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Introduction

China is a large country, with a huge population and poor telecommunications infrastructure (although communications are being improved rapidly). The level of social and economic development differs greatly between the coastal areas of the country and the rural areas in the west. Health resources are relatively well developed and easily available in the coastal areas, while there are shortages of medical care and drugs in the poor and rural areas. Patients in rural areas often experience difficulties in accessing medical care. If they travel long distances to access higher-quality medical care, they incur a heavy financial burden.

Telemedicine past and present in China

In industrialized countries, the concept of using communications technology to distribute medical expertise is not particularly new. However, the development of tele-health is relatively new in China. The earliest telehealth activities began in the late 1980s. An emergency consultation in 1986 that was provided for a ship’s crew via radiotelegrams is recognized as the earliest telehealth activity in China. In 1988, the General Army Hospital in Beijing carried out a neurosurgery case discussion with a German hospital. Shanghai Medical University developed one of the earliest tele-medicine systems in China. In September 1994, they succeeded in performing a tele-consultation between the Huashan hospital and staff at the Shanghai Jiaotong University.¹

The first generation of telemedicine systems in China was based on videoconferencing via the telephone network (PSTN). In 1995, with the support of the Shanghai Education and Research Network, Shanghai Medical University launched a pilot tele-medicine project and established a telemedicine centre.² At about that time, people began to employ the Internet to search for medical help. One of two well-known cases occurred in March 1995: a girl named Yang Xiaoxia in Shandong Province had an unidentified disease and asked for help through the Internet. The disease was finally diagnosed as a phagocytic bacterial infection in her muscles. The other case was in the same year. A student named Zhuling at Beijing University was sick for unknown reasons. After searching for help via the Internet, more than 1000 reply emails helped her to prove that she had heavy-metal poisoning.¹

At this stage, a few health-related institutions began to develop experimental tele-health systems. The authorities noticed this trend, and began to support these tele-health activities.

In 1997, the telemedicine system of Shanghai Medical University obtained the re cognition of the country leaders at the national IT exhibition. This boosted interest in telehealth. Various organizations and institutions began their telehealth programmes. The late 1990s was a period of rapid progress for telehealth in China. The Jin-Wei (Golden Health) Telemedicine Network began operation in July 1997, and many national-level hospitals in Beijing and Shanghai were included in this network. The network provided remote consultation and remote education services for hospitals in 21 provinces, including Yunnan, Sichuan, Tibet and Xinjiang, via satellite communication. In the same year, the International Medical Network Committee of the China Medical Foundation established their telemedicine network. Following these two large telemedicine programmes, many others emerged. The Shuang-wei (Satellite Health Education Network of the Ministry of Health) network was sponsored by the Ministry of Health, and the MediChina BYL telemedicine network was sponsored by the Shanghai municipal government. There were also many telehealth programmes initiated in other areas, including Guangdong, Sichuan, Fujian and Yunnan provinces.³ When telehealth activities began to grow in China in the late 1990s, the national health authority recognized the importance of supervising them, and the Ministry of Health established a set of rules for telehealth in 1999.⁴

The rapid development of telecommunications infrastructure in the late 1990s helped to make telehealth a routine activity in China. The ordinary telephone network, the ISDN network, satellite communications and the Internet were all employed for telehealth purposes. Many different organizations, including the government, medical universities, hospitals and even some private companies, built telehealth networks and made telehealth a routine application. Generally, they provided remote consultations and remote education services for users of their networks.

Telehealth programmes in China

Since 1997, many different telehealth programmes have been conducted in China. These programmes have been sponsored by different entities, have employed different telecommunication means and have operated at different scales. Some programmes have built large telehealth networks and connected many different health organizations.

