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Journal supplement reviews evidence for the efficacy of telemedicine and telecare

Despite the growth of computer networks and the Internet, telemedicine continues to fall short of its potential. One reason is the lack of high-quality evidence to convince clinicians, policymakers, and others that this technique deserves more widespread use in health care. Research on telemedicine and telecare is conducted at the Evidence-based Practice Center of the Oregon Health and Science University, which is supported by the Agency for Healthcare Research and Quality (AHRQ) (contract 290-02-0024).

A March 2005 workshop based on this research was sponsored by AHRQ and the Centers for Medicare & Medicaid Services. Papers commissioned for the workshop were published in Volume 12, Supplement 2, 2006, of the Journal of Telemedicine and Telecare. The papers discuss the poor and uneven evidence base for telemedicine, what telemedicine services are covered by insurance, lessons learned from other countries, use of telemedicine addressing problems of access and specialty shortages, and its role in the national information technology strategic framework. The papers are briefly summarized here. Single reprint copies (Publication No. OM07-0004) are available from the AHRQ Publications Clearinghouse.

Hersh, W.R., Hickam, D.H., and Erlichman, M., "The evidence base of telemedicine: Overview of the supplement," pp. 1-2.

In this overview, the authors summarize the general themes of the journal supplement. The main theme is that telemedicine has unfulfilled potential for delivery of health care. While the rationale for its use is still strong, and studies do not show any harm, the lack of a substantial evidence base makes its benefits unrealized. There is a need for robust clinical trials to test its efficacy in its most promising clinical domains, such as dermatology, psychiatry, and home health care. Growth of the evidence base may be aided by the increased use of electronic health records to facilitate systematic data collection and growth in use of health information technology in general.

Hersh, W.R., Hickam, D.H., Severance, S.M., and others, "Diagnosis, access and outcomes: Update of a systematic review of telemedicine services," pp. 2-31.

This update of a systematic review originally published in 2001 concludes that the quality of evidence for telemedicine continues to be uneven and, for the most part, poor. The authors reviewed the literature for three types of telemedicine services that substitute for face-to-face medical diagnosis and treatment. The evidence of efficacy for store-and-forward services, most commonly studied in dermatology, has been mixed. Several limited studies showed the benefits of home-based telemedicine interventions in chronic diseases. Studies of office/hospital-based telemedicine suggest that telemedicine is most effective for verbal interactions such as videoconferences for diagnosis and treatment in specialties like neurology and psychiatry.

Brown, N.A., "State Medicaid and private payer reimbursement for telemedicine: An overview," pp. 32-39.

This paper reviews what telemedicine services are being covered by U.S. States and their rationale for coverage. Since 1998, when States were given the option of paying for telemedicine services with Medicaid, 34 States have added coverage of telemedicine services to their Medicaid programs. However, a survey showed wide variations in service coverage, payment policies, and geographical and other restrictions. Another survey showed that over half of the 72 telemedicine programs in 25 States were reimbursed by private insurance companies. In 1999, 43 percent of responding telemedicine networks saw reimbursement as a barrier to long-term sustainability, while in 2004 only 22 percent did so. Thus, it appears that some progress has been made in Medicaid and private payer reimbursement for telemedicine.

Ohinmaa, A., "What lessons can be learned from telemedicine programmes in other countries?" pp. 40-44.

Some telemedicine programs in other countries may be applicable to implementation of telemedicine in the United States, asserts the author of this paper. He queried eight international experts in telemedicine and reviewed a few key publications in the field to identify examples of successful telemedicine programs that had the potential to be successfully implemented in the United States. He concluded that international telemedicine applications in some specific areas would be suitable for implementation in the United States. These areas included teleradiology, telementalhealth, telegeriatric applications, e-referrals and discharge letters, and integration of health care organizations with telemedicine networks.

Rheuban, K.S., "The role of telemedicine in fostering health care innovations to address problems of access, specialty shortages and changing patient care needs," pp. 44-50.

