[Seal of the National Library of Medicine, 1836]

Dr. Lindberg: Okay. Ladies, gentlemen, welcome to good old Lister Hill auditorium. You probably already understand that this -- this auditorium has a certain amount of magic that it works from time to time.

And happily, this time is going to be a very nice lecture and you're all very welcome and I'm glad you're here. Let me tell you just a very few things about our speaker, Professor Rashid Bashshur, who will tell us about the history of telemedicine.

No one better than he to give us that lecture because he's really been a student of that field for, I guess, 40 years. Maybe more.

He got his education in an interesting place, at the American University of Beirut back in the '50s when it was properly -- the city was known as the Paris of the Middle East and the university was the finest in the Middle East.

I don't know if either condition holds true now. But it -- it's sort of pleasant for me to romanticize it because Mary and I had always planned, ourselves, to make a faculty position at American University for a while. And our timing was terrible.

I remember saying it once to another person from NLM, namely Calvin Plimpton, who used to run international programs here but then became president of the university -- American University in Beirut.

And I said to him that we would keep thinking that it would really be nice to do that. It's an interesting place, interesting city, interesting part of the world.

And he said -- to those of you who remember Calvin Plimpton, you'll know the way he addressed such problems. In this case he said, "Donald," he said, "don't you give it a thought." He said, "Whenever you decide to come, just pick up the telephone and I'll fix it all up." you decide to come, just pick up the telephone and I'll fix it all up." you decide to come, just pick up the telephone and I'll fix it all up."

Which he probably would've been able to do but unfortunately that got us off the hook and we continued to ride horses or sailboats or whatever it was we were engaged in. And the time passed and the city was -- fell into warfare basically.

So, subsequent to that early training, Dr. Bashshur completed, not yet another, but in this case doctoral degree in sociology at Michigan. And so, that fully equipped him. It isn't really a license to kill but it's a license to study anybody he wants to study.

And so he just thought he'd -- I guess, that he would study we biomedical people trying to do telemedicine. And I appreciate your faithfulness to that course. I appreciate your taking the time to come and tell us about your latest book on the topic. Dr. Bashshur.

[Applause]

Dr. Bashshur: Thank you very much, Dr. Lindberg. I consider that I have the unique distinction of having Dr. Lindberg listen to me three times, granted his undivided attention three times now. And all three were in this hallowed building. So -- so, whatever happens, my life is complete.

Before I start my talk, I would like to offer Dr. Lindberg a copy of the book that is dedicated to him.

Dr. Lindberg: All right. Thank you very much.

Dr. Bashshur: And Dr. Ackerman. I -- I thought he read the book.

My co-author is Gary Shannon. He's sitting there, distinguished-looking gentleman there. And he belongs to the podium just as I do on this -- on this occasion. But because I'm older he gave me that first chance so -- if you have difficult questions at the end, I would rather you address them to Dr. Shannon.

Spare me. I will talk for about 50 minutes given the time now. Once I start, I don't know how to stop so if you would signal or something. Start wrap it up. I would like to leave a little time at the end so I can answer questions.

And I think that way we would have some degree of interaction. We acknowledged Dr. Lindberg and Dr. Ackerman in -- in the book formally. And I should also tell you that we dedicated the book to Dr. Lindberg. Reason being that he -- he really was the source of the idea.

He planted the idea in my head. And I'm a slow thinker. It took me about five years when I -- after he approached me, the idea of writing this book. And -- and then I thought it was long gone. I was busy doing other things and then I wrote him an e-mail. I said: Dr. Lindberg, you know, a few years back you had this idea.

I'd understand, you know, if priorities are different and so on and budget difference and so on. If you don't want me to do it, fine. If you want, I'll be happy to do it now. Now I have time. And he had a very quick response. I learned to appreciate it. When can you start?

So, that was the -- the way the -- the book started. I should also mention that initially the agreement that we would be supported for one year to finish the book. We did not finish it in one year. It took us two years. And at the end of the -- well, toward the -- toward the end of the first year, I talked to Dr. Lindberg.

I said, you know, we really couldn't finish the book and we need another year of support. So, he said, well, that's simple. You have to come to the NLM and impress us. If you do, you'll have the second year. So, he's a gracious man. I don't know how well I did but I came here. He said you have the second year.

It's really a pleasure to -- you know, to have people like that who act so graciously and so positively and I appreciate this. Now, I want to start talking about the -- the book a little bit. Before we -- when we started writing this book, we had to ask ourselves some questions there.

Is there really a story? Is it an interesting story? Is it worth telling? I mean, is -- we want to do this thing, would people really be interested. And if -- if it is so, has it been told, has it been written somewhere else so that we don't have to reinvent the wheel.

And -- and then we asked also whether there was like a -- is it like a separate episodes? Is it pieces? Bits and pieces? Or is it -- is there a unifying theme for the whole thing? And the answers that we came up with is that, yeah, of course, it's a very rich story. But it's available in bits and pieces. You have to kind of pick it up.

There's no kind of single source that puts it all together. So, it's not cohesive. And another thing we discovered that there were many inaccuracies. We thought we should -- we should set the record straight. I won't go into details about the inaccuracies but maybe some of them will come up in the discussion.

And then we felt: Is there kind of an organizing theme for the whole thing? And -- and the answer to that is kind of continuity and -- and change. And we carry that theme, I think, throughout the book. Great deal of continuity and great deal of change. The -- the terms may be contradictory but they're really not.

And then there's kind of a concrete theme for -- for the book in that there's a convergence in the case of this specific application convergence of the information technology in medicine. So, the book essentially carries three historical streams or discusses three historical streams.

One is changes that occurred in medicine or, if you will, the science of medicine, the changes that occurred in the information technology, and the changes that occurred in health care delivery. And then we found in these three streams the common denominator is the story of continuity and change.

In medical science, it's really a neverending quest for improved prevention, diagnosis, and treatment of disease. In health care delivery, it's the neverending quest for improved access, efficiency, and effectiveness in health care. When we say "never ending," it doesn't mean that it was like a continuous line in the graph.

You know, with everything is progressing upwards, there were stops and goes. The -- you know, plateaus, and -- and dips in -- in the curve. But nonetheless, it is kind of a never ending quest for -- for continued -- for improvement. And the same thing is true in terms of information technology in terms of improved connectivity over distance as well as information processing and exchange.

Now we started way back from the ancient Greeks and took it to the -- to the modern time. I remember an episode where I wrote to Dr. Lindberg that we got bogged own in discussing the history of -- of the technology and we went back to the ancient Greeks and so on, so forth. Am I wasting my time?

And it's kind of really time-consuming and so on. And his response to me, can you at least talk about the last one hundred years and get done with it, so....But there was drama and -- and I want to kind of pick a few highlights in the drama of this -- of this neverending quest. We picked the Claude Chappe who's the French inventor of the optical -- he invented the optical telegraph.

The reason I picked him is because he -- for -- for kind of a drama, if you will, that he committed suicide at the age of 42. He got ill at one point just before he committed suicide. And he became depressed. And -- and he thought that -- that there was a conspiracy. Somehow that his invention was going to be taken away even though he has three brothers who were working with him.

