The Role of Telemedicine in the Delivery of Healthcare Services



 Information Management, Lancaster University, UK

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Health care is an important part of social welfare; it involves a considerable part of our daily life. Telemedicine is not only a medical tool or equipment, but also an application of Information and Communication Technologies (ICTs) which delivers high-quality health care services without geographic boundary.

This dissertation discusses with the historical viewpoint of ICTs, health care services, and society and future health care development. Furthermore, some suggestions have been made for the possibility of future telemedicine in health care services such as the benefit of modern technologies in health care service, quality of care, and strategy utilized. The study framework followed Hebert (1998) in the impact of IT on health care professionals. This combined both quality of care in Donabedians elements of structure-process-outcome, and Grusecs three levels of IT impact: direct substitution, proceduralization, and new capabilities. Both frameworks provide a clear viewpoint with which to identify the problem of modern technologies in the health care process.

Telemedicine consists of health care informatics, clinical, education and training, and administrative services to provide different levels of health care solutions. Therefore, this dissertation categorizes the telemedicine system as clinical and non-clinical technologies (i.e. health care informatics) in order to avoid confusion in future research. The study results conclude that, for these new medical issues, telemedicine systems may provide cost-efficiency and high-quality of care services, however, many factors should be taken into account, such as human factors, policy issues, and the economic viewpoint. Therefore, the investment of telemedicine still requires circumspect planning and integrates possible resources for providing the quality of care.


Firstly, I would like to thank my supervisor, Professor Brian Bloomfield, for providing me with a great opportunity to participate in this research. His continuous encouragement and advise have been invaluable.

I am also grateful to all the professors, lecturers and staff at the Management School, Professor Peter Checkland, Dr Paul Lewis, Dr David Silk, Mr David Brown and Mr Mark Winter. Also, special thanks to Ms Sylvia Wilson, the course secretary. They have all given me warm and sincere support throughout the course.

I am greatly indebted to Professor Richard Wootton, the director of Institute of Telemedicine and Telecare (The Queens University of Belfast, UK), and Mr Paul Taylor, a researcher at the Centre for Health Informatics and Multiprofessional Education (University College London, UK) for their support and guidance in this specialist area. I am also grateful to Dr Marilynne Hebert, Clinical Faculty in Department of Health Care and Epidemiology (University of British Columbia, Canada) for her discussion of the research framework and Dr Tracy Ibbotson, the principal researcher in the Department of Nursing & Mifewifery Studies (University of Glasgow, UK) for the medical knowledge.

Thanks also go to my friends and colleagues, whose contributions, ideas, and lively debates were also very helpful. In particular, I would like to acknowledge Ms Sue Bailey, for her help with proofreading this dissertation.

Finally, I am indebted to my family for their support and encouragement during my study in the United Kingdom. Without them, this dissertation would not have been possible.

List of Figures

Figure 1 Impatient in-patients (Source: Department of Health, Office of Health Economics cited in The Economist [May 23rd 1998: p.34]) *

Figure 2 Health care informatics *

Figure 3 Boundaries in the healthcare system where demand is generated and examples of tools used to manage that demand (Source: Pencheon, 1998: p. 1666) *

Figure 4 Framework of referral decision-making (Source: Dowie [1983] cited in Jones [1992: p. 99]) *

Figure 5 Research framework (Source: Hebert [1996: p. 372] cited in Hebert [1998: p. 71]) *

Figure 6 Teleconsultation in UK *

Figure 7 Comparison of referral process (left: before introduction of telemedicine, right: after introduction of telemedicine) *

Figure 8 Boneline project improves communication between GPs and specialists, and reduces unnecessary referral (left: topical referral process; right: Boneline project) *


List of Tables

Table 1 Summary quality of health care service in Donabedians elements of model *

Table 2 History of Telemedicine (Source: GAO, 1997; pp. 17-18, Field, 1996; pp. 35-40 and Reiser, 1978; pp. 196-226) *

Table 3 Comparison telemedicine in used (Source: Darkins et al., 1996; pp. 93-99) *

Table 4 Views of general practitioners and specialists who participated in 54 teleconsultations (Source: Harrison, Clayton, and Wallace, November 1996; p. 1378) *

Table 5 Diagnostic accuracy for all scans (Source: Wootton et al., 1997; pp. 213) *



Abstract *

Acknowledgments *

List of Figures *

List of Tables *

1 Introduction *

1.1 Background *

1.2 Aims of the research project *

1.3 Overview of this dissertation *

2 Research framework *

2.1 Research background *

2.2 Impact of ICTs in the evaluation of quality health care *

2.2.1 Structure-Process-Outcome model *

2.2.2 Substitution-Proceduralization-New capabilities *

3 ICTs and Healthcare services *

3.1 What is telemedicine? The history of telemedicine *

3.2 What can telemedicine do? How does telemedicine provide services? *

3.2.1 Services *

3.2.2 Applications *

4 Challenges of telemedicine investment for healthcare services: benefits and potential problems *

4.1 Benefits *

4.1.1 Reduce healthcare delivery costs *

4.1.2 Bring specialist expertise to the patient *

4.1.3 Improve communication between primary and secondary health care in order to improve the referral process and resource utilization *

4.1.4 Improve professional medical education *

4.2 Potential Problems *

4.2.1 The need for high standards affects technical capacity and diagnostic accuracy *

4.2.2 Patient and doctor satisfaction *

4.2.3 Quality paradox *

5 Conclusion & Learning Points *

Bibliography *

  1. Introduction
    1. Background

Since the last century, clinicians, health care researchers and workers, and service providers have been investigating information and communication technologies (ICTs) to improve health care services. Modern technologies are being increasly utilized. They are not only changing the clinical technique in general, but also change the role of attitude forwards technologies in health care services. Telemedicine is medicine carried out at a distance (The Lancet, 1995) images, videos and medical information are transmitted by advance telecommunication links, which break through the geographical barriers and provide more opportunities for patients to obtain suitable services. Additionally, they support long-distance medical services. In fact, the telemedicine services depend on the level of technologies involved, their main purpose, and transmission time, causing variation of services (GAO, 1997). At the lowest level, telemedicine could be the exchange of health or medical information via the telephone or facsimile equipment. At the next level, telemedicine could be the exchange of medical information including data, image, audio and video on a delayed basis, which means the medical information goes through the store-forward technique to provide off-line services. At the top level, interactive and real-time audio or video consultation have been utilized, which support both on-site and off-site health worker communication in different locations.

