education, and public awareness in the same manner as telehealth and telemedicine. teleaudiology main article: tele-audiology tele-audiology is the utilization of telehealth to provide audiological services and may include the full scope of audiological practice. this term was first used by dr gregg givens in 1999 in reference to a system being developed at east carolina university in north carolina, us. teleneurology teleneurology describes the use of mobile technology to provide neurological care remotely, including care for stroke, movement disorders like parkinson's disease, seizure disorders (e.g., epilepsy), etc. the use of teleneurology gives us the opportunity to improve health care access for billions around the globe, from those living in urban locations to those in remote, rural locations. evidence shows that individuals with parkinson's disease prefer personal connection with a remote specialist to their local clinician. such home care is convenient but requires access to and familiarity with internet. a 2017 randomized controlled trial of "virtual house calls" or video visits with individuals diagnosed with parkinson disease evidences patient preference for the remote specialist vs their local clinician after one year. teleneurology for patients with parkison's disease is found to be cheaper than in person visits by reducing transportation and travel time a recent systematic review by ray dorsey et al. describes both the limitations and potential benefits of teleneurology to improve care for patients with chronic neurological conditions, especially in low-income countries. white, well educated and technologically savvy people are the biggest consumers of telehealth services for parkinson's disease. as compared to ethnic minorities in the us. teleneurosurgery telemedicine in neurosurgery was historically primarily used for follow-up visits by patients that had to travel far to undergo surgery. in the last decade, telemedicine was also used for remote icu rounding as well as prompt evaluation for acute ischemic stroke and administration of iv alteplase in conjunction with neurology. from the onset of the covid-19 pandemic, there was a rapid surge in the use of telemedicine across all divisions of neurosurgery: vascular, oncology, spine, and functional neurosurgery. not only for follow-up visits, but it has gained popularity for seeing new patients or following established patients regardless of whether they underwent surgery. telemedicine is not limited to direct patient care only; there are a number of new research groups and companies focused on using telemedicine for clinical trials involving patients with neurosurgical diagnoses. teleneuropsychology teleneuropsychology is the use of telehealth/videoconference technology for the remote administration of neuropsychological tests. neuropsychological tests are used to evaluate the cognitive status of individuals with known or suspected brain disorders and provide a profile of cognitive strengths and weaknesses. through a series of studies, there is growing support in the literature showing that remote videoconference-based administration of many standard neuropsychological tests results in test findings that are similar to traditional in-person evaluations, thereby establishing the basis for the reliability and validity of teleneuropsychological assessment. telenutrition telenutrition refers to the use of video conferencing/ telephony to provide online consultation by a nutritionist or dietician. patient or clients upload their vital statistics, diet logs, food pictures etc. on a telenutrition portal which are then used by nutritionist or dietician to analyze their current health condition. nutritionist or dietician can then set goals for their respective client/ patients and monitor their progress regularly by follow-up consultations. telenutrition portals can help people seek remote consultation for themselves and/or their family. this can be extremely helpful for elderly or bed ridden patients who can consult their dietician from comfort of their homes. telenutrition showed to be feasible and the majority of patients trusted the nutritional televisits, in place of the scheduled but not provided follow-up visits during the lockdown of the covid-19 pandemic. telerehabilitation main article: telerehabilitation telemedicine in rehabilitation telerehabilitation (or e-rehabilitation) is the delivery of rehabilitation services over telecommunication networks and the internet. most types of services fall into two categories: clinical assessment (the patient's functional abilities in his or her environment), and clinical therapy. some fields of rehabilitation practice that have explored telerehabilitation are: neuropsychology, speech–language pathology, audiology, occupational therapy, and physical therapy. telerehabilitation can deliver therapy to people who cannot travel to a clinic because the patient has a disability or because of travel time. telerehabilitation also allows experts in rehabilitation to engage in a clinical consultation at a distance. most telerehabilitation is highly visual. as of 2014, the most commonly used mediums are webcams, videoconferencing, phone lines, videophones and webpages containing rich web applications. the visual nature of telerehabilitation technology limits the types of rehabilitation services that can be provided. it is most widely used for neuropsychological rehabilitation; fitting of rehabilitation equipment such as wheelchairs, braces or artificial limbs; and in speech-language pathology. rich web applications for neuropsychological rehabilitation (aka cognitive rehabilitation) of cognitive impairment (from many etiologies) were first introduced in 2001. this endeavor has expanded as a teletherapy application for cognitive skills enhancement programs for school children. tele-audiology (hearing assessments) is a growing application. currently, telerehabilitation in the practice of occupational therapy and physical therapy is limited, perhaps because these two disciplines are more "hands on". two important areas of telerehabilitation research are (1) demonstrating equivalence of assessment and therapy to in-person assessment and therapy, and (2) building new data collection systems to digitize information that a therapist can use in practice. ground-breaking research in telehaptics (the sense of touch) and virtual reality may broaden the scope of telerehabilitation practice, in the future. in the united states, the national institute on disability and rehabilitation research's (nidrr) supports research and the development of telerehabilitation. nidrr's grantees include the "rehabilitation engineering and research center" (rerc) at the university of pittsburgh, the rehabilitation institute of chicago, the state university of new york at buffalo, and the national rehabilitation hospital in washington dc. other federal funders of research are the veterans health administration, the health services research administration in the us department of health