And -- and so he -- he jumped into a -- a well. And -- and -- and kind of a -- a very -- very unfortunate. He's the one who introduced the term "telegraph." And it wasn't his first choice. His first choice was the tachygraph. Tachy for speed and telefph [phonetic], of course, for distance. And a friend of his convinced him to change it to -- to telegraph so that it's really Claude Chappe who did that.happe who did that.

There's a kind of a infrequent, if you will, mention what -- like an American -- American hero. A dentist by the name Mahlon Loomis who did this experiment to prove that you can carry signals over the airwaves. This is in the Blue Mountain Ridge here nearby -- well, Virginia. And this is a -- a kite.

He took this kite up and -- and strung it on a thin copper wire. And -- and then he had a kite here reciting galvanometer is this. You know, the -- that's what their first used for the EKG. And he -- he sent some signals from this kite to this kite. And so, he -- he demonstrated. And I think -- here's the handsome gentleman.

I picked up an entry from his journal that I'd like to read. You could read it, I guess. I know that I am by some, even many, regarded as a crank, by some perhaps as a fool for allowing myself to the sacrifice of material advantages to abandon a lucrative profession. He was a dentist. And pursue the ignis fatuus but I know that I'm right.

And if the present generation lives long enough, its opinions will be changed. And its wonder will be that it did not perceive it before. I shall never see it perfected. But it will be. And others will have the honor of the discovery.

And I also selected Elisha Gray because -- and I think there was some recent press about Elisha Gray and whether it was Alexander Graham Bell or Elisha Gray who really invented the telephone.

It is a fact that Elisha Gray had the caveat on the invention, a practice that the patent office abandoned early 1900s or 19 -- about 1911, 1914.

At any rate, he had the -- the caveat [?]  for -- for his invention and he didn't have the money to -- to pay -- to convert the caveat into a full patent. I forgot what the amount was at the time but it wasn't really a great deal of money.

And, finally, he -- he decided to do it. Alexander Graham Bell preceded him to the patent office by a few hours. And so, it -- it was Bell. And the rest, as they say, is history. I thought it was kind of an interesting story. There were also hoaxters and I thought also interesting to kind of report those.

In 1916, a physician, Albert Abrams, devised the greatest medical hoax of all time. He called it the "Electronic Reaction of Abrams" or "ERA" machine. And his contention was that all diseases could be measured and treated by these electronic boxes. And it was popular...1923, 3,500 practitioners were using his machines.

And what he -- he charged $200 for -- for a battery operated one. 250 for DC. And then you had to pay him 250 -- $5 a month. With the condition that you can never open the machine. It will do the trick but you can't open it. Here are pictures of the -- this is the radio disease killer, RDK. And -- and this is the ERA machine. There were also visionaries.

This is the Edison telephonoscope. And in this, he's talking to his daughter and asking her about the charming young lady who was here with her son playing the game. This is, I think -- I gather this is the bedroom where they -- they had the -- the telephonoscope.

And he's asking her who is the pretty young lady over there and she -- she has -- she's just come over from England. I'll introduce her as soon as the game is over. Tom Swift is kind of an interesting story. Tom Swift was working on the photo telephone. And it's reported that he was talking to his dad.

And said, Dad, I'm going to invent the -- this telephone that shows pictures. And his dad says, No, it can't be done. You can't do it. I know you're bright and all that kind of stuff, but you can't. And -- and he -- he's the one who introduced the term "Yes, I can." So... [laughter] But radio doctor is not really -- not really science fiction but close to it.

This is 1924. But Gernsback was very interested in these kind of devices which he thought were coming along. They did not exist but he thought they would -- they would be coming along. Here's another depiction. This is called a "teledactyl" because you operate it with your -- with your -- with your fingers.

And this is kind of a full depiction of the -- of the teledactyl where there's -- there are radio signals as well as images. And the -- the tool here is operated by the doc with -- with the fingers. And the patient here is being diagnosed from a distance. This is around 1925, '26. There was also genius. I think George Boole definitely was a genius.

I don't know if you know that he was the son of a cobbler. Barely got an education. Eventually, ended the chairman of the mathematics department at Queen's College. And you -- you heard, of course, about Boolean algebra. Yeah, in this one, he is ordering his -- his lunch. Then Claude Shannon, relative of Jim? No -- I don't think they're -- I don't know if they're related or not.

Anyway. We're proud of Claude Shannon because he comes from Michigan -- Petoskey -- in Petoskey, Michigan. He -- he got his degree from the University of Michigan. And then went to MIT. And at one point, remarkably, he got his master's degree and his Ph.D. in the same year. A -- a true genius and this is his theory of information.

You know, the sender, the message, the code. The -- the -- the zero, 1, and so on that. But he is brilliant algebra essentially. So, from this, I want to kind of shift gears a little bit. Talk about the -- the -- the heatlh care context. At the early part of the last -- this century, early 1900s, as you all know, there were major reforms in -- in medical education and the concern was about the -- the quackery in medicine.

How to kind of make things more -- more scientific and so on. But I put early concern with quality and access. But I think the -- the -- the earliest concern was with quality and then kind of subsequently emerged to concern about -- about access. And the concern at the early part of the, early 1900s was that there were too many -- too many physicians with poor training or no training.

Too many people practicing medicine without being certified or going to -- and, of course, you know the rest of it with the Flexner Report and so on. So, that is kind of a source for us to think about the evolution of issues in health care that led eventually and -- and blended with the developments in information technology.

And to my mind, the -- probably the most significant development in -- in -- for the -- for improving access to care was the concept of -- of regionalization. We can be proud of the Regional Medical Program, the RMPs that we developed in this country the early '60s. But it really started in the -- in the U.K.

Start in early 18, in the late 1880s by Muwat [phonetic] who developed the plan for the regionalization of hospital service areas in London. And then ended with the Bernard Dawson who developed the so-called Dawson report. And then he developed this plan where primary care unit and secondary care and so all connected to hospitals in the kind of regional -- regional scheme.

When he submitted his report -- when was it, again? In 1920? Dawson -- he submitted his report. It was soundly rejected. Mostly by the medical profession and also by the hospital group in -- in the U.K. They thought that it was going to destroy the hospital the way we know it. It wasn't really great hospital at the time.

Most of it was cottage industry but they thought this was a destructive move that should be -- that should be -- should be stopped.

Interestingly, in 1945, Dawson's ideas became one of the basis of the National Health Service in the U.K. In -- in our country, I think one of the perhaps more -- more intelligent -- there may be a better word for it. One of the brightest notions we had about organizing medical services in this country is -- is regionalization.

Much to my chagrin we -- we going to watch the thing -- regionalization develop and -- and then -- and then die down.

And in this case, you see this is Michael DeBakey who was the -- who was asked by President Johnson to head the President's Commission on Heart Disease, Cancer, and Stroke. The -- the plan was ambitious but highly rational. It still makes sense today to organize things.

The reason why we take -- take time to discuss regionalization is because the -- the idea was to distribute medical services physically. That is to locate them in places where they make the most logical sense. Whereas, in telemedicine, you know, that kind of -- you don't need the physical.

There's this person. Do you know who this one is? Yeah. He's one of the early pioneers who advocated the use of computers in medicine. We are left from that era, from that entire -- entire history with -- with the -- with several unresolved issues. One of them has to do with physician supply.

