History of Telemedicine

When millions of Americans opened a laptop in the spring of 2020 to see a doctor, most assumed they were trying something brand new. They weren’t. The idea of examining a patient through a screen is older than color television in most American homes. In 1959, clinicians at the University of Nebraska wired two buildings together with cameras and microphones so a neurological exam could be watched across the street, a date the Institute of Medicine later called the commonly accepted starting point for medical video in the United States.

The story that follows runs through a psychiatric hospital on the Nebraska plains, a medical station at Boston’s Logan Airport, a NASA project on an Arizona reservation, and a long stretch of federal rulemaking. Each stop explains a piece of why your doctor can now see you on a phone.

Before the Screen: Wires, Radios and a 1924 Prediction

Medicine at a distance didn’t start with television. Physicians in medieval Europe diagnosed patients by letter, sometimes with a urine sample sent along for inspection. The electrical age simply gave that old habit faster tools.

The clearest early example comes from Leiden in the Netherlands. Willem Einthoven, the physiologist who built the first practical electrocardiograph, had a problem: his string galvanometer was enormous, delicate and nearly impossible to move. His solution was to bring the heart to the machine instead. On 22 March 1905, he recorded a patient’s heartbeat sent over a telephone line roughly 1.5 kilometers long, running from Leiden’s academic hospital to his laboratory. He called the result a “telecardiogram,” and he described it in print in 1906.

Radio added a second channel. Ships at sea began calling shore for medical advice by wireless in the early twentieth century, and the public imagination ran ahead of the engineering. The April 1924 cover of Hugo Gernsback’s magazine Radio News showed a “Radio Doctor” who could check a patient’s pulse and temperature and see them on a screen from miles away. It was partly an April Fool’s joke, and partly an accurate forecast.

Three things had to come together before Gernsback’s cartoon could become a clinic:

• A picture, not just sound, so a doctor could watch how a patient moved, spoke and responded.
• A two-way connection, so the patient could see and hear the doctor too.
• A reason to pay for it, which would turn out to be the hardest piece of all.

Omaha, 1959: Closed-Circuit Television Enters the Clinic

Closed-circuit television means a private video system: cameras feed screens over a dedicated cable or link instead of broadcasting to the public. In the 1950s it was mostly a tool for security and classroom teaching. Cecil Wittson, the head of the Nebraska Psychiatric Institute in Omaha, saw something else in it.

Wittson had the institute’s new building wired for television as early as 1955 and hired technician Van Lear Johnson to run the system. In 1957 he brought in Reba Benschoter, who had just finished a master’s degree on television in education. By 1959 the team had joined two cameras, two microphones and two television sets between the institute and the University of Nebraska’s anatomy department across the street. They tested it first for teaching, then asked a neurologist to examine a patient over the link, and finally asked a psychiatrist to run group therapy through it. All three worked.

The bigger test came five years later. In December 1964, a microwave link (a line-of-sight radio connection between towers, the same technology then carrying long-distance phone calls) connected the institute to Norfolk State Hospital, 112 miles away. A federal grant paid for it. Over that link, Omaha psychiatrists held therapy rounds on Norfolk’s wards, a neurologist watched exams and brain-wave recordings from a distance, and grand rounds lectures went out as “telelectures” to Norfolk’s staff. The system also carried family “TV visits,” eight hours a week, so relatives in Omaha could see patients without the long drive. The Norfolk hospital’s inpatient population fell from more than 900 in 1965 to 476 by the end of 1968, a drop Wittson’s team linked in part to better access to specialists, though the deinstitutionalization movement of the era was pushing the same way.

Wittson was not modest about what he’d started. He predicted that “Nebraska may well become the first state to do away with state mental hospitals.” That didn’t happen, but his basic model did survive: a specialist in one place, a patient in another, and a live picture between them. It’s the same arrangement that today’s telehealth platforms are built on, whether they come from hospital IT departments or from outside software firms such as Glorium Technologies, which develops healthcare software including tools for remote care. The cameras are smaller and the link runs over the internet instead of microwave towers, but a 1964 Norfolk psychiatrist would recognize the setup at once.

Boston’s Three-Mile Stethoscope: Logan Airport and Kenneth Bird

The Nebraska project was about psychiatry and teaching. The next landmark grew out of an emergency.

On 4 October 1960, an Eastern Air Lines turboprop struck a flock of starlings while taking off from Logan Airport and crashed into Winthrop Bay. Rescue and treatment were slowed by the distance to Massachusetts General Hospital and by crowds that blocked ambulances. In the years after, the airport opened a medical station near its gates, and Kenneth Bird, an internist at Mass General, became its first head.

At first, staff at the airport station could reach hospital doctors only by telephone. Bird quickly ran into the limits of that. A spoken description of an injury, he found, left too much out. With a three-year grant from the U.S. Public Health Service and help from engineers at CBS and Boston’s public television station WGBH, Mass General built a microwave link between the hospital and the airport. Mass General dates the program to 1967; the telediagnostic clinic opened to patients in April 1968.

