Telemedicine: Will Telemedicine Improve the Quality of

Telemedicine: Will telemedicine improve the quality of healthcare and its delivery for remotely located advanced healthcare para-professionals? The basic purpose of this study is to discuss whether telemedicine will improve the quality of health care and it's delivery for remotely located advanced health care para-professionals. The scope of the study is over seeing as it covers the implication of implementation of telemedicine as a professional genre.

It would also show how the installation of telemedicine means to other researchers, who want to take this field further and analyze it other context such as financial system of medical systems, telemedicine implicaiton on Medicare etc. The researcher plans to adopt a case study / historical methodology of research by first collecting a literature review and then finally using it as a base for the analysis of the hypothesis questions. The researchers will also plan to use both primary and secondary sources.

Primary sources will consist of government documentation and first hand interviews documented in reports. Secondary resources will include articles, web sites etc. Resources The following is a proposed resources for the study. Dakins, D.R., "Wild-Eyed Revenue Projections Create Moving Target for Home Healthcare Market," Telemedicine and Telehealth Networks, 1995, 2:3:3. Consensus Statement, First Mayo Telemedicine Symposium, 1993 Grigsby J, Barton PL, et al. Analysis of expansion of access to care through use of telemedicine and mobile health services. 3: Telemedicine policy: quality assurance, utilization review, and coverage. Denver: Center for Health Policy Research; 1994:8.

Fishman, Dorothy J., Telemedicine: bringing the specialist to the patient. Vol. 28, Nursing Management, 07-01-1997, pp 30(3). H.L. Smits, and A. Baum, "Health Care Financing Administration (HCFA) and Reimbursement in Telemedicine." Journal of Medical Systems 19, no. 2 (1995): 139-42. IOM, Telemedicine: A Guide to Assessing Telecommunications in Health Care, M.J. Field, ea., (Washington, D.C.: National Academy Press, 1996),p.1. Zundel, K.M., "Telemedicine: History, Applications, and Impact on Librarianship," Bulletin of the Medical Library Association, 1996, 84:1:71-79.

Statement of Problem/Question to be Researched Due to high demand of medical care need especially for those who do no have access to medical centres. These are usually concentrated in the rural areas or suburbs.

The researcher aims to find answers to the following research studies: Will telemedicine improve the quality of health care? Will it improve the delivery of health care to remote areas? Is telemedicine cost effective? How can it be made cost-effective? Survey of the Literature Telemedicine is perhaps one of the fastest growing revolutionary technologies after computer-based patient records. According to a recent study, telemedicine, in all likelihood worth billions of precious health care dollars along with replacing 5% of hospital stays, 5% of nursing home care and another 20% of home health visits.

(Dakins 1995) The primary advantage that can be acquired through the field of telemedicine is that it allows patients and doctors to interact at a rapid speed mainly by way of computers and patient video cameras. To put it simply, physical distance between a doctor and a patient is greatly reduced as this interactive method of finding health practitioners brings the former to the patients thereby giving them a wide variety of doctors and surgeons to choose from.

The twenty first century is undoubtedly the age of the mass media and as society seeks to actualize its potentials one finds that telemedicine will provide an interactive telecommunicative forum that will enable the patients to find people that can really help them with their problems thereby finding an instant cure to their ailments, instead of looking around and going doctors that may not know what is really wrong with them.

If telemedicine is allowed to flourish, one will find that this means of communication will be made available on demand, quite like the way a telephone service is used these days. Furthermore telemedicine will also be applicable to situations where person-to-person contact is essential instead of impersonal methods. Therefore one can say that the application of these telecommunication links to the field of medicine can be defined as telemedicine.

Currently the potential of telemedicine is being explored so one cannot say for sure what the effects of this revolutionary technology will be in the field of medicine, especially with regard to providing medical help to remote and inaccessible regions of the world. At present there is a need to analyze whether telemedicine will be able to produce enough income so as to sustain itself instead of depending on other financial resources, before the concerned authorities can seriously think about implementing such systems on an extensive scale.

The issue at hand with regard to income generation is reimbursement, which is on the verge of impossible for telemedicine because it is quite likely that the service will be misused/overused by the masses. Research Design and Collection of Data: The researcher plans to adopt the case study / historical methodology where no instruments will be used but the data collected through a survey of literature review will be taken into account to provide for a detailed background on telemedicine and its benefits to the users.