How many? What's the right proportion between physician to population? What's the right proportion of hospital beds to -- to there are formulae for that but we -- we hadn't really resolved that -- that question to anybody's satisfaction. And then where to place them. Should they all be in urban areas where they tend to be concentrated for the opportunities and so are and the facilities are?

Or should they be -- should be distributed? One of the problems that we have grappled with in this country and still haven't resolved -- I mean, we grappled, I think, for a good -- good 50 years is what is the proper mix between specialty and primary care. For a long time, there was talk about parity. You know, 50/50 is the ideal.

Don't think that that 50/50 split is kind of based on any logical effort - it's just a guess, you know. 50/50 makes sense, you know. But anyway. We never reach the 50/50.

And then if we have to kind of provide, you know, services where the need is, is there kind of a hierarchy so we can figure out, you know, let's say the proportion of population who get heart disease in relation to the number of people who provide services for -- for heart patients.

So, there's kind of a hierarchy of need. You know, a lot of people get these self-limiting conditions and so on. And then fewer and fewer people get the  most complex cases. But are the resources then also similarly organized in this fashion? Is there kind of a sense they're putting them together?

And probably one of the issues that -- that we have yet to resolve and the more we think about it, the more it baffles us.

And the more economists get into the picture, I think the more we get confused. Is the -- is the issue of technology and cost. Technology got a bad rap early on because economy said, you know, technology increases cost. Why?

Because expensive equipment and so on would cost more money. And so, the argument was that, you know, if somehow we reduce the use of technology, we can save cost. But then, you know, if somebody needs an expensive kind of treatment and you don't give it to them, they don't do so well.

So, I find that -- I find that whole argument, that technology is the culprit, I find it unconvincing.

Maybe some of you will -- will argue with that. So, let me now more shift gears and talk about telemedicine as best we were able to document. Some of you may have, you know, different information. I would be happy to hear -- to -- to hear it from you. But we tried our best to kind of go to the original sources, try to document everything we're going to write about.

And -- and this is essentially what we came up with. During the Civil War, there was a physician, Albert Meyer, who was in the U.S. Army. He was with the union Army. Thought that, you know, you could use the telegraph. See these guys are stringing line for the telegraph. Used it to order supplies for the battlefield.

So -- so, this is the battlefield. And -- and then he would send telegraphs that we need, you know, so many bandages, so many of this, so many of that. And we thought that was kind of an interesting place where it started. There's a great deal of speculation about the -- the message that was sent to -- to -- from Bell to Watson.

Including yesterday I heard [?] was -- they were asking him about the development of the network and he said, you know, I didn't do like Mr. Bell thought. "Mr. Watson, please, come here. I need your help." This document is available at your library. That's where we found it. And there is no mention of asking of Alexander Graham Bell asking Mr. Watson to come and help him.

All he said, can you hear me? And he said, much to my delight he heard me. And I said come over here and he came over and that's what these -- these were. These -- I'm sure you can't read them. So -- so, that really was not a true story.

And then we investigated further. How the heck did the story become popularized so much that it became -- became almost fact? There was a movie made.

And in the movie, they changed things. And  Mr. Bell said, "Mr. Watson, come here. I need your help," because he spilled the acid on his crotch and so on. And somebody wrote recently, they said, You know, if somebody spills acid in your crotch, you're not going to be so calm saying, Mr. Watson, come here. I need your help. So, that's not really a true story. Okay? So, we don't credit -- we don't credit it.

There was a telephone call that was made by a mother of a sick baby. This was an American story but but published in the Lancet. And this mother was concerned about her baby having the croup so she calls the doctor on the phone.

It was late at night. It was raining or snowing or something. The doc says, can you put the telephone next to the baby's chest so I can hear. So, she did, and he said, don't worry, he's going to be okay. I'll see you -- I'll see you tomorrow.

And -- and says, well -- you know, then the mother and the baby were okay for the night and all that. It was all that. There was also mention about James Garfield who was shot, like, what, about four months after he was in office on July 2nd ,1881. And this is -- this is Alexander Graham Bell right here. And he's using the telephone to detect the location of the bullet.

And we got, like, two or three different reports so we don't know exactly which one was correct except that he did not identify the location of the bullet. One claim is that the bed was a metal bed so that the magnets in the thing did not detect -- or detect -- or another story says they detected -- what they detected was something below it in the bed here was a metal piece.

But anyway that story is to be dismissed as well. Then we came to the major discovery of all ages. Who was the father of telemedicine. It really was a Dutch physician, Willem Einthoven. Born in Java.

His father died. And he came back and studied medicine and so on. Make a long story short he -- he was the first to transmit an ECG using telephone line over a distance of 1.5 kilometers, over one mile.

And, to kind of make us all proud -- at least make me proud -- he got the Nobel Prize in 1924. But I should also mention that he really did not get the Nobel Prize for the use of the ECG and the telephone line but it was included among other -- other inventions of his. This is the -- well, see. This is the equipment he used.

The -- the galvanometer and -- and then it was connected to wires and so on. So, that truly as best as we can tell was the origin of -- of telemedicine. 1905 in -- in cardiology. Of course, there were other developments later on.

Shortly after that, 1917, in Australia, he flying doctor added the convenience of having radios to transmit messages.

In -- in Norway, in 1920, they started a maritime program where the kind of ship-to-shore radio where they will instruct from the home base -- from the Haukeland Hospital. They will instruct the -- the people on board ships who are having trouble somehow to deal with their -- their problems.

There are some accounts of -- of surgical procedures being done under this kind of instruction, monitoring kind of a thing. And the Italians started in 1935, the French 1945, and they put that here in Italy, the program, International Radio Medical Center, which is kind of similar connected with ships and remote islands. Continues to the present day.

A few years after they -- they started the program, they made it into a foundation. And now the foundation continues to -- to operate today. On this side of the pond, in 1950, an inventor named Cooley worked in Philadelphia, Pennsylvania.

He -- he was tinkering with facsimile machines and so on at the time. But he teamed up with Gershon-Cohen who was a radiologist.

And together they -- they demonstrated the use of -- of a system which they referred to as telenurses. Telediagnosis. They combined it into telediagnosis. And then kind of an interesting story of how that kind of succeeded. Somebody who -- who was influential person was constipated in some horrific degree. And they took the x-ray and they sent it to Philadelphia from Chester County Hospital.

They sent it to Philadelphia. And then one day they saw the [?] and said, you know, this is -- this is what the problem is -- because the guy was in severe pain and so on -- as to what you can do.

And it solved the problem. And the guy, I think, was very influential politician. I don't know what he was. And that kind of gave a big boost to the thing.

And the Canadians are very, very proud to say that they -- they were the original developers of -- of -- of telemedicine because of Albert Jutras who worked in Montreal at the Hospital Hotel Dieu.

And he demonstrated the use of telefluoroscopy where he -- he showed that because they couldn't send high resolution images that if they -- they took it on tape and then sent the whole tape, the motion in the tapes were enough to overcome the limitations of the resolution.

And he published a couple papers on that. When I mention this to my Canadian friends, it doesn't make them very happy because they -- they -- there's a lot of claim. Everybody wanted to be the first, you know -- and I don't know why. I mean, science, I think, develops everywhere by everybody.

But in this field, I think we're -- we're a little bit crowded with hacks who want to show that they're the first in everything.

