Telemedicine

1. Telemedicine Kelly Halbert Verizon E-Business Business Solutions February 2001

2. Agenda • Definition • History • Medical Specialties and Applications • Successful Business Models • Factors and Advantages • Technologies • Framework for Evaluation • Obstacles • Links

3. Definition • Telemedicine is the use of electronic information and communications technologies to provide and support health care when distance separates the participants. • Telemedicine is the transfer of electronic medical data (i.e. high resolution images, sounds, live video, and patient records) from one location to another. • Telemedicine is the use of telecommunications and information technology to provide clinical care at a distance.

4. History of Telemedicine (1960s-70s) • 1924 – Radio News magazine featured “radio doctor” on front cover. • 1950 – First reference to telemedicine in medical literature. • 1959 – University of Nebraska used closed-circuit television to transmit neurological examinations. • 1959 – Canadian doctor conducted diagnostic consultation based on fluoroscopic images transmitted by coaxial cable. • 1963 – Massachusetts General Hospital established telecommunications link with a 24 hour medical station at Boston’s Logan Airport. • 1965 – Ship-to-shore transmission of electrocardiograms and x-rays. • 1960s-1970s – Space Technology Applied to Rural Papago Advanced Health Care (STARPAHC) – A joint venture of the U.S. Indian Health Service, NASA, and Lockheed testing satellite-based communications to provide medical services to astronauts and to the isolated Papago Indian reservation in Arizona.

5. History of Telemedicine (1970s-80s) • 1971 – 26 sites in Alaska were chosen by NLM to see if reliable communication would improve village health care. It used ATS-1, the first in NASA’s series of Applied Technology Satellites launched in 1966. • 1974 – NASA contracted with SCI Systems of Houston to conduct a study to determine the minimal television system requirements for telediagnosis. • 1977 – Memorial University of Newfoundland developed MUN Teleconferencing System which has installations in all provincial hospitals, community colleges, university campuses, high schools, town halls, and education agencies. • 1984 – An Australian project tested a government satellite network (Q-Network) for the purpose of providing health care to the Aborigines. • 1989 – NASA conducted the first international telemedicine program called SpaceBridge to Armenia/Ufa. In December 1988 a massive earthquake hit the Soviet Republic of Armenia. Under the auspices of the U.S./U.S.S.R. Joint Working Group on Space Biology, telemedicine consultations were conducted using one-way video, voice, and facsimile between a medical center in Armenia and four medical centers in the U.S.

6. Government Institutions • National Library of Medicine (NLM) – An institute of the National Institutes of Health under the umbrella of the U.S. Dept of Health and Human Services. • Institute of Medicine (IOM) – Created by Congress in 1970 for the purpose of identifying concerns in medical care, research, and education. • National Information Infrastructure (NII) - Sometimes called the "information superhighway." The NII is an interconnection of computers and telecommunication networks, services and applications.

7. Medical Specialties • Dermatology • Oncology • Radiology • Pathology • Surgery • Cardiology • Psychiatry • Home Health Care

8. Current Applications • Rural Health – Allows people in rural areas to access timely, quality, specialty medical care. • Physicians Link – Doctors can share patient records and diagnostic images despite geographical separation. • Distance Learning – Educating medical students at remote or satellite institutions. Learning solutions for Primary and Secondary school districts, Colleges and Universities, and Corporate training. • Correctional Facilities – Reduce the costs of bringing a medical specialist to a prison or transporting a prisoner to a medical center.

9. Successful Business Models • Teleradiology – Successful because of full reimbursement by Medicare and the ability to transmit over various bandwidths. • Telecardiology – Diagnostic imaging is fully reimbursable. Telemedicine offers quicker turn around time since echocardiograms are transmitted more quickly over IP networks. • Prison Telemedicine – Profitable because it alleviates the large expense associated with transferring prisoners to and from medical facilities. • Telehome Health – A relatively inexpensive application using regular phone lines. Telehome care has been shown to reduce emergency room visits and hospitalizations in elderly populations with chronic diseases.

10. Factors that Drive Telemedicine • Decrease cost of care through increased efficiency and decreased provider time in travel. • The need to increase access to care for underserved populations. • Better communication and convenience to the patients, which increases patient compliance. • The desire to capture new markets or new patient populations. • Coordination of care throughout facilities separated by distance. • Sharing of Services. • More efficient use of provider expertise. • Affiliation agreements supported by electronic links to referring hospitals.

