As the health care system continues to change and adapt to the new realities associated with finance and management restructuring, the technological side of patient care also has changed. Telemedicine is a new word found in the constantly changing vocabulary of the American health care system. But what is telemedicine? Telemedicine is the use of electronic information and communication technologies to provide and support health care when distance separates the participants. It is a system that connects primary care physicians, providers, specialists and patients. Telemedicine is not a new concept. It has existed for a number of years in the form of the telephone and fax machines. In recent years, with the improvements made in access, technology, and communications systems, telemedicine has expanded and, in a time of limited resources, has become a feasible alternative for smaller and rural medical facilities to provide routine and specialized services. Particularly in rural areas, it offers the potential of both improved access to care and improved quality of care.
The primary applications of telemedicine are clinical, educational, administrative, and research. Clinical applications include initial patient evaluations, diagnosis (telediagnosis), and consultation (teleconsultation). Physician supervision of non- physicians and monitoring of patient status are possible. Continuing education for professionals is available, as is patient and community education (tele-education). Administrative uses, such as conferences, scheduling, and utilization and quality review may be provided. Research is enhanced by aggregation of data from multiple sources and coordination.
Telemedicine allows access to the wealth of information available on the Internet. This allows information to be at the touch of a finger. The availability of e-mail allows an efficient mechanism of communication between consulting and primary physicians. Communication between facilities is enhanced.
Transmission and Equipment
Text, images, and sound are transmitted. Text includes EKG results (heart tracings), lab results and patient records. Images range from still photographs to full motion imagery. Radiological images, slides and graphics may be transmitted, as well as voice and chest sounds. Transmission may be done in one of two methods: Real-time or Store and Forward. Real-time transmission is utilized when immediate feedback is essential. Emergency triage, interactive treating situations and meetings are a few examples. When immediate feedback is not required, store and forward may be implemented. Data is stored, forwarded and accessed at the hub at a scheduled time or at the convenience of the hub personnel. This is less costly as data can be compressed and batched for transmission. Transmission equipment varies according to the transmission mode, analog or digital, and the means of transporting the mode, satellite or terrestrial. There are two transmission modes. The first is analog, which is the transmitting of waves, similar to television broadcasts. Its advantages include high resolution and familiarity. The high expense associated with transmission, large size, and complexity of required hardware are disadvantages. The digital mode utilizes the transmission in the form of "bits". Transmission costs, smaller equipment, simplicity of operation, ease of interface, (including the storage and revival systems for image and data) are several benefits of this mode. The digital mode is preferred due to cost, usability, and expansion potential.
The transmission mode may be transported via satellite or terrestrial media. Terrestrial modes include microwave, fiber-optic, and conditioned copper cables. Satellite transmission allows a full motion broadcast quality picture. Most satellites transmit analog signals. Signals may be transported on C-Band or KU-Band. The C-Band is often utilized by local telephone companies, requiring coordination of availability. The KU-Band, utilized by television stations, is more widely available.
Satellite transmissions have no boundary restrictions. It allows transmission of large amounts of information. It is ideal for sending visual information to multiple locations. The disadvantage is the cost. It is approximately eight times as expensive as terrestrial transmission. The cost may be as high as $450 per hour for prime time use to $250 per hour for non-prime time.
Terrestrial transmission is less expensive to operate on an hourly basis but is limited to areas that are linked to the appropriate line. Video transmission normally requires a bandwidth (carrying capacity) of 90 million bits per second (Mbps). A telephone call requires 64 thousand bits per second. The fastest speed available with current digital technology is 1.54 Mbps. This requires a bandwidth commonly referred to as T1. T1 consists of 24 voice channels which may be combined with higher bandwidth as needed. The higher the bandwidth, the better the image quality. Higher cost is the trade off for better image quality.
Fiber-optics are available from long distance and local telephone companies. Optical fibers consist of strands of hair-thin glass and uses light to transmit telecommunication signals. They may be leased as a dedicated line or on-demand basis. Optical-fiber has a wide bandwidth allowing for choices of transmission speed. Due to cost constraints, T1 line is not available in all areas. Satellite transmission requires an up-link to the satellite and a down- link to the location. The KU-Band satellite dish is relatively small and portable on a truck. The C-Band satellite dish is large and not very portable. If the satellite transmission is digital, equipment is needed at each site to translate analog signal to digital.
