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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
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
PATIENT'S PERSPECTIVE
- 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.
PROVIDER'S PERSPECTIVE
- 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
- Policy development
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.
- Human factors
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
- Liability, malpractice
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
- Interstate licensure
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
- Confidentiality, security
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
- Investment Opportunities
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.
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