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

Provenance Data Management in Health Information Systems: A Systematic Literature Review

AIMS

This article aims to perform a Systematic Literature Review (SLR) to better understand the structures of different methods, techniques, models, methodologies, and technologies related to provenance data management in health information systems (HISs). The SLR developed here seeks to answer the questions that contribute to describing the results.

METHOD

An SLR was performed on six databases using a search string. The backward and forward snowballing technique was also used. Eligible studies were all articles in English that presented on the use of different methods, techniques, models, methodologies, and technologies related to provenance data management in HISs. The quality of the included articles was assessed to obtain a better connection to the topic studied.

RESULTS

Of the 239 studies retrieved, 14 met the inclusion criteria described in this SLR. In order to complement the retrieved studies, 3 studies were included using the backward and forward snowballing technique, totaling 17 studies dedicated to the construction of this research. Most of the selected studies were published as conference papers, which is common when involving computer science in HISs. There was a more frequent use of data provenance models from the PROV family in different HISs combined with different technologies, among which blockchain and middleware stand out. Despite the advantages found, the lack of technological structure, data interoperability problems, and the technical unpreparedness of working professionals are still challenges encountered in the management of provenance data in HISs.

CONCLUSION

It was possible to conclude the existence of different methods, techniques, models, and combined technologies, which are presented in the proposal of a taxonomy that provides researchers with a new understanding about the management of provenance data in HISs.

Complex Surgical Infants Benefit From Postdischarge Telemedicine Visits

BACKGROUND

Transition from the neonatal intensive care unit (NICU) to home is challenging for caregivers of complex surgical infants. A prospective, observational cohort pilot study using telemedicine to improve transition was implemented in a quaternary level IV NICU.

PURPOSE

(1) To assess, identify, and resolve patient care concerns in the immediate postdischarge period. (2) To improve caregiver knowledge and care practices.

DESIGN METHODS

Caregivers of medically complex infants participated in telemedicine visits with neonatal providers within 1 week of discharge. Providers reviewed infant health, equipment use, and outpatient follow-up. Video was used to visualize the infant, home environment, and care practices. Caregivers completed a postvisit satisfaction survey.

RESULTS

Ninety-three visits were performed from May 2015 to March 2017. Seventy-six percent of visits were postsurgery patients. Seventy-eight postdischarge issues were identified: medication administration (13%), respiratory (19%), feeding (33%), and surgical site (35%). Fifty percent of caregivers reported that telemedicine visits prevented an additional call or visit to a clinician; 12% prompted an earlier visit (n = 93). Caregiver satisfaction rating was high. Median estimation of total mileage saved by respondents was 1755 miles.

CONCLUSIONS

Postdischarge telemedicine visits with complex surgical NICU graduates identify clinical issues, provide caregivers with support, and save travel time. Advanced practice nurses are instrumental in patient recruitment, with patient visits, and in providing postdischarge continuity of care. Barriers to implementation were identified.

IMPLICATION FOR PRACTICE AND RESEARCH

A randomized controlled study is warranted to measure the value of telemedicine visits for specific patient cohorts.

Mapping telemedicine efforts: surveying regional initiatives in Denmark

OBJECTIVES

The aim of this study is to survey telemedicine services currently in operation across Denmark. The study specifically seeks to answer the following questions: What initiatives are deployed within the different regions? What are the motivations behind the projects? What technologies are being utilized? What medical disciplines are being supported using telemedicine systems?

MATERIALS AND METHODS

All data were surveyed from the Telemedicinsk Landkort, a newly created database designed to provide a comprehensive and systematic overview of all telemedicine technologies in Denmark.

RESULTS

The results of this study suggest that a growing numbers of telemedicine initiatives are currently in operation across Denmark but that considerable variations exist in terms of regional efforts as the number of operational telemedicine projects varied from region to region.

CONCLUSIONS

The results of this study provide a timely picture of the factors that are shaping the telemedicine landscape of Denmark and suggest potential strategies to help policymakers increase and improve national telemedicine deployment.

Cost-utility and cost-effectiveness studies of telemedicine, electronic, and mobile health systems in the literature: a systematic review

OBJECTIVE

A systematic review of cost-utility and cost-effectiveness research works of telemedicine, electronic health (e-health), and mobile health (m-health) systems in the literature is presented.

MATERIALS AND METHODS

Academic databases and systems such as PubMed, Scopus, ISI Web of Science, and IEEE Xplore were searched, using different combinations of terms such as "cost-utility" OR "cost utility" AND "telemedicine," "cost-effectiveness" OR "cost effectiveness" AND "mobile health," etc. In the articles searched, there were no limitations in the publication date.