The CODEC (Coder,DECoder) is the heart of the system. The CODEC transforms the analog signal (the picture) picked up by the video camera to a digital signal and compresses it from transmission to the distant site. Another CODEC, at the distant site, transforms the digital signal for viewing on the video monitor. The CODEC, a computer, needs enough memory to transmit and store text and images, such as patient records and educational material.
Each site requires a camera to transmit live images. At each site a speaker and monitor are required so users can see and hear each other. In addition, a site requires a multiplexer, a device that allows two or more signals to be sent over the same path. A CSU/DSU (Channel Services Unit/Data Services Unit) converter is needed to interface to the T1 service. A wide variety of medical devices (e.g. cardiac monitors) are available for the remote sites.
Benefits of Telemedicine
Telemedicine allows patients to receive medical care in their own community. This increases the financial viability of rural medical facilities and strengthens the rural economy by keeping the flow of resources in local communities. Telemedicine assists in providing specialty care services to rural areas and provides more efficient use of medical resources which may lessen the amount of travel time for both patients and the specialist. Continuity of patient care is enhanced when the patient, primary care physician, specialist and family members are involved during a consultation. Should the patient be required to be transferred to an urban facility, they have already met the physician who will be caring for them.
Physicians and on-site care providers benefit as they receive quick and efficient consultations. The sense of isolation experienced by rural physicians is also reduced. The formation of health care networks between rural and urban facilities provide benefits to both. Urban based facilities provide accessibility of health care to rural areas. However, there are telemedicine networks where the excess capacity of rural facilities can be tapped into to benefit urban patients. It is possible that during peak times rural physicians may be accessed via telemedicine to provide more timely care to patients waiting in congested urban emergency rooms.
Challenges of Telemedicine
Several obstacles remain with regard to the effectiveness of telemedicine. Legal issues regarding physician licensing, liability, and patient confidentiality exist. As physicians are licensed by states, this presents a legal problem when physician consults cross state lines. It is necessary in order to fully benefit from telemedicine that states engage in interstate provision of service. Currently, interstate agreements vary greatly. Several states maintain that physicians must be licensed in both the sending and receiving states. Other states have entered reciprocity agreements with neighbors.
Liability is an obstacle in providing telemedicine. There is debate related to which physician would be liable for a poor patient outcome, the primary care or the consulting physician. In the case of a poor outcome, it is not clear if the patient should file suit in the residing state or in the state the practitioner is located.
Cost is a significant barrier to access. It has been estimated that the startup cost for a rural facility can be $100,000. In addition to start up costs, consideration must be given to the charge by the consultation team. This may range from $75-250 per hour, depending on the type and number of consultants involved. Transmission charges can be costly. Some progress has been made in this area with the passage of the Telecommunication Competition and Deregulation Act of 1996. As of January 1, 1998, the Federal Communications Commission (FCC) and states can require affordable, quality communication services. Included is an amendment requiring public and non-profit rural health care providers access to telecommunication service at prices comparable to those paid by urban customers. The rules specifically authorizes discounted rates for telecommunication distant charges, toll-free access to the Internet, and telecommunication services of bandwidth up to and including Mbps (T-1).
Reimbursement has been another obstacle in providing telemedicine services. Medicaid covers telemedicine consultation in only ten states. Medicare will reimburse for telemedicine services provided in rural counties that are designated as health professional shortage areas. This Medicare provision, authored by North Dakota Senator Kent Conrad, was part of the Balanced Budget Act of 1997. Most commercial payers do not cover routine telemedicine consultation.
Physician reluctance and patient apprehension are also obstacles. Some rural physicians fear the loss of patients to urban facilities. The public and physicians worry about the impersonality of telemedicine.
BENEFITS OF TELEMEDICINE:
In this paper we introduce a brief examination of the benefits realized from the growing use of telemedicine from three perspectives: 1) Economic development and quality of life, 2) Patients, and 3) Providers. We conclude with a brief introduction to telemedicine challenges.