One of the most well-known telehealth programmes was the Jin-Wei Telemedicine Network (the Golden Health Medical Network). This network was established with the support of the Ministry of Health. The network operation centre was located in Beijing and was a satellite network covering the whole country. Many national-level and lower-level hospitals from more than 20 provinces were included in this network. The satellite communication allowed an 8 Mbit/s upload speed and 2 Mbit/s download. Between 1997 and 2003, the Jin-Wei Telemedicine Network provided remote consultation services for more than 1000 patients, and provided remote education services for more than 50 000 doctors and nurses. The Jin-Wei organization also developed a website to provide health-related information services for users. However, the high cost of satellite devices and communications prevented many low-level hospitals from connecting to this network. Subsequently, the Jin-Wei network began to employ ISDN as a second telecommunication method to cover more hospitals.^3,5

The CMF (China Medical Foundation) Telemedicine Network was also a large-scale telemedicine programme. It was supported by a non-profit-making organization, the International Medical Network Association. It began in 1997. From the start, several different methods of telecommunication were employed. First, telephone lines were used to establish a network covering basic level hospitals, then ISDN and the Internet were used to connect higher-level hospitals, and eventually satellite communication was used to connect national-level hospitals. The aim of the CMF Telemedicine Network was different from that of the Jin-Wei network, in that it mainly provided telehealth services for basic-level hospitals. It used telephone line communication and desktop videoconferencing.^3,5

The aim of the Shuang-wei (Satellite Health Education Network of the Ministry of Health) network was to provide remote medical education services for doctors and nurses all over the country. It was supported by the Ministry of Health and began routine operation in 2001. Satellite and optical fibre were employed as the major telecommunication means. The network supported different kinds of remote education, such as live broadcasting, video on demand, the interchange of online education materials, and point-to-point or multipoint videoconferencing.^3,6

The BYL Telemedicine Network was a branch of the China Social Development Network. It was supported by the Shanghai municipal government and connected Shanghai and western areas of China. Various telecommunication media, including satellite, fibre-optic cables, the Internet and telephone lines, were employed in this network. Specialists in Shanghai provided an image consultation service for patients in other areas. When Shanghai provided telehealth services for western areas via this network, they also provided business information services.³

A Chinese Traditional Medicine Telemedicine Network was established by the Chinese Academy of Traditional Chinese Medicine in 1997. It employed ISDN for telecommunication to provide a traditional Chinese medicine consultation service for international and domestic patients.³

Several other telehealth programmes were set up in China in the late 1990s. These included the Sino-Japanese Telemedicine Collaboration for high-resolution medical image consultation, the Sino-Russian Satellite Telemedicine Collaboration, and the telemedicine programmes of the Sun Yet San University, the Shanghai Second Medical University and the Western China Medical University. The Shuang-wei and BYL networks are still in operation. The programmes had different purposes, employed different technologies and telecommunication media, and were supported by different organizations.³ Since 2003, some provinces have established their own regional telemedicine networks: the Fujian Province Telemedicine Network was set up in late 2003 and the Gansu Province Telemedicine Network in late 2007. All these regional telemedicine networks are supported by local government and are still in operation.

Telehealth programme of Shanghai Medical University

Shanghai Medical University (SMU) provided medical services, teaching and research, and had about 5000 students. It had an excellent technical reputation in China. Many departments in SMU-affiliated hospitals were well equipped, and some departments were ranked the best in the country. In 2000, SMU was merged with Fudan University to set up a new Fudan University.

SMU was a pioneer of telehealth in China. In 1994, it began a telehealth pilot project. It developed the first general telehealth system in China, which was based on low-bandwidth videoconferencing over the telephone network. Through this system, a surgeon in Huashan Hospital (an affiliated hospital of SMU) succeeded in providing a remote consultation service for a patient in Shanghai Jiaotong University. In 1995, with the support of the Shanghai Education and Research Network, SMU launched a pilot telehealth programme and established a telemedicine centre. It began to develop telehealth systems conforming to international standards. In 1996, SMU began cooperation with the telecommunications authority in Shanghai. Various telecommunication companies began to establish different telecommunication connections for the telemedicine centre.^2,7

In 1997, SMU established a telehealth network based on the telemedicine centre. The telehealth service providers were 7 affiliated hospitals of SMU, and the telehealth service users were more than 20 hospitals from remote and rural areas. The task of the telehealth centre was to act as the administrative and telecommunication centre. All the service providers were connected to the telemedicine centre by optical fibre. The service users were connected by the ordinary telephone network, the ISDN network or satellite, according to cost. The network connected hospitals from 21 provinces, including Xinjiang, Tibet, Yunnan, Sichuan, Heilongjiang, Jiangsu and Zhejiang. In the telemedicine centre, there were nurses for remote consultation administration and technical staff for support. Each hospital of the service providers and service users had its own operation staff. Figure 20.1 illustrates the structure of the network.⁸