In the United Kingdom, the National Health Service (NHS) is the biggest health care service provider in Europe. For the last ten years, it has been planning a health care programme which sets out long-term health care strategy and action in order to increase the number of population under care and reduce medical barriers (high cost, misuse of resources, etc) by utilizing modern technologies such as telemedicine, which will be diverted from administration into patient care. During the celebrations of the 50th Anniversary of the creation of the National Health Service, Prime Minister Tony Blair addressed the future strategy:

The National Health Service however, is not simply there just to be preserved, we don't just want to save the National Health Service - there's a lot more to be done in order to do that, to give the people the investment in the health service that it needs. We also want to see it improved, to find new and better ways of treating people, to use new technology, to make sure that we have a service that is modernising and moving with the times as well as dependable and secure. (NHS, 1998:

However, The Economist magazine (May 23rd 1998) pointed out a major problem in the NHS the high waiting list. Throughout the 50-year history of the National Health Service, more money has been pumped in, yet the queues have got longer. Indeed, the British government announced a £6 billion ($9.7 billion) increase for health care projects over last year (1997). Yet, there are still around 1.3 million patients waiting for treatment and operations (Figure 1).

Figure 1 Impatient in-patients (Source: Department of Health, Office of Health Economics cited in The Economist [May 23rd 1998: p.34])

Therefore, the demand of telemedicine might be helpful to solve this problem and to facilitate the health care services. Although lots of benefits have been claimed, telemedicine services still require a long-period of introduction in order to avoid telemedicine becoming another health care barrier.


1.2 Aims of the research project

Telemedicine services have existed and been developed for more than forty years for different purposes. Previous health care research has been keen on utilizing telemedicine as a medical technique, but ignore the impact of telemedicine on different levels. For instance, patients obtain on-line treatment by videoconference that reduces unnecessary travel for the patient, but without the face-to-face human touching can patients trust it? Moreover, the modern technologies change decision-making can it (i.e. the computer) make the right decision for the referral process? Consequently, much research focuses on the questions can technologies help the health care service? or Is it necessary to use modern technologies instead of traditional clinical procedure? and ignores the human element.

The aim of this research is finding out the demand of health care services in terms of telemedicine services. It not only focuses on clinical or technological applications, but also discusses the human management aspect including human satisfaction, organization target, and global strategy. In particular, the development of telecommunication has been widely utilized and affects the behavior of human communication. In terms of health care services, telemedicine can influence decision-making, and reduce unnecessary costs and time; but it also changes the relationship between patient, doctor, and health care provider. Therefore, this research also examines the potential drawbacks of telemedicine, in order to reduce maximize the usefulness of future recommendations for the health care service.

This research is based on document review; the sources come from journal, magazine, newspaper, television news, and the electron document in the fields of medical issues, health care management, and telecommunication. In order to go deep into the research and understanding the telemedicine in practical term, the author contacted and consulted with some professional organization such as Rural Health Care (Wales), Institute of Telemedicine and Telecare (The Queens University of Belfast, Northern Ireland), Centre for Health Informatics and Multiprofessional Education (University College London, England), Department of Health Care and Epidemiology (University of British Columbia, Canada), and Department of Nursing & Mifewifery Studies (University of Glasgow, UK). And also discussed with worldwide telemedicine experts through the telemedicine ( and medical informatics ( newsgroups.

    1. Overview of this dissertation

This research project looks at recent United Kingdom health care services and especially at the relationship between telemedicine and health care services in the past, the present and future developments. It is based on a literature review and telephone interview. It presents the strategic viewpoint in the health care informatics system and the role of telemedicine in the delivery of health care services. It consists of the following chapters:

Chapter 2, Research framework In previous telemedicine research, there has been a lack of analysis examine the quality of telemedicine services. Therefore, reference to Donabedians quality of care and Grusecs three levels of technology impact may be helpful in understanding the quality issues and the impact of technology on organizations and society. The first level of Grusecs model will applied in Chapter 3. The rest of levels will be discussed in Chapter 4.

Chapter 3, ICTs and Healthcare services The historical points of telemedicine will be included in this chapter through a literature review. The birth of telemedicine grew from the necessity of providing in treatment various circumstances, such as emergency, battlefield, domicile and hospital care, and improving life saving, long-distance diagnosis, and medical management. In fact, telemedicine integrates with health care informatics, education and training, and administrative services, hence, it is necessary to define different level of technologies utilized in different kinds of telemedicine services. This chapter describes the difference between system and service, especially focusing on its applications: both for clinical and non-clinical purposes (health care informatics).

Chapter 4, looks at the challenges of telemedicine investment for healthcare services, both benefits and potential problems. Following from the previous chapter, evaluation concepts are extremely important. Consequently, benefits and potential problems of telemedicine services will be identified through the of document-based survey, telephone interview, and worldwide discussion (in telemedicine news group and relative bulletin board system). The discussion in this chapter also looks at further investment and practical situations through a deliverable telemedicine framework.

Chapter 5, Conclusion and learning points Conclude with final thoughts during this research, and an account of learning experiences. Finally, there are several deliverable results and recommendations.

  1. Research framework

    1. Research background

Health care services are increasing in capability while Information and Communication Technologies (ICTs) have been widely utilized in daily life. ICTs change the process of health care services and its functions, which increases economic benefits and cost-effectiveness, improves medical processes, clinical accuracy. Meanwhile, the development of ICTs not only changes the clinical process, but also influences the organization as a whole. ICTs have an impact on the health care providers in many senses, such as organization structure, behavior, and function. According to a GAO report (GAO, 1997), the change in the global environment of health care services should integrate and manage every possible resource to provide high-quality medical care, improve access and reduce health care costs. The impact of ICTs in health care services consists of four areas: 

  1. Health care information management (also called informatics)
  2. Clinical
  3. Education and training
  4. Administrative services

In fact, health care informatics has been widely utilized in health care systems such as medical education, the clinical system, and the patient care information system (PCIS). Thus it represents a modern technology which has been utilized not only in health care services themselves, but also managing the health care services. The use of modern technologies in health care services influences the flow of information processed, the delivery and sharing of useful information with the other health workers, and helps health care providers to control and monitor the whole system. Health care informatics is connected with three components: hospital, research laboratory and pharmacy industry, the general practitioner, and the patient (Figure 2). The information channel delivers new medical technique information, patient records, and hospital information system, etc. In terms of health care informatics, the whole health care system has been covered and the information through modern technology connects each component. The area within the dotted line consists of medical informatics, which disseminates medical techniques in order to reduce unnecessary costs and improve communication between each sector.