The system was more than a camera pointed at a patient. Video, X-ray images, heart tracings from electrocardiograms and even microscope views ran to a console in the hospital’s emergency department, where doctors could direct a nurse at the airport through an exam. Bird liked to say that “the doctor’s stethoscope is three miles long.” He’s also widely credited with putting the word “telemedicine” into circulation, using it in a 1970 grant proposal.

Space-Age Medicine: NASA and the Papago Reservation

By the early 1970s, NASA had its own reasons to care about remote diagnosis. Astronauts in long-duration orbit could not be driven to an emergency room, so the agency needed to know whether medical care could be managed from the ground. It found a terrestrial test site in southern Arizona.

The project carried a mouthful of a name: STARPAHC, short for Space Technology Applied to Rural Papago Advanced Health Care. NASA ran it with the Indian Health Service and contractor Lockheed on the Papago reservation, home to the people now known as the Tohono O’odham Nation. A mobile health unit, staffed by a physician’s assistant and a laboratory technician, drove to remote villages. Physicians at a control center in Sells, the reservation’s main town, supervised exams over television and radio links. NASA signed the contract in December 1972, and the demonstration ran through 1977.

STARPAHC showed that the model could reach people far from any hospital, but it also exposed real weaknesses. A 1979 study in the journal Medical Care, based on interviews with 47 of the providers involved, concluded that the major problems were unreliable equipment and the time television consultations took.

Why the First Wave Faded

STARPAHC was not alone. A 1974 report commissioned by the Rockefeller Foundation counted 11 active interactive-television health projects across the country, funded by agencies including the National Library of Medicine, the National Science Foundation and NASA. They stretched from Harlem and Chicago to northern Alaska and Puerto Rico.

By the early 1980s, almost all of them had shut down. Historians generally point to money rather than machinery. The projects ran on federal demonstration grants, and when the grants ended under the Reagan administration’s budget cuts, no insurer was paying for a doctor’s time on a screen. The technology mostly worked. The business model didn’t exist yet.

Rules and Reimbursement: 1996 to 2019

The second life of telemedicine was built less by engineers than by lawmakers and regulators. Three changes in the late 1990s and early 2000s set the terms that still shape it.

• HIPAA (1996). The Health Insurance Portability and Accountability Act, signed in August 1996, led to federal rules on the privacy and security of patient health information. Any system that carries a medical conversation, including a video visit, has had to meet those standards ever since.
• The Balanced Budget Act of 1997. For the first time, Congress told Medicare to pay for consultations delivered by telecommunications, starting no later than 1 January 1999. The catch was geography: the patient had to be in a rural county officially designated as short of health professionals.
• The Benefits Improvement and Protection Act of 2000. This law widened coverage to all areas outside metropolitan regions and dropped a rule that a second practitioner had to sit with the patient during the consultation.

Meanwhile the internet was doing what microwave towers never could: making a video link cheap. By the 2010s, a patient with a smartphone carried more camera and bandwidth than Kenneth Bird’s whole airport console. Yet Medicare’s rural-only rules stayed largely in place, and most Americans still had never had a video visit with a doctor. The law, not the technology, was the bottleneck.

2020: The Year Video Visits Became Ordinary

The COVID-19 pandemic broke that bottleneck in a matter of weeks. In March 2020, federal officials lifted Medicare’s geographic limits for the length of the public health emergency, allowing patients to be seen from their own homes in any part of the country. On 17 March 2020, the Office for Civil Rights at the Department of Health and Human Services announced it would not penalize providers who used everyday apps such as FaceTime or Skype in good faith, a striking relaxation given how strict HIPAA enforcement had been.

The results were dramatic. According to the Department of Health and Human Services, Medicare fee-for-service telehealth visits rose from about 840,000 in 2019 to roughly 52.7 million in 2020, a 63-fold increase in a single year. Behavioral health shifted most of all, with about a third of those visits happening by telehealth. That’s an echo worth noticing: psychiatry was where Wittson’s team began in Omaha six decades earlier.

The same report flagged an old problem in new form. Black and rural beneficiaries used telehealth less than White and urban ones, a reminder that access to a screen and a reliable connection is unevenly spread, much as access to a specialist was in 1964 Nebraska.

A Timeline of Telemedicine

Frequently Asked Questions

When did telemedicine begin? It depends on how you define it. Einthoven sent heart signals by telephone in 1905, but the Institute of Medicine dated medical video in the United States to 1959, when the University of Nebraska began using two-way closed-circuit television.

Who coined the word “telemedicine”? Kenneth Bird of Massachusetts General Hospital is usually credited, based on his use of the term around 1970.

Why did early telemedicine projects disappear? Most ran on temporary federal grants. When that money ended in the early 1980s, no insurer was paying for remote visits, so the programs closed even though the equipment largely worked.

What the Long View Shows

Telemedicine’s history is mostly a story of technology waiting for permission. Omaha had working two-way television in 1959, and Boston was examining airport patients by video in 1968, yet video visits only became routine in 2020. If you’re studying this period, three takeaways are worth keeping:

• The core idea, a specialist and a patient joined by a live picture, hasn’t changed since Nebraska.
• Funding and law, more than hardware, decided when it spread.
• Gaps in access have followed telemedicine from the Nebraska plains to the smartphone era.