Telehealth is "the practice of healthcare delivery using telecommunications technology including but not limited to diagnosis, consultation, treatment, transfer of medical data, education, dissemination of public health alerts and/or emergency updates". Telemedicine is "the use of telecommunications technology to deliver clinical diagnosis, services and patient consultation".1 Applications can be real-time or store-and-forward. For the purposes of this paper we limit discussion solely to telemedicine, recognizing the many inter-locking linkages with the larger topic of telehealth.
The costs of health care impose an enormous burden on the economy. The latest projections from the Centers for Medicare & Medicaid Services show that annual health-care expenditures are expected to reach $3.1 trillion by 2012, growing at an average annual rate of 7.3% during the forecast period or 17.7% of gross domestic product, up from 14.1% today.2 Telemedicine will become a multi-billion dollar industry.3 But just what are the benefits of telemedicine?4, 5
ECONOMIC DEVELOPMENT AND QUALITY OF LIFE PERSPECTIVE
Advancements in delivery of services
Certain health services can be greatly enhanced via telemedicine. For example, home health services are receiving a great deal of attention and investment in some states. Telemedicine technologies enable home health providers to redefine patient treatment plans, as they are able to increase patient visits due to elimination of a significant percentage of travel to patients' homes.6 Rural patients can now have access to specialists.7
Keeps dollars in the local economy
Telemedicine helps provide service locally so people don't have to travel out of the community for care. Spending on health care is an especially significant portion of any economy, especially rural economies. The more of those dollars that can be kept locally the better off the local economy will be. Standard economic multiplier effects also apply here -- any money spent locally ripples through the local economy.
Aids business recruitment and retention
Telemedicine provides the capability to deliver clinical services in the community. Locally available quality health care and quality schools are two important factors in the recruitment of new businesses, especially for businesses in rural communities. So there is a potential business recruitment and retention factor to consider.
Workforce development / jobs
There is a severe shortage of medical staff, particularly nurses, in rural hospitals.8, 9, 10 At the same time there is high poverty and unemployment in our rural communities.11 One way to address that problem is to equip local healthcare facilities with advanced telecommunications services for telemedicine purposes and then to appropriately share the videoconferencing capability in a partnership with educational institutions to train more local people for the jobs in health care that are available locally. Local jobs for local people could be a significant economic impact particularly for people who could not afford to travel outside the community for training.
Quality of life and longevity gains are worth a lot
Use of telemedicine can have a significant impact on individual health and can therefore favorably impact longevity. The value to the economy of improvements in life expectancy is about as large as the value of all other consumption goods and services put together. It is an intriguing thought to contemplate that the social productivity of health-care spending might be many times that of other spending.12
Clinical trials represent a multi-billion dollar business that could apply telemedicine technologies to extend the reach of clinical trials to include provider and patient participation from rural communities.13
Access to healthcare
Access to quality, state of the art health care in underserved areas, such as rural communities, is one of the most important promised benefits of telemedicine. Rural residents are not second-class citizens; they deserve access to health care services that those in metropolitan areas enjoy. Over 55 million people (20% of the U.S. population) reside in rural America and having local quality health care is important to them.
Saves time, travel, and other expenses
Telemedicine entails moving from a service delivery system in which patients (and often parent or guardian) physically travel from a rural area where they reside to an urban area to consult with a medical specialist, to a system in which the specialist consults with the patient and rural primary care provider using telecommunications facilities. An obvious opportunity is the potential for transportation cost savings, such as the potential for saving a portion of the millions spent annually on patient automobile travel expenses, emergency air evacuations or other forms of transporting patients across the large expanses of rural America.
Healthcare at home
Home care and community based health services are becoming an increasingly important part of the healthcare service continuum. There are many reasons for this including: patients are leaving hospital sooner and need some additional care at home while they recover, treating patients at home is less expensive than treating them in the hospital, many patients prefer to stay in their homes as long as possible before moving onto a higher level of healthcare service, e.g. nursing home, hospice. A research project found that telehome care allowed home care nurses to "see" more patients in a day, decreased the visit time and ended up costing 33-50% less than the traditional home care visit.
Health provider integration
Improved collaboration between providers (e.g., shared access to electronic medical records and provider to provider consultations) provides patients with enhanced confidence that all that can be done is being done.