RESULTS

The search identified 35 relevant works. Many of the articles were reviews of different studies. Seventy-nine percent concerned the cost-effectiveness of telemedicine systems in different specialties such as teleophthalmology, telecardiology, teledermatology, etc. More articles were found between 2000 and 2013. Cost-utility studies were done only for telemedicine systems.

CONCLUSIONS

There are few cost-utility and cost-effectiveness studies for e-health and m-health systems in the literature. Some cost-effectiveness studies demonstrate that telemedicine can reduce the costs, but not all. Among the main limitations of the economic evaluations of telemedicine systems are the lack of randomized control trials, small sample sizes, and the absence of quality data and appropriate measures.

Design of a randomized, non-inferiority trial to evaluate the reliability of videoconferencing for remote consultation of diabetes

Background

An estimated 366 million people are living with diabetes worldwide and it is predicted that its prevalence will increase to 552 million by 2030. Management of this disease and its complications is a challenge for many countries. Optimal glycaemic control is necessary to minimize complications, but less than 70% of diabetic patients achieve target levels of blood glucose, partly due to poor access to qualified health care providers. Telemedicine has the potential to improve access to health care, especially for rural and remote residents. Video teleconsultation, a real-time (or synchronous) mode of telemedicine, is gaining more popularity around the world through recent improvements in digital telecommunications. If video consultation is to be offered as an alternative to face-to-face consultation in diabetes assessment and management, then it is important to demonstrate that this can be achieved without loss of clinical fidelity. This paper describes the protocol of a randomised controlled trail for assessing the reliability of remote video consultation for people with diabetes.

Methods/Design

A total of 160 people with diabetes will be randomised into either a Telemedicine or a Reference group. Participants in the Reference group will receive two sequential face-to-face consultations whereas in the Telemedicine group one consultation will be conducted face-to-face and the other via videoconference. The primary outcome measure will be a change in the patient’s medication. Secondary outcome measures will be findings in physical examination, detecting complications, and patient satisfaction. A difference of less than 20% in the aggregated level of agreement between the two study groups will be used to identify if videoconference is non-inferior to traditional mode of clinical care (face-to-face).

Discussion

Despite rapid growth in application of telemedicine in a variety of medical specialities, little is known about the reliability of videoconferencing for remote consultation of people with diabetes. Results of this proposed study will provide evidence of the reliability of specialist consultation offered by videoconference for people with diabetes.

Trial registration number

Australian New Zealand Clinical Trials Registry ACTRN12612000315819.

Strategic Procedures and Revisions for implementing Telemedicine and Telecare in Greece

The development of telemedicine and telecare has been changed all over the world the recent decades as practitioners and health care managers reached better understanding of the use of information and communication technologies to offer urgent and qualified medical services at a distance. Governments and health care providers have shown a large initial interest in the benefits of telemedicine services to reduce costs mostly for patient's transfer to tertiary hospitals or for educational purposes but have been slow to provide strategic plans and procedures in order to proceed the projects into practice. The paper identifies the involvement of governments, healthcare management, healthcare professionals and IT suppliers in telemedicine policy development and reviews the experience of Greece in the specific field which seems that despite the enormous scientific interest for both medicine and health informatics, the practice until now has not gained the expected results. Furthermore, the analysis concerns the critical success factors that have to be revised simultaneously with the main managerial principles for the design and implementation of quality telemedicine and telecare services.

A systematic review of economic analyses of telehealth services using real time video communication

Background

Telehealth is the delivery of health care at a distance, using information and communication technology. The major rationales for its introduction have been to decrease costs, improve efficiency and increase access in health care delivery. This systematic review assesses the economic value of one type of telehealth delivery - synchronous or real time video communication - rather than examining a heterogeneous range of delivery modes as has been the case with previous reviews in this area.

Methods

A systematic search was undertaken for economic analyses of the clinical use of telehealth, ending in June 2009. Studies with patient outcome data and a non-telehealth comparator were included. Cost analyses, non-comparative studies and those where patient satisfaction was the only health outcome were excluded.