And -- but -- Jutras, I think, was influential in that he had his mark in terms of this development. Then we started probing into who really developed, coined the term telemedicine. And -- and we were looking in the literature, okay, to see where there was a kind of a written report. The first we could find was a 1969 paper by -- by Ken Bird. This is Ken Bird. One of the true pioneers of telemedicine.

Some say the -- the pioneer, but he is one of them. And the -- in a paper by him and -- and Ray Murphy -- Raymond Murphy that was given in Tokyo in 19 -- 1969, they used the word "telemedicine."

First sign we saw it in -- you know, with a date and a printed -- in a published -- in a published form. And so, the folks in Nebraska said that it really doesn't matter. Wittson and company -- Cecil Wittson -- I'll talk about him in a minute.

Doesn't really matter who was the first and so on. This is something for the -- for the ages so to speak. So we all -- we are all like in a glimpse in history and so it doesn't really matter who was first. But the best of our judgment, this is how we saw the progression in terms of what we refer to as telemedicine today. Not going back to the early 1900s but say in the kind of the modern -- the modern era.

The first use of circuit TV -- closed-circuit TV in health care [?]  in 1953 at Agnews State Hospital near San -- San Jose. Notice that the -- the patients in wards that have TV were quieter than in wards that did not have TV. So, they know this TV really does something; keeps the patients quiet, so let's try to see if we can kind of study it further, make more sense out of it.

And so, they set up an experiment and sure enough they showed that not only that but then we can use therapy. So, they had like some behavioral therapy programs and so on. And they put it on the -- on the closed circuit TV and they showed that in some instances you can do group therapy. That way do it successfully.

When -- when you read the work of Wittson and his colleagues and -- and they're published quite a bit, there -- there was no mention of -- of [?] and I don't know whether they were aware of it or whether it was -- it was something that they want take more credit.

Anyway there was no mention. But as an application in -- in telemedicine, perhaps credit should -- should go to Cecil Wittson and his colleagues at the Nebraska Psychiatric Institute.

They started it in 1955 and then evolved as time went on. They got a sizable grant from the NIMH to study this system. It -- it was one of the largest grants at the time because they gave it to them for seven years. And that was supposed to be kind of a basis for developing these systems as -- model system for the United States. That's why NIMH was interested.

And I will be talking about them a little bit more. As far as we can see, the first prototype as a kind of a complete system, multiservice and so on, was developed in Boston at Logan International Airport by Ken Bird and his colleagues. It really didn't start in 1963. The medical station at Logan Airport was started in 1963. Kind of interesting story which we -- we report in the book as to why the medical station was established at the airport in the first place.

Some of you -- I don't know. Some of you -- if you recall, that there was an airplane crash at Logan airport in Boston in 1963. Electra prop-jet. You know, the -- I rode in those planes several times -- was taking off from Logan Airport. A bird -- a flock of birds hit the engine upon take off -- starlings -- and they stalled. And it ended up in the -- in the bay.

That area is shallow. And as soon as it happened, it was on radio all over town. And then -- and people wanted to go and see. They want to see the site of the -- of the -- so, when the emergency crew are trying to rescue, come to the rescue, they couldn't because the streets were clogged.

And then when they did an investigation of that afterwards they found that most of the people died from drowning, not from the accident, itself.

They drowned. So, if they got to them in time in a very shallow bay, they could have saved them. So, that led the port authority to establish the medical station at Logan Airport.

And then Ken Bird recounts the story of starting the -- the television -- interactive television system at the -- at the station. Another incident in which a lady, a traveler, fell and hurt her knee or something at the airport.

And then they called the doctor on duty and it was Ken Bird. And they said, gee, I would love to have -- see, and actually of this thing -- before I tell him, you know, how to -- how to treat the -- the patient and so on, well, it's safe to move them and so on. And he said that's when the idea flashed in his mind that -- that we -- that telemedicine would do the trick.

The first network as a network was developed in New Hampshire, Vermont. Kind of a two-state -- Dean Seibert and his colleagues. Something that may be of interest you is that this network really is the first true network that had been sponsored, it was two-state, and so on was heavily subsidized by the National Library of Medicine.

In fact, something interesting we -- we report in the book in that the program started with high hopes of success and everything else.

And it didn't seem to be going anywhere. And so, the National Library of Medicine recruited a consulting firm to kind of study the situation and make recommendations as to how to develop the business side of the -- how to make it as a business.

And the recommendations are really interesting in this [?]. This is Cecil Wittson. Something that I think we should say something about Cecil Wittson is that he was a true visionary.

And not only he developed this system in Nebraska, but that he converted kind of a simple hospital into a modern medical center. He became dean. And eventually, a chancellor.  So, he was very, very successful.

These are pictures, first, that's Nebraska Psychiatric Institute where they use it for educational purposes. This is how nurses used to dress. I don't know if you recall that.

Beautiful uniform. It's really a shame they don't do it anymore. And -- and this is where they -- they have the several monitors. This is the medical station at Logan International Airport as a prototype system.

Those of you who know Logan Airport, there's a kind of a tower and it's on top of that tower. I forgot with the third of fourth floor out there. And this also -- the nurse -- I forgot her first name.

And Ken Bird gives her a lot of credit because she used to kind of usher the patients in. And any of them who hesitated about being seen over the TV, she used to say, she would tell them, the doctor will see you now. And then she'd turn the camera on [?].

Another reason, by the way, he gives her a lot of credit, and this is a phenomenon that was typical in the early development of telemedicine which we do not see much of today. There was a great deal of emphasis on so-called nurse-practitioners.

That nurse-practitioners can do a lot of things that docs do and do them adequately so we should delegate more things to them that they're capable of doing. And then they could be supervised by a physician. It was a -- kind of a big cry in the -- in the -- especially in the seventies, too.

I remember going to a conference in Brandeis University where they called it front -- "front end professional." Front end professional. Because then what -- now [?] from Michigan stood up, said, If you call the nurses front end, what do you call the doctors? [laughter]

So -- they didn't like that. Let me say something about the -- some of the attributes of the -- this kind of early development in telemedicine.

They relied on off-the-shelf equipment. They -- they did not try to design or make changes. The equipment was...expensive. It was certainly bulky and it broke down quite often.

It requires studio-like conditions. Rooms have to be air-conditioned because heat builds up, you know, kind of disrupt the thing. Talk about failures. I mean, they had more failures than successes.

Something interesting at the time, you know, when we talk about these failures, people in industry said, we solved all the technical problems. All you have to do is just put it in place. I said like hell you did. You know. Look -- look how -- how this system -- they don't work. 90 percent you put, turn it on, it doesn't work.

Nonetheless, the people who were developing the system said, you know, this would really solve the nation's problems in health care needs.

This we kind of redistribute resources, do all kinds of wonderful thing. So, we should pursue it. And they were pursuing it on kind of two fronts. One is that there are lots of things that docs do that nurses, nurse-practitioners can do, so we should depend on them.

And the word "medics" was very popular at the time because there were people who were trained in Vietnam, you know, not really sometimes, untrained in the army and so on.

They deliver babies and so on. Did all kinds of things with limited or no training as well. You know, give them a little more training they can do lots of things. And that would be -- that would be great. And very importantly to us still today is they really conducted some very sophisticated scientific studies.

You look at the kind of studies they did. They tried to randomize the subjects. They tried to provide always a control, experimental a group, pre- and post.