11. Advantages of Telemedicine • Access – Specialty care is more accessible to underserved rural and urban populations. Video consultations from a rural clinic to a specialist can reduce travel and associated cost. • Education – Videoconferencing opens up new possibilities for continuing education for isolated or rural health practitioners. • Costs – Cuts medical costs for rural areas.

12. Types of Technology • Store-and-Forward – Digital images such as x-rays, CT scans, or MRIs are stored at one location and then forwarded to another location for interpretation. Typically used for non-emergency situations where a diagnosis or consultation may be made in the next 24-48 hours. • Interactive Video – Two-way interactive television is used for a face-to-face consultation.

13. Telecommunications Technology • Ordinary Telephone – Ordinary copper phone lines have low bandwidth and therefore transmit large amounts of data very slowly. • Bandwidth – Information Carrying Capacity • ISDN – Integrated Services Digital Network – Carries voice, data, and video on one line. • T-1 – Capable of transmitting 1.544 Mbps of electronic information. • MPEG-1, MPEG-2, MPEG-4 and H.323 – Video and image technology. • ATM – Asynchronous Transfer Mode – Information is organized into cells. • Internet/Intranet – The evolution of the Next Generation Internet (NGI) Initiative and the increase in consumer demand for bandwidth are driving up Internet speeds. This is allowing more sophisticated telemedicine applications in the home. • Satellite

15. Guidelines for Designing Telemedicine Network • Interoperability – Create an open architecture that can share the national information infrastructure. • Compatibility – Newer versions of technologies must be compatible with earlier versions. • Scalability – Capable of migrating into expanded capabilities without total replacement. • Accessibility – Vendor’s accessibility in terms of sales, timely delivery, and equipment maintenance should be a purchase evaluation factor. • Reliability – The network and equipment should work as intended.

16. Objective of Telemedicine Report • To encourage evaluations that will guide policymakers, reassure patients and clinicians, inform health plan managers, and help those who have invested in telemedicine to identify shortcomings and improve their programs. • Purpose is not to endorse telemedicine but to endorse the development and use of good information for decisionmaking.

17. Evaluation Criteria • Quality – The degree to which health care services increase the likelihood of desire health outcomes and are consistent with current professional knowledge. • Accessibility – The timely receipt of appropriate care. • Cost – The economic value of resource use associated with the pursuit of defined objectives. • Acceptability – The degree to which patients and clinicians are satisfied with a service or willing to use it.

18. Framework for Evaluation • Basic Principles • Careful Planning Process • Key Evaluation Elements • Fundamental Evaluation Questions

19. Basic Evaluation Principles • Evaluations are treated as an integral part of the program design, implementation, and redesign. • Evaluations are viewed as a forward-looking process for the purpose of providing useful information to decisionmakers rather than an isolated exercise. • Evaluations are designed to compare the benefits and costs of telemedicine with those of current practices. • Evaluations focus on practical and economical ways to achieve desired results rather than investigating the most exciting or advanced telemedicine options.

20. Careful Planning Process • Evaluation planning tailors general evaluation concepts and methods to fit specific circumstances and concerns. • No “one size fits all” evaluation plan exists or can be devised to fit the array of objectives, settings, clinical conditions, populations, and technologies that characterize telemedicine.

21. Key Evaluation Elements • Project Description and Research Questions – The application to be evaluated and the basic questions to be answered. • Strategic Objective – How the project is intended to serve the purposes of the parent organization. • Clinical Objective – How the telemedicine project is intended to affect health by changing the quality, accessibility, or cost of care. • Business Plan – Formal statement of how the evaluation will help decisionmakers and what the project’s management, work plan, schedule, and budget will be. • Perspective – Whether the focus of the research questions and objectives is clinical, institutional, societal, or some combination. • Research Design and Analysis Plan – The strategy and steps for developing valid comparative information and analyzing it. • Documentation – Reporting of the methods employed in the evaluation so that others can determine how the results were established.

22. Fundamental Evaluation Questions • Quality - What were the effects of the telemedicine application on the clinical process of care compared to the alternative? • Quality - What were the effects of the application on patient status or health outcomes compared to the alternative? • Accessibility - What were the effects of the application on access compared to the alternative? • Costs - What were the costs of the application for patients, private or public payers, providers, and other affected parties compared to the alternative? • Acceptability - How did patients, clinicians, and other relevant parties view the application and were they satisfied with the application compared to the alternative?