Results

36 articles met the inclusion criteria. 22(61%) of the studies found telehealth to be less costly than the non-telehealth alternative, 11(31%) found greater costs and 3 (9%) gave the same or mixed results. 23 of the studies took the perspective of the health services, 12 were societal, and one was from the patient perspective. In three studies of telehealth to rural areas, the health services paid more for telehealth, but due to savings in patient travel, the societal perspective demonstrated cost savings. In regard to health outcomes, 12 (33%) of studies found improved health outcomes, 21 (58%) found outcomes were not significantly different, 2(6%) found that telehealth was less effective, and 1 (3%) found outcomes differed according to patient group. The organisational model of care was more important in determining the value of the service than the clinical discipline, the type of technology, or the date of the study.

Conclusion

Delivery of health services by real time video communication was cost-effective for home care and access to on-call hospital specialists, showed mixed results for rural service delivery, and was not cost-effective for local delivery of services between hospitals and primary care.

Teleintervention for infants and young children who are deaf or hard-of-hearing

Advancements in videoconferencing equipment and Internet-based tools for sharing information have resulted in widespread use of telemedicine for providing health care to people who live in remote areas. Given the limited supply of people trained to provide early-intervention services to infants and young children who are deaf or hard-of-hearing, and the fact that many families who need such services live significant distances from each other and from metropolitan areas, such "teleintervention" strategies hold promise for providing early-intervention services to children who are deaf or hard-of-hearing. Unfortunately, little is known about the cost-effectiveness of such teleintervention services. In this article we outline the rationale for using teleintervention services for children who are deaf or hard-of-hearing, describe a teleintervention program that has been serving relatively large numbers of children in Australia since 2002, and summarize what we know about the cost-effectiveness of such an approach. We conclude by summarizing the type of research needed to decide whether teleintervention should be used more frequently with children who are deaf or hard-of-hearing and the potential relevance of the teleintervention approach for the development of intervention systems in the United States.

Telemedicine: What have we learned?

As the health care industry is facing many challenges and is undergoing extensive change, telemedicine is in the position to address these challenges and be an important part of health care's development. Telemedicine has been used for approximately a half century, in which researchers have explored the different technologies utilized, clinical outcomes, cost benefits, perceptions, and adoption challenges of its use. This paper reviews and summarizes these findings and presents possible future research endeavors. Examining what is known about telemedicine can aid in the development of innovative, sustainable and beneficial health technologies that could positively impact health care delivery and outcomes.

The added value of thorough economic evaluation of telemedicine networks

This paper proposes a thorough framework for the economic evaluation of telemedicine networks. A standard cost analysis methodology was used as the initial base, similar to the evaluation method currently being applied to telemedicine, and to which we suggest adding subsequent stages that enhance the scope and sophistication of the analytical methodology. We completed the methodology with a longitudinal and stakeholder analysis, followed by the calculation of a break-even threshold, a calculation of the economic outcome based on net present value (NPV), an estimate of the social gain through external effects, and an assessment of the probability of social benefits. In order to illustrate the advantages, constraints and limitations of the proposed framework, we tested it in a paediatric cardiology tele-expertise network. The results demonstrate that the project threshold was not reached after the 4 years of the study. Also, the calculation of the project's NPV remained negative. However, the additional analytical steps of the proposed framework allowed us to highlight alternatives that can make this service economically viable. These included: use over an extended period of time, extending the network to other telemedicine specialties, or including it in the services offered by other community hospitals. In sum, the results presented here demonstrate the usefulness of an economic evaluation framework as a way of offering decision makers the tools they need to make comprehensive evaluations of telemedicine networks.

A systematic review of the use of telehealth in Asian countries

We conducted a systematic review of the literature on telehealth in Asia. The Medline database was searched, together with three specialist journals, for peer-reviewed articles published in the ten years to June 2007 which were related to any telehealth application involving one or more Asian country. Out of the 1504 abstracts retrieved, 109 articles were selected by two independent reviewers for the final review. The number of published articles on telehealth in Asia increased during the review period. The largest number of studies were conducted in Japan (37%). Most telehealth applications were based on the store-and-forward modality (43%), with 35% using videoconferencing and 15% using a hybrid approach. Most of the studies were descriptive (75%) and only eight included a control group against which telehealth was compared. The most common means of telecommunication was ISDN lines, which were employed in 32% of the studies. Some 40% of the studies mentioned improved quality of health care; about 20% mentioned improved access to health care. Although most studies mentioned cost, only 13 of them assessed resource utilization and cost. The overall findings gave a generally optimistic picture of telehealth in Asia. However, there is a lack of good quality studies.

Can economic evaluation in telemedicine be trusted? A systematic review of the literature

BACKGROUND

Telemedicine has been advocated as an effective means to provide health care services over a distance. Systematic information on costs and consequences has been called for to support decision-making in this field. This paper provides a review of the quality, validity and generalisability of economic evaluations in telemedicine.