Some of these studies really fascinating. Very interesting. Ken Bird was so keen on collecting empirical data that he had records. The first 1,000 cases. The first 2,000 cases. Thousands. Not hundreds, thousands.

And then they were all documented. And then what type of diagnosis, what was done, what was the outcome. Very, very sophisticated by -- by today's standards. Another feature of those -- of those programs where the blending of education and clinical care.

Every one of them tries a little. We can use this for clinical applications. It also applies through -- through a clinical care -- a clinical care education. And as luck would -- I don't know what would have it. But unfulfilled. I mean, people were really disappointed.

Wittson ended up president so, I guess, he -- he did okay. Bird -- Ken Bird was really very unhappy. He did die of a heart attack but that's not because he was unhappy.

He was just a little obese. I don't know what other thing. Maybe he smoked too, I think. At the time, he didn't think smoking was such a bad idea. And Dean Seibert of Dartmouth -- I was told --I visited with him several times and so on. At the time, he -- he had high expectations. They made him dean of something -- continuing education or something.

And he thought he was really going places with this thing. And then it kind of folded. And somebody told me he left Europe or something. He just -- he became very disgruntled. So, there were unfulfilled expectations. Let me move on quickly, and I'm going to try now to be brief because I tend to be verbose. In the -- in the 1970s -- in the 1970s, the Department of Health, Education, and Welfare -- that's the HSS now -- funded seven projects.

And there was a lot of talk about the seven-- the big seven -- seven projects. I'm going to say just a few things about each of these projects because there are more things that I have to say. In Cambridge, there was a -- an experimental program leadership we called the [?] center; at the time where they wanted to see if -- if nurses can perform better with this adjunct. With giving them this -- this facility where they have -- where they can see pictures over just the telephone.

So, they compare telephone, pictures, nothing. And -- and the images apparently did make a difference. Number of projects in Chicago. Chicago was very keen on the picture phone at the time so there are, I think, three or four project connected with -- with picture phones. But their emphasis was on transmitting medical records.

They had these clinics where patients in poor neighborhoods could go to any number of clinic. Any -- I mean, any one of the clinics to which they are eligible. And every time they go from clinic to clinic they have to send somebody to pick up the record and bring it. It was a, you know, paper record. And they said that way takes too much time. Patient has to wait long time. We have to send somebody to pick up the record, bring it.

It really wasn't working too well. So, they thought the picture phone solved the problem and so on. In rural Minnesota, in Waconia, Jonathan -- this is kind of a model city -- developed a multi-speciality practice. They applied the -- and -- and linked it with the -- with interactive television. In Nebraska, this is different than Cecil's thing. There's only a radiology test.

Very, very, primitive by today's standards where they use the telephone to send analog x-ray images. By the way, at the time -- forget DICOM and all that. DICOM came later. They said, hey, it works. They were not too keen about [?]. It works. You know, if you have a -- a big break in the bone, I mean, it shows almost to the blind. But they said, hey, it's yours. You can see it.

There was a program in New York, Mount Sinai in pediatrics. Interesting there was a recent report I read where they -- they refer to this report as -- as a psychiatric program. It really wasn't. And in Cleveland, Gravenstein developed this very sophisticated system to -- to mentor the anesthetist.

So, the anesthesiologist in one place, anesthetist in another place and they kind of talked them through the entire procedure. They used the laser beam to send the messages which was an innovation, which they developed it in-house at Case Western Reserve.

And it was too advanced for the time. One of the interesting features of that program is that if the plane -- you know, the -- if the plane crossed paths they -- they'd lose the image.

Now sometimes with inclement weather so that -- great when it works, terrible when it doesn't. I was going to talk a lot about NASA's program but I'm going to skip because time is short.

Maybe -- maybe I'll single out a couple of these things. You might know, the space program, there was concern about effect of zero gravity on astronauts so they develop all these telemetric equipment and so on. And then NASA tested their system in two places, in Alaska and one of them jointly with the NLM. And one in Arizona, the STARPAHC project. Space Technology Applied to Rural Papago Health Care.

The Papago don't like to be called Papago anymore because you know why? Cause because "Papago" means beans people. They don't like to be called beans people so they call themselves "Tohono O'odham" which means Desert People. In their language, "desert" mean openness, light, you know, brightness, and all that. Who wants to be called beans when you can be bright.

So, STARPAHC project was a joint effort between the Department of Health, Education, Welfare at the time and NASA. And both so common interest and so they were supposed to be jointly funded and so on. And DEHW kept withdrawing, withdrawing, withdrawing the list out saying bad things about the project. Interesting story. We -- we -- we tell it in the book so if you want to read it.

You should read the book. And then we and then -- then STARPAHC became like a huge service provider for the Indians, for the American Indians, for the -- the Tohono O'odham. And then it -- it fizzled. And then we explain in the book the reasons why we think it fizzle. It just was a -- was an overkill.

It was so expensive to continue because NASA wanted to test all their equipment on the Papago. Papago said, you know, if you give us something, please, us something that remains with us because we really want it. But then at the end they folded.

I mean, the whole project ended. It was really kind of interesting when -- unhappy ending. And the ATS series they applied the technology satellite series. And -- and we get kind of compete accounts of -- those are all in Alaska -- all done in Alaska where number of really good scientific studies were done sometimes combining several of these satellites.

There were cities, you know, ATS1, ATS2, 3, 4, 5, 6. Yeah, 6. And then F. The National Science Foundation supported the project in [?]. This fellow some of you know is Jay Sanders. I always like to show his picture and -- and we're -- we're good friends and colleagues and so on because we -- we belong to a kind of a threatened species, you know, and just so -- so few of us left now.

All of us like kind of like to say nice things about Jay. And he says nice things about me. Someday I was hoping he'd be in the audience because I could tell you what some of the others said about Jay. So, I'll say it here and -- and Mike be can tell him that I said it. Jay used to crisscross the world, not just the U.S. by the way, preaching the gospel of telemedicine according to Saint Jay.

So, this is last time I'll ever say that. There was a project supported by Regional Medical Programs even though they're not supposed to be supporting telemedicine on Deer Isle in Maine. Very interesting story there. The Office of Economic Ppportunity supported a sizable project in rural Maine in Franklin County. And the Commonwealth of Puerto Rico supported a substantial program there and revisited the Puerto Rico program.

One of the most touching aspects of that program is when we visited the hospital they told us, you know what the number one problem that we worried about? They -- they -- they bring the accident victims and so on from Ponce. This is the southern part of the island. They bring them from up hills and so on and they put them in the emergency room...

They bring accident victim and put them in the emergency room waiting for their turn. By the time the doctor saw them, a number of them were dead. And they didn't know if they died on the way, they died in the waiting room because nobody was paying attention to them. They said wouldn't it be nice if somehow we got information about these people before they got here. So, they had the accident [?]] so they can send us some images.

So, it was a -- a truly remarkable thing. And I thought, you know, talk about, you know, monumental thing. People dying, you know, and nobody paying attention to them. They didn't -- they didn't have the facilities. Rural areas didn't have it, and the Ponce district hospital is kind of a small hospital. They said, look, you know, here we are. We can't take care of more patients. So, it's not like they were negligent.