Figure 2 Health care informatics


Because of the change in culture and clinical behavior, modern technologies introduced, and prevent epidemic concept (Pencheon, 1998), health care workers now face difficulties in adjusting themselves to utilizing modern technologies. The demand for informatics has become extremely important. The essence of health care systems is to focus on serving and taking care of the general population. For example, Figure 3 represents the patients journey in the health care referral process, and shows aspects of given barriers in decision-making procedures.

Figure 3 Boundaries in the healthcare system where demand is generated and examples of tools used to manage that demand (Source: Pencheon, 1998: p. 1666)


Pencheon (1998) points out the necessity of informatics in the health care system, namely in patient referral decision-making and communication between primary and secondary care. The patient within the system is rather passive, because the publics generally trust the performance of health workers. However, the referral procedure depends on the patients condition, the GPs decision-making, and secondary care support.

The impact of ICTs on clinical procedure consists of two parts: the relationship between patients, general practitioners (GPs) and specialists, and the referral process. The lack of communication channels between primary and secondary care is a problem which mainly affects the quality of health care systems. In 1983, Dowie developed the referral decision-making model from a study of outpatient referral procedures (Figure 4). The study points out that the GPs (or primary cares) referral decision-making is dependent on their cognitive processes and it was also suggested that the GPs had differing degrees of medical knowledge, hence they need to rely on information provided by certain investigations (Dowie [1983] cited in Jones [1992]). Therefore, communication between primary and secondary care becomes an important issue in the referral procedure. In reality, specialists complain of unnecessary referral, lack of patient information when referring to secondary health care (or hospital), and lack of information from specialists or GPs, which might affect the patients rights and delay the treatment process.


Figure 4 Framework of referral decision-making (Source: Dowie [1983] cited in Jones [1992: p. 99])


2.2 Impact of ICTs in the evaluation of quality health care

The increase in demand for quality of health care services has affected health care and organizations are under pressure to create and invest in more cost-effective strategies by utilizing ICTs, in ways which can support high-quality, accuracy, and patient satisfaction. Therefore, in order to meet high standards, the evaluation should be taken into account. The evaluation, following Heberts (1998) framework, combines both quality of care as viewed in Donabedians elements of structure-process-outcome and Grusecs three levels of IT impact (direct substitution, proceduralization and new capabilities) (Figure 5).

Figure 5 Research framework (Source: Hebert [1996: p. 372] cited in Hebert [1998: p. 71])


2.2.1 Structure-Process-Outcome model

Donabedians framework for assessing the quality of patient care came from the exploration of need (Donabedian, 1973). The needs of medical care systems influence medical care processes, which affects clinical decision-making and behavior. Therefore, he suggests it should be measured by three criteria (Donabedian [1966] cited in Russell and Grimshaw [1992]):  

  1. Structure the resources available to the doctor whose care is being evaluated.
  2. Process of care what the doctor does to or for the patient
  3. Outcome the resulting changes in the health of that patient.

The summary of Donabedians model is shown in Table 1, even so, he argued that the patient outcomes are difficult to measure during the analysis procedure. This is because the investigated effects on the outcome of care might depend on different clinical structure and processes especially in terms of modern technologies involved in health care service (Russell and Grimshaw [1992] and Hebert [1998]). This means that activities or resources classified as structure, process, and outcome may change over time.




Measure by


Structure includes all environment related with health care services, such as medical equipment, health care informatics, and clinical system.

  1. Job satisfaction:
  2. Users satisfaction:
  3. Technology performance:

Process of care

the activities between practitioners and patients

  1. the change of users performance (i.e. diagnosis accuracy)
  2. the service volume (time, resource in used)


Outcome is the change of patients current and future health status

  1. Patient satisfaction (waiting list, home care, monitoring service, travel)
  2. Duration of hospital stay
  3. Number of treatment or diagnosis

Table 1 Summary quality of health care service in Donabedians elements of model

Hebert (1998) suggests that Grusecs three levels of impact should be combined with Donabedians assessable quality of care in order to illustrate technologies and organization change. Grusecs three levels model consists of substitution, proceduralization, and new capabilities.


      1. Substitution-Proceduralization-New capabilities

Level 1 Direct substitution affects the way procedures are performed by replacing previous tasks with new ones. At this level, direct impact is shown before and after the new system has been introduced. An old system which cannot necessarily utilize new technology is replaced by a new system which might be more complex and this influences the user directly. For example, conventionally, patient records have been manually arranged. With new computer technologies being introduced into the working health care service, the worker can simply maintain patient record information via a patient database.

Level 2 Proceduralization is the transformations from previous systems into more standardized procedure through the use of techniques. At this level, it is necessary to examine tasks which require human judgement and action. For example, traditional x-ray films require a relatively long development period, whereas modern technologies linking a computer and scanner can display results directly on a monitor. In this case, there are two questions: 

  1. Can monitors displaying x-rays provide better quality visual viewpoint (or performance) than traditional film?
  2. Does it really reduce development time, storage space, and meet the cost-benefit principle?

Although this level evaluates the effect of proceduralization, actually it also reflects the substitution level task. According to the example above, the ICTs break through the traditional x-ray development procedures (level two) and reduce the workforce and clinical time (level one). The impacts using ICTs for x-ray procedures are as follows:

  1. The direct impact of changes in x-ray development reduces the number of health care workers involved, such as radiologist, trainee, nurses, etc. At the same time, the development period has been reduced, because the results are directly transmitted to a computer monitor. Thus, the results can be distributed to the specialists regardless of location required by telemedicine linkage.
  2. After the ICTs have been introduced in x-ray services, the traditional procedures are required to be re-designed in order to fully exploit the capabilities of modern technologies.

Level 3 In arriving at this level, new capabilities have been discovered. However, this may result from the two previous levels or only one. Moreover, the final result needs to be investigated and its effectiveness evaluated. For example, the new capabilities might be less effective than the old ones, because of inconvenience or great effort required in practical terms, e.g. training of staff to use the ICTs. Therefore, the framework will show the general effect of the introduction of ICTs in the quality of care services.