METHODS

A systematic literature search in all relevant databases was conducted and forms the basis for addressing these issues. Only articles published in peer-reviewed journals and written in English in the period from 1990 to 2007 were analysed. The literature search identified 33 economic evaluations where both costs (resource use) and outcomes (non-resource consequences) were measured.

RESULTS

This review shows that economic evaluations in telemedicine are highly diverse in terms of both the study context and the methods applied. The articles covered several medical specialities ranging from cardiology and dermatology to psychiatry. The studies analysed telemedicine in home care, and in primary and secondary care settings using a variety of different technologies including videoconferencing, still-images and monitoring (store-and-forward telemedicine). Most studies used multiple outcome measures and analysed the effects using disaggregated cost-consequence frameworks. Objectives, study design, and choice of comparators were mostly well reported. The majority of the studies lacked information on perspective and costing method, few used general statistics and sensitivity analysis to assess validity, and even fewer used marginal analysis.

CONCLUSION

As this paper demonstrates, the majority of the economic evaluations reviewed were not in accordance with standard evaluation techniques. Further research is needed to explore the reasons for this and to address how economic evaluation in telemedicine best can take advantage of local constraints and at the same time produce valid and generalisable results.

Telerehabilitation clinical and vocational applications for assistive technology: research, opportunities, and challenges

Rehabilitation service providers in rural or underserved areas are often challenged in meeting the needs of their complex patients due to limited resources in their geographical area. Recruitment and retention of the rural clinical workforce are beset by the ongoing problems associated with limited continuing education opportunities, professional isolation, and the challenges inherent in coordinating rural community healthcare. People with disabilities who live in rural communities also face challenges accessing healthcare. Traveling long distances to a specialty clinic for necessary expertise may be troublesome due to inadequate or unavailable transportation, disability specific limitations, and financial limitations. Distance and lack of access are just two threats to quality of care that now being addressed by the use of videoconferencing, information exchange, and other telecommunication technologies that facilitate telerehabilitation. This white paper illustrates and summarizes clinical and vocational applications of telerehabilitation. We provide definitions related to the fields of telemedicine, telehealth, and telerehabilitation, and consider the impetus for telerehabilitation. We review the telerehabilitation literature for assistive technology applications; pressure ulcer prevention; virtual reality applications; speech-language pathology applications; seating and wheeled mobility applications; vocational rehabilitation applications; and cost-effectiveness. We then discuss external telerehabilitation influencers, such as the positions of professional organizations. Finally, we summarize clinical and policy issues in a limited context appropriate to the scope of this paper.

Smart home technologies for health and social care support

BACKGROUND

The integration of smart home technology to support health and social care is acquiring an increasing global significance. Provision is framed within the context of a rapidly changing population profile, which is impacting on the number of people requiring health and social care, workforce availability and the funding of healthcare systems.

OBJECTIVES

To explore the effectiveness of smart home technologies as an intervention for people with physical disability, cognitive impairment or learning disability, who are living at home, and to consider the impact on the individual's health status and on the financial resources of health care.

SEARCH STRATEGY

We searched the following databases for primary studies: (a) the Cochrane Effective Practice and Organisation of Care (EPOC) Group Register, (b) the Cochrane Central Register of Controlled Trials (CENTRAL), (The Cochrane Library, issue 1, 2007), and (c) bibliographic databases, including MEDLINE (1966 to March 2007), EMBASE (1980 to March 2007) and CINAHL (1982 to March 2007). We also searched the Database of Abstracts of Reviews of Effectiveness (DARE). We searched the electronic databases using a strategy developed by the EPOC Trials Search Co-ordinator.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), quasi-experimental studies, controlled before and after studies (CBAs) and interrupted time series analyses (ITS). Participants included adults over the age of 18, living in their home in a community setting. Participants with a physical disability, dementia or a learning disability were included. The included interventions were social alarms, electronic assistive devices, telecare social alert platforms, environmental control systems, automated home environments and 'ubiquitous homes'. Outcome measures included any objective measure that records an impact on a participant's quality of life, healthcare professional workload, economic outcomes, costs to healthcare provider or costs to participant. We included measures of service satisfaction, device satisfaction and healthcare professional attitudes or satisfaction.

DATA COLLECTION AND ANALYSIS

One review author completed the search strategy with the support of a life and health sciences librarian. Two review authors independently screened titles and abstracts of results.

MAIN RESULTS

No studies were identified which met the inclusion criteria.

