Telemedicine: applications, benefits, and challenges

¶ … Technologies Involved in Telemedicine and Its Role in Future Medicine

TELEMEDICINE

Issues in Telemedicine

The Institute of Telemedicine defined telemedicine as the "use of electronic information and communications technologies to provide and support health care when distance separates the participants." (Field, 1996.) Telemedicine were established almost 40 years ago, but the technology has grown considerably in the past decade. This paper will discuss the benefits, challenges, and technologies involved in telemedicine and its role in future medicine.

Benefits

Telemarketing benefits are as follows: 1): Telemedicine can provide and improve access to health care in previously un-served or under-served areas; 2) Telemedicine allows the consultation to take place among the referring physician, the consulting physician, the patient, and the patient's family through interactive video with critical information of the patient available online; and 3) The travel cost of the patients for specialty care, the travel cost for health care professionals for continuing education or consultation, the personnel / equipment cost for not having to keep specialty care facility in rural hospitals, and other costs can be either eliminated or reduced. (Grisby & Sanders, 1998)

Patients

1. Populations Served

Populations that telemedicine serves include the following: rural populations, urban underserved populations, for example, the homeless or inner city; the homebound; the elderly; institutionalized populations; military personnel; trauma patients, and international customers Some of these categories overlap. For example, many of the homebound are elderly people living in rural areas. (Bower, 1998)

B. Healthcare providers number of major metropolitan medical centers offer telemedicine services to rural clinics as well as to hospitals overseas. A number of major medical centers have established telemedicine facilities to extend their expertise beyond the campus.

C. Payers

Most people have health insurance paid for partly or entirely by their employers, and many others have individual insurance policies. The corporate health plan may be fee-for-service or managed care. The policy specifies what services are covered and reimbursable. The elderly have Medicare, a form of health insurance provided by the federal government. The poor are eligible for Medicaid, a cooperative program of the federal government and the states.

II. Challenges

A. Acceptance.

Physicians have taken to it also, and professional associations such American Medical Association and the American Psychiatric Association have endorsed it. They find videoconferencing a boon even for ordinary meetings; rather than spending a whole day and fighting traffic for a one-hour weekly meeting, they can attend meeting simply by walking down the hall to the conference room, or even with a personal video conferencing system on their desktops. Many radiologists, for example, even have computer imaging equipment installed in their homes so that they can do readings while at home. For example, in a trial project at the Pregnancy Institute in Louisiana also laid to rest concerns about acceptance. Patients and their families get nervous without the presence of the physician; the telemedicine station put them at ease by enabling them to maintain real-time contact with the doctor throughout the labor. (Automation: Starting Small, LA Organizers Hope Telemedicine Will Boost Access to Care, "1996).

B. Training/Education.

Telemedicine provides a peer and specialist contact for patient consultations and continuing education. For consultations between colleagues and between patients and physicians, it has been found that color, full motion video is critical as it creates a simulated face-to-face communication where verbal and visual communication. Also, the physicians or other personnel at remote locations can be educated during the consultations with specialty physicians and other experts, increasing their ability to treat other similar cases in the future.

C. Legal Issues

1. Federal/OIG Legislation. Since the 1960's, the federal government has supported the development of telemedicine through grants, contracts, the National Aeronautics and Space Administration and the Department of Defense budget line items that total several hundred million dollars. Several agencies provide support and their representatives (Bowers, 1998)

2. State Legislation Several states have passed legislation mandating private payer reimbursement of telemedicine services. These states include: Louisiana, California, Oklahoma, Texas, and Kentucky. More private insurers are funding limited telemedicine coverage in certain states. For example, the California Managed Risk Medical Insurance Board awarded $1.8 million to Blue Cross California to expand their telemedicine technology and help to encourage expansion of telehealth services. Blue Cross plans to use the money to help serve the medically underserved populations and provide equipment and support to 22 new telemedicine sites in 18 counties. (Telemedicine Reimbursement Report, 2003

