Telerehabilitation position paper

Though the use of telerehabilitation technologies is expanding quickly as a viable method of service delivery for many practitioners within the field of health care, there remain issues of efficacy, cost, reimbursement, legal and ethical ramifications, and practitioner competence. There is a significant need for occupational therapy practitioners to document, research, and publish on the efficacy of consultation, intervention, and follow-up services provided using telerehabilitation technologies. Further investigation of the use of telehealth technologies in professional development and supervision is needed to clarify effectiveness and efficiency, as demand for services, particularly in rural areas, threatens to exceed services available. Occupational therapy practitioners using telerehabilitation methods must adhere to the AOTA Occupational Therapy Code of Ethics (AOTA, 2000), maintain the AOTA Standards of Practice (AOTA, 2005), and comply with state regulations, ensuring both their proficiencies as practitioners and the well being of their clients.

[Economic aspects of telemedicine]

The aim of health technology assessments is to study the incremental impact of health interventions within a complex care system characterised by a multitude of individual behaviours and institutions. Most frameworks available for telemedicine evaluation simply examine financial costs relative to face-to-face consultations. Current data collection systems are poorly suited to rigorous analyses of new networks in everyday situations. Randomised trials are designed to remove sources of interference that could mask a causal relationship between a new organization and a set of results. Their methodology, which introduces the term ceteris paribus into the principles of good practice, is poorly suited to analyzing individual behaviours. Observational studies attempt to describe actual treatment situations as accurately as possible. By definition, however, they assume that the natural course of events is not deviated by interventions. The absence of an experimental plan increases the likelihood of bias and makes it more difficult to test for causal relationships. These approaches are poorly suited to testing for incremental effectiveness. Quasi-experimental studies and a staged approach would be more suited to a comprehensive assessment of telemedicine initiatives. In this way its impact on effectiveness, integration of care, quality of life and social costs may be identified in normal conditions of use.

Randomized clinical trial of a postdischarge pharmaceutical care program vs. regular follow-up in patients with heart failure

OBJECTIVE

To assess the efficacy of a multifactorial educational intervention carried out by a pharmacist in patients with heart failure (HF).

METHOD

A randomized, prospective, open clinical trial in patients admitted for HF. The patients assigned to the intervention group received information about the disease, drug therapy, diet education, and active telephone follow-up. Visits were completed at 2, 6, and 12 months. Hospital re-admissions, days of hospital stay, treatment compliance, satisfaction with the care received, and quality of life (EuroQol) were evaluated; a financial study was conducted in order to assess the possible impact of the program. The intervention was performed by the pharmacy department in coordination with the cardiology unit.

RESULTS

134 patients were included, with a mean age of 75 years and a low educational level. The patients of the intervention group had a higher level of treatment compliance than the patients in the control group. At 12 months of follow-up, 32.9% fewer patients in the intervention group were admitted again vs. the control group. The mean days of hospital stay per patient in the control group were 9.6 (SD=18.5) vs. 5.9 (SD=14.1) in the intervention group. No differences were recorded in quality of life, but the intervention group had a higher score in the satisfaction scale at two months [9.0 (SD=1.3) versus 8.2 (SD=1.8) p=0.026]. Upon adjusting a Cox survival model with the ejection fraction, the patients in the intervention group had a lower risk of re-admission (Hazard ratio 0.56; 95% CI: 0.32-0.97). The financial analysis evidenced savings in hospital costs of euro 578 per patient that were favorable to the intervention group.

CONCLUSIONS

Postdischarge pharmaceutical care allows for reducing the number of new admissions in patients with heart failure, the total days of hospital stay, and improves treatment compliance without increasing the costs of care.

The legal and economic forces that will shape the international market for cybersurgery

BACKGROUND

Despite the common use of medical devices most health care providers have little understanding how a device alters medical malpractice litigation. Such knowledge will be increasingly valuable as cybersurgery (i.e. remote robotic surgery) becomes routine.

METHODS

Review of the laws governing products and telecommunication liability.