They just were overloaded. They were myths about these area, a number of people said, you know, telemedicine rural. Hogwash. If you can't be mixed and so on. Only two of them were rural. Many people said, you know, they use high technology. That's why they fail. Hogwash. Microwave at the time was no big deal. They were using it in the standard television, SDS and so on. Four years they, you know, programs -- picture phone.

Only when use delays I had mentioned, you know, the [?]. Some mentioned that, you know, they were for poor people. No, they were not. Some said they were -- the reason they folded is because they -- they were for research only. Only four of 18 were set up as research projects. So, why did they end? You know, I had mentioned a few times before that the history of telemedicine is the history of failure.

But that's really kind of overstating it. It's the phoenix, you know, that came out of the ashes. But telemedicine had a rise in the sixties and seventies and then the eighties and then a kind of huge decline; it almost faded out of existence. And -- and I was here in Washington. I was at National Academy of Sciences. Before, the Institute of Medicine used to be called "Board on Medicine."

Not Board of Medicine, Board on Medicine. Anyway, I was here and the National Science Foundation recruited me to -- to look at these systems as kind of a solution for the nation's problems in health care and so on. And I thought, you know, I would have a career working in this state.

And dammit if this career didn't go down the drain, there was nothing -- I mean, I could write -- write up, write up. So, I tried to write a few papers here and there. Most of the time their editors at the journal said, you know, this is irrelevant. Anyway. Some people said the money dried up. Well, it did dry up. So, is -- is that a bad explanation?

No, it was not a bad -- there was a -- this was kind of the transition to the Carter Administration and there was a very strong sentiment in the Carter against technology. That's why I said, you know, the economists did us a lot of harm. And they said, you know, one way to save money -- if you remember, there was high inflation and economy wasn't going anywhere.

And so, there was a great deal of concern about, you know, how do we deliver care more efficiently and how can we save on the cost of care and so on. And a number of economists -- and the prominent economists in this country said, let's reduce the dependence on technology. So, there was kind of an empty technology sentiment. But my explanation is this: That there was a rush to judgment.

There were unrealistic expectations. We thought that we were going to conquer the world, do this whole thing in a very short time. So, every project -- this number is seven. There were 18 of them in all. But seven supported by the HEW. They gave them initially two years. Two years in which they had to find the technologic solution.

They had to find the band, you know, do give them the -- install it, test it, get it to work, put patients on it. Okay. And then prove that it was cost-effective. But it was cheaper than the alternative. And I remember a talk I gave -- there's a conference place down here somewhere -- what do you call Virginia.

Audience member: Airlie House.

Dr. Bashshur: Airlie House. I came to the Airlie House. There was this guy from telecommunications. I said, you know, it cost less money to take the 747, nice little plane to go to London, get care, and come back than to use this equipment. Why? Because we have this very expensive equipment, very unreliable. And we have very few patients using it at the time.

The only one who drummed up business in here was -- was Ken Bird. But at any rate, very, very little use. So, if you amortize the cost per visit per patient to the cost of the equipment and all that, it was unbelievable. At the same time, the concept made sense. The concept made sense. The application was nowhere where it -- where it should be. And there were a number of design flaws.

I mean, I could tell you stories about design flaws in Boston, for example, at the -- they -- they set up a program where the doctors were on the sixth floor of this building, sixth floor ... The telemedicine was on the first floor.

It was locked because they had equipment, expensive equipment in it. So, when the docs get the telemedicine consult, they had to pick up the key, take the elevator, go down to the first floor and -- and open the gate, go to inside. If they got a phone, they get message from their floor.

So, it was -- it was really a bad -- it was a bad -- it was a bad arrangement. So, anyway. And there are other things, you know. There was one program where the -- they put the equipment in the so-called "bereavement room." And that bereavement room in the hospital was kind of a dinky place, you know. And so, that's where the equipment.

And the people in this town, oh, that's, you know, one of your relatives die that's where you go, where they talk to you, say, please, sorry. You know, we couldn't survive your -- your papa and so. Now I said of all stupid places why did they have to put it in the bereavement room? They said, well, that's the only equipment place they gave us. Interesting thing is, that why did it come back?

It changed and then it came back. Why did the phoenix rise from the ashes? Well, I think because there were unresolved problems in health care that were amenable. So, like, you know, there's a solution that wasn't -- wasn't really tried right but now it makes sense. Literally -- we literally took a big interest in it. And I think that gave it a big boost.

But perhaps most important there were vast improvements in the technology, not because of medical application, by the way, because of other things. But [/} did more good for us than we realize, by the way, because they had to do animation, all kinds of stuff. And so, they developed a lot of programs and said, hey, you know, it works here. And very importantly the huge decline in price.

So, you can get more for less. So, gee, can't lose. In the book, we covered the -- the maturation field really kind of starting in the -- about '93, '94 where staewide programs began to develop throughout the country. We singled out kind of the -- the -- I mean, Georgia, Arizona, Texas, and Alaska for discussion.

And then Canada is kind of an interesting case. And then I thought -- I'd say something about Georgia program, probably at the time the most promising. Question is, why did it fail? I mean, it did fail. Fall down. Now it's coming back from the ashes. But the vision was on target. The need was demonstrated. The goals were great. The plan was, every citizen in the state of Georgia was to get this care, the care they need through the system.

And the funding was substantial. We got this huge amount, $50 million as a settlement between the telephone company for overcharging. And then the state decided to -- instead of giving the money all back to the consumers, they said how about using this for health care and education. Two good things in the state. So, that's how telemedicine got its funding.

So, to my mind and Jay's mind, we thought that the down side of instant wealth. You know -- I don't know if this -- this is a true term or not... the lottery syndrome. You know, you get lots of money. Now you don't know what the heck to do with it. And so, something like that, I think, happened. They had so much money. They had -- they had about $50 million and kind of a license to kill, you know.

So, they -- they went overboard in terms trying to figure out the expensive system just stuck in place and everybody has to do exactly the same thing that they told about to do, including the design of the cabinets and the dimensions and all that. I said, My god, you know. Who the hell is going to take this crap from you? I mean, that's too much. So, and then they artificially impose. If you want to participate, you come to us.

So, if you're a doc anywhere in Georgia, they don't go to you. You have to come to them. And so it, they ignored all of the established referral relationships with physicians, go to this hospital, that -- all of that we ignored. They thought that once we have this thing in place it's not like you build it, will come. No, we build it, they will come, they have to come because we're it. We are it. Well, they didn't come.

And then they got all this money up front. They couldn't, they did not figure out how it's going to be sustained over a period of time. So the money will dry up. They put the money -- no matter how much money, by the way -- if you keep spending from capital, the capital will dissipate and go. So, they were unprepared to deal with that. Now let me say a few words and Dr. Lindberg may or may not appreciate it. No, I think he will appreciate it.

I hope you appreciate it. Innovations succeed when they meet vested interest, resources, expectations, and major gatekeepers. Who are the gatekeepers? What are their expectations? What do they want and does it fit with their vested interest and so on? And so, the question -- and a lot of people -- a lot of people have posed this question. Why didn't telemedicine take off in any bigger way than it did? Why?

I mean, it made sense logically in everything else. Why didn't it? Some people say we don't have sufficient evidence. In other words, the -- the study -- because studies that were done were not too randomized, clinical trials with large number of [?] cases and so on so forth so we don't really have all the evidence.

