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Telemedicine for the Medicare Population

Summary

Evidence Report/Technology Assessment: Number 24

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Please Note: The evidence report this summary was derived from has been updated. For the updated report, go to http://www.ahrq.gov/clinic/tp/telemeduptp.htm.


Under its Evidence-based Practice Program, the Agency for Healthcare Research and Quality (AHRQ) is developing scientific information for other agencies and organizations on which to base clinical guidelines, performance measures, and other quality improvement tools. Contractor institutions review all relevant scientific literature on assigned clinical care topics and produce evidence reports and technology assessments, conduct research on methodologies and the effectiveness of their implementation, and participate in technical assistance activities.

Overview / Reporting the Evidence / Methodology / Findings / Conclusions / Future Research / Availability of Full Report



Overview

Telemedicine is the use of telecommunications technology for medical diagnostic, monitoring, and therapeutic purposes when distance separates the users. Because modern computer and communications technology has the ability to capture and quickly transmit textual, audio, and video information, many have advocated its use to improve health care in rural areas, in the home, and in other places where medical personnel are not readily available. There is a growing call for telemedicine services to be covered by health insurance, though its benefits and costs are not clear.

This report assesses specific telemedicine study areas, with a focus on those that would substitute for face-to-face medical diagnosis and treatment of the Medicare population. Thus, this report targets face-to-face clinical specialties (as opposed to radiology and pathology) and the Medicare population (adults as opposed to children and pregnant women).

The report identifies health care services that could be provided using telemedicine and describes existing programs in three categories of telemedicine:

  1. Store-and-forward.
  2. Self-monitoring/testing.
  3. Clinician-interactive services.

It also summarizes scientific evidence on the efficacy, safety, and cost-effectiveness of these services; identifies gaps in the evidence; and makes recommendations for evaluating telemedicine services.

Store-and-forward telemedicine services collect clinical data, store them, and then forward them to be interpreted later. These systems have the ability to capture and store digital still or moving images of patients, as well as audio and text data. A store-and-forward system eliminates the need for the patient and the clinician to be available at the same time and place. Store-and-forward is therefore an asynchronous, noninteractive form of telemedicine. It is usually employed as a clinical consultation (as opposed to an office or hospital visit).

A key question associated with store-and-forward telemedicine is: Can store-and-forward telemedicine consultations be acceptable alternatives to real-time consultations?

Self-monitoring/testing telemedicine services enable physicians and other health care providers to monitor physiologic measurements, test results, images, and sounds, usually collected in a patient's residence or a care facility. Post-acute-care patients, patients with chronic illnesses, and patients with conditions that limit their mobility often require close monitoring and followup. Telemedicine programs use a variety of strategies to accomplish this monitoring while reducing the need for face-to-face visits that may be inconvenient or costly for the patient. The close monitoring afforded by these approaches may allow better care through earlier detection of problems, and may therefore reduce costs.

Clinician-interactive telemedicine services are real-time clinician-patient interactions that, in the conventional approach, require face-to-face encounters between a patient and a physician or other health care provider. Examples of clinician-interactive services that might be delivered by telemedicine include online office visits, consultations, hospital visits, and home visits, as well as a variety of specialized examinations and procedures.

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Reporting the Evidence

For each of the three study areas, an analytic framework was developed to guide the review of the literature. This framework includes questions answered by general descriptions of telemedicine programs (question 1a for each study area) as well as those answered by a systematic review of the evidence from peer-reviewed literature (the remaining questions for each study area).

Store-and-Forward Telemedicine

The use of store-and-forward telemedicine services in Medicare-eligible patient populations was examined, asking the following questions that compare telemedicine to face-to-face medical encounters:

  1.  
    1. What components does store-and-forward telemedicine share with traditional clinical encounters?
    2. Does store-and-forward telemedicine result in comparable diagnosis and appropriateness of recommendations for management?
    3. Does the availability of store-and-forward telemedicine provide comparable access to care?
  2. What are the potential adverse effects of store-and-forward telemedicine?
  3. Does store-and-forward telemedicine result in comparable health outcomes?
  4. Does store-and-forward telemedicine result in comparable patient and/or clinician satisfaction with care?
  5. Does store-and-forward telemedicine result in comparable costs of care?
  6. Is store-and-forward telemedicine cost effective?

