Telemedicine for the Diabetic Foot: A Model for Improving Medical Care, Developing Decision Support Systems, and Reducing Medical Cost

  • Adriana Fodor
  • Eddy Karnieli
Part of the Annals of Information Systems book series (AOIS, volume 7)


The main purpose of this chapter is to discuss the place of telemedicine in the modern medicine, its present and future application in the clinical medicine. It covers aspects of clinical telemedicine practice, technical advances, principles and practices, health policy and regulation, and health services research dealing with clinical effectiveness, efficacy, and safety of telemedicine and its effects on quality, cost, and accessibility of care. The diabetic foot problem was chosen as a suitable model to examine whether the use of telemedicine technology will improve the quality of medicine and reduce medical costs.

According to the American Telemedicine Association, telemedicine is the exchange of medical information from one site to another using electronic communication, such as telephone, Internet or videoconference to improve patients’ health status [1]. Related with telemedicine is the term “telehealth ,” which covers a quite broader definition of remote healthcare, being more focused on other health-related services that do not always involve direct patient clinical services. Telemedicine practices allow for specialist consultation, direct patient consultation, patient monitoring, and medical education.

Although the term telemedicine is a relatively recent one, since 1970s, medicine has long made use of various communication technologies dating back to 1906. Wilhelm Einthoven, inventor of the electrocardiograph, created the “telecardiogram,” which transmitted electrocardiograms via telephone from the clinic to his office, enabling him to monitor his patients’ condition at a distance [2]. In the early 1990s, telemedicine experienced a considerable progress due to rapid advancements in information and telecommunications technologies and digital data transmission. Since then, the interest in the use of telemedicine procedures and the number of related publications had rapidly increased. A search of MEDLINE in 1990 found six publications on telemedicine; while by February 2009 there were more than 10,700 entries under the search term “telemedicine.”