The SMU Telemedicine Centre developed many administrative rules for remote consultation in China. Only professors or associate professors were eligible to provide telehealth services. The operation staff had to have completed special training in the network. When the service users requested a remote consultation, they had to submit full information about the patients. Because most of the hospitals in the network from remote and rural areas lacked digital devices, they often needed to digitize images using a digital scanner. The Telemedicine Centre provided a set of operational guidelines for the service users after their research in this field. The Telemedicine Centre also designed a procedure for remote consultation administration. In 1999, it developed a web-based remote consultation administration database. By using this database, the service users could apply for remote medical consultation services via the network, and the Telemedicine Centre could despatch remote consultation requests to the appropriate service providers. Also, the consultation providers in Shanghai could schedule the remote consultations via the network. As a multimedia database, it could accept data in the form of images, video and audio information relating to the remote cases that needed consultation.⁸

Figure 20.1 The structure of the SMU Telehealth Network

In 1996, the SMU Telehealth Network began to experiment in distance medical education. It provided distance education services for the doctors and nurses in the hospital on Chongming Island. Subsequently, the SMU Telemedicine Centre developed a remote education system. This comprised two parts. One was a videoconference system, by which teachers and students could have real-time discussions. The other part was a media system, which could be used for media broadcasting, video on demand, recording and editing. By using this system, teachers could finish their own tasks via the Internet.

The SMU Telehealth Network (now part of Fudan University) is still in operation. It has provided remote consultation services for more than 2000 patients in remote and rural hospitals. These patients have been from various specialties, including cardiology, oncology, surgery, neurology and paediatrics. In their remote consultations, the specialists only provide a second opinion or suggestion for the doctors in the user hospitals, because of the absence of legislation that would permit them to make a diagnosis. The network has also provided more than 1000 hours of distance medical education for the Dali Medical College in Yunnan province and other hospitals in the network.

After they began providing telehealth services for remote and rural users, the specialists received much feedback about the services. A letter from the hospital of Xindu, Sichuan province described how patients benefited from telehealth. For example, one patient with colon cancer made a full recovery after the operation, following the advice provided in the teleconsultation. She was the oldest patient to have recovered following such an operation at that hospital. Another patient with colon cancer recovered fully without requiring chemotherapy following the advice provided in the tele-consultation. One patient with heart disease avoided an operation to implant a pacemaker.

Video and audio quality varies, depending upon how the rural sites are connected with the telemedicine centre. The best quality is achieved with a digital connection (DDN), followed by ISDN and satellite; unsurprisingly, the quality is quite low via an ordinary telephone line. In China, when providing a telehealth service via telephone line, it can be expected to be interrupted every 5–10 minutes because of connection problems. The quality of the consultation service is therefore poor, and remote education cannot easily be delivered via telephone line.

The costs of the different communication methods also differ greatly. Satellite communication is the most expensive, followed by DDN and ISDN. Telephone line and Internet communication are the cheapest.

Satellite communication is not suitable for a remote consultation service, because of the time delay. However, it is suitable for a unidirectional broadcast service, such as that required for remote education.

When considering all the factors relating to the quality of the system, cost and breakdown rate of the service, it appears that ISDN communication is the most appropriate means of communication for telehealth services in China at present. Internet communication can be used in non-real-time applications, for example to access databases and to apply for remote consultations. Because the bandwidth of Internet communication has been much improved, it can also be used for videoconferencing and remote education, for example video on demand and broadcasting for distance education. Thus, Internet communication has great potential as a communications method for telehealth in China.