Self-Monitoring/Testing Telemedicine

The use of self-monitoring/testing telemedicine services in Medicare-eligible patient populations was examined, asking the following questions relative to face-to-face encounters:

  1.  
    1. What are the characteristics of self-monitoring/testing telemedicine in terms of patients included, services provided, equipment used, and information transmitted?
    2. Does self-monitoring/testing telemedicine result in comparable diagnosis and appropriateness of recommendations for management?
    3. Does the availability of self-monitoring/testing telemedicine provide comparable access to care?
  2. What are the potential adverse effects of self-monitoring/testing telemedicine?
  3. Does self-monitoring/testing telemedicine result in comparable health outcomes?
  4. Does self-monitoring/testing telemedicine result in comparable patient or clinician satisfaction with care?
  5. Does self-monitoring/testing telemedicine result in comparable costs of care?
  6. Is self-monitoring/testing telemedicine cost effective?

Clinician-Interactive Telemedicine

The use of clinician-interactive telemedicine services in Medicare-eligible patient populations was examined, asking the following questions comparing telemedicine to face-to-face medical encounters:

  1.  
    1. Which clinical services are or might be provided by clinician-interactive telemedicine?
    2. Does clinician-interactive telemedicine result in comparable diagnosis and appropriateness of recommendations for management?
    3. Does the availability of clinician-interactive telemedicine provide comparable access to care?
  2. What are the potential adverse effects of clinician-interactive telemedicine?
  3. Does clinician-interactive telemedicine result in comparable health outcomes?
  4. Does clinician-interactive telemedicine result in comparable patient or clinician satisfaction with care?
  5. Does clinician-interactive telemedicine result in comparable costs of care?
  6. Is clinician-interactive telemedicine cost effective?

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Methodology

The Evidence-based Practice Center (EPC) team that developed this report sought to identify procedures, programs, and services in the three study areas. Members of the team first conducted a general literature search for information about ongoing telemedicine programs and activities within each program throughout the world (question 1a for each of the study areas). They then searched for peer-reviewed literature for the systematic review (the remaining questions for each study area). Both literature searches used the MEDLINE, EMBASE, CINAHL, and HealthSTAR electronic bibliographic databases.

They also searched through telemedicine reports and compilations, including their reference lists, as well as Internet sites. Finally, they contacted known telemedicine experts to find additional resources to identify and describe telemedicine programs.

The criterion for inclusion in the general literature review was that the article described an activity in at least one of the three telemedicine study areas. The inclusion criteria for the systematic review were that the study was relevant to at least one of the three study areas, addressed at least one key question in the analytic framework for that study area, and contained reported results. Exclusion criteria for the systematic review were that the study population was not relevant to the Medicare population (i.e., children and pregnant adults) or that the service did not historically require face-to-face encounters (e.g., radiology or pathology diagnosis).

The team used the articles included in the general literature review to develop an inventory of relevant programs and activities. The abstracted data were entered into a relational database for aggregation and interpretation. For the systematic review, included articles were categorized by the key question(s) they addressed. The included studies for each study area and key question were critically appraised to determine the strengths and limitations of the most important studies following a detailed rationale for the appraisal of study characteristics related to quality.

For each study area, team members constructed a summary table of activities with the strength of the evidence for each key question. The summary tables indicate which procedures or services are either supported or not supported by evidence in published studies. Thus, they essentially identify gaps in telemedicine research by identifying procedures that are currently being delivered or could be delivered by telemedicine, but for which there is no evidence of efficacy in the peer-reviewed scientific literature.

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Findings

General Observations

Through the EPC team's review of the general literature, they identified 455 telemedicine programs, of which 362 are in the United States. Among U.S. programs, 111 are located at academic medical centers and 68 are in hospital-based health care networks; 80 are Federal, military, or Department of Veterans Affairs medical centers. Over 30 medical specialties are represented. Many programs include more than one activity.

The most common telemedicine activities are:

  • Consultations or second opinions (290).
  • Diagnostic test interpretation (169).
  • Chronic disease management (130).
  • Posthospitalization or postoperative followup (102).
  • Emergency room triage (95).
  • "Visits" by a specialist (78).

About 50 programs provide services in patients' homes.

Many diverse populations are served by telemedicine. More programs serve rural patients than any other group. Of the 455 programs catalogued in the general literature review, approximately 120 (26 percent) provide health care to rural populations. Telemedicine also serves a large number of veterans and elderly. The numbers of telemedicine encounters increased steadily throughout the 1990s, with significantly more consults in 1997 and 1998 than in previous years.

A total of 177 articles were determined to potentially have evidence for the efficacy of one of the three study areas, and were included in the systematic review. After exclusion criteria were applied, there were 15 articles that assessed store-and-forward telemedicine, 14 articles that evaluated self-monitoring/testing, and 48 articles that assessed clinician-interactive services. A total of nine randomized controlled trials (RCTs) were identified, one in store-and-forward, six in self-monitoring/testing, and two in clinician-interactive services.

Specific Results

Individual studies were assessed for evidence based on criteria applicable to the study question. Each question was analyzed from the framework of Medicare-eligible patient populations, relative to face-to-face medical encounters. Studies were too heterogeneous and their quality varied too much to undertake any quantitative aggregate analysis (i.e., meta-analysis).

