International Journal of Medical Informatics 61 (2001) 139–146
Telemedicine in China
Richard K.C. Hsieh *, N. Magnus Hjelm, Joseph C.K. Lee, John W. Aldis
601 Stacy Court, Towson, MD 21286- 2940, USA
Abstract
Telemedicine has been shown to have a considerable impact in medical education, conferencing and consultation.
As a result, the People’s Republic of China has been keen to develop telemedicine. In her attempts to further the
development of telemedicine, China has looked to the progress of medical services in Western countries such as
Europe and North America. The United States of America, however, has exceeded the rest in exchange of health-care
information and telemedicine technologies with China. Although China has been enthusiastic about the exchange,
telemedicine in China requires development in the technical infrastructure and professional infrastructure. © 2001
Elsevier Science Ireland Ltd. All rights reserved.
Keywords : China" International collaborations" Telemedicine" Telemedicine infrastructures
www.elsevier.com:locate:ijmedinf
1. Introduction and background
For the past decade, it has been a privilege
to work with colleagues in Mainland China
on Telemedicine. Our collective effort has
been to demonstrate and evaluate telemedicine
for its promise in medical education,
conferencing and consultation. We felt
strongly that our Chinese colleagues were
ready to join with Asia, Europe, and the
United States in telemedicine.
This paper attempts to cover several issues
related to telemedicine in Mainland China.
China is a large country and is rapidly modernizing.
In reporting about telemedicine in
China as well as reporting about all technology
associated with computer and communication
applications in China, one can never
be sure whether one’s information is up to
date, complete and accurate. Our main objective
in this paper is to share the information
we may have so that others will have a lead
to develop future contacts in China.
If one attempts to trace the development of
Western medical and health service in China,
one might say China, like many other developing
countries, has looked at the models of
the former Soviet Union, Europe and North
America to deal with many of her problems.
Since 1978, however, the United States has
exceeded all other ‘‘developed’’ countries in
* Corresponding author.
E-mail addresses : richard@hsiehnet.com (R.K.C. Hsieh),
magnus-hjelm@hotmail.com (N.M. Hjelm), joelee@cuhk.edu.
hk (J.C.K. Lee), jwaldis@email.msn.com (J.W. Aldis).
1386-5056:01 - see front matter © 2001 Elsevier Science Ireland Ltd. All rights reserved.
PII: S1386-5056(01)00136-8
R.K.C. Hsieh et al. :International Journal of Medical Informatics 61 (2001) 139–146 140
exchange of experiences of health-care technologies
with China [1]. In China, American
health-care technologies and the American
system of medical education are considered
to be among the strongest in the world. By
and large, the United States is also the most
generous in the offering of technical assistance
to their colleagues in China. There are
thousands of Chinese students receiving graduate
education in the United States medical,
dental and nursing schools, and there are
more American professors lecturing in Chinese
medical and health institutions every
year. These scholarly exchanges have brought
new vision to medical professionals in China.
For example, the medical educators in China
want to include in their curricula the recent
advances in molecular biology, computers
and telecommunication, along with other
newer developments in science and technology.
The leaders of hospital centers want to
incorporate the application of the latest technologies
in the delivery of medical services
and they also want to include in their teachings
of young health professionals the newer
diagnostic and curative strategies for the
management of illness and health.
As in most other countries, China has the
highest concentration of medical resources
(personnel, information, and facilities) in her
major cities. It is only natural that the initiation
of telemedicine began in major cities.
The telemedicine program in China, however,
is founded on the promise that it is an excellent
mechanism to balance the considerable
difference between the level of access to medical
resources between the large cities to rural
and the remote regions.
2. Telemedicine in context
Telemedicine is defined as the ‘Delivery of
healthcare and the exchange of health care
information across distance’ [2]. This definition
differs with an earlier definition proposed
by Vassallo only in one aspect — the
speed of the delivery of health care and the
exchange of health-care information: ‘Rapid
access to shared and remote medical expertise
by means of telecommunications and information
technologies, no matter where the
patient or the relevant information is located’.