Opportunities for telehealth in China

China has the largest population in the world: at the end of 2005, it was 1.3 billion. Health expenditure in China is rising: in 2004, it was 75.9 billion RMB, and accounted for 5.6% of the gross domestic product. In 2004, the per capita expenditure in urban areas was about 4.2 times that in rural areas.⁹

The health sector in China faces two opposing demands: first, it must provide expanded and equitable access to high-quality health care services; second, it must reduce, or at least control, the rising costs of health care. Telehealth offers the promise of giving people equal access to high-quality medical care at affordable cost.

As in most other countries, the highest concentration of medical resources (personnel, information and facilities) in China is in the major cities, so telehealth could be a useful mechanism to balance the differences in the level of access to medical resources.

Information technology in China has grown very rapidly in the last few years. There has been rapid expansion of the telecommunication market and very fast diffusion of the Internet. By December 2007, there were 210 million Internet users in China.¹⁰ Health IT is also developing very rapidly in China: many hospitals have developed a hospital information system, and now health information-sharing networks are developing in many cities. This will facilitate the development of telehealth in China.

The large population and relatively insufficient health resources have produced demands for China to develop telehealth, and the rapid development of IT has provided the opportunities to do so. In 2003, China formulated its national strategy in e-health. The plan outlined the strategy and activities for China to develop e-health in 2003–2010. The plan described the background information, the principles, the goals and the main tasks for China to develop e-health.¹¹ Telehealth development is part of this plan.

Challenges for telehealth in China

Although there are undoubted opportunities, telehealth also faces many challenges in China.¹² Despite the successes of early telehealth systems in China, not many of them were self-sustaining, and few are still in operation today. A number of implementation barriers remain to be overcome. These include the following.

A lack of understanding of telehealth by society

Often, telehealth is perceived by health authorities as a low spending priority. Because telehealth is not clearly defined, there are different definitions of telehealth, which makes it difficult for patients to understand its potential. Telehealth might adversely affect the relationship between health professionals and patients compared with normal face-to-face consultations. The reasons include physical and mental factors, depersonalization, different process of consultation, reduced confidence of patients and health professionals, different knowledge and skills required of health professionals, and ergonomic issues. There are also various factors that prevent health professionals from accepting telehealth, including too much change, lack of a user-friendly interface, failure to collect the most important information, inadequate training of physicians to use the system, and lack of control by the organization over physician practices. Factors such as doubt about the quality of the telehealth and conflicts between the telehealth procedure and traditional clinical schedules will prevent patients and health professionals from accepting the new system.

Incomplete telehealth organizational structure and lack of human resources

In many health institutes that conduct telehealth programmes, there are no special telehealth departments or staff. Lack of organizational and personnel resources is a major constraint on telehealth development.

Lack of standards

In China, the telehealth systems and services are developing very rapidly, but the standardization of telehealth lags behind. Standardization of telehealth system components and services is an important element for integration of heterogeneous systems. There are no standards for telehealth in China, and this has restricted developments. For example, in the rural hospitals, there is no digital X-ray equipment, so, when they need to transmit X-ray images to specialists in the cities, the X-ray films are often digitized using a scanner. In practice, poor-quality images result, which would be much improved if there were standards to control the digitization process.

Absence of legislation and regulation

Lack of legislation and regulation is also a major barrier to telehealth development and deployment. There are some national regulations for telehealth, such as regulations governing remote consultation administration. But the work on regulation lags far behind the development of telehealth. There are also some legislative barriers. There is no related law focusing on telemedicine, electronic signatures and patient privacy protection. There are problems with medical malpractice liability, because of legal uncertainties.

High cost and insufficiency of funds for telehealth development

Telehealth depends on new technologies. The devices are often relatively expensive. Also, telecommunication costs can be high. However, funds for telehealth are insufficient, because the benefits of telehealth are mainly realized by the patients. Thus, investors do not have a great interest in this field. Another problem is that hospitals in remote and rural areas have a higher demand for access to telehealth services, but also have smaller budgets.

Unbalanced development in different areas in China

Because of unbalanced development, many hospitals in remote and rural areas cannot apply telehealth, owing to limitations of equipment, human resources and telecommunications.

Lack of reimbursement for telehealth services

In China, health insurance does not cover expenditure on telehealth services. Thus, patients need to pay for telecommunications and specialists’ fees themselves. This represents a major economic burden for patients.