RESULTS

Litigation after cybersurgery will be complex. In addition to being able to sue physicians and hospitals, patients who sustain an adverse outcome after cybersurgery will have the potential to sue the robotic manufacturer and telecommunication company. Robotics manufacturers can obtain virtual immunity from liability if they elected to place their devices on the market after obtaining [see text]360 per-market approval from the FDA. However, because [see text]360 pre-market approval is expensive and time consuming most medical devices on the market (including the robotic surgical instruments) do not have immunity to products liability. Consequently, after an adverse cybersurgical outcome a manufacturer of a robotic surgical instrument faces liability for failure to warn, design defects, and failure to properly manufacture. As for telecommunication providers, existing law provides them with immunity from liability.

CONCLUSIONS

Litigation following cybersurgery will involve multiple defendants who are likely to use "finger pointing" defenses. Accordingly, there will be liability traps associated with providing cybersurgery.

Design and implementation of the telemedicine-enhanced antidepressant management study

OBJECTIVE

Evidence-based practices designed for large urban clinics are not necessarily transportable into small rural practices. Implementing collaborative care for depression in small rural primary care clinics presents unique challenges because it is typically not feasible to employ on-site mental health specialists. The purpose of the Telemedicine-Enhanced Antidepressant Management (TEAM) study was to evaluate a collaborative care model adapted for small rural clinics using telemedicine technologies. The purpose of this paper is to describe the TEAM study design.

METHOD

The TEAM study was conducted in small rural Veterans Administration community-based outpatient clinics with interactive video equipment available for mental health, but no on-site psychiatrists/psychologists. The study attempted to enroll all patients whose depression could be appropriately treated in primary care.

RESULTS

The clinical characteristics of the 395 study participants differed significantly from most previous trials of collaborative care. At baseline, 41% were already receiving primary care depression treatment. Study participants averaged 5.5 chronic physical health illnesses and 56.5% had a comorbid anxiety disorder. Over half (57.2%) reported that pain impaired their functioning extremely or quite a bit.

CONCLUSIONS

Despite small patient populations in rural clinics, enough patients with depression can be successfully enrolled to evaluate telemedicine-based collaborative care.

Tele-cardiology

After defining tele-medicine, we describe its situation in the public health service of South Africa and its application to cardiology. Methods of communication relevant to tele-cardiology are outlined, together with their bearing on primary healthcare. The range of tele-cardiological applications to electrocardiology, echocardiology, auscultation, imaging and pathology are indicated. Tele-cardiology's contributions to a range of cardiological problems and types of management are described briefly. Finally, a mention is made of the relevance of tele-medicine to education and the costs related to cardiology, with an indication of some future needs for tele-cardiology.

Cost-effectiveness analysis of telemedical devices for pre-clinical traffic accident emergency rescue in Germany

OBJECTIVES

The purpose of this study is to assess the cost-effectiveness (net costs per life year gained) of telemedical devices for pre-clinical traffic accident emergency rescue in Germany.

METHODS

Two equipment versions of a telemedical device are compared from a societal perspective with the baseline in Germany, i.e. the non-application of telemedicine in emergency rescues. The analysis is based on retrospective statistical data covering a period of 10 years with discounted costs not adjusted for inflation. Due to the uncertainty of data, certain assumptions and estimates were necessary. The outcome is measured in terms of "life years gained" by reducing therapy-free intervals and improvements in first-aid provided by laypersons.

RESULTS

The introduction of the basic equipment version, "Automatic Accident Alert", is associated with net costs per life year gained of euro 247,977 (at baseline assumptions). The full equipment version of the telemedical device would lead to estimated net costs of euro 239,524 per life year gained. Multi-way sensitivity-analysis with best and worst case scenarios suggests that decreasing system costs would disproportionately reduce total costs, and that rapid market penetration would largely increase the system's benefit, while simultaneously reducing costs.

