Telemedicine: where it is and where it's going

Challenges to rural medical education: a student perspective

The key feature of the Greater Murray Clinical School model is the attachment of students to patients. Students follow their patients through the health care system, in contrast to the standard approach where students are attached to doctors or specialty based clinical units. The patient/student coupling occurs at the primary care level, which mostly but not exclusively will occur in the GP's office. Students anchor their knowledge by seeing the natural progression of common illnesses, the impact of behavioural aspects on health and disease, and by experiencing continuity of care. Along their path they develop good problem solving skills and learn to understand the health care system they will become part of. The main obstacle in teaching a medical undergraduate curriculum in a rural setting is that large geographical distances separate students, teachers and resources. Consequently, information technology will play an important role in terms of delivery of the GMCS curriculum. Moreover, there is potential for flow-on benefits to the community following integration of new information technology into the local health infrastructure.

Legal issues in teleradiology-distant thoughts!

Advancements in computer technology and telecommunications have meant that all diagnostic images can now be acquired as digital signals, however the ethicolegal concepts surrounding this innovation remain unclear. In the UK there are limited practice guidelines on legal issues relating specifically to telemedicine or teleradiology. It is not yet clear whether the current law relates to telemedicine in the same way that it does for other medical specialties, or whether telemedicine raises new legal issues that need clarification. This article attempts to outline some of the potential legal issues, but the absence of case law and legislation in this area will ensure that many questions remain unanswered. The legal implications of teleradiology/telemedicine are addressed, and literature, laws and professional guidelines from the UK, USA, Australia and New Zealand are reviewed, focusing on the American licensure laws, professional relationships with patients with regards to liability, responsibility, accountability and duty of care issues, as well as issues of missed diagnosis, misdiagnosis, security and confidentiality. Teleradiology, while being actively practised worldwide, gives rise to many unanswered medicolegal questions. It is suggested that guidelines need to be implemented to safeguard patients and professionals alike.

Columbia University's Informatics for Diabetes Education and Telemedicine (IDEATel) Project: rationale and design

The Columbia University Informatics for Diabetes Education and Telemedicine (IDEATel) Project is a four-year demonstration project funded by the Centers for Medicare and Medicaid Services with the overall goals of evaluating the feasibility, acceptability, effectiveness, and cost-effectiveness of telemedicine in the management of older patients with diabetes. The study is designed as a randomized controlled trial and is being conducted by a state-wide consortium in New York. Eligibility requires that participants have diabetes, are Medicare beneficiaries, and reside in federally designated medically underserved areas. A total of 1,500 participants will be randomized, half in New York City and half in other areas of the state. Intervention participants receive a home telemedicine unit that provides synchronous videoconferencing with a project-based nurse, electronic transmission of home fingerstick glucose and blood pressure data, and Web access to a project Web site. End points include glycosylated hemoglobin, blood pressure, and lipid levels; patient satisfaction; health care service utilization; and costs. The project is intended to provide data to help inform regulatory and reimbursement policies for electronically delivered health care services.

Clinical outcomes resulting from telemedicine interventions: a systematic review

BACKGROUND

The use of telemedicine is growing, but its efficacy for achieving comparable or improved clinical outcomes has not been established in many medical specialties. The objective of this systematic review was to evaluate the efficacy of telemedicine interventions for health outcomes in two classes of application: home-based and office/hospital-based.

METHODS

Data sources for the study included deports of studies from the MEDLINE, EMBASE, CINAHL, and HealthSTAR databases; searching of bibliographies of review and other articles; and consultation of printed resources as well as investigators in the field. We included studies that were relevant to at least one of the two classes of telemedicine and addressed the assessment of efficacy for clinical outcomes with data of reported results. We excluded studies where the service did not historically require face-to-face encounters (e.g., radiology or pathology diagnosis). All included articles were abstracted and graded for quality and direction of the evidence.

RESULTS

A total of 25 articles met inclusion criteria and were assessed. The strongest evidence for the efficacy of telemedicine in clinical outcomes comes from home-based telemedicine in the areas of chronic disease management, hypertension, and AIDS. The value of home glucose monitoring in diabetes mellitus is conflicting. There is also reasonable evidence that telemedicine is comparable to face-to-face care in emergency medicine and is beneficial in surgical and neonatal intensive care units as well as patient transfer in neurosurgery.

CONCLUSIONS

Despite the widespread use of telemedicine in virtually all major areas of health care, evidence concerning the benefits of its use exists in only a small number of them. Further randomized controlled trials must be done to determine where its use is most effective.