The whole research framework (including both Donabedians quality of care and Grusecs IT Impact of organization) represents the impact of the relationship between health care service, society, and ICTs, and aims to provide quality measures and guidelines for development (Figure 5). The arrows (Figure 5) are meant to represent a general direction of impact of telemedicine services on different levels. If there are any Outcomes from one level to another (no matter whether it is level one to two or level one to three), it means that the system possesses the ability to move to new steps. However, Grusecs model suggests that users become more sophisticated in their use of technology and what it can do, which suggests a move through levels one, two, and three. However, Hebert argues this framework is not a linear process in some particular cases. After evaluating level one, the Outcome will move to level three, because some applications do not require proceduralization tasks before using ICTs for new capabilities.

The present research into the telemedicine system follows Heberts model for developing an effective telemedicine framework. Applying the Heberts framework, and generate some specific research questions which should be taken into account:

  1. Clinical expectations The change of modern technologies, which affect the decision-making process in the clinical system, also alters the relationship between patient, primary care, and secondary care.
  2. Economic factors Telemedicine is a high-expenditure activity Is it worth it? and Why not buy more beds or equipment or build more health centers?
  3. Matching technology to medical needs The lack of clinical and technical standards might cause overuse, malpractice, or too much dependence upon technologies and without health care workers judgement. Meanwhile, medical technology development needs to meet health care service requirements.
  4. Universal social issues and organizational factors physician acceptance, patient acceptance, privacy and security of medical data, and malpractice liability.

  1. ICTs and Healthcare services

    1. What is telemedicine? The history of telemedicine
    2. The birth of telemedicine began with long-distance health care services, and is related to telecommunication. The first telephone technology existed in 1876, invented by Alexander Graham Bell. After the 1880s some physicians experimented with telecommunication technologies (such as the telephone, telegraph and wireless) in managing medical practices. Some doctors used the telephone to accept appointments, or make an on-line diagnosis in advance, instead of long-term waiting and unnecessary travel. Yet telephone technology was undeveloped until the First World War, which enhances traditional health care and brings health care into the new age.

      The possibility of long-distance transmission of medical information was established in the 1900s. Willem Einthoven developed the long-distance broadcast of graphic data in 1905 and later this technique was widely utilized in transmitting electrocardiographs in the Presbyterian Hospital of New York in 1910. Moreover, long-distance diagnosis had been concerned with communicating between rural physicians and urban hospitals after World War . Table 2 shows the history of telemedicine, which details the early pioneering experiments and especially focuses on long-distance medical services.





      Telephone and telegraph diagnostic

      Emergency medical services via telephone network



      Willem Einthoven exploited long-distance diagnosis by telephone line to transmit ECG between his laboratory and Leyden hospital and named this telecardiograms


      Telephone stethoscope

      Long-distance auscultation between London and the Isle of Wight (UK)


      Radio Doctor

      Ideal interactive vision images (or Television?) for treatment? (Radio News, USA)

      1947 1948


      radiology images transmitted by telephone between West Chester and Philadelphia, Pennsylvania (USA), a distance of 24 miles


      Video communications

      Two-way interactive television to transmit neurological examinations and medical transmission across campus to medical students (University of Nebraska, USA)


      Diagnostic consultation

      Fluoroscopy (X-ray) images transmitted by coaxial cable (Canada)


      Video communications (continous University of Nebraska program)

      A telemedicine link with the Norfolk State Hospital (112 miles away) to provide speech therapy, neurological examinations, diagnosis of difficult psychiatric cases, case consultations, research seminars, and education and training


      ECG transmission

      Emergency ECG transmission, and linking with hospital

      1960s 1970s

      Satellite communication support telemedicine

      Utilized satellite to transmit medical information and provide health care services to the Appalachian, Rocky Mountains, Alaska (National Aeronautics and Space Administration [NASA])

      1970s 1980s


      Digital Imaging Network project for Teleradiology (U.S. Public Health Service and the Department of Defense

      Table 2 History of Telemedicine (Source: GAO, 1997; pp. 17-18, Field, 1996; pp. 35-40 and Reiser, 1978; pp. 196-226)

      During the 1960s, computer and telecommunication technologies grew in maturity. The long-distance medical service made breakthroughs in geographical distance and improved health care services in many different fields such as emergency care, battlefield aid, home care, continuous medical education, on-line treatment and diagnosis to prevent chronic disease, etc.

      The first well-known telemedicine project was established in the 1960s, as the University of Nebraska (USA) transmitted neurological examinations across its campus for medical purposes. Moreover, the university demonstrated a telemedicine link with the state hospital (Norfolk State Hospital, Nebraska State) 112 miles away, which provided speech therapy, neurological examinations, diagnosis for difficult psychiatric cases, case consultations, research seminars, and education and training (GAO, 1997: pp. 17 and Field, 1996: pp. 36) in 1964.

      The National Aeronautics and Space Administration (NASA) was a pioneer of satellite communication to demonstrate telemedicine services in the 1960s, which supported rural area health care and overcame the radio communication problems. For example, NASA tested satellite-based communication to reach remote areas where it was difficult to receive radio waves such as spacecraft, aircraft, mountains, and valleys. By way of satellite communication, the health information system brings the specialists to the patients, and balances rural and urban medical resources.

      During the early 1970s a shift towards digital communication took place, the telemedicine improved in quality, accuracy, convenience, and low-cost health care.

      The definition of telemedicine includes different functions and technologies, but all focus on overcoming geographical distance and providing high-quality health care service. For example:

      The investigation, monitoring and management of patients and the education of patients and staff using systems which allow ready access to expert advice, no matter where the patient is located (Van Goord and Christensen, 1992, cited in Gott, 1995: p. 10)

      Telemedicine is defined as the use of electronic communication and information technologies to provide and support health care when distance separates the participants. (Congressional Research Service, 1996, cited in GAO, 1997) 

    3. What can telemedicine do? How does telemedicine provide services?
        1. Services

As in the definition above, the telemedicine system should include possible technologies (especially telecommunication technology), medical information management (health care management and research) and education (medical education and continuous education), and medical activities. Gott (1994) in her research summary distinguishes the needs for telemedicine between primary and secondary health care services. Telemedicine systems tend to integrate medical with social, educational and proactive health services for the aim of reducing the medical cost and unnecessary waste of medical resources. Moreover, they emphasize the interaction of treatment procedure, potential epidemic disease prevention and health care activity research. Two main telemedicine applications are teleconsultation and telenursing:

Teleconsultation utilizes two-way real-time interactive video, audio, or image that provides remote diagnosis, remote treatment, continuing education, and emergency care, etc. between two or more sites. The telecommunication technology links a remote specialist and an off-site health worker; the on-site specialist uses a computer monitor to assess real-time situations and provide suggestions. A well-known teleconsultation project in the Bosnian Civil War was the biggest telemedicine project yet attempted (named Operation Primetime III [Berry Jr., 1996]). The main purposes of the Primetime project were: 

During 1995 and 1997, the Department of Defense (DoD, US) established telemedicine links via satellite that connected the battlefield with several different medical centers on the European continent, America, and nearby aircraft carriers. The system reduced referral times and saved lives. The capabilities of this project included computerized medical records; full-motion remote video consultation between theater medical units and tertiary care facilities; forward delivery of laboratory and radiological results and prescriptions; digital diagnostic devices (such as ultrasound and filmless teleradiology); and medical command and control technologies (GAO, 1997).

Teleconsultation eliminates geographical barriers not only in wartime, but also in peacetime too. By way of integration of ICTs, teleconsultation has become increasingly utilized in health care service. The development of the Internet (health care web site) provides more medical information and off-site consultation, thus promoting the self-care and reducing the cost. 

Telenursing This involves home care nursing and monitoring services. The main purposes of telenursing are avoiding unnecessary travel and waiting which reduces the elderly, expectant mother, and disabled patients hospital stay and provides point-of-care (POC) services (Bayne, 1997). It allows patients or nurses who are in the community to conduct, monitor, and give consultation using portable equipment (such as X-ray, ECG, blood testing, temperature testing, etc) and store information in the portable machine or use on-line links with health care centers for further treatment.

Furthermore, telenursing supports the self-care service; few off-site nurses monitor the real-time update of patients records by utilizing residential facilities. For example, the alarm system is a cheap and effective aid to support independent living (Gott, 1995), which allows elderly or disabled people living on their own through health care network to achieve self-care services. Once the emergency has happened, the nurse can contact a nearby ambulance by the health care network.  

      1. Applications

In terms of modern technology, there are several techniques used in telemedicine systems such as digital signal processing (data coding and compression), internetworking (network topology and model, transmitting protocol), and computing (such as database, multimedia system, software engineering, etc.). 

Clinical purpose application

Telecardiology After Willem Einthovens pioneer study in the electrocardiogram (ECG), termed telecardiograms in 1910 (Reiser, 1978), the importance of long-distance diagnosis was recognized. Moreover, during the 1960s, computing technology and the telephone network made telecardiology possible. In 1967, a cardiologist in France sent a cardiogram to Washington, D.C. and asked for teleconsultation over the telephone network. After 15 seconds computing consultation and analysis, the clinical results and suggestions were sent back to France through the computer. Recently, telecardiology has covered all the cardiac diagnosis transmissions such as ECGs, echocardiograms, angioplasty and cardiac pacemaker monitoring (Fishman, 1997).

In particular, within emergency care in Maryland State (Gagliano, 1998), telecardiology equipment has been established in the ambulance by wireless telecommunication links with off-site consultants. The consultant received real-time updated patients information from the ambulance (such as ECGs) and gave suggestions for first aid.  

Teleradiology Teleradiology is the most widely used application in telemedicine technology (Ruggiero, 1998). It covers radiological images (such as X-ray, ultrasound, magnetic resource image [MRI], computerized axial tomography [CAT] scans, etc.) which are transmitted to remote consultants for clinical or educational purposes. According to the ACR (ACR, 1996), the goals of teleradiology include:  

  1. providing consultative and interpretative radiological services in areas of demonstrated need;
  2. making services of radiologists available in medical facilities without on-site radiologist support;
  3. providing timely availability of radiological images and radiological image interpretation in emergent and non-emergent clinical care areas;
  4. facilitating radiological interpretations in on-call situations;
  5. providing subspecialty radiological support as needed;
  6. enhancing educational opportunities for practicing radiologists;
  7. promoting efficiency and quality improvement; and
  8. sending interpreted images to referring providers. 

The benefits of teleradiology and computer networking include increasing the number of images read by radiologists, reducing physical storage space and improving radiological film preservation, and reducing image transmission and development time.

Telepathology Telepathology was introduced in the 1980s, and transmits high-resolution images of frozen sections, cytologic smears, lesions, etc. Basically, pathology requires high-resolution images for pathological diagnosis and research. The digital-based video-microscope has replaced the traditional microscope, and enhances cell and microbe observation. It also helps the pathologist store and search image files. 

Telepresence Telepresence consists of robotics, virtual reality, and desktop conference (including data, audio, and video), which benefits teleconsultation, telenursing, remote continuous education, and medical simulation.

The growth of telepresence in surgery is an epochal application of telemedicine, which supports surgery simulation and distance learning with utilizing virtual reality (VR) techniques. The system allows medical students or trainee surgeons to work wearing a lightweight headset camera during the operation. The video signal could transmitted to a remote consultant and display operation procedures. The system can allow the remote consultant synchronous observation and permit him/her to comment on the procedures. 

Non-clinical (Management) purpose application Health care information management and computerized patient record (CPR)

The computerized patient record system drives and directs patient care activities in part by building upon basic functions of an electronic medical record, such as documentation of medical encounters, prescription writing, generation of consultation letters and materials for patient education, and other care-related activities (Bingham, 1997). The computerized patient record system benefits the health care worker through ready access to clinical data and a decision-making facility (such as referral process awareness, and possible prevention of hereditary and epidemic disease). The role of CPR for clinical purpose include the following: 

The role of CPR for management purpose include the following:

In order to enhance the security and authenticity of computerized patient records, the system requires high performance access authentication to ensure patients confidence. The smart card (or health care card) is a key for patients entering the health care services, which can be recognized by the magnetic stripe or microchip, similar to the recent credit card or telephone card. The magnetic stripe or microchip carries data in a digital format which might include the medical record, identification, driving license number and account (termed electronic cash). The patient can utilize the smart card and licensed personal identification number (PIN) for identification and register for obtaining health care services. The clinical results will be recorded on the smart card and database, and the payment will transmitted from a personal account into the service provider via electronic data interchange (EDI). The health care provider can monitor the whole treatment process to avoid errors.

