical examination can be completed with the assistance of appropriately trained health aides who are with the remote patient. Upper level and senior students would be responsible for these same tasks, with the addition of generating their own assessment and treatment plans. The students and faculty physicians would be at one site providing verbal instructions and receiving feedback from clinical providers and patients at a distant site. Following these encounters, a physician faculty member would review the students' findings, evaluate their decisions, and then assist in finalizing care recommendations to share with the patient and community health team.
In an alternative scenario, patients would be seen by students in a more focused approach. For example, a student may be asked to take a thorough social history or perform an advanced neurological examination, and a physician would then complete the remainder of the consultation. Additionally, encounters could be pre-sorted and scheduled based on the patient's chief complaint or problem list in order to better fit a curriculum or educational need.
Adding continuity to these encounters, schools could visit their partner communities on regular service-learning or "mission" trips. Many medical schools already participate in such trips with established communities both domestically and internationally. This can be considered when creating a telemedicine partnership.
Finally, with permission, schools could record patient encounters and use them as learning tools. This would encourage enhanced feedback and also serve to assessing quality. Unique cases and didactic encounters could be integrated into lectures for the benefit of all students.
At the very least, medical schools could adopt a telemedicine elective course to better equip young physicians with the knowledge and skills to incorporate telemedicine into their future practices.
| Moving Forward/Impact|| |
As technology evolves and with it new opportunities emerge in healthcare and education, so do new applications for telemedicine. The progressive model of medical education fosters collaboration, communication, longitudinal care and teaches students needed skills for their future practices. If multiple schools adopt this model, education dollars could be effectively channeled to better train students, while simultaneously providing low-cost care to underserved communities.
This technology, however, does not come without controversy and potential concerns. How will virtual communications affect the doctor-patient relationship, and how much does this technological approach discount the importance of the human touch? How will further digitizing medicine raise new confidentiality issues, and what kind of medico-legal challenges will this technology present? In order for telemedicine to be successful, legal frameworks and national eHealth policies need to be developed. Challenges to this medical education model include the difficulties of establishing and maintaining equipment in low-income, remote and international sites. Also challenging is the training and support for local community health providers who will use new technology to relay patient information back to teaching centers. Securing grants, donations and other sources of funding to purchase equipment will be a hurdle, with costs varying with the scale of the system and its intended use. Internet connection speeds, reliability and security may also pose obstacles. After establishing systems, patients will need to be educated about the telemedicine process, including the role of the student in the encounter. Care should be taken to be sure that telemedicine does not lead to unnecessary patient transfers from students to physicians; the patients' needs should be a priority. Language and cultural issues may also pose barriers in international settings. Whether or not students are bilingual, information can get lost or misinterpreted as it is relayed to and from the patient, translator, student and faculty.
Despite these obstacles, it seems inevitable that telemedicine will be a part of medical education's future. We feel that the time to broaden telemedicine within education is, now, for the benefit of both patients and providers. Educators should become informed on the opportunities and approaches of telemedicine in education, and play a role in its implementation and regulation.
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