The first world is moving towards higher concentrations of older people and fewer carers. Just 20 years ago there were 30 potential cares for each person needing care. By 2010 this will have reduced to only three potential carers. National economies will not be able to sustain the levels of care enjoyed to date and a potential crisis looms. Fortunately the technological advances that have extended lifetimes are also spawning the means of caring through Information Technology (IT). The demands placed on telecommunications networks will dictate wide band services, with human scale delays and interfaces.

An Ageing Local Population
The population of the developed world is ageing rapidly with our life expectancy now approaching 80. At the same time, the birth rate is declining and the number of people available to support this ageing population is decreasing (Fig 1) and a critical imbalance is rapidly developing. In some parts of the world, this imbalance is expected to reach the point where there is only one supporter for every two adults needing care. Japan is already addressing this dilemma by developing robots to undertake basic care and rehabilitation. Interestingly, the opposite trend is evident in much of the less developed world, there being a relative abundance of young people to take on the role of carers. Information Technology (IT) and telecommunications offer a potential solution to this geographical anomaly by teleporting expertise, experience and presence. Indeed, technologies are already with us that allow surgeons at remote locations to "be" with or even inside a patient's body. Similarly, robots are already being used in hip replacement, brain and eye surgery. Before long we will see surgical operations performed remotely with tele-robotics, so that a surgeon in California can operate on a patient in London.

Fig 1. Ratio of 15-64 year olds to over 65's

Further developments include the remote monitoring of patients through electronic interfaces mounted on, and in, the body. It is already possible for diabetics and other drug dependent people to be monitored by remote computers that administer and optimise dosage. So far experiments have been confined to hospital wards, but there is no reason why this cannot be realised globally via telecommunications. The ultimate goal is that the trip to a doctor's surgery or the hospital outpatient's department, and other routine care activities, become an automated and remote activity.

Info-medical Advances
Whilst IT can be used to give people independence for as long as possible, and informal health care can be transformed to self-care, the question nevertheless arises - is it possible to more effectively utilise finite medical resources? For example:

• Can nursing practitioners take some of the load off GP's?
• Can GP's and nursing practitioners work together more effectively?
• Can consultants and specialists be more accessible?
• Could the social services be more effective?
• Could help be on tap when required?

Fig 2. Networked medical care

With such technology perhaps the smart patients will choose to access medical care and help directly by themselves? And perhaps the really smart patients will access the same information as the medical professionals!

Networked Medicine Future
When doctor and patient meet, in the flesh or on-line, medical records could be instantly accessed. Symptoms could be recorded, and the computer can despatch intelligent software agents to identify a range of causes and treatments. At the point when a doctor might normally decide to refer a patient to a specialist, remote access the specialist's own expert system may prove sufficient. If the diagnosis is still unclear, agents could search databases world-wide for a match to the symptoms. By allowing such agents to carry diagnostic and visual information, doctors will be able to get help from any medical facility connected to the network. In essence, the doctors will become cybernauts. If a consultant proves necessary, telepresence technology will allow a doctor to act as the consultant's eyes and ears and examine the patient under remote guidance.

Fig 3. Tele-endoscopy over ISDN-2. Remote consultation

In theory the data and images produced by any form of electronic diagnostic equipment can be conveyed over a network and viewed in as many locations as necessary. In certain medical fields this is already being trailed with notable success. For example, patients receiving endoscopic examinations have benefited from the participation of a consultant at a remote location (Fig 3).

Fig 4. Endoscope images over the ISDN

Fig 5. Endoscope display with inserted view of examination room

Images from the endoscope (Figs 4,5), as well as audio/visual commentary from the attending medical staff, are conveyed to the consultant over the ISDN, who in turn was able to offer advice on treatment. Medical training is also benefiting from such technology (Fig 6).

Fig 6. Tele-endoscopy over ISDN-6. Remote education and training

Orthopaedic surgery is also benefiting from networking. During a recent knee operation (Fig 7), the attending surgeons were linked with a consultant at a remote location equipped with a 3-D display (Fig 8). A binocular view of the procedure was delivered by a stereoscopic camera headset worn by the surgeon conducting the operation (Fig 9).

Fig 7. Camera view of knee operation

Fig 8. Consultant orthopaedic surgeon at a remote location

Fig 9. Stereoscopic camera headset worn by attending surgeon

One diagnostic ability not yet achievable remotely is touch. However by 2015 this should be possible through the use of synthetic skin that has all the tactile qualities and sensations of human skin. A doctor will then be able to extend the sense of touch anywhere on the planet. Such technologies will deliver true telepresence and allow doctors and carers anywhere to provide the best service possible. Achieving this quality of service may also involve a migration away from a network of GP's supported by a large general hospital, to a series of 'smart' cottage hospitals supported by advanced facilities dispersed across the globe.

Telepresence will allow a surgeon anywhere in the world to oversee, and eventually perform, an operation anywhere in the world. For example, it is already possible to operate remotely using crude 'remote hands' and robots. Experimental robots are now being used in certain operations in a supporting role. Early experiments have involved robots controlled by tomographic scanners to remove brain tumours with a precision higher than that of surgeons. A further success is in stapedotomy operations, where the surgical robot has demonstrated a performance superior to that of humans when drilling bone. Robots are now being introduced into retinal and joint replacement surgery.