Interesting about, the thing about the evidence is that the preponderance of the evidence -- the huge number of studies that is mostly -- most of them are in the positive direction, a few are not.

But the preponderance of it is positive but it's not like a sledge hammer. You know, it's just a few hits here and there. So, how about the -- the evidence, I think, is necessary. You need to convince the -- the cynics and people who challenge you. You need to convince them. And the only way to do that is to provide the evidence. Is that enough by itself?

I don't believe so. I think without figuring out the business case or business basis and how you're going to get recurring revenue, reimbursements, it will never be sufficient. So, that's, you know, my explanation -- Gary's explanation about diffusion of telemedicine. And then I want to spend maybe a couple minutes -- I really should shut up before too long -- about the way we see telemedicine now transforming.

Everybody in the telemedicine field kind of got preoccupied with connectivity. You know, putting you in touch. But the technology took a leap forward, beyond that. Created opportunities for us to do more things than just -- just sheer connectivity because of the capability in data storage, data retrieval, data processing.

Capabilities that we didn't think existed just a little while ago. And -- and some of these applications are now becoming quite substantial. In disease management, for example. But, you know, chronic illness is on the increase worldwide, and we're doing all kinds of bad things to make it worse. You know, continue to smoke, we overeat. We do, you know, other things that -- contributeto it.

And we -- we're surviving to older age which is bound to create chronic illnesses and so on. Cost of it is very high. And so, if you can somehow take care of chronically ill patients in -- in their homes, away from hospitals, you can save a lot of money. So, now there's a great deal of interest in this electronic monitoring.

Even the government now is beginning to take a [?]look at it, saying yeah, maybe that's one way that -- there are clinical decisions' support systems where, you know, the providers can have access to the standard information that you folks provide from the National Library of Medicine in addition to special, specific information, blending it to so that fewer errors are committed and so on.

And that now is coming to the fore as a major new application. I've seen we've had tremendous -- over the -- a lot of programs are -- are using it. And I think it's going to grow by leaps and bounds. No two ways about it. Your computer has physician order entry system is really kind of one branch or application of decision support systems but mainly dealing with medication prescribing and so on.

And now, of course, because of events and so on, disaster preparedness and response, all this information can be used to do that. And then the question I -- I pose you. You know, if you're talking about all of these other things, it's just straight telemedicine. Sometimes it telehealth, or e-health. And do you know what my answer to that? Who cares. I certainly don't.

So, here's my conclusion, folks. My conclusion is the future of telemedicine, whatever else you want to call it, it's secure. But it is not for the timid, the greedy, or the impatient. Thank you very much.

[Applause]

Did I provoke any questions? [inaudible speaker] Yes. Thank you.

Dr. Lindberg: So, I'm very grateful to you for the talk and I, we invite questions. I have to say parenthetically that I totally endorse your view about the importance of regional medical programs. And I think, if we continued it, we wouldn't be in the dilemma we presently find ourselves. There was support at -- RMP did support telemedicine although they're, I guess, independent [?].

Dr. Bashshur: One thing, I think, I may have misreported a little bit. The program in Maine that got supported by RMP was occurred after the RMP was defunded. They did support the -- the program in Minnesota and maybe one other one. But when they're the last, in the last year they were in business, the Congress revived them for a little while. And during that interim period, they supported as kind of a continuing resolution thing.

Audience Member: I'm interested in this concept that, I think, you were beginning to put forward about the fact that the technology wasn't really ready for the need at certain times and that might be one explanation for why there was a mismatch between what was, you know, some of the programs continuing.

So, I'm wondering if, in that context, now that we have -- so -- so, we -- in -- in some ways, I think, in science in what we support, we sometimes put the cart before the horse because people say, Well, this is what we need. And, Oh, here's some technology. Let's match these things up.

But I'm wondering if now, in moving forward, it might be more useful for us to sit back and say the technology of communications is evolving in this way and we see it -- you know, social networking and tweeting and twittering and the way cell phones are used -- and the way PDAs are used.

Does it make more sense for us to say how do we utilize this technology the way we see it going and incorporate it into the need because then, would not the technology and the needs-based response evolve together and then be more linked to each other?

Dr. Bashshur: I think you said it very nicely. You know, the question, you know, some people said, if the technology is moving so fast, should we wait until it is perfected then -- then we use it? The answer to that is no, you can't wait. The same thing as with desktop. You know, like, we change our desktop -- I don't know how often you -- so, if I'm going to -- and wait for the whatever -- the optimal computer to come out, I will never have a computer.

But -- but so we invest but we invest for obsolescence. And it part of our business planning. In other words, we have to be smart in the way we invest so that we see a return on the investment and a plan for the obsolescence of the equipment. And I think you're right in that, you know, these evolving things are really remarkable. And in fact, we don't fully know or understand where they're going.

And we come up with things that we didn't think about before. So that we remain open for opportunities in -- in the technology development. But that we use what we got and you know, stay open, stay tuned, you know, just keep -- keep doing it. I think -- [inaudible speaker] Yeah.

Audience Member: I spent about 35 years in my career, most of it overseas practicing medicine, taking care of Americans in the Navy and the Foreign Service. And, of course, we use telemedicine all the time -- phone calls, e-mails. Desperate methods of communication. The worse examples of telemedicine was when the technology kept getting in the way with sort of "Star Warsy" approaches that, like you say, the equipment barely worked.

Most medicine practiced these days in America is a 15-minute office visit. The doctor doesn't even spend 15 minutes with the patient. You can't do that with telemedicine. It's absolutely impossible due to that rapid -- that rapid turnover of -- of patient care.

I think when you try to apply telemedicine to the average urgent care clinic setting; that is, that kind of turnover, it's -- it's never going to work because-- and the ultimate point in telemedicine is still a doctor sitting with, so to speak, a patient that that human interface is -- is sometimes simply not economically feasible in the telemedicine approach.

Dr. Bashshur: One, you can have two esponses to your -- to your observation. Observation is -- is correct. I think early on in the some of the studies they are that, you know, it was taking a little bit longer in terms of minutes, by the way, to -- to conduct what they call telemedicine counsel versus the in-person counsel [?]. You know, taking a little bit more time. Now the thinking was about a -- a fixed mode of telemedicine which is live, online, patient there, physician there.

So, they both have to -- to be available to each other at that time. And they have problems in scheduling and things like that. Then about -- what, about ten years ago now it came up with the idea of -- is called -- is called "store and forward" where you really don't have to -- the patient doesn't have to be with the physician at the same time. So, you're a physician sending, say, images from -- from a ship or something that you want this expert to see it and give you an opinion.

So, you send it. They pick it up. So, you store it forward. When the specialist, radiologist, at the other end is available, they will send you the -- the thing. You get it in a very timely fashion. Usually less than 24 hours, and it solved the problem. Okay. Here's where the government does sometimes stupid things. I'm sorry to say. See, see...[?]

Said, look, we will reimburse it if it's like -- if it's not like we didn't -- won't reimburse. So, why the hell don't you? I mean, if it is economical that way, efficient, makes everything works, why -- why don't you? Because -- so, we want -- we want to rule out the abuse of the system because people, you know, want to do -- a "chin-chang", you know, heard of that that. Charge, charge, charge.

Say it will cost too much. But -- but the -- those -- those questions that you raised are answerable. It's just that you don't have to kind of be fixated on one solution is going to work forever. No, it doesn't.  Yes...