3. Medical Errors. Some providers are concerned that the use of telemedicine may increase their risk (for example, a technical failure) could lead to an adverse patient outcome, or telemedicine could provide an image of inferior quality that hinders a physician's ability to make an accurate diagnosis. Interactive video may be used with narrower bandwidths if data compression algorithms are used, but the images are sometimes too jerky to permit resolution of detail or subtle movements and this can cause problems (Grisby & Sanders, 1998)

4. Malpractice. One of the impediments to the growth of telemedicine applications is liability and malpractice (Granade, 1995). Conversely, some physicians are concerned that if the use of telemedicine provide high-quality medical care, that they might be liable for failure to use it. The situation is compounded by interstate variability in the handling of malpractice claims. Because no one has been sued yet for malpractice related to telemedicine, it is possible to assess the validity of these concerns.

III. Technologies

A. Reliability, performance, quality

Healthcare professionals have been concerned about the technicalreliability of equipment employed in telemedicine, particularly when real-timeobservation and monitoring are required. Through hard use of equipment, thetechnology has proved itself to be highly reliable, and confidence in it isincreasing.Complementing the performance and reliability of the equipment arethe customer service and support that the vendors provide. Vendors offerdesign and installation, maintenance and training, service and on-site repair, and may even take the responsibility of network operation.

B. Image/data transmission

The concept of a telemedicine system is very simple: 1)• Video conferencing system and Imaging/diagnostic peripherals to gather data from a patient; • Computer hardware and software to record data; • Communications lines to send the data from one location to another; Auxiliary equipment may be employed to exchange information electronically, such as graphics stands, facsimile machines, and telewriters, so that the participants can clarify points of the discussion by exchanging documents or other material. In addition, with medical peripherals such as electronic stethoscopes, dermascopes, otoscopes, etc., close-up images of body areas and even internal organs can be transmitted.

C. Applications

1. Clinical healthcare delivery. The clinical applications of telemedicine are even more varied than the technologies, although considerable attention has been focused on the application of interactive video for specialty and subspecialty consultation in rural areas. The generic interactive video telemedicine system typically uses a fixed, studio-type video equipment to link a rural facility with an urban tertiary care center.

Almost every clinical specialty has used telemedicine in some ways, although some have used it more than others have. Radiologists, for example, have embraced the technology on a large scale. Cardiologists, dermatologists, and psychiatrists long have been the clinical specialists most actively involved in telemedicine. The reasons for this are unclear, but this distribution may represent a kind of "founder's effect" because physicians practicing these specialties were among the clinicians to first become involved with telemedicine.

2. Image/data readings. When a physician examines a patient, the process generally includes taking the patient history and conducting a physical examination, and perhaps an electrocardiogram and x-rays. The physical examination includes auscultation (listening to sounds emanating from the body's organs such as heart, lungs, and gastric system) with a stethoscope, looking at the skin, checking the eyes with an ophthalmoscope, examining ears, nose and throat (ENT), and perhaps employing various instruments for invasive examination (e.g., laparoscope, sigmoidoscope, colonoscope, gastroscope, rhinolaryngofiberscope). All of these things can be accomplished via telemedicine.

3. Teleconsultation. One of the most important applications of telemedicine is teleconsulting. Consultants communicate with patients and often with their primary care providers in an interactive situation. The precise configuration of these networks varies, ranging from a single source of referrals (for example, a rural community hospital) and a single source of consultants (such as academic medical center) to complex "hub-and-spoke" networks involving many referring and consulting facilities.