[3]
The use of electronic information and communication
technologies to provide and support
health care across distance is to fulfill
the requirement of ‘rapidness’. Rapidness is a
particularly important characteristic in the
application of telemedicine in medicine since
it can support the timely delivery of medical
services and medical information to people
living in isolated mountains, islands and
deserts. It opens a new way to reduce the
problem of shortage of medical personnel,
and it is a sensible mechanism to alleviate
difficulties for the patient, family members
and medical personnel who must to travel
when medical needs arise. Another motivation
of applying telemedicine in China, in
addition to the delivery of services to people
living in rural and isolated regions, is its
promise to conduct more medical conferences
with international medical institutions, and to
offer continuous medical education by domestic
medical centers of excellence.
3. International collaboration
China has a national policy to encourage
international collaborations for her modernization
initiatives. The international collaboration
on telemedicine as a tool to improve
the medical education, medical conferences
and medical consultation in China is pursued
in two avenues. One is the direct collaboration
between a Chinese medical institution
R.K.C. Hsieh et al. :International Journal of Medical Informatics 61 (2001) 139–146 141
and a Western medical institution. Another is
a three-party collaboration adding the Medical
Faculty of the Chinese University in
Hong Kong and its teaching hospital, the
Prince of Wales Hospital (CUHK). The successful
collaboration with CUHK and the
Prince of Wales Hospital is reported in a
separate paper in this issue.
4. Evolution and current application of
telemedicine — evolution of
telecommunication for medical application
One of the earlier international collaborations
in telecommunication for medical application
(or telecommunication for information
transfer) in China was to access MEDLARS
from the United States National Library of
Medicine (NLM). MEDLARS is the
acronym for a collection of biomedical databases
including the well-known bibliographical
database MEDLINE, which is important
to all medical researchers, educators, and
clinicians. The Chinese Academy of Medical
Sciences (CAMS) recognized its importance
to her medical research and education community
and thus formally established a Chinese
International MEDLARS Center in the
Institute of Medical Information in 1988 as a
prerequisite to access MEDLARS from
NLM. Due to the relatively poor quality of
the telecommunication infrastructure in
China and the high cost of international
(long-distance) telephone calls, CAMS decided
to start a MEDLARS service with a
leasing of data tapes from NLM. Users who
required bibliographic information on a particular
medical subject heading would ask
trained CAMS staff to formulate a search
strategy as well as to run data tapes on its
computer system instead of performing an
online search. This batch processed search
service continued for many years, although
medical professionals in China, like their colleagues
in the United States, could use a PC
with the online connection to NLM in
Bethesda, Maryland (USA) to conduct their
own required searches without the service of
an intermediary since 1988 [4]. The online
access of information from NLM by biomedical
professionals in China is increasing
rapidly along with the more recent (1998)
implementation of the Internet in national
universities and major medical research centers
in China.
Beginning in 1990, the advancement in local-
and wide-area networks technology
prompted a strong enthusiasm in
telemedicine (using real-time video conferencing
units to support health professionals who
wish to exchange medical information with
colleagues over vast distances) in the United
States and other developed countries. The
Proceedings of Medinfo 92 (The International
Medical Informatics Association’s triannual
conference), for example, included
many papers reporting telecommunication
applications. They are the transmission of
text, graphics and radiographic images on
X-terminal workstations" the use of e-mail on
a health-care bulletin board" the support of
medical information on patients who are under
a home-care system" and the use of multimedia
workstation for cooperative clinical
trials. [5] A much larger number of
telemedicine applications can be found in a
book published in 1996 by the Institute of
Medicine (USA). This publication, entitled
Telemedicine, A Guide to Assessing Telecommunication
in Healthcare, is the outcome of
the Committee charged by the Institute of
Medicine with the responsibility to evaluate
clinical applications on telemedicine [6].
China has been using telephones for medical
consultation between national medical
centers and their affiliated hospitals and clinics.