Treatment of Data or Information Discovered: Data collection is liable to be biased and sometimes not credible. The researcher plans to filter the various articles, by categorizing their validity and credibility. For instance the researcher will use journal articles and books as the main framework for the study but it would also be supported by periodicals etc. Conclusions After having review the literature, the researcher will analyze in the context of the hypothesis question and prove whether they have proven true or not.

The researcher will then make recommendations at the end of the study to show how effective telemedicine proves to the consumers. Telemedicine: Will telemedicine improve the quality of healthcare and its delivery for remotely located advanced healthcare para-professionals? Chapter 1: Statement of the Problem Introduction Telemedicine is perhaps one of the fastest growing revolutionary technologies after computer-based patient records. According to a recent study, telemedicine, in all likelihood worth billions of precious health care dollars along with replacing 5% of hospital stays, 5% of nursing home care and another 20% of home health visits.

(Dakins 1995) The primary advantage that can be acquired through the field of telemedicine is that it allows patients and doctors to interact at a rapid speed mainly by way of computers and patient video cameras. To put it simply, physical distance between a doctor and a patient is greatly reduced as this interactive method of finding health practitioners brings the former to the patients thereby giving them a wide variety of doctors and surgeons to choose from [First Mayo Telemedicine Symposium, 1993].

The twenty first century is undoubtedly the age of the mass media and as society seeks to actualize its potentials one finds that telemedicine will provide an interactive telecommunicative forum that will enable the patients to find people that can really help them with their problems thereby finding an instant cure to their ailments, instead of looking around and going doctors that may not know what is really wrong with them.

If telemedicine is allowed to flourish, one will find that this means of communication will be made available on demand, quite like the way a telephone service is used these days. Furthermore telemedicine will also be applicable to situations where person-to-person contact is essential instead of impersonal methods. Therefore one can say that the application of these telecommunication links to the field of medicine can be defined as telemedicine.

Currently the potential of telemedicine is being explored so one cannot say for sure what the effects of this revolutionary technology will be in the field of medicine, especially with regard to providing medical help to remote and inaccessible regions of the world [Grigsby et al., 1994]. The Telemedicine symposium held in 1993 in this regard clearly stated the following: "Effective telemedicine will dramatically improve the ability of mid- level providers (e.g., physician assistants, nurse practitioners, etc.) to participate in health care delivery to underserved populations.

Mid-level practitioners represent an important resource for improving access to care with a lower increase in health care costs. Effective telemedicine will both improve the resources available to these practitioners and decrease their sense of isolation in underserved areas.

Developments in telemedicine should recognize this important link and fully develop its potential." At present there is a need to analyze whether telemedicine will be able to produce enough income so as to sustain itself instead of depending on other financial resources, before the concerned authorities can seriously think about implementing such systems on an extensive scale.

The issue at hand with regard to income generation is reimbursement, which is on the verge of impossible for telemedicine because it is quite likely that the service will be misused/overused by the masses. As a result of the potential overuse concerns, certain limitations are most likely to be placed on the use of the service.

This would include restricted coverage in those situations where the patient in all likelihood cannot be moved along with situations in which the patient is located in a geographically remote region of the country/world. Not only this but it is also important to examine the ways in which non-physicians would be reimbursed in the field. Needless to say that research in this regard would probably solve a number of problems that most non-physicians find themselves facing in settings other than the one being discussed at present.

One must bear in mind that teleradiology is perhaps the oldest form of telemedicine on which sufficient literature can be found along with the fact that the FDA has been extensively involved with this issue since 1977. This kind of technology basically focuses on the creation and transmission of medical images e.g. x-rays to different places, mainly those that are not easily accessible.

The image is transmitted by way of a digital signal and once the image is received on the other end, the expert is able to analyze them, which is helpful in making a diagnosis. Critics have compared this kind of transmission to the sending of x-rays and other such images through the postal service. Of course telemedicine is a lot faster than teleradiology.

The medical community along with the FDA is equally responsible for ensuring that the medical devices used in the process are not harmful to one's health in anyway and that the image being sent is adequate in order for a correct diagnosis to be made within a short span of time.

According to an FDA official: "The question that the doctor should ask is, 'Is the resulting image adequate for the purposes intended? If an image will be used for diagnosis, then the clinician must be certain that it has sufficient detail to permit accurate interpretation." Those in favor of telemedicine argue that this way of providing health care would ensure that the patients get the required help in time, especially in rural areas where the doctors are few in number and where most people would rather the disease/ailment go away by itself instead of going long distances to visit a doctor for something as inconsequential as the common cold perhaps.