Comfort-level with the technology
Television and computer applications are more common and not a foreign concept. Patients are now more at ease and accepting of the use of this application of technology.
Emergency Room “front line” support
Instant access to information, whether it be about a certain patient or a certain topic, can be essential or even life saving. Here we cite the story of a rural doctor who had never before done an amputation being helped through the procedure by a well practiced physician over a video link. The two saved the life of the amputee, who did not have enough time to reach the larger facility.14
Accuracy of diagnosis / reduction of medical errors
Reduction of medical errors is a huge concern for the medical community.15 Getting it right on the first try is obviously the preferred way of doing things. With "tele-assistance" (e.g., communication with specialists), it is hoped that it will be easier for a doctor to get a "second opinion" on their diagnosis of a patient. With greater access to help, more patients will be treated correctly, the first time. This leads to even more benefits, such as quicker average recovery time, less use of unneeded medicines, and reduced costs to patients and hospitals.
A multifold increase in efficiency
Travel times for patients and doctors could be significantly reduced as well as research time and "paper handling" of medical records (which can be unbearably slow). It has already been seen that telemedicine on foreign military bases has sped up the whole process of treatment for soldiers abroad. Consultations from major medical centers to the military bases make diagnosis quicker and more accurate. Telemedicine saves time over traditional "paper-based" data transfer.
Continuing Medical Education / Lifelong learning
Telemedicine can enhance educational opportunities for health care providers, patients, and families, improving clinical outcomes and reducing hospitalizations. The opportunity to participate in continuing education on the latest in medical advances without having to travel long distances saves providers time, dollars and minimizes air pollution.
CHALLENGES TO TELEMEDICINE
Health care organizations should develop telemedicine policies. To be successful and sustainable, telemedicine must be fully integrated into existing health structures and processes in a practical and policy manner. Integration can be achieved through aligning telemedicine initiatives with existing strategic health plans, policy goal-setting, accompanying action steps, and attention to policy barriers. Establishment of a policy forum that focuses on telemedicine policy would facilitate these needs. Telemedicine policies should incorporate capacity for education, research, and administrative functions, as well as healthcare functions.
Expansion of usage
Education about the nature and scope of telemedicine should further expand utilization. It should also increase the appreciation of the critical issues associated with successful implementation and evaluation, including a fundamental understanding of the technology and financial structures. Adequate reimbursement mechanisms would likely drive a more rapid expansion of telemedicine.
Connectivity to rural and remote communities /standards / interoperability
To facilitate access to many bandwidth intensive telemedicine applications increased broadband connectivity is needed, particularly to rural and remote communities. Standards need to be defined and agreed on to ensure interoperability of networks and applications. Technology modalities (broadband, narrowband, web-based) and applications (videoconferencing, data monitoring, telephone) should be viewed as synergistic, not competitive, and the most appropriate tool applied (i.e., hybrid connectivity solutions are recommended). A role still remains for simpler technology, such as the telephone, and can be used successfully for patient assessment, triage, monitoring, reminders, or direct intervention.
Costs / Evaluation / Outcomes
Although much anecdotal evidence exists, there is scant hard evidence that the communications technology will provide appropriate health care at a reasonable cost, despite the fact that in certain situations the cost-effectiveness of telemedicine appears obvious. Therefore, before payers and providers are willing to move on the issue, they want to know the likely economic effects of the use of telemedicine. Reimbursement policy issues are further complicated by rapid changes in equipment technology and faster communications networks that are making telemedicine capability more mobile, available for more applications, and with lower equipment costs and operational expenses. Metrics for telemedicine outcomes should be developed to demonstrate sufficient evidence of socio-economic benefit to indicate ongoing investment is appropriate. Evaluations should include examination of the social, cultural, organizational, and policy aspects of telemedicine. Suitable frameworks for economic analysis should capture non-monetary and unintended consequences, as well as monetary measures. Full integration of telemedicine will increase its use and decrease the per contact episode cost. Investment in information and communications technology infrastructure should be considered as an investment not only in health, but also in business, education, and other e-sectors. Sustainable telemedicine 'programs' and not 'projects' should be targeted.16
Reimbursement / Funding / Sustainability
Ongoing political developments raise the perennial question about whether telemedicine will survive in the face of reduced federal government grants. More directly, if programs receive fewer grant dollars, what will become of telemedicine practice in the U.S.? Grants can provide the funds for initial capital investment, but programs need to devise, right up front, a business plan for keeping this going after the seed money is gone. Telemedicine is a cost center, not a revenue center. Information technology is also a cost center, proving you have to have them even if it doesn't make money. Telemedicine can be used to drive patients to revenue centers, as well as a pathway to revenue generating centers. We need to explore traditional as well as non-traditional sources of funding, including internal revenue sources, government grants, corporate support, public and private insurers, and statewide purchasing groups.