One of the smart card pilot studies in the UK the Exeter Care card trial- ran from 1989 to 1992. It was sponsored by the Department of Health and involved 13,000 patients and a local health care provider (Hopkins [1990] cited in Neame [1997: p. 574]). Patients were issued with a smart card that carried administrative, clinical, emergency, and prescription data, and only authorized health care workers were permitted to change medical records. The evaluation of the Exeter Care Card study showed significant changes:

The role of modern technologies in health care informatics makes telemedicine more possible by linking with the other important components such as telemedicine infrastructure, clinical and patient information management. The integration of health care informatics shifts the emphasis from a paper-based to a computerized system, which offers more effective support and supplies information to the accreditation organization.

  1. Challenges of telemedicine investment for healthcare services: benefits and potential problems
    1. Benefits
      1. Reduce healthcare delivery costs

Telemedicine can enhance the effectiveness of working practices in the health service. It can deliver patient information, treatment records, clinical decisions and medical education, which can shorten diagnostic time, reduce treatment waiting list, and paper-based processes. Telemedicine can also reduce travel costs otherwise incurred when patients and specialists have to travel for consultations.  

The applications of telemedicine can improve the case of emergency treatment in remote environments such as on the battlefield, the ambulance service, on ships, and in airplanes. For example, the Lancashire Ambulance Service has joined the pan-European HECTOR (Health Emergency Care through Telematic Operational Resources) project which utilizes existing telecommunication technologies to improve emergency care service. The Lancashire Ambulance Service was chosen to run two pilot programs as part of the HECTOR project:  

  1. Transmission of 12-Lead ECG (electrocardiogram)
  2. Transmission of telematic images.  

An ambulance was fitted with four cameras (one on the front and rear of ambulance, and a macro camera inside the ambulance plus one on the paramedics helmet), and 12-Lead ECG via GSM (Global System for Mobil Communications or Group Special Mobile) telephone network linking with A&E consultants at Blackpools Victoria Hospital. All the rescue procedure is transmitted to the hospital automatically. The consultants at A&E assess the patients condition and will give advice to the paramedics when required. After viewing the patients condition, the doctors at the hospital can also have a better understanding and prepare for necessary treatment before the patients arrive. Lancashire Ambulance Service has proved the quality of HECTOR project: 

With this equipment, the time to treatment is greatly reduced and this reduction improves the patients’ chance of survival by an unprecedented amount…United States emergency services have been using the same equipment for nearly five years and the number of lives saved has increased by over 80%. (Lancashire Ambulance Service, 1998) 

The advanced informatics in medicine (AIM) program has created a patient record standard which defines the storage and transmission formats for x-ray images, photographs, medical signal (including ECG and ultra sound), and laboratory results (Kalra, 1994; pp. 1358-1361). There are two main functions of AIM as follows: 

a. The digitized medical information improves communication between pharmacy, laboratory, hospital information systems, GPs, patients, and worldwide specialists.

  1. To reduce delivery and storage costs: The use of telemedicine technologies in radiology and dermatology can reduce the need of x-ray or high-resolution photographs. The utilization of the monitor instead of the traditional plastic film provides even better resolution for diagnosis and improves space utilization. It also improves the management of radiographic and information transmission.  

The role of electronic patient records (electronic medical records or computerized patient records) is improving medical information processing and reducing costs. For example, one electronic patient record project in Ohio state in America aims to reduce costs in order to improve the quality of care delivery (Khoury, 1997). The project seeks to: 

  1. Make medical records readily available at all times and any to wherever they are in demand.
  2. Monitor medical resources in use by creating automatic, up-to-date information.
  3. Provide accurate patient status and prevent chronic disease.
  4. Enhance clinical decision-making and drugs in use. 

One project which linked an accident and emergency department (A&E) in Belfast and a minor treatment center (MTC) in London represents a good example of the cost-effectiveness and diagnostic reliability of telemedicine (Fig. 6).

Figure 6 Teleconsultation in UK


The three-way video consultation linked patients and nurse practitioners in MTC, A&E in Belfast, and local GPs or Hospital (Fig. 7), which improved the patient referral procedure and reduced the number on the waiting list. Since the project began, MTC has provided a walk-in service, and the number of patients has increased to over 800 per month. The nurse practitioners in the MTC access telemedicine links and transfer patient information to the A&E department in Belfast. Then the consultant makes suggestions and contacts the GPs or makes a referral to the nearest A&E department.


Figure 7 Comparison of referral process (left: before introduction of telemedicine, right: after introduction of telemedicine)

This project proves the effect of telemedicine on the referral pattern (Table 3), which in turn reduces unnecessary expenditure on resources, for instance, an on-site mid-grade doctor costs approximately £50,000 per annum and yet the annual cost of the videoconference link was £7250. At this point, telemedicine provides help in determining whether initial primary treatment in the MTC or onward referral to another agency is necessary, but does not support definitive diagnoses.

The telemedicine link for trauma and minor injuries was an extremely cost-effectives way of providing medical expertise to cover the clinical risk of the 0.5-1.5% of the case load that required expert medical opinion (Darkins et al., 1996)  



Before introduction

(12 months)

After introduction

(12 months)

Number of patients seen



Number of referral to nearest A&E

155 (2.3%)

147 (1.5%)

Number of referral to GP

Number of patients using teleconsultations directly

802 (11.9%)


383 (3.8%)


Table 3 Comparison telemedicine in used (Source: Darkins et al., 1996; pp. 93-99)

4.1.2 Bring specialist expertise to the patient

Information and communication technologies (ICTs) can change traditional treatment and medical activities by shortening the distance between patients and expertise (Wootton, 1996). For example, there are only 12 specialist fetal medicine centers in the UK, compared with over 200 district hospitals with maternity units. Therefore, expectant mothers need to travel to a fetal medicine center or the nearest district hospital. In order to minimize both the risks and prevent potential disease, the fetal telemedicine services provide a link between expectant mothers in rural areas and specialists in remote fetal care centers.

Recently, a survey by Fisk et al. (1995 & 1996) reports remote consultation by transmitting ultrasound and video in real-time over a 30-channel ISDN (Integrated Services Digital Network) link (transfer rate is almost 2 Mbit/Sec) between the Center for Fetal Care (CFC) at Queen Charlottes and Chelsea Hospital in London and St Marys Hospital in the Isle of Wight from November 1994 to May 1995.