and human services, and the department of defense. outside the united states, excellent research is conducted in australia and europe. only a few health insurers in the united states, and about half of medicaid programs, reimburse for telerehabilitation services. if the research shows that teleassessments and teletherapy are equivalent to clinical encounters, it is more likely that insurers and medicare will cover telerehabilitation services. in india, the indian association of chartered physiotherapists (iacp) provides telerehabilitation facilities. with the support and collaboration of local clinics and private practitioners and the members iacp, iacp runs the facility, named telemedicine. iacp has maintained an internet-based list of their members on their website, through which patients can make online appointments. teletrauma care telemedicine can be utilized to improve the efficiency and effectiveness of the delivery of care in a trauma environment. examples include: telemedicine for trauma triage: using telemedicine, trauma specialists can interact with personnel on the scene of a mass casualty or disaster situation, via the internet using mobile devices, to determine the severity of injuries. they can provide clinical assessments and determine whether those injured must be evacuated for necessary care. remote trauma specialists can provide the same quality of clinical assessment and plan of care as a trauma specialist located physically with the patient. telemedicine for intensive care unit (icu) rounds: telemedicine is also being used in some trauma icus to reduce the spread of infections. rounds are usually conducted at hospitals across the country by a team of approximately ten or more people to include attending physicians, fellows, residents and other clinicians. this group usually moves from bed to bed in a unit discussing each patient. this aids in the transition of care for patients from the night shift to the morning shift, but also serves as an educational experience for new residents to the team. a new approach features the team conducting rounds from a conference room using a video-conferencing system. the trauma attending, residents, fellows, nurses, nurse practitioners, and pharmacists are able to watch a live video stream from the patient's bedside. they can see the vital signs on the monitor, view the settings on the respiratory ventilator, and/or view the patient's wounds. video-conferencing allows the remote viewers two-way communication with clinicians at the bedside. telemedicine for trauma education: some trauma centers are delivering trauma education lectures to hospitals and health care providers worldwide using video conferencing technology. each lecture provides fundamental principles, firsthand knowledge and evidenced-based methods for critical analysis of established clinical practice standards, and comparisons to newer advanced alternatives. the various sites collaborate and share their perspective based on location, available staff, and available resources. telemedicine in the trauma operating room: trauma surgeons are able to observe and consult on cases from a remote location using video conferencing. this capability allows the attending to view the residents in real time. the remote surgeon has the capability to control the camera (pan, tilt and zoom) to get the best angle of the procedure while at the same time providing expertise in order to provide the best possible care to the patient. telecardiology ecgs, or electrocardiographs, can be transmitted using telephone and wireless. willem einthoven, the inventor of the ecg, actually did tests with transmission of ecg via telephone lines. this was because the hospital did not allow him to move patients outside the hospital to his laboratory for testing of his new device. in 1906 einthoven came up with a way to transmit the data from the hospital directly to his lab. transmission of ecgs one of the oldest known telecardiology systems for teletransmissions of ecgs was established in gwalior, india in 1975 at gr medical college by ajai shanker, s. makhija, p.k. mantri using an indigenous technique for the first time in india. this system enabled wireless transmission of ecg from the moving icu van or the patients home to the central station in icu of the department of medicine. transmission using wireless was done using frequency modulation which eliminated noise. transmission was also done through telephone lines. the ecg output was connected to the telephone input using a modulator which converted ecg into high frequency sound. at the other end a demodulator reconverted the sound into ecg with a good gain accuracy. the ecg was converted to sound waves with a frequency varying from 500 hz to 2500 hz with 1500 hz at baseline. this system was also used to monitor patients with pacemakers in remote areas. the central control unit at the icu was able to correctly interpret arrhythmia. this technique helped medical aid reach in remote areas. in addition, electronic stethoscopes can be used as recording devices, which is helpful for purposes of telecardiology. there are many examples of successful telecardiology services worldwide. in pakistan three pilot projects in telemedicine were initiated by the ministry of it & telecom, government of pakistan (moit) through the electronic government directorate in collaboration with oratier technologies (a pioneer company within pakistan dealing with healthcare and hmis) and pakdatacom (a bandwidth provider). three hub stations through were linked via the pak sat-i communications satellite, and four districts were linked with another hub. a 312 kb link was also established with remote sites and 1 mbit/s bandwidth was provided at each hub. three hubs were established: the mayo hospital (the largest hospital in asia), jpmc karachi and holy family rawalpindi. these 12 remote sites were connected and on average of 1,500 patients were treated per month per hub. the project was still running smoothly after two years. wireless ambulatory ecg technology, moving beyond previous ambulatory ecg technology such as the holter monitor, now includes smartphones and apple watches which can perform at-home cardiac monitoring and send the data to a physician via the internet. teleradiology main article: teleradiology a ct exam displayed through teleradiology teleradiology is the ability to send radiographic images (x-rays, ct, mr, pet/ct, spect/ct, mg, us...) from one location to another. for this process to be implemented, three essential components are required, an image sending station, a transmission network, and a receiving-image review station. the most typical implementation are two computers connected via the internet. the computer at the receiving end will need to have a high-quality display screen that has been tested and cleared for clinical purposes. sometimes the receiving computer will have a printer so that images can be printed for convenience. the teleradiology process begins at the image sending station. the radiographic image