CONCLUSION

The net costs per life year gained in the application of the two versions of the telemedical device for pre-clinical emergency rescue of traffic accidents are estimated as quite high. However, the implementation of the device as part of a larger European co-ordinated initiative is more realistic.

My computer, my doctor: a constitutional call for federal regulation of cybermedicine

Color it green. In a health care era driven by consumer demand, consumers are increasingly seeking Internet-based health services. Every day approximately seventy-three million Americans access the Internet in search of health information, with an average of six-million people seeking health advice. At present, a supply of over one-hundred thousand health-related websites serve the public’s demand for information and advice, with an average of one-thousand five hundred new sites added monthly. Surprisingly, consumers and students make up more than 30% of all healthrelated website users.4 From this union of cyberspace and the medical field, cybermedicine has emerged.

What does cybermedicine encompass? Cybermedicine is “the science of applying Internet and global networking technologies to medicine and public health, of studying the impact and implications of the Internet, and of evaluating opportunities and the challenges for health care.” General use of the Internet under this definition encompasses exploration and exploitation of the Internet for consumer health education, patient self-support, and professional medical education and research.

Auto TeleCare – understanding the failures and successes of small business in telehealth

Auto TeleCare provided an automatic daily telephone service for people living alone. The business used an interactive voice response (IVR) system to call clients at a set time each day. The clients were required to press a button on their telephone to listen to a message (e.g. joke of the day), thereby indicating that they were alright. If the client did not respond, staff would call the given list of contacts to check on the client's welfare. The service was first offered in December 2003 and there was a lot of interest from clients and health-care groups. Although the technology was sophisticated, it was very simple for the clients to use. However, it was the marketing and advertising costs of the business that in the end proved to be too costly. The number of clients required for commercial viability was calculated to be 3,000, and after nearly 15 months of business it was decided to close the business.

Telemedicine in radiotherapy: a study exploring remote treatment planning, supervision and economics

In January 2002, the departments of radiotherapy at the University Hospital of North Norway and the Norwegian Radium Hospital were connected through a 2 Mbit/s digital telecommunication line. The treatment planning systems at the two institutions were connected and videoconferencing units were installed. We explored the feasibility of remote treatment planning, supervision, second opinions and education. Tests involved two dummy cases and six patients. Remote simulation procedures were carried out for five patients. A cost-minimization analysis was performed. Treatment planning was not completely successful as the software could not handle plans including bolus or weighting between the fields. Remote supervision was possible. A common patient record and radiotherapy system, including digital imaging, digital prescription and approval forms and digital signature, were felt to be desirable. The threshold (break-even point) comparing the costs of telemedicine with those of transportation by air was 12 patients/year. Telemedicine in radiotherapy appears to be feasible, but some limitations must be overcome.

Telemedicine in haemodialysis: a university department and two remote satellites linked together as one common workplace

A common workplace was established between the renal unit at the University Hospital of North Norway and two satellite dialysis centres, in Alta and Hammerfest. A 2 Mbit/s ATM network was employed for IP-based videoconferencing. A common electronic medical record system and dialysis monitoring software were used. During an eight-month study period, nine patients were enrolled and 225 videoconferences were performed for daily visits and regular rounds. A bandwidth of 768 kbit/s was required for satisfactory teledialysis. Although technical (28%) and logistical problems (10%) were frequent, five hospitalizations and one-third of the planned visiting rounds were avoided. An economic analysis showed that annual savings amounted to US$46,613, while annual costs were US$79,489. Despite the technical difficulties in about 30% of conferences, the nurses were satisfied with the videoconferencing system. Digital X-rays were communicated without problems. The pilot study indicates that satellite units may be incorporated into the daily management at the central institution by telemedicine.