Once telemedicine is introduced, these people will be able to receive medical care and attention of health practitioners that are experts in their fields within the jurisdiction of their respective community. An example of this can be illustrated from what doctor Cox in Kansas feels about the whole issue. He explains that he has established a relationship with a local oncologist and hematologist at the Kansas University Medical Center.

These specialists visit the patients in doctor's Cox's jurisdiction twice a month but they are also available via telemedicine on other days: "Thus, we have a specialist available in our town twice a week either in person or electronically. The result is that we're able to deliver more health-care services to the community. In addition, the level of quality at our local hospital is bolstered, so our staff feels better working here.

Everyone benefits." It is important to mention here that the expenses incurred by prescriptions and tests through this service are borne locally and so the community reaps immense financial benefits via telemedicine. Therefore it is obvious that telemedicine is a cost-effective strategy because it greatly reduce health care costs that are incurred by way of tests, prescriptions and other related medical expenses, which most people are unable to afford otherwise.

This way medical care can be available to every member of the society simply because the costs are minimized by way of this service. However there are a number of problems that hamper the progress of telemedicine as a regular service in the country, out of which the issue of reimbursement has already been discussed.

Teleradiology as mentioned earlier is being researched upon since the seventies and so has gained some level of acceptance in within health care insurance companies with the result that they are willing to pay for it now. But telemedicine is a relatively unexplored field and so companies are hesitant to be the first ones to initiate anything, especially since it hasn't gained official approval as yet. There is also immense concern with regard to the medical liability involved in telemedicine.

This means that those health practitioners that are not physically present to deliver treatment maybe considered as providing inadequate medical care. It is also quite possible that things could go terribly wrong if a health practitioner is not present with the result that he/she maybe blamed in totality for any mishap that might occur. The doctor could then be sued for malpractice and would have to face the consequences of his/her actions.

It is obvious of course that telemedicine is a developing field at the moment and that there are chances of unforeseen problems that could arise at any time. It is the cost-effectiveness that is scary for most people at the moment but it is also important to remember that with time telemedicine can be just as feasible an option as perhaps e-medicine or something to that effect.

Background of the Problem Perhaps the biggest problem that telemedicine is faced with at the moment is that virtually no one is willing to invest in it. As mentioned earlier, the cost-effectiveness is a bit too much to handle for most firms and so they are not quite ready to fund the research in the field. There are of course some rural telemedicine sites but that is federally funded and so one can imagine that it does not leave too much scope for further research and development in the field.

Technology costs in this regard are decreasing but the fact of the matter is that telemedicine is an expensive field and most companies don't have that kind of money to finance an explored arena of interactive medicine. There are of course some ways by which this cost can be reduced. For example doctor Gifford recently pointed out that telemedicine would in fact be cost-effective if the cost of the units fell within the $10,000 range.

Even though telemedicine does appear extremely exorbitant, at least in the initial phases, the savings do appear during the treatment later on. According to Dr. Julius: "I've seen about 150 patients, and we did an analysis of the first 88. We looked at the cost of their care for the 6 months before I saw them and for the 6 months afterward.

As far as we could estimate on the basis of CPT codes and medications and their hospitalization rates, the cost was probably 40 to 50% less for the 6 months after I saw them than before." Not only this but also as the field expands the rise in savings will be rather immense.

Experts foresee price reductions in the future to an extent that the doctors and medical institutions will be able to buy the units and lease them out to individual physicians or perhaps even groups so that more people in the country will be able to avail the facility. Purpose of the Study The basic purpose of this study is to discuss whether telemedicine will improve the quality of health care and it's delivery for remotely located advanced health care para-professionals.

Questions that will be answered in the Study Will telemedicine improve the quality of health care? Will it improve the delivery of health care to remote areas? Is telemedicine cost effective? How can it be made cost-effective? Variables Availability of the required technology Patients response to telemedicine The services provided through telemedicine Cost-effectiveness Geographical accessibility The Medical and legal concerns involved in the process Limitations The information and techniques used to explain the effectiveness of telemedicine can of course vary greatly and depends to a large degree on individual interpretations.

Rationale This paper will attempt to explain whether telemedicine will improve the quality of health care and its delivery for remotely located advanced health care para-professionals. The rationale provided by the researcher is based on the fact that medical facilities in the United States is still limited where accessibility is concerned. The introduction of telemedicine bridges this gap between the rural and urban medical facilities. In doing, so the integration of the system would benefit those consumers who do not live in the vicinity of medical health care centers.