Store-and-Forward Telemedicine

While store-and-forward telemedicine programs operate in many clinical domains, studies assessing the efficacy are lacking for most of them. In addition, for settings where studies have been done, the evidence is of insufficient quality to judge the efficacy of store-and-forward telemedicine. Teledermatology is the most-studied clinical specialty in store-and-forward telemedicine; its diagnostic accuracy and patient management decisions being made are comparable to those of in-person clinical encounters. It may improve access to care and have adequate patient acceptance.

1a. To what extent does store-and-forward telemedicine differ from a traditional clinical encounter? Store-and-forward telemedicine differs from face-to-face encounters in that a history and physical examination is not performed by the clinician. Rather, the clinician gets a report of the history and physical examination along with audio or video data (in an asynchronous manner).

1b. Does store-and-forward telemedicine result in comparable diagnosis and appropriateness of recommendations for management? Very few studies assess diagnosis and management using store-and-forward telemedicine. The strongest evidence for comparable diagnostic and management recommendations relative to face-to-face encounters comes from teledermatology.

1c. Does the availability of store-and-forward telemedicine provide comparable access to care? Studies show that teledermatology increases access to dermatologists when none are available locally.

2. What are the potential adverse effects of store-and-forward telemedicine? Store-and-forward telemedicine is reported to be more time-consuming than in-person consultations for both referring and consulting physicians.

3. Does store-and-forward telemedicine result in comparable health outcomes? No studies were found that assessed health outcomes using store-and-forward telemedicine.

4. Does store-and-forward telemedicine result in comparable patient or clinician satisfaction with care? There is insufficient evidence to determine whether patients or clinicians are as satisfied with store-and-forward telemedicine as they are with face-to-face encounters.

5. Does store-and-forward telemedicine result in comparable costs of care? There is insufficient evidence to determine whether store-and-forward telemedicine affects the costs of care.

6. Is store-and-forward telemedicine cost effective? The EPC team found no studies that assess the "marginal" cost effectiveness of store-and-forward telemedicine.

Self-Monitoring/Testing

Self-monitoring/testing telemedicine is used less frequently than the other two types of telemedicine studied in this report. It is most commonly used for management of chronic diseases or specific conditions, such as heart disease, diabetes mellitus, or asthma. As with store-and-forward telemedicine, there are programs operating in many clinical domains where there is little evidence from peer-reviewed studies to support its use. Some studies show it results in comparable outcomes, improves access, increases satisfaction with care delivered, and may be cost effective.

1a. What are the characteristics of self-monitoring/testing telemedicine in terms of patients included, services provided, equipment used, and information transmitted? The most common situation where self-monitoring/testing telemedicine is successfully used is in the management of a chronic disease or specific condition, particularly heart disease, diabetes mellitus, or asthma. The holistic support and care of at-risk patients is another important use for self-monitoring/testing programs.

1b. Does self-monitoring/testing telemedicine result in comparable diagnosis and appropriateness of recommendations for management? Since diagnosis and management decisions are usually not the focus of self-monitoring/testing, there are few studies assessing them. There is some evidence, however, that spirometry and skin wound monitoring can be done in the home environment comparably to in-person visualization.

1c. Does the availability of self-monitoring/testing services provide comparable access to care? There is insufficient evidence to determine whether self-monitoring/testing telemedicine changes access to care.

2. What are the potential adverse effects of self-monitoring/testing telemedicine? No studies have assessed the potential adverse effects of self-monitoring/testing applications.

3. Does self-monitoring/testing telemedicine result in comparable intermediate outcomes? There is variable evidence for the effect of self-monitoring/testing telemedicine for health outcomes. Some studies show the benefit of various interventions in lowering Hgb A1C levels in diabetic patients, but others do not. One randomized controlled trial (RCT) reports small benefits for interventions in hypertension. Another reports comparable outcomes of care when interactive video communications are provided in the home. Evidence from small, noncontrolled studies also indicates that self-monitoring/testing telemedicine may improve activities of daily living and reduce hospitalization and nursing home placement.

4. Does self-monitoring/testing telemedicine result in comparable patient or clinician satisfaction with care? Evidence from small, noncontrolled studies indicates that self-monitoring/testing leads to greater patient satisfaction than usual care methods. No studies report on clinician satisfaction.

5. Does self-monitoring/testing telemedicine result in comparable costs of care? There is insufficient evidence that self-monitoring/testing applications affects costs of care.

6. Is self-monitoring/testing telemedicine cost effective? There is some evidence for the cost-effectiveness of self-monitoring/testing with an automated telemedicine application in an older hypertensive population in one study, but no other adequate studies of cost.