Improved access to subspecialist diabetes care by telemedicine: cost savings and care measures in the first two years of the FITE diabetes project

We have used telemedicine clinics supplemented by online education to provide effective care for children with diabetes. Before the programme began, the mean interval between visits was 149 days; in year 1 of the programme it was 98 days, and in year 2 it was 89 days. Before the programme, there were on average 13 hospitalizations a year (47 days) and this decreased to 3.5 hospitalizations a year (5.5 days). Emergency department visits decreased from 8 to 2.5 per year. On 10 occasions after the programme started, ketosis was managed by telephone intervention alone, relying on family-initiated calls. Over 90% of patients and family members expressed satisfaction with the telemedicine service and wished to continue using it. In all, 95% felt little self-consciousness. Over 90% felt their privacy was respected. The programme saved US dollar 27,860 per year. The present study demonstrated improved access to specialized health care via telemedicine in combination with online education improved health status and reduced costs by reducing hospitalizations and emergency department visits.

Comparing willingness to pay for telemedicine across a chronic heart failure and hypertension population

This paper presents estimates of the willingness to pay for a new telemedicine technology in the absence of market data. The study utilizes a contingent valuation method to determine patient willingness to pay for access to telemedicine services. Willingness to pay was assessed in two populations: patients who are being treated for chronic heart failure (CHF) and patients who are being treated for hypertension. Patients who were approached to participate in these studies were asked about their preference for using telemedicine technologies. We find that patient willingness to pay has the expected negative relationship between price and the likelihood of purchase and that patients with CHF are less responsive to price changes than those with hypertension.

A cost analysis of participation via personal attendance versus telemedicine at a head and neck oncology multidisciplinary team meeting

Multidisciplinary team (MDT) meetings are used for establishing diagnosis, for tumour, node, metastasis (TNM) classification and for treatment in head and neck tumour patients in the western region of Sweden. Because of the distances, telemedicine was introduced to link the regional hospital to two of the three district general hospitals (DGHs). We evaluated the costs of presenting patients face to face (FTF) versus via telemedicine. Cost analyses were based on questionnaires completed by patients presented at the MDT meeting. A total of 39 patients were included in the FTF group and 45 patients in the telemedicine group. The cost analysis showed that FTF presentation cost SEK 2267 versus SEK 2036 by telemedicine (difference not significant). The small difference was explained by the fact that the responsible physician accompanied only six of 39 patients when presented FTF, but when presented via telemedicine the DGH physician always participated. A sensitivity analysis revealed that if the responsible physician always accompanied his/her patient for presentation FTF, the cost would be SEK 5366 per patient. This study shows that costs may be saved by carrying out MDT meetings by means of telemedicine instead of FTF.

Research findings and strategies for assessing telemedicine costs

With varying degrees of enthusiasm, researchers and decision-makers support the use of telemedicine. Forms of telemedicine are appearing in health-care delivery, and are often integral to transforming health-care information technology. Despite this, the appropriate role of telemedicine in the delivery process remains ambiguous, at least partly because of its uncertain impact on costs. Cost savings and benefits are often suggested by the logic of its impact on health care and by the promise of technology, but definitive information on the costs and benefits remain elusive. The objectives of this paper are to review the state of telemedicine cost research, to examine major issues affecting the yield from this research, and finally to recommend strategies for improving future research. As this paper demonstrates, the productivity of telemedicine cost studies suffers from an under-utilization of appropriate program evaluation and economic methods. This review of telemedicine cost literature will appraise telemedicine cost studies and their findings within a broad analytic framework. Telemedicine cost studies will be assessed on their methods of statistical inference, use of critical economic concepts, and contextual definition for the determination of costs and benefits.

Implementing a teledermatology programme

Although teledermatology has been beneficial and cost-effective in some settings, many programmes have failed, not because of the technology but because teledermatology was implemented in isolation. A thorough understanding of an organization's business process and business model is crucial before teledermatology is begun. Unless teledermatology is integrated into the current business process and model, the likelihood of success is greatly reduced. Important steps therefore include: (1) understanding how the organization delivers care; (2) analysing the alternatives, including cost-benefit analysis; (3) obtaining organizational support; (4) formulating an execution plan; (5) training staff and monitoring the process. If implemented correctly in the appropriate setting, teledermatology can significantly improve access and quality of care, while reducing or containing costs.