AUTHORS' CONCLUSIONS

This review highlights the current lack of empirical evidence to support or refute the use of smart home technologies within health and social care, which is significant for practitioners and healthcare consumers.

Approaching the management of hospital units with an operation research technique: The case of 32 Greek obstetric and gynaecology public units

Controlling healthcare costs is a multifaceted problem for governments all over the world, as they have the difficult task of ensuring that patients receive high quality care, and that this is delivered as efficiently as possible. Through the use of quantitative analysis, an attempt is made to determine the areas of activity of 32 Greek Public Obstetrical and Gynaecological Units which present problems with regard to their performance. Based on the results that emerge from the application of Data Envelopment Analysis in the 32 hospital units of the sample, information is provided to their managers, which refer to: (i) the degree of utilization of their production factors, (ii) the particular weight of each factor of production in the formation of the relative efficiency score, (iii) the utilization level of each factor of production, and (iv) those hospital units that utilize their factors of production in an optimal way and constitute models for the exercising of effective management. The derived information assists in the formulation of an appropriate policy mix per hospital unit which should be applied by their management teams along with a set of administrative measures that need to be undertaken in order to promote efficiency.

Information and communications technology in chronic disease care: what are the implications for payment?

New information and communication technology (ICT) has the potential to improve care for chronic conditions, deliver better health outcomes, and reduce direct and indirect costs. However, realizing these gains necessitates new forms of care delivery, through adoption of ICT, the specific choice of ICT, and changes to existing forms of health care delivery. Realizing these new forms of delivery requires appropriate payment policies. The authors review the literatures on health care payment and ICT in chronic care and then apply theoretical economic analysis to determine how ICT alters health care payment policy recommendations. Using diabetes as an example, the authors identify and illustrate the disease and technology features that determine the optimal form of payment. Overall, ICT shifts the optimal blend of fee-for-service and capitation toward greater capitation. Carve-outs for ICT-supported preventive care enable more high-powered payment while addressing selection concerns.

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.

Cost-minimization analysis of a wide-area teleradiology network in a French region

OBJECTIVE

The objective of our study was to perform a cost-minimization analysis of a wide-area teleradiology network.

DESIGN

A prospective analysis of all transmissions over 1 year (data transmitted at the time of the remote consultation, and health outcomes of patients from medical record).

INTERVENTION

The inter-hospital teleradiology network of the Aquitaine area (RIHRA) is a telemedicine system enabling the management of remote emergencies and elective radiology consultations.

MAIN OUTCOME MEASURE

A cost-minimization study enabled a comparison of care procedures following the use of the network with those which would have been implemented without the network. The outcome measures of effectiveness were the transfers, hospitalizations, and consultations avoided or added. Fixed and variable costs were estimated.

RESULTS

Among the 664 transmissions included in the study, 562 (85%) were performed in emergency and 102 (15%) for elective (non-emergency) cases. In emergency, 48% of transfers were avoided. For elective teleconsultations, a transfer was avoided for 37% of the patients and hospitalization for 12%. An extra consultation occurred after remote consultation for 2% of the patients. Annual saving can be estimated at 102,779 EUR for the Aquitaine area.

CONCLUSIONS

This study underlines the efficiency of an inter-hospital teleradiology network. A qualitative evaluation of the impact of the use of the system should be carried out to improve technical and organizational operations.

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.

The socio-economic impact of telehealth: a systematic review

We reviewed the socio-economic impact of telehealth, focusing on nine main areas: paediatrics, geriatrics, First Nations (i.e. indigenous peoples), home care, mental health, radiology, renal dialysis, rural/remote health services and rehabilitation. A systematic search led to the identification of 4646 citations or abstracts; from these, 306 sources were analysed. A central finding was that telehealth studies to date have not used socio-economic indicators consistently. However, specific telehealth applications have been shown to offer significant socio-economic benefit, to patients and families, health-care providers and the health-care system. The main benefits identified were: increased access to health services, cost-effectiveness, enhanced educational opportunities, improved health outcomes, better quality of care, better quality of life and enhanced social support. Although the review found a number of areas of socio-economic benefit, there is the continuing problem of limited generalizability.