Patients with normal fetuses can be reassured over the link, while many with straightforward abnormalities can have the diagnosis confirmed and be counselled without needing to travel. (Fisk et al., 1996)

During this six month trial period twenty-nine expectant mothers underwent ultrasound examination via teleconsultation at St Marys hospital on the Isle of Wight with information transferred to London in real-time. The obstetricians at CFC advised the Fetal Care department in the Isle of Wight on advance examination or referral of the patients. Before teleconsultation, thirteen women (45%) had been advised and referred for treatment. However, only four women (16%) needed to travel to London after teleconsultation. Moreover, the results suggest that 80% of expectant mothers felt that teleconsultation reduced their anxieties. Furthermore, teleconsultation reduces the physical effects of referral and waiting.

      1. Improve communication between primary and secondary health care in order to improve the referral process and resource utilization
      2. More effective working practices in the health service lead to reduction in waiting lists, early diagnosis of conditions and quicker, more convenient provision of services. In the past, the communication between GPs and specialists has often been poor. For instance, specialists complain of unnecessary referral, lack of patient information when referring to secondary health care (or hospital), and lack of information from specialists or GPs (Roland and Bewley, 1992). Moreover, these situations could affect the health care services and delay treatment process, information transmission, and patient satisfaction. In fact, more efficient use of equipment and medical resources reduces unnecessary medical care. Therefore, the NHS has identified twenty-one priority areas to improve the interface between primary and secondary care by using ICTs in order to provide better quality service (Department of Health, 1998).

        The definition of primary and secondary health care from the recent British Governments Green Paper A first class service Quality in the new NHS is: 

        Primary care – Family health services provided by family doctors, dentists, pharmacists, nurses, midwifes, health visitors, opthalmic medical practitioners.

        Secondary care – Specialist care typically provided in a hospital setting or following referral from a primary care or community health professional.

        The green paper states that it is keen to improve the quality of the health care services, and the major health care problems such as waiting lists that have hit a record high demanding more hospitals and health care workers. Therefore, the government has allocated an extra £500 million to the NHS in the budget in order to cut waiting lists and improve patient care. It has also suggested utilizing new technology to support health care services. Warden (1997 and 1998) reports that the government paper states those modern technologies will become the new strategy for current NHS policy. 

        Computer technology, including telemedicine, will be diverted from administration to patient care. A nurse led telephone helpline, NHS Direct, will advise patients on self treatment round the clock. (Warden, 1997; p. 1559) 

        One of the pilot studies using telephone services to improve communication between specialists and GPs was called Boneline and was based at Doncaster Royal Infirmary (Roland and Bewley, 1992). In order to contact the consultants, the GPs in Doncaster had to ring the operator via the hospital switchboard. Depending on the requirements, the GPs will be connected to appropriate specialists. During telephone consultation, the specialists could discuss the clinical situation and give advice to GPs for further treatment. The Boneline service had an effect on GPs referral patterns and the service also enabled the GPs to avoid unnecessary referring to hospital. The process has been shown as follows (Figure 8): 

        Figure 8 Boneline project improves communication between GPs and specialists, and reduces unnecessary referral (left: topical referral process; right: Boneline project)

        Topical referral is usually a decision-making process controlled solely by GPs without advice from another source. Thus it depends on the GPs experience and knowledge. However, the Boneline project provides additional advice and consultation before GPs make decisions for the referral process. The project cut down the number of unnecessary referrals from GPs. In this six-month study, referral was avoided in 22 per cent of the cases. Moreover, for those patients who need referral, GPs can make an appointment with the Hospital to prepare further treatment.

        As telecommunication technologies have developed and become more widely used in daily life, the traditional telephone network has been replaced by modern telecommunication (such as videoconference, image transmission, etc.). Modern telecommunication supports high-range capability for providing high-quality communication channels.

        A study of teleconsultation examines and evaluates the satisfaction and acceptance by utilizing ICTs to communicate between GPs and specialists in hospitals (Harrison et. al, 1996). The specialists and GPs were equipped with standard videoconference equipment for a desktop PC and the relevant software through ISDN lines to support high quality interactive communication channels. A total of 54 teleconsultations was booked and conducted during five months study; forty-three GPs and forty-eight specialists at the Royal Free Hospital in London participated. The system allows the doctors to demonstrate real-time image, audio, and video transmissions, which enhances clinical procedure operation, further treatment, and avoids delaying treatment.

        This study also improves communication between primary and secondary health care in the form of joint consultations and improves the quality of health care services without the need to leave the work place. The results of the research showing the extent of the doctors satisfaction are as follows (Table 2). 

        No (%) of doctors who agreed or strongly agreed with statement


        GPs (n=43)

        Specialists (n=48)

        Communication was adequate

        42 (98%)

        41 (87%)

        Information I obtained was adequate

        40 (93%)*

        43 (94%)

        Rapport with the patient was good

        39 (93%)


        I was satisfied with the patients response

        40 (95%)

        41 (87%)

        Quality of the sound was satisfactory

        35 (81%)

        26 (54%)

        Quality of vision was satisfactory

        34 (79%)

        26 (54%)

        Overall quality of the telelink was good

        39 (91%)

        32 (68%)

        Arrangements worked well

        40 (93%)

        41 (85%)

        *Not all questions were answered in each completed questionnaire

        Table 4 Views of general practitioners and specialists who participated in 54 teleconsultations (Source: Harrison, Clayton, and Wallace, November 1996; p. 1378)


      3. Improve professional medical education

Distance learning (or telelearning) is an important component in telecommunication technologies. Healthcare workers (including nurses and GPs) through modern telecommunication links (i.e. video conference, voice and audio transmission) for continuing medical education and on-line help services can provide professional critical feedback. Moreover, interactive remote distance learning can save costs and time which may benefit healthcare workers in any location. Rural areas especially have always had fewer medical resources than urban locations and lack of education and training delays the lifesaving process. Distance education can improve the skills of staff in local health care services. For example, seventeen nurses in eight rural general practices participated in a distance education project in Wales (Jarrett et. al, 1996). Videoconference equipment was used for image transmission and an interactive communication channel. The rural nurses at the distant locations were able to participate fully in the exercise since they could be seen by conference presenters and could ask questions, present patients or clinical problems, etc.