A major difference from this new wave of
R.K.C. Hsieh et al. :International Journal of Medical Informatics 61 (2001) 139–146 142
telemedicine applications is the use of realtime
audio and visual signal communication.
It requires a very reliable telephone network,
a higher bandwidth communication system,
and computer-based video conferencing
equipment. In other words, the telemedicine
application requires a reliable and broadband
telecommunication infrastructure and audio–
video-related equipment.
5. Development of telemedicine
Telemedicine by today’s definition is the
use of computer communication and technology
for face-to-face meetings linking many
people independent of distances between the
sites. This arrangement will potentially save
both travel times and costs. In China, and in
all other countries where telemedicine is promoted,
it is too early to fully evaluate its
success [7].
There was no shortage of enthusiasm to
engage in the demonstration and development
of telemedicine in China. The Chinese
University of Hong Kong Faculty of
Medicine has provided technical and financial
support to several major medical universities
on the Mainland in their initiation of
telemedicine programs. As one of the first
demonstration projects in (1996), a teleconference
between Beijing and Hong Kong accommodated
over 1000 persons. This
demonstration project brought out several
major points for telemedicine in China. These
are, in a local community, basic requirements
for telemedicine: (a) a suitable community
infrastructure for information technology, (b)
professional and organizational infrastructure
and (c) adequate funding. [8] The required
technical requirement includes
audio-visual conferencing equipment" and a
network with sufficient bandwidth for transmitting
sound and vision of good quality (a
minimum of 384 mho:s by ISDN for medical
consultation and conference). These facilities
are available in China, but they are not commonly
accessible by all medical institutions in
all cities.
6. Suitable technical infrastructure for
information technology
One factor limiting the development of
telemedicine in China is the telecommunication
infrastructure. Until 1978, China had a
relatively slow pace in the modernization of
her telecommunication infrastructure. Since
that time, the resumption of trade with the
United States led the Chinese post, telephone
and telegraph (PTT) authority to begin cooperative
agreements with foreign telecom companies
toward the modernization of China’s
telecommunication infrastructure. There were
some modern telephone communication systems
available in major Chinese cities by
1994, but when international medical universities
approached their Chinese colleagues to
participate in telemedicine conferences in that
year, services from some local telephone companies
were inadequate in meeting the teleconferencing
requirement. A telemedicine
video conferencing unit (VCU) requires a
minimum of 384 k:s or multiple lines of 64
k:s bi-directional flow of signals. Although
major cities in China have reliable telephone
services for voice-grade signal transmission,
they have difficulty meeting the requirements
for conducting medical teleconferencing using
VCU at medical universities. The problem,
heretoforth not examined, could be the
switches in the main station, connectors at
the sub-station, or the switchboard within the
university campus.
For the transmission of medical images
such as radiographs and microscope images,
an even wider bandwidth is required. China
R.K.C. Hsieh et al. :International Journal of Medical Informatics 61 (2001) 139–146 143
has planned to jump over the implementation
of the faster and wider bandwidth integrated
service digital network (ISDN) and began an
even wider bandwidth satellite system in the
second decade of next century. While satellite
systems can offer the highest bandwidth for
telecommunication, they are still much more
costly. However, between 1994 and 1999, due
to a popular demand by the business community,
the National Chinese Post, Telegram
and Telephone authority made an ISDN service
available in Beijing, Shanghai, Canton,
Dalian, Wuhan and other major cities in
China. This ISDN service was utilized successfully
in 1997 for pediatric case conferences
conducted between the affiliated
Pediatric Hospital of the Shanghai Medical
University and the affiliated Queen Mary’s
Hospital of Hong Kong University. Also, this
ISDN service was used for the May 1999
teleconference on ‘‘Evidence-based Traditional
Chinese Medicine: Acupuncture and
Herbal Medicine’’. This teleconference was
participated by staffs of the Chinese
Academy of Traditional Medicine, the Royal
Society of Medicine (UK), the University of
Maryland College of Medicine (US), the
George Washington Medical Center (US)
and the Chinese University of Hong Kong
Faculty of Medicine.