Information access
Medicine as a science is characterised by the amount of analysis based on subjective data. This, and the breadth of the data, has in turn bred the "specialist", many of whom, of necessity, are involved at some stage in the care of an individual patient (Fig 10). (Contrast this with the "font of all knowledge" that medics in early society were).

Fig 10. Knowledge trend in recent society

The diagnostic process can therefore be long and complex, needing many referrals and tests which may result in uncertain conclusions by a process of elimination. In many professions it is not unusual to spend up to 85% of your time trying to find information, 10% putting it into the right format, and only 5% making the critical decision. Help is required to navigate through the growing field of information, find, access and manipulate data, and finally get down to the kernel - decision and action! The necessary technologies are all under development and use a combination of Artificial Intelligence (AI) for navigation and location, Hebbian decay filing, and automatic text summarisation. However, there are still significant problems associated with the complexity and size of systems, data bases and connectivity expected by the year 2000.

Searching for information is extremely wasteful in terms of human time and effort. Software "agents" working on our behalf are now able to roam networks and electronic libraries across the planet, find data and retrieve it in a mater of minutes. The next step is to educate them to format the data for the human users and their particular applications.

The single biggest impediment to realising an effective system is the huge legacy of patient data, case histories, techniques and information recorded in paper form. If all of this was available electronically, access to the global experience would be possible. Furthermore, trend data could be produced and made available on a continuous basis. Critical features such as hot spots, errors, corrections, new correlation's and effects, new diseases, and outbreaks could then be detected and acted upon within hours rather than months or years.

Smart Copier - Dumb Pacemaker
Smart copiers and fax machines are now common in offices. When they break down they automatically log the failure, call the service engineer, and presents a readout of likely causes. The same technology is finding its way into food and drink vending machines, garage forecourts, automatic bank tellers and telephone kiosks. Soon it will reside in your washing machine, tumbler drier, microwave oven, hi-fi, TV, and computer. None of these directly affect life and death - but the faltering pacemaker does, and yet at present it is dumb by comparison! As the number and use of artificial body parts increases there will be a logical and necessary need to monitor both the outside and inside of humans, with the wide variety of operational parameters being relayed to a 'caring computer'. Preventative maintenance is always preferable to curative medicine!

Real Time Drugs Administration
Vast amounts of time and hospital space are currently taken up by people who merely require continual or periodic monitoring, or basic medication to be administered. Today the administration of everything from insulin to steroids requires the involvement of trained medical staff. A modest level of instrumentation and AI could obviate this. For example, prototype technology already exists to monitor and administer the correct dosage of a drug, optimised through real time bio-feedback to match an individual's body mass and metabolism. To take a specific example: an artificial pancreas is already at the research stage, and some hospitals in the USA are experimenting with the dispensing of drugs by such mechanisms. The next step is obvious - the patients remain at home and are remotely monitored and advised over the telecommunications network.

The Machine as Doctor
There is some evidence that patients prefer an impersonal, inanimate questioner at the initial stage of the diagnostic process. Talking to a computer about personal issues may be less embarrassing and more acceptable, and the patient can be more candid, thus improving the quality of information and subsequent diagnosis. Furthermore, it has now been demonstrated that machines are often more accurate than human doctors in the preliminary diagnostic phase. It is likely that such machines will outpace humans as the amount of information increases through the use of improved biometrics. In this situation AI could be a means of reducing diagnostic uncertainty as it has the potential to consider all previous case histories and diagnoses on a global scale.

Real Time Monitoring
Other advances will change the mode of home care from passive to active. The technology used in wrist-sized computing will also generate diagnostic information and location detection. People who elect to wear such devices will benefit from round-the-clock monitoring. Similarly, a PC in the home can learn the wearer's preferences and daily routine, and thus recognise when medication has been missed or the possibility of an accident and raise the necessary alarms. Combining these may allow the onset of sickness to be detected earlier and provide the means for timely treatment. Using location detectors, people who go missing or get ill could be rapidly found and treated.

CamNet based telepresence
In this system an operator utilises a conventional audio headset augmented with head mounted TV camera and television screen (Fig 11). The principle behind CamNet is simple - by projecting the view from someone's head back to a site that could be a thousands of miles away, it is possible to remotely perceive their world. Instructions, schematics, fixed and moving images can then be transmitted back to the wearer, who can receive the latest information about the problem being worked on.

Fig 11. The CamNet headset in field use

Fig 12. CamNet at a road traffic accident

CamNet has been used to link ambulance paramedics with hospital specialists so that care can be administered during transit, and the necessary hospital facilities got ready (Fig 12). The addition of tactile and prosthetic transmission, plus remote instrumentation, would create the ultimate teleportation of human abilities. Expertise on demand, anywhere, any time!