Definitions Telemedicine can be defined as the use of electronic and advanced telecommunication devices to provide health care in areas where medical facilities are inaccessible and/or not feasibly located. Telehealth is an expansive term that includes almost everything from preventive public health communications to the current medical education programs in hospitals and finally telemedicine itself.

E-health can be defined as the use of internet to provide health care facilities to all those people who are able to access the internet from their homes, places of works or perhaps even through cyber cafes. The Internet in this manner performs a role similar to the telecommunicative devices used in telemedicine by connecting the health care professionals with the patients that are in dire need of medical assistance.

Scope of the Study The scope of this study is to investigate whether telemedicine is a viable and feasible option for improving the quality of health care and if it will be able to provide health care in remotely located areas to advanced para-health professionals. Also it will highlight some of the strong and weak points of telemedicine along with focusing on the long-term cost effectiveness of telemedicine. Finally it will explain the benefits that will arise if telemedicine is implemented and if it gains official acceptance.

Basically, a study in the field of telemedicine will provide medical practitioners with information on the effectiveness and the major concerns involved in this field. Any recommendations that they could make to the health care providers. The research is also beneficial for those students who would like to have a framework to study the issues involved in telemedicine in the future. For the academics, the research will provide the crucial information as to the effectiveness of telemedicine.

Chapter II: Survey the Literature THE HISTORY OF TELEMEDICINE Telemedication is not a new phenomenon. The experiment for this practice has been in vogue since 1959 by the University of Nebraska. However, its implementation has only been recently captured the interest of medical institutions and patients. For instance the "Space Technology Applied to Rural Papago Advanced Health Care (STARPAHC) program of the early 1960s and the various systems set up by the Massachusetts General Hospital beginning in the late 1960s" are good examples of the initial stages of telemedicine.

In this system, the link between the medical facilitator and those of patient is through a two-way video link and the transmission of diagnostic information through dedicated communications link. At the time the system proved too expensive for proper implementation. As a result of this, the application required a series of add on equipment to be effective. However, the success of the system only came about during the 1980s when the integration approach of the application of telemedicine became enhanced.

Yet even in the new model of integration there were problems, for example there were primary problems where the issue of utility maximization was the major concern. Telemedicine then, was viewed as means to communicate with the medical practitioners but not actually treating patients. In order to do that the patients had to go to the centers themselves. Furthermore the low level of information management tool did not allow the providers to have access to quality care. These impediments became the major deterrents for its progress [Smits, and Baum, 1995].

TELEMEDICINE APPLICATION The concept of telemedicine stemmed from the idea that telecommunication and technologies have evolved rapidly over the years. It has created an environment in which individuals remains at home and communicate their needs. Technology has developed so much that it also allowed the consumers to interact with someone quite far off without having to be present there [Zundel, 1996]. The high demand for integration of telecommunication system along with high demand for medical facilities in remote areas have given rise to telemedicine.

As a result of this situation, the application of technologies in the field of medical health care have come about. The resolution was to provide health care to those who do not have reach to the medical centers due to social impairment like disabilities, retirees, old age or simply no commute system. As a result of this demand, the medical professionals thought the medical potential of technologies to be incorporated in the health care system.

Furthermore, it has been observed that the abundance of physicians in large and well financed health centers do not actually provide for the kind of medical facilities that is required out of them. Hence they work under capacity while the majority of the patient are in demand of their professional care. As a result of integration of telemedicine system into the professional health care system, management of these institutions are able to generate higher capacity and medical services to the patients [Fishman, 1997].

The need for far reaching medical facility stem from the fact that well financed health care system in many areas in the United States are still facing difficulty in deliverance. Especially those living in the rural areas. They do not have access to the medical centers due to several reasons: They do not have access to quality medical service They are not able to reach quality care service centers They are unable to benefit from the facility due to low income The requirement for emergency treatment.

Hence, according to the medical professionals, telemedicine is the only revolutionary solution for this dilemma. However, even in this dimension, medical providers should have technical advances in communication practice in order to provide the facilities in an effective manner. The reach of the specialists therefore must be so encompassing that it would benefit the patients geographically as well as socioeconomically. The importance of health care professionals' participation in such a model is therefore imperative provided they use the new mode of communication and consultation [DeBakey, 1995].

TELEMEDICINE TECHNOLOGY According to a Department Veteran Affairs Undersecretary for Health Thomas L. Garthwaite, the product tested in the various medical services and the hospital selected identified patients as having delayed service at medical facilities. For this reason, a system of medical facility like telemdicine and such technology should be provided to this segment of the consumers.