Cost analysis of telehomecare

The demand for home health care has skyrocketed in recent years. The aging population and the push for more efficient delivery of hospital services have fueled this growing demand. However, health care financing reforms have constrained the industry's growth. Home health agencies struggle to deliver high-quality services while staying within the financial limitations imposed by reimbursement changes. Telehomecare is one way to provide cost-effective care in the current environment. Personal computers and video equipment can transmit data over ordinary telephone lines and allow home health providers to monitor patients and provide care at a much lower cost than earlier technologies that required wider bandwidth telephone lines and more complex equipment. But can telehomecare yield cost-savings for home health agencies? This article addresses the costs associated with a telehomecare intervention in a large, urban, home health agency. The purpose of the study was two-fold: (1) to test the effects of telehomecare on clinical outcomes, and (2) to estimate the financial costs associated with providing telehomecare services. Our results show that, while telehomecare imposes additional expenses for care delivery, it contributes substantial savings without compromising quality. Additionally, we found that the financial benefit increases exponentially as the duration of the patient care episode increases.

Review of telemedicine projects in Taiwan

Taiwan is a heavily populated country, with a small land area and many mountains and isolated islands. Because medical resources are unequally distributed, high quality accessible medical care is a major problem in rural areas. Medical personnel are unwilling to practice in rural areas because of fear of isolation from peers and lack of continuing medical education (CME) in those areas. Telemedicine provides a timeless and spaceless measure for teleconsultation and education. The development of telemedicine in Taiwan began under the National Information Infrastructure (NII) Project. Distance education and teleconsultation were the first experimental projects during the initiation research stage. The cost and effectiveness of the hardware and network bandwidth were evaluated. In the promotion research stage, applications in different medical disciplines were tested to promote multipoint videoconference, electronic journals and VOD. Investigation of user satisfaction put on more emphasis on improving application functions. In 1998, a new Cyber Medical Center (CMC) international collaboration project was begun, integrating technologies of multimedia, networking, database management, and the World Wide Web. The aim of the CMC is to create a multimedia network system for the management of electronic patient records, teleconsultation, online continuing medical education, and information services on the web. A Taiwan mirror site of Virtual Hospital and two international telemedicine trials through Next Generation Internet (NGI) were done at the end of 1998. In the future, telemedicine systems in Taiwan are expected to combine the Internet and broadband CATV, ADSL, and DBS networking to connect clinics, hospitals, insurance organizations, and public health administrations; and, finally, to extend to every household.

Telesurgery. Remote monitoring and assistance during laparoscopy

In comparison to open surgery, laparoscopy results in less postoperative pain, shorter hospitalization, more rapid return to the work force, a better cosmetic result, and a lower incidence of postoperative intra-abdominal adhesions. These advantages are indisputable when comparing large series for cholecystectomy and smaller series for pelvic lymph node dissection, nephrectomy, and bladder neck suspension in experienced hands. Urologists have an obligation to explore the application of these methods to urologic disease and to adjust the standard of care accordingly. Several barriers to the expansion of urologic laparoscopic surgery exist. The experience in extirpative and reconstructive urologic procedures is limited when compared with the data on cholecystectomy. These procedures are technically complex and demand advanced laparoscopic skills and familiarity with laparoscopic anatomy. The steep learning curve translates into long operative times and an unacceptably high rate of complications for inexperienced laparoscopic surgeons. Most practicing urologists have no formal training in advanced laparoscopy, and no formal credentialing guidelines exist. Telesurgical technology may provide one solution to this problem. Through telesurgical mentoring, less experienced surgeons with basic laparoscopic skills could receive training in advanced techniques from a world expert without the need for travel. These systems could also be used to proctor laparoscopic cases for credentialing purposes and to provide a more uniform standard of care. This review has outlined some of the exciting progress made in the field of telesurgery over the past 10 years and described some of the technical and legal obstacles that remain to be surmounted. During the 1990s, urologists were at the forefront of innovation in remote telepresence surgery. As the scope of minimally invasive urologic surgery expands during the first few decades of the twenty-first century, telesurgical mentoring should have an increasingly important role.

The use of telemedicine in child sexual abuse evaluations

OBJECTIVE

To describe the advantages, disadvantages and current status of child abuse consultations conducted through telemedicine networks.

METHOD

The results of a telephone survey of seven statewide telemedicine networks are reported and discussed with respect to goals, funding, technical support and expertise, infrastructure, and extent of use. Quality assurance and liability issues concerning telemedicine child abuse consultations are also reviewed.

RESULTS

The goals of telemedicine networks in child abuse are to provide (1) expertise to less experienced clinicians primarily in rural areas; (2) a method for peer review and quality assurance to build consensus of opinions particularly in sexual abuse cases; and (3) support for professionals involved in an emotionally burdensome area of pediatrics. Problems encountered by existing networks include: (1) funding for equipment and reimbursement for consultation; (2) consistent technical support: (3) clinician lack of technical expertise, knowledge, or motivation; and (4) lack of network infrastructure. Legal considerations include licensure exemptions for consulting across state lines, potential for malpractice, patient confidentiality and security of images forwarded over modem lines, and liability of the equipment, consulting site, and the consultant in criminal proceedings.

CONCLUSIONS

Telemedicine consultations offer a unique opportunity to raise the standard of care in child abuse evaluations, but success depends on clinician motivation, appropriate infrastructure, and ongoing funding and technical support.