7. Professional and managerial infrastructure
Hospitals in China began using computer
applications quite early. These hospital-based
computerized information systems are essentially
business systems to record and tabulate
patient expenditures, and to collect fees from
patients or third-party payers. Some medical
centers have imported patient-monitoring
equipment for intensive care units where
computers can help in the monitoring of patients’
vital signs.
Computer-based audio-video teleconference
systems in medical centers are a relatively
late arrival compared to hospital
computer information systems (HIS) in
China. Therefore, the administration of VCU
may or may not be assigned to managers of
the computer centers. The rational seems to
be that the medical faculty should retain direct
control of the operation of a
telemedicine service. That is, the presentation
and exchange of information during a
telemedicine conference must not deviate
from the standard medical protocol and procedures
familiar to medical personnel attending
the conference.
In most Chinese medical university and
hospital settings where telemedicine programs
have been started, there is a shortage of
trained supporting technical and managerial
staff. The contact person for telemedicine
(see Section 8) is frequently a professor of a
medical department. This medical person has
a strong interest in telemedicine but also has
many responsibilities in the medical institution.
She or he must seek the support of
qualified technical and managerial staff (both
qualitatively and quantitatively within the
same institution) for the telemedicine team.
8. Current application of telemedicine
In relative terms, telemedicine programs in
China are an expensive investment for the
medical centers. International collaborators
have donated some of the telemedicine equipment
used in China today, and medical universities
themselves have purchased much
more. The purchasing of VCU and the installation
of telephone lines are expensive in
China, but they are a one-time expense. Once
a teleconferencing system is installed, the
telecommunication costs incurred with each
consultation or educational conference are
R.K.C. Hsieh et al. :International Journal of Medical Informatics 61 (2001) 139–146 144
considered ‘‘additional’’ expenses. The university
does not always budget for the recurring
telecommunication expenditures, and
therefore, they are looked upon by the program
director from a different perspective.
Many telemedicine program directors in
China believe they have saved money (for
telecommunication) for their institution by
not conducting medical conferences and education
activities, but in fact they may have
inadvertently wasted valuable capital investment.
That is, when the available
telemedicine equipment, facilities and personnel
are not fully utilized, they lose the
opportunity to gain a full appreciation from
their capital investment, not to mention their
replacement cost.
China has successfully participated in
many national and international
telemedicine conferences for clinical consultation
as well as professional meetings. More
are planned for the future. When the volume
of international and national conferences
and consultation increases, each center will
require more technical and managerial manpower
to support the telemedicine facility
and equipment — an area of concern
among directors of telemedicine programs in
China.
All telemedicine programs in China have
plans to offer continuous education programs
for doctors, dentists, pharmacists and
nurses away from medical universities. Using
telemedicine to offer continuous education
programs for former students no longer assembled
on campus is still in a ‘‘demonstration
project’’ statues in China. Many
medical universities believe that continuous
education programs might be more receptive
to their former students when they do not
have to travel to take continuous education
courses and to teachers when they do not
have to travel to teach. However, distantlearning
programs will need new learning
material, which are different from the traditional
classroom teaching material. This
recognition of the need for more specialized
distant-learning material has already begun,
and their faculties are already developing the
special learning material in China.
There are many innovative applications of
telemedicine in China. Among them is the
introduction of the scientific basis to Traditional
Chinese Medicine (TCM). The evidence-
based diagnosis and treatment
concepts in Western medicine have been discussed
in telemedicine conferences by the
faculty of TCM in China, Japan and the
United States.
There are many important telemedicine
sites in China, and each has a different level
of telecommunication capabilities as well as
international contacts. It is hoped that staffs
of telemedicine programs in medical universities
will increase their dialogues within and
outside of their own institutions to share
their experience and knowledge. This paper
is an attempt to cover some important sites
using higher speed ISDN and real-time audio
video conferencing units for telemedicine
in China. A complete list of medical centers
that have ISDN and satellite level of communication
capability for telemedicine applications
is difficult to compile as changes are
occurring almost daily in China. The list
below is not arranged in any particular order.