Supporting frail older people and their family carers at home using information and communication technology: cost analysis

AIM

This paper describes a cost analysis of a home-based support service for frail older people and their family carers in two municipalities in West Sweden and using information and communication technology.

BACKGROUND

A key challenge facing nurse managers across Europe is an increasingly aged population, combined with reduced numbers of young adults of working age. New solutions are needed to provide quality, cost-effective community care services to frail older people and their family carers.

METHODS

A case study methodology involving five families was used, and included a detailed cost description of the technology-based service compared with usual services. Cost data were collected in June 2002. This work formed part of a larger project exploring the impact of a technology-based service known as, Assisting Carers using Telematics Interventions to meet Older Persons' Needs (ACTION). In addition to cost data, information was gathered on the quality of life of frail older people and their family carers, and the job satisfaction and work methods of nurses and other practitioners based in the community. The cost analysis comprised a description of the family and their caring situation, the perceived benefits of the telematic based support service and an assessment of its impact on the use of other care services. These analyses were carried out with the help of needs assessors who were known to the families, and nurses working in the ACTION call centre. All results were validated by the five participating families.

RESULTS

Cost savings were achieved in all cases, and the benefits to older people and their carers were also considerable. As a result of the cost analysis and overall evaluation data, ACTION has been implemented as a mainstream service in the municipalities involved.

CONCLUSION

Researchers, nurses, other practitioners and community care managers can work together with frail older people and their family carers to develop quality, cost-effective support services that reduce demands on staff whilst providing benefits to users.

An incremental cost analysis of telehealth in Nova Scotia from a societal perspective

We examined the costs of telehealth in Nova Scotia from a societal perspective. The clinical outcomes of telepsychiatry and teledermatology services were assumed to be similar to those for conventional face-to-face consultations. Cost information was obtained from the Nova Scotia Department of Health, the Canadian Institute for Health Information, and questionnaires to patients, physicians and telehealth coordinators. There were 215 questionnaires completed by patients, 135 by specialist physicians and eight by telehealth coordinators. Patient costs for a face-to-face consultation ranged from $240 to $1048 (all costs in Canadian dollars), whereas patient costs for telehealth were lower, from $17 to $70. However, from a societal perspective, the overall cost of providing face-to-face services was lower than for telehealth: the total costs for face-to-face services ranged from $325 to $1133, while the total costs for telehealth services ranged from $1736 to $28,084. A threshold analysis showed that, above a certain patient workload, telehealth services would be more cost-effective than face-to-face services from a societal perspective. This workload is attainable in Nova Scotia.

Neues Ostwestfälisches Postoperatives Therapiekonzept (NOPT)

BACKGROUND AND PURPOSE

In-hospital rehabilitation can improve recovery of patients after surgery, but also contributes to the high costs of the German health system. Therefore, the possibility of a telemedically monitored rehabilitation at home as an alternative to an in-hospital rehabilitation was evaluated in a pilot study.

PATIENTS AND METHODS

In an open trial, 100 patients performed an ambulatory rehabilitation after heart surgery under coverage of telemedical monitoring for 3 months. 70 patients performed a regular conventional in-hospital rehabilitation for 3 weeks. Physical performance, quality of life (questionnaire), complications, and costs were assessed and compared between the two groups.

RESULTS

6 and also 12 months after surgery, maximal physical performance was significantly increased by 46-54 W in both study groups compared to their baseline value. Moreover, physical and psychological quality of life had increased in both study groups compared to baseline values. However, only in the ambulatory group all items had increased with statistical significance. Fewer insults of angina pectoris were reported during follow-up in the ambulatory group compared to the in-hospital group (p < 0.01). Total costs of the rehabilitation were 59% lower in the ambulatory group compared to the in-hospital group.

CONCLUSION

An ambulatory rehabilitation improves physical performance, quality of life, and is safe and cheap. The data of this study indicate that rehabilitation at home can be established instead of an in-hospital rehabilitation for patients after heart surgery.