Veteran Health Administration Telemedicine Service Primary Care Consultation Sick Fund Telehealth Program 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    American Telemedicine Association Web site. ATA Defining Telemedicine. Accessed 15 March 2009.
  2. 2.
    Stanberry B. Telemedicine: barriers and opportunities in the 21st century. J Intern Med 2000;247:615–628.CrossRefPubMedGoogle Scholar
  3. 3.
    Botsis T, Hartvigsen G. Current status and future perspectives in telecare for elderly people suffering from chronic diseases. J Telemed Telecare 2008;14:195–203.CrossRefPubMedGoogle Scholar
  4. 4.
    Bowles KH, Baugh AC. Applying research evidence to optimize telehomecare. J Cardiovasc Nurs 2007;22:5–15.PubMedGoogle Scholar
  5. 5.
    Jennett PA, Affleck Hall L, Hailey D et al. The socio-economic impact of telehealth: A systematic review. J Telemed Telecare 2003;9:311–320.CrossRefPubMedGoogle Scholar
  6. 6.
    Mack D, Brantley KM, Bell KG. Mitigating the health effects of disasters for medically underserved populations: Electronic health records, telemedicine, research, screening, and surveillance. J Health Care Poor Underserved 2007;18:432–442.CrossRefPubMedGoogle Scholar
  7. 7.
    Mair F, Fraser S, Ferguson J et al. Telemedicine via satellite to support offshore oil platforms. J Telemed Telecare 2008;14:129–131.CrossRefPubMedGoogle Scholar
  8. 8.
    McGee R, Tangalos EG. Delivery of health care to the underserved: Potential contributions of telecommunications technology. Consensus conference entitled “Telemedicine and Access to Care”. Mayo Clin Proc 1994;69:1131–1136.PubMedGoogle Scholar
  9. 9.
    Raza T, Joshi M, Schapira RM et al. Pulmonary telemedicine – a model to access the subspecialist services in underserved rural areas. Int J Med Inform 2009;78:53–59.CrossRefPubMedGoogle Scholar
  10. 10.
    Wootton R. Telemedicine support for the developing world. J Telemed Telecare 2008;14:109–114.CrossRefPubMedGoogle Scholar
  11. 11.
    Callahan CW, Malone F, Estroff D et al. Effectiveness of an Internet-based store-and-forward telemedicine system for pediatric subspecialty consultation. Arch Pediatr Adolesc Med 2005;159:389–393.CrossRefPubMedGoogle Scholar
  12. 12.
    Geissbuhler A, Bagayoko CO, Ly O. The RAFT network: 5 years of distance continuing medical education and tele-consultations over the Internet in French-speaking Africa. Int J Med Inform 2007;76:351–356.CrossRefPubMedGoogle Scholar
  13. 13.
    Brandling-Bennett HA, Kedar I, Pallin DJ et al. Delivering health care in rural Cambodia via store-and-forward telemedicine: A pilot study. Telemed J E Health 2005;11:56–62.CrossRefPubMedGoogle Scholar
  14. 14.
    Vassallo DJ, Swinfen P, Swinfen R et al. Experience with a low-cost telemedicine system in three developing countries. J Telemed Telecare 2001;7(pl 1):56–58.CrossRefPubMedGoogle Scholar
  15. 15.
    Stamford P, Bickford T, Hsiao H et al. The significance of telemedicine in a rural emergency department. IEEE Eng Med Biol Mag 1999;18:45–52.CrossRefPubMedGoogle Scholar
  16. 16.
    Beach M, Goodall I, Miller P. Evaluating telemedicine for minor injuries units. J Telemed Telecare 2000;6(Suppl 1):S90–S92.CrossRefPubMedGoogle Scholar
  17. 17.
    Schwamm LH, Rosenthal ES, Hirshberg A et al. Virtual TeleStroke support for the emergency department evaluation of acute stroke. Acad Emerg Med 2004;11:1193–1197.CrossRefPubMedGoogle Scholar
  18. 18.
    Haskins PA, Ellis DG, Mayrose J. Predicted utilization of emergency medical services telemedicine in decreasing ambulance transports. Prehosp Emerg Care 2002;6:445–448.CrossRefPubMedGoogle Scholar
  19. 19.
    Varkey P, Schumacher K, Swanton C et al. Telemedicine in the work site: A study of feasibility, and patient and provider satisfaction. J Telemed Telecare 2008;14:322–325.CrossRefPubMedGoogle Scholar
  20. 20.
    Pan E, Cusack C, Hook J et al. The value of provider-to-provider telehealth. Telemed J E Health 2008;14:446–453.CrossRefPubMedGoogle Scholar
  21. 21.
    McLean TR, McLean AB. Hageseth’s principle of extraterritorial jurisdiction and international telemedicine. J Telemed Telecare 2008;14:282–284.CrossRefPubMedGoogle Scholar
  22. 22.
    Krupinski EA, Jiang Y. Anniversary paper: Evaluation of medical imaging systems. Med Phys 2008;35:645–659.CrossRefPubMedGoogle Scholar
  23. 23.
    Finkelstein SM, Speedie SM, Demiris G et al. Telehomecare: Quality, perception, satisfaction. Telemed J E Health 2004;10:122–128.CrossRefPubMedGoogle Scholar
  24. 24.
    Hailey D, Roine R, Ohinmaa A. Systematic review of evidence for the benefits of telemedicine. J Telemed Telecare 2002;8(Suppl 1):1–30.CrossRefPubMedGoogle Scholar
  25. 25.
    Shea S, Weinstock RS, Starren J et al. A randomized trial comparing telemedicine case management with usual care in older, ethnically diverse, medically underserved patients with diabetes mellitus. J Am Med Inform Assoc 2006;13:40–51.CrossRefPubMedGoogle Scholar