It only offers a reference to those who
wish to establish contacts in Mainland
China.
1. Peking Union Medical College (PUMC)
China Jin Wei (Golden Health Medical
Network) Telemedicine Center
Purpose: clinical consultation and
teaching
Communication support: dedicated
satellite
Number of points: 50
Bandwidth: 2 Mbps
R.K.C. Hsieh et al. :International Journal of Medical Informatics 61 (2001) 139–146 145
Video conferencing equipment:
Polycom
Initiation: 1997
Contact Person: Prof. Chen Zhi-Jun,
Medical Services, PUMC
China Medical Board (NY)
Telemedicine Service Network
Purpose: Clinical consultation
Communication support: telephone
modemInternet servers:clients
Number of points: 100
Bandwidth: 28.8 kbps
Video conferencing equipment: PC and
monitor
Initiation: 1996
Contact person: Prof. Chen Zhi-Jun,
Medical Services, PUMC
PUMC and Hong Kong University Link
Purpose: Clinical consultation
Communication support: ISDN
Number of points: 2 (point to point)
Bandwidth: 384 kbps
Video conferencing equipment:
Trandberg
Initiation" end of 1999
Contact person: Prof. Chen Zhi-jun,
Medical Services, PUMC
Sino-Japanese Collaboration —
Telemedicine
Purpose: Clinical services and teaching
Communication support: dedicated
satellite
Number of points: 3
Bandwidth: 2 Mbps
Video conferencing equipment:
Polycom
Initiation: 2000
Contact person: Prof. Lee Bao-luo,
Medical Information Center
2. Chinese Academy of Traditional
Medicine
Telemedicine Center
Purpose: medical conference, education
and consultation
Communication support: ISDN
Number of points: 2 (point to point)
Bandwidth: 384 kbps
Video conferencing equipment: Picture
Tel VCU
Initiation: 1997
Contact person: Prof. Zhao Ying-kai, Institute
of Medical Informatics
3. Beijing Hospital
Telemedicine
Purpose: Clinical consultation
Communication support: ISDN
Number of points: 2
Bandwidth: 384 kbps
Video conferencing equipment:
Polycom
Initiation: 1997
Contact person: Prof. Yang Zhen-hua,
Dept of laboratory Medicine
4. Beijing Medical University
Telemedicine
Purpose: clinical consultation and
education
Communication support: ISDN
Number of points: 2
Bandwidth: 384 kbps
Video conferencing equipment:
Picture Tel VCU
Initiation: 1998
Contact person: Prof. Duo Jia-qi,
Medical Information Center
5. Shanghai Medical University
Telemedicine program
Purpose: clinical consultation,
medical education and conferencing
Communication support: ISDN,
satellite, asynchronous transmission
mode (ATM)
Number of points: 2 and also
multi-points
Bandwidth: 384 kbps
Video conferencing equipment:
Picture Tel, Polycom, Vcon
R.K.C. Hsieh et al. :International Journal of Medical Informatics 61 (2001) 139–146 146
Initiation 1994
Contact person: Prof. Zhao Jia-Ao
6. Sun Yet San University
(Information to be added)
7. Shantou Medical University
Telemedicine program
Purpose: clinical consultation,
medical education and conferencing
Communication support: ISDN,
satellite, ATM
Number of points: 2 and also
multi-points
Video conferencing equipment:
Polycom
Contact person: (information to be
confirmed)
8. Tongji Medical University
Telemedicine Center
Purpose: for education of leaders in education
for middle level healthcare practitioners
(nurses, medical technologists,
physiotherapists, etc.)
Communication support: ISDN, ATM
Number of points: 2
Bandwidth: 384 kbps
Initiation 2000
Contact person: Prof. Zhang Min-Cai.
Acknowledgements
The authors wish to acknowledge help received
from many colleagues, particularly
Prof. ZhaoYing-kai of the Institute of Medical
Informatics" ATCM, and Prof. Lee Bao-luo of
the Medical Information Center" PUMC.
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发表于 2003-9-7 04:54:41