The Need for Economic Evaluation of Telemedicine to Evolve: The Experience in Alberta, Canada

Economic evaluation of telemedicine applications is required to provide decision makers in health care with appropriate information on costs and benefits of this information and communications technology. The level of economic evaluation should evolve as telemedicine applications mature. At the basic level, economic evaluation may include basic cost analysis and primarily observational data on nonmonetary benefits. The focus will change as telemedicine programs develop. At this intermediate level, practice patterns and workforce issues are addressed as they affect utilization and costs of telemedicine services. Longer-term economic evaluation, thus far not achieved in telemedicine assessment, should focus on assessment of health outcomes and economic impact. Alberta, Canada has made progress assessing telemedicine applications in psychiatry, radiology, rheumatology, and rehabilitation. Data availability and analytic resources continue to present challenges to economic assessment of telemedicine.

Clinical and educational telepsychiatry applications: a review

OBJECTIVE

Telepsychiatry in the form of videoconferencing brings enormous opportunities for clinical care, education, research, and administration. Focusing on videoconferencing, we reviewed the telepsychiatry literature and compared telepsychiatry with services delivered in person or through other technologies.

METHODS

We conducted a comprehensive review of telepsychiatry literature from January 1, 1965, to July 31, 2003, using the terms telepsychiatry, telemedicine, videoconferencing, effectiveness, efficacy, access, outcomes, satisfaction, quality of care, education, empowerment, and costs. We selected studies for review if they discussed videoconferencing for clinical and educational applications.

RESULTS

Telepsychiatry is successfully used for various clinical services and educational initiatives. Telepsychiatry is feasible, increases access to care, enables specialty consultation, yields positive outcomes, allows reliable evaluation, has few negative aspects in terms of communication, generally satisfies patients and providers, facilitates education, and empowers parties using it. Data are limited with regard to clinical outcomes and cost-effectiveness.

CONCLUSIONS

Telepsychiatry is effective. More short- and long-term quantitative and qualitative research is warranted on clinical outcomes, predictors of satisfaction, costs, and educational outcomes.

From flying doctor to virtual doctor: an economic perspective on Australia's telemedicine experience

Current funding mechanisms can impede the efficient use and integration of telemedicine services. Telemedicine has developed in Australia against a background of complex funding arrangements and interwoven health-care responsibilities. These impediments are not unique to telemedicine but are accentuated by its ability to cover different locations, clinical areas and purposes. There is also a link between economic evaluation and funding mechanisms for telemedicine. While economic evaluations provide important information for the efficient allocation of resources, the funding environment in which telemedicine is established is also crucial in ensuring that services are efficient. Given these complexities, should telemedicine be funded? We conclude that this will depend on: the objectives and priorities of the health system; the efficiency of telemedicine relative to that of other forms of health-care delivery; and the funding environment. In terms of resource allocation processes, the optimum scenario is likely to be where the decision to invest in telemedicine services is made taking local needs into account, but where considerations such as market structure and network compatibility are examined on a broader scale and balanced against the principles of efficiency and equity.

What constitutes success in telehealth?

Before telehealth applications can be judged, there must be some general understanding about what constitutes success. At first sight it seems that defining success in a telehealth application should be relatively easy: a successful application is one that produces high-quality care at low cost. However, the calculation of cost requires some care, since it depends on assuming a particular financial perspective (the patient's, the health-care provider's, or society's) and is meaningless without a statement of the workload being handled. Other factors include the context in which the service is being delivered. Ultimately, the political imperative may override any rational judgement of success.

Teleradiology in Croatia

A teleradiology system connecting 35 workstations in 27 hospitals was established in Croatia. In two years of operation, 2071 consultations were conducted using the system at an average rate of four neurosurgical teleconsultations per day. Eighty patients required urgent transfer to the tertiary hospital and 181 required non-urgent transfer. An additional 181 patients remained in their local hospital and were treated under the supervision of the tertiary hospital. The avoidance of unnecessary patient transfer led to significant cost savings.

Program management of telemental health care services

Telemedicine is a new adjunct to the delivery of health care services that has been applied to a range of health care specialties, including mental health. When prospective telemedicine programs are planned, telemedicine is often envisaged as simply a question of introducing new technology. The development of a robust, sustainable telemental health program involves clinical, technical, and managerial considerations. The major barriers to making this happen are usually how practitioners and patients adapt successfully to the technology and not in the physical installation of telecommunications bandwidth and the associated hardware necessary for teleconsultation. This article outlines the requirements for establishing a viable telemental health service, one that is based on clinical need, practitioner acceptance, technical reliability, and revenue generation. It concludes that the major challenge associated with the implementation of telemental health does not lie in having the idea or in taking the idea to the project stage needed for proof of concept. The major challenge to the widespread adoption of telemental health is paying sufficient attention to the myriad of details needed to integrate models of remote health care delivery into the wider health care system.