  26. 26.
    Darkins A, Ryan P, Kobb R et al. Care Coordination/Home Telehealth: The systematic implementation of health informatics, home telehealth, and disease management to support the care of veteran patients with chronic conditions. Telemed J E Health 2008;14:1118–1126.CrossRefPubMedGoogle Scholar
  27. 27.
    Kobb R, Chumbler NR, Brennan DM et al. Home telehealth: Mainstreaming what we do well. Telemed J E Health 2008;14:977–981.CrossRefPubMedGoogle Scholar
  28. 28.
    Whitten P, Mickus M. Home telecare for COPD/CHF patients: Outcomes and perceptions. J Telemed Telecare 2007;13:69–73.CrossRefPubMedGoogle Scholar
  29. 29.
    Wilkins EG, Lowery JC, Goldfarb S. Feasibility of virtual wound care: A pilot study. Adv Skin Wound Care 2007;20:275–276, 278.CrossRefPubMedGoogle Scholar
  30. 30.
    Duke C. The Frail Elderly Community-Based Case Management Project. Geriatr Nurs 2005;26:122–127.CrossRefPubMedGoogle Scholar
  31. 31.
    mith GE, Lunde AM, Hathaway JC et al. Telehealth home monitoring of solitary persons with mild dementia. Am J Alzheimers Dis Other Demen 2007;22:20–26.CrossRefGoogle Scholar
  32. 32.
    Rojas SV, Gagnon MP. A systematic review of the key indicators for assessing telehomecare cost-effectiveness. Telemed J E Health 2008;14:896–904.CrossRefPubMedGoogle Scholar
  33. 33.
    Seto E. Cost comparison between telemonitoring and usual care of heart failure: A systematic review. Telemed J E Health 2008;14:679–686.CrossRefPubMedGoogle Scholar
  34. 34.
    Toshiyuri K. The robot designed to “live with humans” 2003. Accessed 15 March 2009.
  35. 35.
    Stephenson G. Dr Robot Tested at Hopkins 2003. http://wwwhopkinsmedicineorg/press/2003/AUGUST/030805HTM. Accessed 15 March 2009.
  36. 36.
    Britton BP. First home telehealth clinical guidelines developed by the American Telemedicine Association. Home Health Nurse 2003;21:703–706.CrossRefGoogle Scholar
  37. 37.
    Brown M, Shaw N. Evaluation practices of a major Canadian telehealth provider: Lessons and future directions for the field. Telemed J E Health 2008;14:769–774.CrossRefPubMedGoogle Scholar
  38. 38.
    Giansanti D, Castrichella L, Giovagnoli MR. New models of e-learning for healthcare professionals: A training course for biomedical laboratory technicians. J Telemed Telecare 2007;13:374–376.CrossRefPubMedGoogle Scholar
  39. 39.
    Groth K, Olin K, Gran O et al. The role of technology in video-mediated consensus meetings. J Telemed Telecare 2008;14:349–353.CrossRefPubMedGoogle Scholar
  40. 40.
    Clarke M, Thiyagarajan CA. A systematic review of technical evaluation in telemedicine systems. Telemed J E Health 2008;14:170–183.CrossRefPubMedGoogle Scholar
  41. 41.
    Lim AC, Egerton IB, Shumack SP. Australian teledermatology: The patient, the doctor and their government. Australas J Dermatol 2000;41:8–13.CrossRefPubMedGoogle Scholar
  42. 42.
    Broens TH, Huis in’t Veld RM, Vollenbroek-Hutten MM et al. Determinants of successful telemedicine implementations: A literature study. J Telemed Telecare 2007;13:303–309.CrossRefPubMedGoogle Scholar
  43. 43.
    Aas IH. The future of telemedicine – take the organizational challenge! J Telemed Telecare 2007;13:379–381.CrossRefPubMedGoogle Scholar
  44. 44.
    Boulton AJ. The diabetic foot: A global view. Diabetes Metab Res Rev 2000;16(Suppl 1): S2–S5.CrossRefPubMedGoogle Scholar
  45. 45.
    Frykberg RG, Zgonis T, Armstrong DG et al. Diabetic foot disorders. A clinical practice guideline (2006 revision). J Foot Ankle Surg 2006;45:S1–S66.CrossRefPubMedGoogle Scholar
  46. 46.
    Peleg M, Wang D, Fodor A et al. Lessons learned from adapting a generic narrative diabetic-foot guideline to an institutional decision-support system. Stud Health Technol Inform 2008;139:243–252.PubMedGoogle Scholar
  47. 47.
    Bangs I, Clarke M, Hands L et al. An integrated nursing and telemedicine approach to vascular care. J Telemed Telecare 2002;8(Suppl 2):110–112.CrossRefPubMedGoogle Scholar
  48. 48.
    Clemensen J, Larsen SB, Ejskjaer N. Telemedical treatment at home of diabetic foot ulcers. J Telemed Telecare 2005;11(Suppl 2):S14–S16.CrossRefPubMedGoogle Scholar
  49. 49.
    Larsen SB, Clemensen J, Ejskjaer N. A feasibility study of UMTS mobile phones for supporting nurses doing home visits to patients with diabetic foot ulcers. J Telemed Telecare 2006;12:358–362.CrossRefPubMedGoogle Scholar
  50. 50.
    Wilbright WA, Birke JA, Patout CA et al. The use of telemedicine in the management of diabetes-related foot ulceration: a pilot study. Adv Skin Wound Care 2004;17:232–238.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2010

Authors and Affiliations

  1. 1.Institute of Endocrinology, Diabetes and Metabolism, Rambam Medical CenterHaifaIsrael
  2. 2.Diabetes, Nutrition and Metabolic Diseases CenterCluj-NapocaRomania
  3. 3.Galil CenterTechnion-Israel Institute of TechnologyHaifaIsrael

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