23. Quality Question – What Were the Effects of the Telemedicine Application on the Clinical Process of Care Compared to the Alternative? • Was the application associated with differences in the use of health services (e.g. office visits, emergency transfers, diagnostic tests, length of hospital stay)? • Was the application associated with differences in appropriateness of services (e.g. underuse of clearly beneficial care)? • Was the application associated with differences in the quality, amount, or type of information available to clinicians or patients? • Was the application associated with differences in patients’ knowledge of their health status, their understanding of the care options, or their compliance with care regimens. • Was the application associated with differences in diagnostic accuracy or timeliness, patient management decisions, or technical performance? • Was the application associated with differences in the interpersonal aspects of care?

24. Quality Question – What were the effects of the telemedicine application on immediate, intermediate, or long-term health outcomes compared to the alternatives? • Was the application associated with differences in physical signs or symptoms? • Was the application associated with differences in morbidity or mortality? • Was the application associated with a difference in physical, mental, or social and role functioning? • Was the application associated with differences in health-related behaviors (e.g. compliance with treatment regimens)? • Was the application associated with differences in patients’ satisfaction with their care or patients’ perceptions about the quality or acceptability of the care they received?

25. Accessibility Question – Did telemedicine affect the use of services or the level or appropriateness of care compared to the alternative? • What was the utilization of telemedicine services before, during, and after the study period for target population and clinical problems? • When offered the option of a telemedicine service, how often did patients - accept or refuse an initial service or fail to keep an appointment? - accept or refuse a subsequent service or fail to keep an appointment? • What was the utilization of specified alternative services before, during, and after the study period for the target population and clinical problems? (e.g. consultants and patients traveling to distant sites, consultation by mail, transfers to other facilities, self-care). • Was the telemedicine application associated with a difference in overall utilization (e.g. number of services or rate) or indicators of appropriateness of care for specialty care, primary, care, transport services, or services associated with lack of timely care?

26. Accessibility Question – Did the application affect the timeliness of care or the burden of obtaining care compared to the alternative? • Was there a difference in the - time of care - appointment waiting times for referrals? • What were patient attitudes about the - timeliness of care - burden of obtaining care - appropriateness of care? • What were the attitudes of attending and consulting physicians about the - timeliness of care -burden of providing care - appropriateness of care?

27. Cost Question – What were the costs of the telemedicine application for participating health care providers or health plans compared to the alternative? • Was an application associated with differences in attending clinicians’ costs for personnel, equipment, supplies, administrative services, travel, or other items? Was an application associated with differences in revenues or productivity? What was the net effect? • Was an application associated with differences in consulting clinicians’ or consulting organizations’ costs for personnel, equipment, supplies, space, administrative services, travel, or other items? Was an application associated with differences in revenues or productivity? What was the net effect? • Was an application associated with differences in the cost per service, per episode of illness, or per member (health plan enrollee, capitated lives) per month.

28. Cost Question – What were the costs of the telemedicine application for patients and families compared to the alternative? • Was the application associated with differences in direct medical costs for patients or families? • Was the application associated with differences for patients or families in other direct costs (e.g. travel, child care) or indirect cost (e.g. lost work days)?

29. Acceptability Question – Were patients satisfied with the telemedicine service compared to the alternative? • How did patients rate their physical and psychological comfort with the application? • How did patients rate the convenience of the encounter, its duration, its timeliness, and its cost? • How did patients rate the skills and personal manner of the consultant and the attending personnel (e.g. primary care physician)? • Was the lack of direct physical contact with the distant clinician acceptable? • Did patients have concerns about whether the privacy of personal medical information was protected? • Would patients be willing to use the telemedicine service again? • Overall, how satisfied were patients with the telemedicine services?

30. Acceptability Question – Were attending/consulting clinicians satisfied with the telemedicine application compared to the alternative? • How did attending/consulting clinicians rate their comfort with telemedicine equipment and procedures? • How did attending/consulting clinicians rate the convenience of telemedicine in terms of scheduling, physical arrangements, and location? • How did attending/consulting clinicians rate the timeliness of consultation results? • How did attending/consulting clinicians rate the technical quality of service? • How did attending/consulting clinicians rate the quality of communications with patients? • Would the clinicians be willing to use the telemedicine services again? • Overall, how satisfied were the attending/consulting clinicians with the telemedicine service?