Surrogate Head
An obvious extension of CamNet is to place two cameras at eye level on the wearer, and at the remote location to a virtual reality style of headset. People at a remote location (or locations) can then effectively sit behind the eyes of the wearer and enjoy a full binocular (3D) view. Including two microphones at ear level, with earphones at the remote location/s, further enhances the teleportation. The experience is then one of sitting inside someone's head looking (and hearing) out! This concept of a surrogate head could have profound implications in medical practice and training (Fig 9).

The tactile
The time taken for information to travel from our fingertips to our brain is of the same order as the time taken for a single photon to travel from the UK to the USA on an optical fibre (~ 10-30 ms). Given that the delay with touch is dominated by synaptic processing, an extended hand across the Atlantic is feasible. The "feely gloves" and "prosthetic arms" now being developed will allow the VR participant to reach out and not only grab virtual entities, but also feel and react to their tactile qualities. Leading on from this, data suits would allow sensory information to be communicated for the whole body. Current research suggests that direct sensory stimulation will be practical in the next decade or two, which should eventually improve the feeling of teleportation. These developments will also aid the development of full-sense prostheses.

Decision support (AI)
Medical research is generating new information at an exponential rate. To benefit from this information explosion, doctors must be able to find the facts that are relevant to the case in hand. Since the early days of computing, expert systems for medical diagnosis have been a target for AI researchers. Whilst the early systems proved as accurate as human doctors, they suffered from a lack of confidence and accountability in the medical community. However, the growth in information and recent improvements in AI techniques, such as knowledge elicitation and representation, has seen systems surpass their human creators in accuracy. Whilst it may be some time before automatic diagnosis is the preferred option, such systems will at least give doctors decision support and on line reassurance in diagnosis and treatment.

Criticalities
While our society will become much older, the technologies to help the older members are already being developed. Travel substitution will allow us to work, play and socialise from anywhere. Telemedicine will revolutionise the way doctors work and communicate with each other and their patients. The same technology will allow experts in all fields to share expertise world-wide without having to travel.

Experiments with delay introduced into a communication channel have highlighted how human co-ordination can be critically affected. For example, with a delay of only a fraction of a second between hand and eye, we have trouble writing. With a mere 200ms delay between lips and voice, we behave like a talking mannequin. At 300ms we can experience severe co-ordination problems and confusion. Generally speaking a delay exceeding 100ms between sight, sound and touch will unacceptably degrade our ability to communicate effectively and safely. A telecare system capable of meeting the future needs of society can therefore only be realised with delays and interfaces matched to our inherent capabilities. Optical fibre networks offer the ideal bearer for such a future with their massive bandwidth and delays of only 30ms between London and New York. Signal coding and software however need critical attention. A new attitude is required so the developmental trend is aimed at greater efficiency and minimum delay rather than size and proliferation. We need to trade bandwidth, processing power and memory capacity for human effectiveness, which after all is our most precious commodity.

Probably the greatest challenge will be the design and engineering of interfaces that can be successfully mastered by an old, infirm, and sometimes confused population. The emphasis has to be a human one as increasingly it will be the machines that care!

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Author biographies
Peter Cochrane joined the British Post Office in 1962 and is a graduate of Trent Polytechnic and Essex University. He is a fellow of the IEE, IEEE, and Royal academy of Engineering, a visiting professor to Essex, Kent and University College London. He joined BT Laboratories in 1973 and has worked on a variety of analogue and digital switching and transmission studies. He has been a consultant to numerous international companies on projects concerned with systems, networks and test equipment development. In 1978 he became manager of the Long Lines Division and directed the development of optical fibre systems, photonic amplifiers and wavelength routed networks for terrestrial and undersea applications. He received the Queen's Awarded for Technology in 1990 as manager for the production of optical receivers for TAT-8 and the PTAT-1 undersea cable systems. In 1991 he was appointed to head the Systems Research Division at BTL which is concerned with future computing and communications developments. He was further promoted in 1993 to head the Advanced Applications and Technologies Department with 620 staff.

David Heatley obtained BSc (Hons 1st class) and MSc degrees in electronics in 1978 and 1981 respectively, and a doctorate in Optical Communications Systems in 1989. He joined BT Laboratories in 1978 to work on the development of analogue and digital optical fibre systems designed for video and broadband services. In 1985 he was appointed to head a group responsible for the development of optical receivers for terrestrial and undersea fibre systems. In this capacity he was a member of the team that received the Queen's Award for Technology in 1990. He is presently with the Advanced Media Unit and heads a team with special responsibility for mobile telecommunications, future studies and telemedicine. During his career he has published widely on telecommunications, ranging from discrete components, through to systems, networks and services. He is a Member of the IEE and a Chartered Engineer.

Ian Pearson graduated in 1981 in Applied Mathematics and Theoretical Physics from Queens University, Belfast . He spent four years in the defence industry and joined BT Laboratories in 1986, analysing the performance of computer networks and protocols and helped to develop ATM transmission over optical networks. He has periodically worked on broadband networks and services, but now mainly focuses on mapping the progress of new developments throughout information technology, considering both technological and social implications. He currently works in the Centre for Human Communications. He has received five awards for papers, including the Best Paper award at the 1993 FITCE Conference, and the IEEE Benefactors premium in 1994.