IEEE TRANSACTIONS ON INFORMATION TECHNOLOGY IN BIOMEDICINE, VOL. 5, NO. 2, JUNE 2001 171 Communications ______________________________________________________________________ Adopting Telemedicine Services in the Airline Framework Francesco Beltrame, Member, IEEE,Ken Boddy, and Piergiulio Maryni, Member, IEEE Abstract—This paper gives a general overview of the telemedicine ser- vice on board airplanes, by considering the problems associated with it, the institutions that are already operating in the field, and the main projects (public and private) that are investigating in this direction. It also reports a brief discussion about the potential market and concludes with a number of issues related to such a service. Most of this information comes from the authors’ active participation in several European projects that are partic- ularly focused on telemedicine. Index Terms—Airlines, bioengineering, healthcare telematics, Internet, telecommunications, telemedicine. I. I NTRODUCTION Telemedicine services are coming forth in the aeronautical domain and their adoption is being considered by an increasing number of air- line companies. Technology is offering medical devices and commu- nication equipment at affordable costs and commercial companies are already selling medical services that range from teleconsultation to the provision of devices and training. Moreover, in the highly competitive airline market, the availability of telemedicine might drive passengers’ airline choice, especially for long distance flights. Recent pilot experi- ences have also shown that high-revenue services such as entertainment or the “flying office” can motivate the installation of high-bandwidth satellite equipment, which can also be used for telemedicine purposes. Furthermore, under a legal perspective, the decision as to whether or not an aircraft should be diverted under a medical emergency on board always rests with the captain. He has to consider the conditions of the sick passenger, the likelihood of them deteriorating, whether a med- ical doctor is on board, and the availability of medical facilities at the diversion airfield. Accepting this decision can be much simpler if tech- nology is available to give the cabin crew and the captain direct access to medical expertise and, hence, a clearer idea of what is wrong with the passenger. This paper briefly considers a number of issues related with the adop- tion of telemedicine on board airplanes. Such issues are related with market perspectives, with the legal problems, with the medical settings on board airplanes, and with the telemedicine services offered today. The paper is organized as follows. Section II outlines the market di- mension. Section III contains a brief introduction to legal issues. Sec- tion IV drafts the “state-of-the-art” on board the aircraft, while Sec- tion V goes through case examples of medical service providers. Sec- tion VI draws conclusions and presents a number of open issues. Manuscript received February 24, 2000;revised November 1, 2000.This work was supported by the Trans European Network for Telemedicine under Project 45563. F. Beltrame and P. Maryni are with the Department of Communication, Com- puter and System Sciences, University of Genoa, Genoa, 16145 Italy (e-mail: francesc@dist.unige.it; pg@dist.unige.it). K. Boddy is with the Edinburgh Healthcare Telematics, Edinburgh EH3 9EW, Scotland (e-mail: boddyk@telemedicine.clh.ed.ac.uk). Publisher Item Identifier S 1089-7771(01)02027-1. II. P OTENTIAL M ARKET In the simplest terms, the total available market is the total numbe aircraft worldwide that operate on long-haul flights. Worldwide figur are unknown. However, there are believed to be about 7000 domest and international commercial flights in the U.S. alone, with plans for an increase of 4000 airplanes over the next ten years. In the Europe Union,figures are in the order of 3000 airplanes. Moreover, as trav- eling is becoming easier and cheaper, the number of passengers flyi on long-haul routes is continually increasing, especially including th elderly high-risk age group. For example, in the last decade, passen- gers in the U.S. have doubled [1] and the Airline Transport Associa- tion estimates that 27% of its passenger miles are international; maj airlines may have as high as 40% international passenger miles. 1 Gen- eralpassenger air transport is expected to increase at an average of 7.9% per year until the year 2000. 2 Another important potential market, in the aeronautical field, is represented by corporate airplanes utiliz by business executives: more than 650 business airplanes all over th world have already been equipped with satellite connectivity and the number is increasing at a quite high pace. 3 III. LEGAL I SSUES Every country in the world has complete and exclusive sovereignty over the airspace above its territory. The only exception to this rule is that the “high seas” are free from acquisition by individual states and the airspace above them is, therefore, referred to as “internatio airspace” because it does not belong to any single country. Hence, in general, jurisdiction over an aircraft is concurrent. In fact, when a c airliner is flying in the international airspace, it adopts the law of its country of registration. If, however, the aircraft is flying over anothe country and is, therefore, in that country’s airspace, then the courts that country have jurisdiction. An Italian registered aircraft is no lon a little piece of Italy when flying over another country, but the aircra and all its passengers are bound by the laws of the territory over wh they are flying at the same time as being concurrently bound by the extraterritorial aspects of their own national laws. Consider, just as example, the situation of citizens belonging to different countries/re ligions that have to be medically treated on board airplanes which, i turn, legally represent an “extension” of the airline national territory There are still several legal differences among different countries in medical issues. An example is given by the possibility of keeping pas sengers’ medical records. Another legal problem is related with the mote diagnosis: who owns the responsibility? Statistics show that nin out of ten international flights carry a doctor or nurse [2], however, it is believed that in 40%–50% of in-flight medical emergencies, no doctors would come forward to offer any help [1]. The serious litiga- tion problem is making medical experts on board reluctant to volun- teer their help. The U.S. Good Samaritan Law that protects rescuers for example, has virtually no application in the sky. 4 Health insurance companies might pose further problems in this complex framework. 1 Information obtained from 1997 Bureau of Transportation studies (further details unknown). 2 Key Note Publications, Airlines, 1997. 3 Inmarsat website. [Online]. Available http: http://www.inmarsat.com 4 Statement of Joan Sullivan Garret, President, MadAire, May 21, 1997. 1089–7771/01$10.00 © 2001 IEEE