Technology like Scripttalk have been identified as a system that would prove beneficial for the users such as the "Blind Rehabilitation Centers as well as geriatric patients who have difficulty reading small prints and other impairments." According to Dr. Garthwaite, the system is not only automated to serve the consumers efficiently but it is also to serve the management system. [The Washington Times, 07-16-2001]. Telemedicine and telemedical facilities and technology is responsible for the new development in medical facility provision of the 21st century.

With the introduction of machines by Medstream Telecommunications, patients today enjoy a privilege superceding convenience and emergency health care. For instance with the telemedicine system introduced by Medstream, the patients could have interactive sessions with patients despite distant location of the patient. Based on the need of the patients, the cost of the service is charged. The utility it provides and the easiness of delivery could categorize the benefit of such a system.

Any patients that live outside the peripherals of urban sprawl or the suburbs can benefit similar health care [Bergman, 1993]. According to the company "The MedStream TeleCommunications' application will allow for remote diagnosis of patients via telemedicine's use of videoconference and other specially designed diagnostic equipment. It also provides a vehicle for continuous patient management.

While electronic data transmission is not uncommon in the digital information age, live interactions between patients and physicians at distant locations are just becoming an accepted method of healthcare delivery." Hence, the company proved revolutionary to telemedicine field. Furthermore, the chief of the company claimed that the technology is likely to increase the speed of diagnosis and initiate the trend of immediate care. The steps taken by Medstream is not only revolutionary but also provides for change in the era of managed care.

Beneficiaries of this new technique of Medicare will eventually realize that the old method of medical care for remote areas is no longer effective. The time taken for physicians to arrive at the hospitals, to take up an assignment / patient and finally reaching there is not only a waste of system resource but it also entails long chain of commands. Telemedicine on the other hand require instance service where a second opinion should also be available to treat symptoms immediately.

For instance a cardiologist in an emergency room will be able to take up a second opinion immediately without having to confer through system commands. He could provide consultation through the telemedicine system. Medsteam also propose that since the medical data are transmitted quickly and efficiently through the system, they are able to treat out of reach patients who do not have the capability to reach medical centers. For instance retirees, children, disabled require extra assistance when it comes to medical care and their emergency treatment.

Telemedicine solve this problem by making available medical service in instance. Many people have the preconceived notion that telemedicine is impersonal. It does not provide "humanistic" treatment. Medical care, which require doctors / human beings to come into contact with the patient before they could treat, should not be handled over the telephone or through a computer system. Patients according to them are not treated effectively. They demand highly personalized service and instantly.

Although technology could provide instantaneous medical advice but it does not provide for the kind of personal attention that the patients require. Proponent of telemedicine declare that health care technology and the telemedicine environment is a practical solution. A physician cannot be expected to be at several place at one time. Telemedicine allows this. They provide personal medicinal advice but at the same time provides it to different patients as well. This way they are able to cover a wide sphere of patients at one district.

Hence, according to First Mayo Telemedicine Symposium, Consensus Statement (excerpt) [1993]: "Effective telemedicine will dramatically improve the ability of mid- level providers (e.g., physician assistants, nurse practitioners, etc.) to participate in health care delivery to underserved populations. Mid-level practitioners represent an important resource for improving access to care with a lower increase in health care costs. Effective telemedicine will both improve the resources available to these practitioners and decrease their sense of isolation in underserved areas.

Developments in telemedicine should recognize this important link and fully develop its potential" CURRENT APPLICATIONS OF TELEMEDICINE Telemedicine systems can be described by the specialty or practice environment in which they are used, but they may all be classified into two main types -- teleconferencing-based and image-based. Both types of systems must have the following capabilities: 1. Collecting video and/or audio information.

This function may utilize a video camera and microphone, a video camera with the capability to accept fiber-optic input (from a modified otoscope, ophthalmoscope, or microscope), an electronic stethoscope, or a high-resolution digital scanner. 2. Processing this input into a form suitable for digital transfer. This can be accomplished by the use of software installed on a microcomputer, hardware built into or attached to a microcomputer, or telecommunications hardware attached directly to a communications network. 3. Transferring the data generated.