    1. Potential Problems

      1. The need for high standards affects technical capacity and diagnostic accuracy
      2. Although some of the professional organizations have been established medical patterns for improving care services, but the lack of clinical and technical standards for treatment and information transmission in telemedicine term is a major barrier that constrains the development of telemedicine. For example, Taylors researches (1998) into the safety and efficacy of telemedicine systems demonstrates the need for a suitable standard for telemedicine otherwise there will be no guaranteed improvement in performance in medical services.

        According to the survey, the quality of the images and the information received via telemedicine may directly influence the diagnostic performance. Wootton et al. (1997) also presents the effect of transmission bandwidth on diagnostic accuracy in fetal ultrasound. Either low-bandwidth (384 kb/sec, 6-B channels ISDN) or high-bandwidth (1920 kb/s, 30-B channels ISDN) videoconference was utilized to transmit 18 patients recorded on VHS videotape with high-resolution. The general results of diagnostic accuracy (Tab 3) represent the potential risk if there are no standards within the teleconsultation processes. Although low-bandwidth systems have financial advantages over high-width systems, their reduced image quality could cause false diagnosis. Therefore, the need for a telemedicine standard should be qualified in health care services in order to maintain the quality of services. 

        384 kb/s

        1920 kb/s


        29 (31%)

        13 (15%)

        Half Correct

        9 (9%)

        5 (6%)


        57 (60%)

        66 (79%)




        A diagnosis was recorded in 179 of the 192 cases (93%).

        Table 5 Diagnostic accuracy for all scans (Source: Wootton et al., 1997; pp. 213)


      3. Patient and doctor satisfaction
      4. Patient satisfaction is one of the most important issues facing the acceptance of telemedicine. Concerns about patient satisfaction have focused on human factors (such as lack of understanding about technology and confidentiality) and treatment impact. According to Field (1996), human factors affect acceptance of telemedicine. It changes the physician-patient relationship because the personal touch may be absent (Tan, 1997).

        Other possible human factors include the publics lack of knowledge about current technologies (such as computers, and the Internet) and patient record security. TIMTEM, the project run by Pisa University in Italy, presents the difficulty of installing teleconsultation in a Greek rural area (Cavina et. al. 1998). The aim of the project is to improve the care of people living on Tilos Island (Greece) by utilizing telemedicine. However, none of the inhabitants knows the exact possibilities of communication by using computer facilities.

        The use of digitized patient records is an application of telemedicine which provides recording, storage, transmission, and retrieval of patient information. Centralized control of patient records supports diagnosis, and referral. However, nobody can guarantee the privacy of patient records and without this the patient may have less confidence with telemedicine services in use (Rindfeisch, 1997). Field (1996) describes the role of confidentiality in the health care service. Confidentiality refers to a relationship (e.g., between patient and doctor) that includes an expectation that personal information obtained as part of that relationship will be protected. One report suggests that 53% of pathologists (256 members) in the Austrian Society of Pathology were concerned about data security (Mairing et al., 1998), 43% were worried that the quality of images would cause problems in telepathology, and 60% did not expect telepathology to change diagnostic quality.


      5. Quality paradox

The quality of care is the most important issue and difficult to measure, especially after introducing ICTs into health care services. The ICTs in the health care service reveal many problems that the health care provider and executor should take into account, such as user confidence, where the user includes the patients, physicians, and health care workers, and all those directly or indirectly involved in the high-tech occurrence. Hence,  

The quality of care is the degree to which health care services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. (Field, 1996: p. 8) 

The definition covers most potential users in health care services and focuses on the demand of health care policy perspectives. Modern technologies help the service process, but because of inappropriate understanding of modern technology it can become another barrier. For example:

These three barriers come from the users (health care workers and patients) with regard to clinical expectation. However, if there is no standardization for clinical technologies and no training given in use of the new technology, how can the users trust the services?

One of the important roles in telemedicine services is self-care, which is a new way to reduce medical costs and hospital stays within the health care service by educating people. In order to let people obtain ability to deal with illness, health care providers transmit information through the public media such as the health care network (helpline and home care network), newspapers and health care manuals. In the United Kingdom, the White Paper The New NHS (Department of Health, 1997) emphasizes the importance of the self-care service in utilizing the modern technologies to improve the health care service without distance and time barriers.

Yet as most patients or their families are without medical knowledge and training, the self-care can be risky and possibly result in serious illness. Barela (1998) points out the key questions about self-care:

Indeed, whether the users of self-care utilize modern technologies or through the NHS direct (24 hours helpline service) for medical aid, the self-care system is still uncertain to guarantee the quality of services.


  1. Conclusion & Learning Points

Telemedicine is not only a clinical tool, but also an index of the future health care service. The development of technologies has changed our life and created more opportunity for increasing our worldview. However, in this kind of civilized and technical society, so does the way of managing health care processes, which in term creates new opportunities for the health care organizations.

After the digital revolution in the 1970s, the development of modern technology such as internetworking, signal processing and computing technologies enhanced the capability of utilization. It not only improves the efficiency, accuracy and practicability, but also reduces risk and human error factors. For example, computerized office automation (OA) supports complex financial reports, predetermined costs, and information sharing, and many complex tasks have now been replaced by modern technologies. Meanwhile, the user-friendly system has been developed, and the modern technologies make impossible tasks possible. In medical terms, the introduction of the ICTs into health care services offers opportunities for improving the quality of care. However, the application of the infrastructure requires high expenditure for upgrading, and maintaining the systems, along with educational training, and management.

For example, as health care providers continue to introduce modern technologies either for clinical purpose, or patient and hospital management, both require advance equipment (which means more accurate, confidential, and safer) rather than general market products. Therefore, the system needs a standardized policy, training, and monitoring to maintain the health care performance. However, according to the life cycle of products, the health care system needs to re-evaluate and eliminate the old style systems through performance standards. Consequently, the purpose of modern technologies in the health care service should have clear definition to balance the cost and quality. 

The findings of this research, can be summarized as follows:

To conclude the work done on this research, we might suggest that although telemedicine projects exist in several countries, in the past decade, more and more health care workers and policy makers have been introducing the modern technologies into organizations blindly, and ignore the most important element in health care service general population needs. The general population wishes to obtain safety, privacy, and convenience from health care services. The increasing of budgets is not the only solution for providing high-quality health care service. Only with effective utilization and management of available resources can one avoid the formal or political decision-making, and provide acceptable health care services which incorporate and benefit from the modern technology. 


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