A critical hurdle must be overcome if telemedicine is to have a favorable impact on health care. The products and systems, processes, and procedures that make up telemedicine must be usable. The degree to which telemedicine's components are usable will either inhibit or facilitate its acceptance, use, and growth and its effectiveness as a model for medical care provision. Poor usability could at a minimum retard the growth of telemedicine and drastically reduce acceptance of telemedical technologies. The addition of nonprofessionals to the ranks of users will amplify the role of human factors in facilitating interaction in telemedical areas. This large audience will be less educated and less sophisticated than practitioners and will include a wide range of capabilities and limitations.17
The changes telemedicine will bring to medical practice exacerbate the changes deriving from the proliferation of managed care integrated delivery systems and the contraction of the health care industry. The solo practitioner revered by Norman Rockwell is rapidly becoming extinct, superseded by groups of providers employed by or engaged in contractual partnerships with one or more integrated managed care plans. The community hospital of the mid-twentieth century has merged, remerged "Benefits of Telemedicine" Page4 Telemedicine Association of Oregon Revised: 16 January 2004 http://www.atsp.org/business/otalink/homepage.asp and now emerged as part of an organized network of hospital services, often affiliated with one or more health plans. Among the implications we need to better understand in the context of the changes occurring in the practice of medicine as a result of telemedicine is that of "shared liability" applicable to health plans and managed care entities.18
Telemedicine holds great potential to expand service to medically underserved populations and improve their access to health care. Yet, when patients and practitioners are located in separate states the issue of practitioner licensure arises. State-level licensure laws that regulate interstate telemedicine practice are not uniform from state to state, in part because of the varying political climate. Like any other type of statute, these laws have been shaped by their respective stakeholders, and can be considered either restrictive or reciprocal. A number of states have not passed an interstate telemedicine licensure law and therefore do not fall neatly into either category.19
Because medical information is connected to telecommunications lines and computers, they will always be at risk. Even with high tech firewalls and other security devices there is a great deal of risk. The electronic misappropriation of health information is very real as there is a market for the sale of private information. Telemedicine practitioners will be held liable for breaches of security and any unauthorized access. The legal issue will be not whether electronic patient information systems can provide airtight security, but whether such systems can provide privacy protection equal to or better than paper record systems. The customary privacy and confidentiality of the medical setting cannot be guaranteed in telemedicine, because the patient's records and medical history are conveyed not only to the consulting physician, but also, by necessity, to several individuals outside the traditional medical team. The transmission procedure requires technical staff at both ends. In small communities, it is possible that the patient knows the non medical personnel socially, compounding the sense of loss of privacy. Thus, the nature of the doctor patient relationship changes dramatically with telemedicine, challenging traditional concepts of privacy and confidentiality.20
Research, development and investment opportunities abound in this rapidly growing arena. Opportunities in telemedicine technology include equipment sales, transmission, service and maintenance. The sector is ripe with opportunities for information technology vendors and service and training providers.21
The advent of telemedicine brings some very useful technology to the medical community of the Oregon and the rest of the U.S.. Yet many challenges remain ahead. Everything about the suggested programs for telemedicine also depends on the hurdle of availability. WILL BROADBAND INTERNET SERVICES BE AVAILABLE TO ALL AMERICANS? Within the answer to this question lies the answer to whether telemedicine is going to be a beneficial product of the technological age.
Telemedicine, if used to its full extent, has the potential to cause great and far-reaching effects on the field of medicine. That is why it is important to take a look at the possibilities and limitations now. In that way we prepare to make the most of the technology available to us in the 21st Century.