Audience Member: From -- from what I've heard at various meetings recently, one of the biggest barriers to adoption is what you just raised at the end there is reimbursement. And I'm wondering in some of those earlier models how -- what was the conception? How did you pay the nurse-practitioner? How did you pay the remote doctor? Or -- and -- or what sort of model do you envision for being able to pay for it?

Dr. Bashshur: The restrictions on reimbursement is a modern phenomenon. We live near -- at the time in the sixties, people were not concerned about reimbursement. It wasn't -- it was a non-issue at the time.

Audience Member: So, is there hope?

Dr. Bashshur: Yeah. For them --

Audience Member: Is there hope in America with the current system of health insurance and reimbursement?

Dr. Bashshur: Pardon?

Audience Member: Do you think that there is any hope? I mean, you would need to have codes for...

Dr. Bashshur: Is there any hope?

Audience member: ...consultation?

Dr. Bashshur: There's always, there's always hope. And, you know, I -- we're not going to be blind forever. I mean, you know, we -- the thing that has been happening that interests me is that in the case of reimbursement, the Congress of the United States has been nudging toward relaxation of the restrictions on reimbursement.

HCFA initially -- when Bruce Vladeck was in charge of HCFA -- and I remember in 1992 he said, in six months, we're going do come up with a policy on how to reimburse for telemedicine. He left -- take the number other administrators [?]. They never did. And the reason why they were concerned about the trust on -- they said we break the trust on.

If we open the floodgate and there's all this pent up demand for service, you know, all these rural [?]] start using service. We're going to flood the system. We're going to cost a lot of money so we can't afford it. So, they put the clamps on it. The Congress of the United States went in the opposite direction.

And the Congress of the United States has been nudging HCFA in bits and pieces to allow reimbursement. So, under certain conditions. This and that. So, my private interpretation is that there was dam, you know, which was constructed by -- for out of fear. You know, you had -- why the fear is because their projections in 1965 about Medicare and Medicaid were not true.

I mean, the costs are much higher than any projection they had. Much, much higher. And they said we're -- we're damned if we're going to burn twice in a lifetime. So, they're holding the reins. So, the Congress keep nudging them. And the reason Congress is nudging them is because a number of representatives come from rural district and -- the rural constituents say, Hey, we need it. We want it.

And so, now there's like a growing constituency in Congress in support of these things. And each time we see a nudge forward which I interpret as a breach in the dam. So, I'm thinking maybe that the dam is going to be breached.

Dr. Lindberg: I'd like to add that it's important that this telemedicine do something that people want and that's useful. I mean, as a Regional Medical Program activity in Missouri, I did EKG statewide --

Dr. Bashshur: Yes.

-- because the doctors wanted it. Because they didn't know how to interpret EKGs. And it was lapped up. It was a big success. No problem whatsoever. And nothing to do with reimbursement. I think you, first of all, have to do something useful, that's wanted, and do it well.

Audience Member: Yes.

Audience Member: Private view.

Dr. Bashshur: Thank you.

Dr. Lindberg: Oh, I'm sorry. Elliott.

Audience Member: I wonder if you could comment on the experiences of a Mayo Clinic which showed reimbursement doesn't have an issue there and presumably they find it useful. Are there success stories here that others should emulate?

Dr. Bashshur: You know, the Mayo Clinic is a very interesting example in the way, you know, reality unfolds. As you well know, they have three -- three sites for -- for their facilities. And in the beginning, they went whole hog. You know, they developed the satellite thing.

You should see the huge dishes they have. And they were sending -- and specialists in Rochester were kind of a -- let's say -- I don't know want to call them "higher breed." But there were more specialists in Rochester than in Florida and in Arizona. And they were using them for consultations.

The volume of patients in the other places that were kind of satellite became huge. And then they built up the capabilities in the other places to the point where they really did not need it as much. It's kind of, you know, say, from a -- from a practical point of view, if you don't need to -- to have a consultation, you know, why do it.

And so, if you are a specialist in Scottsdale, Arizona, and you got this, you know, [?] and so on, you could interpret them and -- and do everything you need. So, you know, I -- I don't really need to -- so, I think that's what happened with -- with -- with the Mayo.

They -- they succeeded in staffing the satellite facilities to the point where they matched the -- the core specialists they had in...and now I'm told -- [?] was telling me -- that they are using it but more quietly. They're not making big fanfare out of it.

For example, they're using a lot of e-mail that is like below radar screen. You know, like, nobody's noticed -- they say somebody -- you know, they -- they know each other first name say, I have this case, you know. And I have this rash and the rash doesn't disappear, I don't know.

I gave him ointment and, you know, do the -- and doesn't seem to be that -- what do you think? The guy says,  try such and such. So, there's a lot of that going on. So, you know, for you and me, sir, Well, that's telemedicine. You know? I mean, they're using the facilities to address clinical issues --

But -- but I don't think Mayo going to two other locations was an experiment in telemedicine. It was an experiment in management. I mean, if you contrast let's say Mayo's success with Cleveland Clinic's total abysmal failure in going to Florida, I mean, that's not telemedicine. That's difference in management.

Dr. Bashshur: Yes. Yeah. And -- and then they were thinking originally, by the way, also of centralizing a lot of functions that, after a while, they said, you know, for business purpose, you really don't need to -- to have billing from one place or this and that. You don't need to centralize a lot of managerial functions so -- this central --

Dr. Lindberg: Right, the times changes where we centralize the EK -- interpretation of the EKGs is now all on a single chip in the machine. I mean, it's -- there's a further comment from the Royal Navy, please.

Audience member: Somebody mentioned the reimbursement being a problem. But -- but you mentioned doing EKGs in Missouri but you didn't mention you were doing them for Kansas, Nebraska also. We have the problem of licensure. Can you really practice medicine across state lines with telemedicine? We also have the problem with malpractice.

The -- who covers your malpractice claim when you've made a mistake? And I don't have the answers for that. Believe me. We asked many times. There isn't a good answer.

Dr. Lindberg: Well, we just -- limited it ourselves in Missouri. We didn't take on that big a problem... And we didn't make any mistakes anyway. [laughter]

Dr. Bashshur: That's true. You know, that interstate licensure is certainly an issue. The board took up the issue. They cannot relax some things. There's restricted other things. It's -- it's an unsolved problems. And the way -- there are, you know, like dark in the darkness.

Some programs where they [?] going national where you can send the thing and get it from anywhere. The way they're doing it is the hard way. They get licensing. They get somebody to go and actually get the licensing in other states.

And they -- neighboring states like between us and Ohio, if you're so many miles from the border or something. So, that is a real issue is being resolved but we haven't resolved it and it is -- you know, it's true that this country is a union of states so that fact remains.

With regards to reliability, there was a lot of worry in the beginning about -- about liability. And that really has subsided because there haven't -- there have not been court cases that anybody is being convicted. So, I say, well, you know, it seems to be working.

But whether we are skating on thin ice or on -- [laughter] -- something that's going to help it -- that -- that concern have not really materialized in any big way.

Dr. Lindberg: So, I'll ask the hardcore to join me in thanking our speaker.

Dr. Bashshur: Thank you.

[Applause]

Dr. Bashshur: I got a prize. This is the -- this is the NLM water. The holy water.