Case-based support in a cooperative medical diagnosis environment

Many medical services are often not available to people living in remote areas because of the lack of medical specialists. This problem would be alleviated if a suitable environment was designed to allow physicians to collaborate and exchange ideas with centrally located medical specialists. This article describes an ongoing research project to design and implement a collaborative multimedia environment to allow medical specialists to cooperate in diagnosis. The environment will support remote database access for medical images, the retrieval of relevant medical cases to support diagnosis, and communication among participants through telepointers and image annotation by free-hand drawing.

What do we really know about the cost-effectiveness of telemedicine?

Telemedicine is still in its infancy, but undergoing rapid development. It is very difficult to evaluate telemedicine. We performed a literature survey (Medline). During the period 1990-8, over 1500 articles on telemedicine were published. Of these, 246 mentioned economic aspects in the abstract (16%). We selected 29 studies although few had demonstrated cost-effectiveness. Benefits for the patients in the form of reduced travel and waiting time must often be weighed against increased provider costs. Up to now, telemedicine in general has not had any significant effect on medical practice, or the structure and organization of health-care. In order to utilize the potential of telemedicine, its integration with traditional health-care is very important. There are country-specific variations in the health systems that make it difficult to generalize the results from one country to another.

Assessment of telemedicine in surgical education and patient care

OBJECTIVE

To analyze the value of teleconferencing for patient care and surgical education by assessing the activity of an international academic network.

SUMMARY BACKGROUND DATA

The uses of telemedicine include teleeducation, training, and consulting, and surgical teams are now involved, sharing diagnostic information and opinions without the need for travel. However, the value of telematics in surgery remains to be assessed.

METHODS

During a 2-year period, weekly surgical teleconferences were held among six university hospitals in four European countries. To assess the accuracy of telediagnosis for surgical cases, 60 randomly selected cases were analyzed by a panel of surgeons. Participants' opinions were analyzed by questionnaire.

RESULTS

Seventy teleconferences (50 lectures and 271 case presentations) were held. Ninety-five of the 114 participants (83.3%) completed the final questionnaire. Eighty-six percent rated the surgical activity as good or excellent, 75.7% rated the scientific level as good or excellent, 55.8% rated the daily clinical activity as good or excellent, and 28.4% rated the manual surgical technique as good or excellent. The target organ was identified in all the cases; the organ structure and pathology were considered well defined in 93.3%, and the fine structure was considered well defined in 58.3%. Diagnosis was accurate in 17 cases (28.3%), probable in 25 (41.7%), possible but uncertain in 16 (26.7%), and not possible in 2 cases (3.3%). Discussion among the remote sites increased the rate of valuable therapeutic advice from 55% of cases before the discussion to 95% after the discussion. Eighty-six percent of the surgeons expressed satisfaction with telematics for medical education and patient care.

CONCLUSIONS

Participant satisfaction was high, transmission of clinical documents was accurate, and the opportunity to discuss case documentation and management significantly improved diagnostic potential, resulting in an accuracy rate of up to 95%. Teleeducation and teleconsultation in surgery appear to be beneficial.

Role for telemedicine in acute stroke. Feasibility and reliability of remote administration of the NIH stroke scale

BACKGROUND AND PURPOSE

Immediate access to physicians experienced in acute stroke treatment may improve clinical outcomes in patients with acute stroke. Interactive telemedicine can make stroke specialists available to assist in the evaluation of patients at multiple urban or remote rural facilities. We tested whether interrater agreement for the NIH Stroke Scale (NIHSS), a critical component of acute stroke assessment, would persist if performed over a telemedicine link.

METHODS

One bedside and 1 remote NIHSS score were independently obtained on each of 20 patients with ischemic stroke. The bedside examination was performed by a stroke neurologist at the patient's bedside. The remote examination was performed by a second stroke neurologist through an interactive high-speed audio-video link, assisted by a nurse at the patient's bedside. Kappa coefficients were calculated for concordance between bedside and remote scores.

RESULTS

Remote assessments took slightly longer than bedside assessments (mean 9.70 versus 6.55 minutes, P<0. 001). NIHSS scores ranged from 1 through 24. Based on weighted kappa coefficients, 4 items (orientation, motor arm, motor leg, and neglect) displayed excellent agreement, 6 items (language, dysarthria, sensation, visual fields, facial palsy, and gaze) displayed good agreement, and 2 items (commands and ataxia) displayed poor agreement. Total NIHSS scores obtained by bedside and remote methods were strongly correlated (r=0.97, P<0.001).

CONCLUSIONS

The NIH Stroke Scale remains a swift and reliable clinical instrument when used over interactive video. Application of this technology can bring stroke expertise to the bedside, regardless of patient location.

The basis for using the Internet to support the information needs of primary care

Synthesizing the state of the art from the published literature, this review assesses the basis for employing the Internet to support the information needs of primary care. The authors survey what has been published about the information needs of clinical practice, including primary care, and discuss currently available information resources potentially relevant to primary care. Potential methods of linking information needs with appropriate information resources are described in the context of previous classifications of clinical information needs. Also described is the role that existing terminology mapping systems, such as the National Library of Medicine's Unified Medical Language System, may play in representing and linking information needs to answers.