Introduction
Telemedicine and telemetrics are increasingly important for occupational and environmental medicine and many routine and research approaches use technology of this field for different purposes [
1]. One definition is that “Telemedicine is the use of electronic information and communication technologies to provide and support health care when distance separates the participants” [
2]. The first telemedical activities were documented in 1897, when the telephone was used to confirm a diagnosis [
3], and there are reports from 1922 which certify the exchange of medical information between ships and coast guards [
4]. Since then telemedicine plays an important role for all aspects of public health. Especially in areas, which are not densely populated, telemedicine may serve as a powerful tool to implement improvements of the public health system.
The invention of television induced the first wave of telemedicine projects. In 1959 Jutras succeeded to interconnect several hospitals via a cable supported TV system. This system enabled the transmission of roentgenograms over a distance of up to five miles [
5]. With the development of new telecommunication technologies such as UMTS, infrared or Bluetooth telemedicine is today a growth market with high potentials and great opportunities for global health care. Telemedicine is most beneficial for populations living in isolated communities and remote regions and is currently being applied in virtually all medical domains. This new technology has mostly been used as a communication and consultation tool between a general practitioner and a specialist available at a remote location. In recent years, the focus has also been on monitoring a patient at home using known devices like blood pressure monitors and transferring the information to a caregiver. These telemonitoring solutions have a focus on current high morbidity chronic diseases, such as chronic heart failure or diabetes mellitus. Telemedicine holds big promises to solving major health care problems; hence, in the last years various studies were concluded. However, there is no in-depth bibliometric analysis of the current state of research regarding telemedicine available. Due to the importance of telemedicine for public health, the NewQIS project (New Quality and Quantity Indices in Science) [
6‐
8] elected the topic of telemedicine as a primary research focus and established an in depth scientometric study. Large-scale data analysis and bibliometric approaches including density-equalizing mapping were performed.
Discussion
The NewQIS platform decided to assess telemedicine on a scientometric level due to its increasing importance for public health and occupational and environmental medicine. Especially in countries in which the health systems are not area-wide, or occupational offshore settings, telemedical inventions may be of utmost importance. The present study provides a first precise international bibliometric evaluation of telemedicine-related research in a closed an defined time period which was set between 1900 and 2006. The methodology is based on internationally established databases, such as the Web of Science [
10], and novel bibliometric tools including density-equalizing mapping [
14]. The time span in some search routines was restricted to the period between 1976 and 2006. This period was chosen because the worldwide number of published items before 1976 was relatively low. Generally, there is a constant increase of interest in this field since the middle of the 1990ies. The main reason for this is the rapid progress and development in the field of communication technologies in this era. New methods of digitizing images and compressing data, as well as video coverage via low bandwidth enabled new telemedical options [
15]. This strong progress in the area of computer and network technologies mainly initiated the development of telemedicine.
Data analysis of productivity parameters shows that research groups from the US maintain a leadership position in research productivity concerning telemedicine, along with Great Britain and Canada. More than 56 % of all publications are originated from these three countries.
By bringing the number of publications in relation to the respective population it can be seen that the USA with a ratio of approx. 4.3 publication/1 m residents do have a significantly lower output than the UK with 7.8 publication/1 m residents. Making the same calculation for Australia, Norway and Finland, a comparatively high ratio of approx. 10 publication/1 m for Australia, 12.4 publication/1 m for Norway and 9.2 publication/1 m for Finland can be found.
The reason for these results might be that territorial states such as Australia or Scandinavia do have special requirements regarding medical care, which accelerate the development of telemedicine in these countries [
16]. Therefore, telemedicine is very advanced in those countries where medical specialists are not available in most of the regions, or where climate issues cause serious transportation issues, as is the case in wide territories of Scandinavia.
While telemedicine is highly accepted and used in countries such as Scandinavia, Australia or the USA, Germany still struggles with this new technology [
17]. In Germany only 2.3 published items per 1 m residents could be found. One of the main reasons for this is the unregulated compensation situation, together with the high physician concentration. Medical professionals in Germany are still very conservative regarding telemedicine, because they are afraid of possible staff savings and quality losses caused by this new technology [
18].
Whereas the number of published items was considered as an indicator for research productivity, the average citation per item was used as a sign for research quality as generally accepted. Therefore all articles were analyzed regarding the average citation of items published in each particular country. Using this average citation per item index without thresholds, Bangladesh appears to have the highest rank, followed by Iceland and Saudi Arabia. It has to be annotated that the results for those countries with a very small amount of published items appear disproportionately high. To objectify these outliers, a threshold of ten published items was introduced and, as a result, Bangladesh (1 publication), Iceland (1 publication) and Saudi Arabia (1 publication) are no longer included in the ranking. Ireland (10.19 citations/item and 80 publications) moves up to first position, followed by New Zealand and Finland (Table
2).
This result once again underlines the importance of telemedicine in territorial countries, such as New Zealand or Finland. Because of Finland being highly developed in matters of telecommunications, numerous telemedicine projects could successfully be established in this region [
19]. Today telemedicine is very well implemented in the Finish health care system, so that necessary waiting time shortenings for seeing a medical specialist could be achieved [
20].
When focusing on assigned categories in the Web of Science database related to telemedicine, the field “Health Care Sciences & Services“plays a leading role, with a steep increase of published items since 1997. More than 36 % of all publications are assigned to this category, followed by “Medical Informatics” with 9.72 % and “Medicine, General & Internal” with 8.84 % of all publications. This trend confirms the high impact of telemedicine for the health care system. Telemedicine is no longer only a vision which is covered in theoretical or technical fields, such as “Computer Science, Theory & Methods” or “Computer Science, Information Systems”. Today telemedicine is reality and successfully applied in a high number of medical fields [
21]. Hence, more and more publications deal with the application of telemedicine in order to optimize the health care system. It is also an interesting aspect that the number of publications in the category “Health Care Sciences & Services” was insignificantly low till the mid 1990ies and then abruptly took a turn to become the most important field (Fig.
9). This change can be explained with the improvement of telecommunication technologies in that time, which eventually enabled the development of telemedicine.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
DAG, SR, MB, MS, AG and BK have made substantial contributions to the conception and design of the study, acquisition of the data and interpretation. They have been involved in drafting and revising the manuscript. All authors have read and approved the final manuscript.