31. Obstacles to Telemedicine • Difficult to put together systems in which the components operate predictably and smoothly together. • Technical systems still may be poorly adapted to the human infrastructure of health care, that is, the work environment, needs, and preferences of clinicians, patients, and other decision-makers. • In a period characterized by increased competition, structural realignments, and surpluses of some categories of health professionals, clinicians may see telemedicine as an economic threat.

32. Obstacle: Human Factors • Telemedicine technologies are typically not “user friendly.” • Problems with the convenience, reliability, quality, and integration of equipment. • Lack of time to learn the correct use of complicated hardware or software. • Equipment purchase decisions based on grants. • Lack of flexibility with proprietary systems. • Vendor restrictions on equipment leasing. • Constantly changing sales representatives.

33. Obstacle: Physician Acceptance • Meager evidence for clinicians that an application will benefit them in their day-to-day practice. • Inadequate assessment of practitioner and community needs by those promoting telemedicine. • Practical difficulties in incorporating telemedicine into daily practice and existing physical space. Reluctant to change practice patterns. • Limited, although growing, clinician familiarity with information and telecommunications technology. A general discomfort with technology. • Uncertainties and even fears about how telemedicine will affect clinicians and organizations in a period characterized by increased competition, structural realignments, and surpluses of some categories of health professionals. Physicians fear a loss of patients. • Physicians prefer to transfer sicker patients to the hospital rather than continue to manage them with the help of the telemedicine specialist. • Fear of malpractice suits.

34. Obstacle: Reimbursement • Reimbursement – Medicare only provide full reimbursement for teleradiology and the interpretation of transmitted tests such as echocardiograms, EKGs, and EEGs. • The Balanced Budget Act of 1997 placed severe limitations on the types of providers reimbursed, services covered, and geographic areas. • Currently, only 15 states reimburse for telemedicine services under Medicaid: AR, CA, GA, IL, IA, KS, LA, MT, ND, NC, OK, SD, TX, VA, and WV. • Coverage by private payers is gradually increasing, but progress is slow as most private payers tend to follow Medicare’s lead.

35. Obstacle: State License Laws • State licensure laws are an obstacle for physicians providing services across state lines. • Telemedicine challenges the traditional concept of the face-to-face encounter between the physician and patient. The issue today is where a telemedicine physician should be licensed if the physician and patient are located in different states. • The debate lines have been drawn between those who favor limited licensure and those who propose a national licensure.

36. Legislation • Telecommunications Bill of 1996 – Competition between local and long distance companies. Rural phone providers are compensated through universal funds. • H.R. 1344 – Triple-A Health Improvement Act • H.R. 5661 - Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 • S. 770 Comprehensive Telehealth Act • S. 980 Promoting Health in Rural Areas

37. The Possibilities • Telemedicine has the potential to be more practical, affordable, and sustainable than traditional programs. • Telemedicine could fundamentally alter the personal, face-to-face relationship between patient and practitioner that has been the model for medical care for generations.

38. Future • Once the current barriers are resolved, the practice of telemedicine will likely undergo a radical change and transition from its current state of grant-funded projects, military demonstration projects and a few self-funded programs, to become a major industry within the health care field. • Virtual On-Line Medical System

39. Virtual Tour • 3Com Solutions Lab Virtual Tour • 3Com Telemedicine Overview • American Telemedicine Association (Links) • East Carolina University Telemedicine • Telehealth Technology Guidelines • University of Iowa Virtual Hospital

40. Telemedicine Sites • American Telemedicine Association (ATA) • Association of Telemedicine Service Providers (ATSP) • Center for Telemedicine Law • Health Sciences Communication Association (HeSCA) • International Society for Telemedicine (ISFT) • NASA Telemedicine • Telemedicine Information Exchange (TIE) • U.S. DOD Telemedicine • Veteran's Affairs Telemedicine Initiatives

41. Federal Funding for Telemedicine • The Health Resource Service Administration • The National Library of Medicine • The National Telecommunications and Information Administration's Office of Telecommunications • The Rural Utilities Services Telemedicine Program (USDA)

42. Telemedicine Publications • Telehealth Magazine • Telemedicine Journal and e-Health • Telemedicine Primer • Telemedicine Today Magazine

44. Sources • Telemedicine: A Guide to Assessing Telecommunications for Health Care. The National Academy Press, 1996. • National Information Infrastructure (NII) • National Library of Medicine (NLM) • Telehealth Technology Guidelines • Telephone Information Exchange (TIE)