Lack of evaluation of telehealth programmes

Policy makers lack evidence from evaluation research to help them to decide how to support the development of telehealth.

Policy recommendations

China can learn from experiences in industrialized countries.¹² This suggests that, for the development of telehealth in China, it is necessary to do the following:

• Strengthen the leadership of government in telehealth development. The government should establish a special organization to lead telehealth development and promote a government focus on telehealth.
  
  
• Strengthen the supervision of telehealth development. In China, many different organizations are involved in telehealth activities. Many of these organizations are not health related. It is important to strengthen the supervision of telehealth and prevent unqualified organizations from taking part in telehealth.
  
  
• Promote the development of telehealth standards. Health authorities should promote the development of telehealth standards with users, researchers, technical and scientific bodies, and industry. Establishing national standards and adopting international standards will be important tasks for China.
  
  
• Develop a legal and regulatory infrastructure that will facilitate telehealth. Legislation related to telemedicine, electronic signatures and patient health information protection should be constituted.
  
  
• Increase the investment in telehealth. The government should strengthen its financial support for telehealth development. Also, other sources must be attracted to invest in telehealth. In China, there is a high demand for telehealth services, especially for remote medical education services. Many early distance medical education programmes are still in operation today.
  
  
• Train health professionals and technical staff in telehealth. Training will help health professionals to understand telehealth, and will also promote the efficiency of telehealth systems.
  
  
• Promote international collaboration, sharing and learning experiences from industrialized countries. This will help China to develop telehealth. Telehealth is relatively new to China. It can overcome geographical barriers and make high-quality services available without regard to location. This can help to reduce the unbalanced distribution of health resources. Because telecommunications are developing rapidly in China, there are many opportunities to develop telehealth. There are also many challenges for telehealth to overcome. If the importance of telehealth for China is widely recognized, it will have a better future in China.

Telehealth is relatively new to China. It can overcome geographical barriers and make high-quality services available without regard to location. This can help to reduce the unbalanced distribution of health resources. Because telecommunications are developing rapidly in China, there are many opportunities to develop telehealth. There are also many challenges for telehealth to overcome. If the importance of telehealth for China is widely recognized, it will have a better future in China.

Further reading

Fujian Province. [Telemedicine Network of Fujian Province]. Available at: www.thydmed.com.

Hsieh RK, Hjelm NM, Lee JC, Aldis JW. Telemedicine in China. Int J Med Inform 2001; 61: 139–46.

References

¹ Zhu SJ, Cai JH, Yang QS. The establishment and development of telemedicine. Hosp Adm J Chin PLA. 1998; 5: 277–98.

² Zhao JA, Xu YX, Chen J. The implementation of telemedicine network group. Chin Hosp Manage 1998; 18: 27–8.

³ Fu Z, Lian P. Telemedicine. Beijing: People’s Military Medical Press, 2005.

⁴ Ministry of Health, People’s Republic of China. [Rules for the Development of Telemedicine]. Available at: www.moh.gov.cn.

⁵ Li BZ. The progress and prospect of Jinwei program. Chin Hosp Manage 1998; 18: 41–3.

⁶ Ministry of Health, People’s Republic of China. [Satellite Health Education Network of Ministry of Health. Shuang-wei Network]. Available at: www.sww.com.cn.

⁷ Xu YX, Mo MQ, Zhao JA. New Progress on the Internet and Using It in Medicine. Shanghai: Fudan University Press, 2001.

⁸ Xia ZY. The administration of telemedicine. Medl Inf 2005; 18: 907–9.

⁹ Ministry of Health, People’s Republic of China. [Official website]. Available at: www.moh.gov.cn.

¹⁰ China Internet Network Information Center. Statistical Survey Report on the Internet Development in China. January 2008. Available at: www.cnnic.org.cn/uploadfiles/pdf/2008/2/29/104126.pdf.

¹¹ China Centre for Information Industry Development. [e-Health Development Plan for China in 2003–2010]. Available at: industry.ccidnet.com/art/793/20051024/356253_1.html.

¹² Xia ZY. Challenges faced for telemedicine development in China and corresponding recommendations. Med Inf 2005; 18: 206–9.

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