IV. Information Management

A. Confidentiality

Confidentiality problems that may arise include the inappropriate disclosure of individual patient information to persons who are unauthorized to receive it. Disclosure of information about a specific patient maybe be as likely with electronic records as with conventional paper records. Certain types of disclosure, such as the sale of lists of individual patients with a specific diagnosis to marketer, mailing-list brokers, or insurance salespersons, may be facilitated by the use of electronic databases. Access to electronic records must be carefully restricted to those who have must have access to provide care. Even encryption and firewalls may be only temporary barriers to a person motivated to obtain unauthorized care. (Gilbert. 1995)

B. Privacy and HIPAA

In 1996, Congress sought to streamline electronic medical record systems while protecting patients, improving health care efficiency, and reducing fraud and abuse. Passing Congress with bipartisan support, the Health Insurance Portability and Accountability Act (HIPAA, Public Law 104-191) became the legislative vehicle to address those issues. Your health information cannot be used or shared without your written permission unless this law allows it. Because telemedicine allows medical information to be sent anywhere in the world, there is a possibility that protected patient information may fall into unauthorized hands. For example, the information could be sent to the wrong addressor left out on the telemedicine desk for unauthorized personnel to look at. Extra security must be built into the telemedicine system to prevent information falling into the wrong hands.

V. Reimbursement

The absence of consistent, comprehensive reimbursement policies is often cited as one of the most serious obstacles to total integration of telemedicine into health care practice. This lack of an overall telemedicine reimbursement policy reflects the multiplicity of payment sources and policies within the current United States health care system.

A. Medicare and Medicaid Reimbursement

Partial Medicare reimbursement for telehealth services was authorized in the Balanced Budget Act (BBA) of 1997. The narrow scope of this reimbursement prompted efforts towards expansion and revision of the Medicare reimbursement regulations. The Benefits Improvement and Protection Act of 2000 (BIPA) included amendments to the Social Security Act and removed some of the prior constraints, yet maintained substantial limitations related to geographic location, originating sites, and eligible telehealth services.

Unlike Medicare, most state Medicaid programs provide reimbursement for health care-related transportation costs. A number of states with telemedicine programs entered into collaboration with state Medicaid programs to develop telemedicine reimbursement policies, often with the anticipation that telemedicine could offer transportation cost savings. Currently, 27 state Medicaid programs acknowledge at least some reimbursement for telehealth services.

B. General Reimbursement

Another barrier to the expansion of telemedicine is a lack of reimbursement for services from private insurance providers. In addition to Medicare and Medicaid payments for telemedicine, several Blue Cross/Blue Shield plans, as well as other private insurers, pay for telemedicine services. The telehealth market operates on the assumption that private payers do not pay for telemedicine and will resist any kind of claims if asked. However, AMD Telemedicine conducted a survey that found that there is a critical mass for private payer reimbursement. According to their findings, 38 programs in 25 states currently receive reimbursements from private payers. Three programs receive reimbursement for store and forward, and seven programs receive reimbursement for facility fees. While the market assumption is that private payers do not reimburse for telemedicine, in reality over 100 private payers currently reimburse for telemedicine.

As with Medicaid, regulations for telemedicine reimbursement by private insurers are set by the states. Five states have enacted laws requiring that services provided via telemedicine must be reimbursed if the same service would be reimbursed when provided in person. Some insurance programs cover specific telehealth services, e.g., behavioral health. Even in the absence of a definitive policy, some insurers and Medicaid agencies will reimburse for telemedicine services as long as the rationale for using telemedicine is justified to the agency's satisfaction. State waivers or special programs offering remote diagnostics, remote monitoring for specific disease entities or for particular populations, allow additional coverage of telemedicine services. A few states simply pay claims regardless of whether the encounter was in person or via telemedicine.

C. Cost

Even a few years ago, however, a console video conferencing system cost approximately $100,000, but now the cost has decreased due to the availability and lower cost of components, including the increased use of very large scale integration semiconductor technology. In recent years, entry-level systems were introduced that brought the cost down to about $30,000 for a rollabout console, and recently new compact systems have been introduced that begin at under $10,000. Now desktop systems are coming to the fore, which can cost only a few thousand dollars. (Grisby & Sanders, 1998)