Clinician-Interactive Telemedicine Services

Clinician-interactive telemedicine is used in more heterogeneous clinical specialties than store-and-forward. As with store-and-forward, however, few studies assess efficacy. Furthermore, for many settings where studies have been done, the evidence for efficacy is of insufficient quality to judge how well clinician-interactive telemedicine works.

Unlike store-and-forward telemedicine, several studies showed interactive teledermatology to be inferior to in-person consultation in making diagnostic and appropriate management decisions, though many of these were done with older technology, unlike the store-and-forward studies. In several other clinical specialties, clinician-interactive telemedicine shows comparable diagnostic accuracy, and in emergency medicine one randomized controlled trial shows it to have comparable health outcomes. Some studies demonstrate improved access to care, patient and provider satisfaction, and reduced costs of care, though most have problematic designs.

1a. Which clinical telemedicine services are or might be provided by clinician-interactive telemedicine? A large variety of clinician-interactive telemedicine services are currently provided, such as history and physical examination, psychiatric examination, and ophthalmologic assessment.

1b. Does clinician-interactive telemedicine services result in comparable diagnosis and appropriateness of recommendations for management? In contrast to store-and-forward teledermatology, the highest quality study of clinician-interactive telemedicine shows it to be diagnostically inferior to in-person dermatology. Several lesser-quality studies also report this effect. Studies in other domains such as cardiology, emergency medicine, otolaryngology, certain ophthalmology conditions, and pulmonary medicine show equivalent diagnostic accuracy.

1c. Does the availability of clinician-interactive telemedicine provide comparable access to care? Observational studies show improved access in neurosurgery, medical-surgical evaluation, and cardiac care.

2. What are the potential adverse effects of clinician-interactive telemedicine? No studies have explicitly addressed adverse effects of clinician-interactive telemedicine.

3. Does clinician-interactive telemedicine result in comparable health outcomes? One randomized controlled trial shows that patients receiving telemedicine rather than in-person care in an emergency room have comparable outcomes in need for followup care or return visits. There is insufficient evidence from other domains to determine whether clinician-interactive telemedicine services improve health outcomes.

4. Does clinician-interactive telemedicine result in comparable patient or clinician satisfaction with care? Uncontrolled studies with nonvalidated instruments demonstrate that clinicians are satisfied with their clinician-interactive telemedicine services experiences. Similar studies find patients, parents of patients, and families of patients satisfied with these services as well.

5. Does clinician-interactive telemedicine result in comparable costs of care? Studies of the costs of clinician-interactive telemedicine services assessing patient-visit replacement via telemedicine and decision support via telemedicine provide some evidence that costs of care can be reduced.

6. Is clinician-interactive telemedicine cost effective? No studies were found that assessed the "marginal" cost effectiveness of clinician-interactive telemedicine.

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Conclusions

This report finds that the use of telemedicine is small but growing. Active programs demonstrate that the technology can work, and their growing number indicates that telemedicine can be used beneficially from clinical and economic standpoints. The longevity of these programs, however, is not clear, and many may fail to survive beyond initial funding or enthusiasm.

The evidence for the efficacy of telemedicine technology is less clear. The problem is not that studies have strong evidence against efficacy, but rather that their methodologies preclude definitive statements. Many of them have small sample sizes that preclude statistical power, and the settings of others may not be equivalent to clinical settings. Still others focus on patient populations that might be less likely than others to benefit from improved health services, such as people who have complex chronic diseases.

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Future Research

The EPC team recommends that, in the future, diseases with a high burden of illness and barriers to access to care should receive the highest priority for telemedicine research. Systematic observation of the effect of a telemedicine service should begin as soon as possible with the use of patient registries, and research on telemedicine in practice networks should be encouraged.

Randomized controlled trials that assess patient outcomes and costs related to entire episodes of care should be encouraged, and demonstration projects avoided. The fact that telemedicine is an emerging technology is not a reason for failing to perform randomized controlled trials. Rather, new methodologies such as "tracker trials" should be used to assess telemedicine systematically. There is also a need for basic research in telemedicine to refine target populations for services, refine interventions prompted by them, develop standardized tools to measure effectiveness and harm, and assess the effect of different methods of delivery and payment.

Finally, journals publishing telemedicine evaluation studies must set high standards for methodologic quality so that those who make decisions on coverage of telemedicine services need not rely on studies with marginal methodologies.

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Availability of Full Report

The full evidence report from which this summary was derived was prepared for the Agency for Healthcare Research and Quality by the Oregon Evidence-based Practice Center under contract No. 290-97-0018. The Evidence Report is archived online on the National Library of Medicine Bookshelf. Print copies are no longer available.

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