This may be provided by a modem connected through standard phone lines to a larger telecommunications network or a direct connection to that larger network." [Moore, 1996] TELECONFERENCING-BASED SYSTEMS The improvement on telemedicine came about when the industry was introduced with teleconferencing-based systems, why relied on traditional video technologies. The new technologies, provide both audio and visual communication between the patients and the health care providers. The system provide a realistic view of the whole process of medical care.

The "realness" of the system played an important role in development of the telemedicine phenomenon. In this sense, the teleconferencing-based system is dependent on how the providers operates then and make it more effective just as the patient would have received such services from a medical center. For instance, the medical practitioner could use a videotape recorder and imaging devices to connect to the video camera. The audio input is then also provided.

An electronic device like the stethoscope, could be used for auscultation from a remote location [PRESCRIPTION FOR THE 21ST CENTURY BY HONEY BERMAN (Via Satellite); 09-24-1998]. This system is extremely useful in a variety of clinical situations. For instance during emergency care, psychiatry, specialty treatment as well as primary care treatment like skin evaluation of a patient. All these facilities does not require the patient to visit the centers.

"A PA working in a rural emergency department could receive help in evaluating a corneal abrasion or in placing a thoracostomy tube in a critically ill or injured patient. A mental health specialist could facilitate a counseling session for a troubled teenager in a rural area." [Moore, 1996]. COST EFFECTIVENESS VS. SYSTEM EFFECTIVENESS Opposition of this system allow that the system cost is too high to be maintained by any kind of medical institution. For instance, the telecommunication devices are highly costly, as well as the teleconference technique used.

The cost could rise as high as "$100,000 for each installation; telecommunications support may cost $10,000 to install and $5,000 monthly to maintain and operate." [Moore, 1996] Where effectiveness of the system is concerned, it is based on the systems adopted by the medical center. For instance in the case of pathology and radiology, image-based system often prove useful for the specific task of transmission for the consultants to provide their medical input. Hence, they are dependent on the effectiveness of the technology provided to them.

Clinical examinations hence depend on the situation and the extensiveness of the interaction capability of the machines. "A system designed for radiology, for example, would be able to take a traditional image from radiography, computed tomography, magnetic resonance, or ultrasound, scan it into a digital image, and then transmit it to a distant radiologist for definitive interpretation. This can be extremely useful for physicians and PAs working in rural areas." [Moore, 1996].

Perhaps the only disadvantage in this system is inherent in the fact that it is lacks the interaction of the specialists and that of the patients, especially in remote areas. When the systems can be purchased as much as $5,000, then it could be operated through phone lines. Users claim that telemedicine is still limited in its scope in health care provision especially when it comes to specific specialties. This system hence can be used as additional medical provisions but it cannot be totally depended upon.

The systems only makes the process faster and not its effectiveness [Moore, 1996]. Proponents of the systems provide that although telemedicine is still at the initial stages, it will eventually provide for the benefits that it is designed for. For instance in addition in providing consulting services, telemedicine system will become integrated into the IT system of the medical center so much that the service provision genre will eventually become more efficient.

Since current day technology is filled with complex communication devices as well as technology to make the experience of interaction more effective it would be beneficial for the organizations to adopt these techniques and technologies to make their own health care system effective. Other systems that needs to be integrated include patient records, schedules, medicine dosage, physical findings and review of findings during the patient's visits. This system would provide for the physical framework for the consultation of the practitioner.

As a result of this the consultants without the help of previous physical records could take up any kind of diagnostic measures. A patient's history will be "online" as and when needed. he/she does not need the same practitioner to treat because all information are lodged in the system automatically [Genesen, et al., 1994]. BARRIERS TO THE USE OF TELEMEDICINE Some of the main issues that faces both the users and the practitioners include practice of standards, provider resistance, lack of coordination and non-physical providers.

These issues have erected the concern that telemedicine system management integration will cause problems more then the utilization of telemedincine, hence it should not be adopted. Aside from those issues, the health care providers are also concerned with the fact that since most of the service does not take place in a physical environment, any legal liability stemming from the professional organizations or the patients' relation will likely to have costly consequences. As a result, it should not be implemented.

Further proponent against telemedicine indicate that the technological development alone is not the issue but rather those who will be operating them. In the process of integration it is imperative that the different technology be channeled to the professionals before they are implemented. Hence the cost benefit of such a system is dependent on how much the organizations are willing to spend on the training sessions.

Aside from that the coordination from the different efforts to utilize the facility all depend on how the professionals could provide the telemedicine [Perednia and Allen, 1995]. Another aspect that concerns the majority of the health care industry is the fact that the practice of telemedicine uses non-physicians, that.