This paper assesses telemedicine studies from the standpoint of fostering innovation in addressing specific health care challenges. The author focuses in particular on access to care, specialty shortages, and changing patient care needs. She asserts that, by incorporating advanced technologies, clinicians will be able to manage the growing volumes of medical information, research, and decision support analytical tools. Also, the deployment of advanced technologies will minimize the barriers of distance and geography to enhance access to care and facilitate the delivery of integrated health care. This is particularly important for rural areas, where there are few local specialists, and for marginalized populations such as prisoners. Telemedicine also improves the opportunity to reach the elderly at home and in nursing homes.

Dimmick, S.L., and Ignatova, K.D., "The diffusion of a medical innovation: Where teleradiology is and where it is going," pp. 51-58.

Teleradiology is one of the more successful applications of telemedicine, note the authors of this paper. A persistent shortage of radiologists combined with the ease of transmitting radiology images led to the rapid adoption of teleradiology. For example, teleradiology had become part of the practices of two-thirds of radiologists who responded to the 1999 American College of Radiology survey. Telecardiology may be the next successfully diffused form of telemedicine. However, the authors caution that one potential problem is the political pressure to avoid outsourcing to foreign countries, particularly those to which U.S. information technology jobs have already been transferred. How the outsourcing issue is resolved will have a significant effect on teleradiology specifically and, perhaps, telemedicine generally.

Speedie, S.M., and Davies, D., "Telehealth and the national health information technology strategic framework," pp. 59-64.

These authors point out that telemedicine does not exist in an information technology vacuum. It may well provide synergistic benefit in concert with electronic health records and the National Health Information Infrastructure. The authors note that goals of telehealth and the national plan are complementary. One focuses on improving access to high quality health care services and the other on the information systems to support those services. Telehealth also needs the fully realized electronic health record to provide the best possible care when patients are geographically and chronologically separated from their providers. The experiences of telehealth in organizing large networks of heterogeneous health care groups can provide useful lessons as the process of implementing health information technology moves forward.

Whitten, P., "Will we see data repositories for telehealth activity in the near future?" pp. 65-71.

This paper addresses the issue of what sources of clinical/patient data exist, either in telemedicine-specific registries or in general electronic health record systems, which would allow investigators to analyze it for research on the efficacy of telemedicine interventions. A number of different organizations operate registries, but there do not appear to be any true telehealth registries. One reason is that Federal requirements through such policies as the Health Insurance Portability and Accountability Act have led to heightened fear of inadvertently releasing confidential or unauthorized information. Also, it would be more efficient if patient data were captured electronically at the local level, ideally through electronic medical records, and then transferred electronically to registries. However, the diffusion of EMRs at the local level is in its infancy, making a telehealth data repository unlikely to be soon.

Yellowlees, P., and Harry, D., "Standards for data collection and monitoring in a telemedicine research network," pp. 72-76.

Although a networked, nationwide health information system is financially and logistically impractical, the development of independent, regional systems is realistic and feasible, assert these authors. A Telemedicine Research Network (TRN) could connect a number of geographically disparate health systems. This would require the reconciliation of policies and practices in five principal areas: partner agreement on project scope; privacy, security and confidentiality; technical standards; telecommunications and computer infrastructure; and change management practices and training. Establishing a first-stage TRN would require very little technical development and would, instead, rely on trust among the partners. The development of standards-based TRNs will greatly increase the quality and quantity of telemedicine research.

Grigsby, J., and Bennett, R.E., "Alternatives to randomized controlled trials in telemedicine," pp. 77-84.

The authors of this paper assess the usefulness of study designs other than randomized controlled trials for the evaluation of telemedicine. Potential methods include those that do not rely on randomization and tight control of the intervention and include analysis of existing administrative and clinical databases. Quasi-experimental designs may also be useful, especially when conducted in association with careful statistical methods, which allow the investigator to control for certain differences between groups. Databases, such as those maintained by the Centers for Medicare & Medicaid Services, contain information on both outcomes and claims, as well as disease/procedure registries. Such databases may be a potential tool for understanding the effect of telemedicine on access to care in conjunction with costs and quality.

Shea, S., "Health delivery system changes required when integrating telemedicine into existing treatment flows of information and patients," pp. 85-90.

The technical issues involved in using telemedicine to improve chronic disease management are numerous, daunting, and complex, note the authors of this paper. However, they assert that many can be addressed using the resources and infrastructure available in large, well-integrated clinical information systems. The cost-benefit balance will change when it becomes possible to use devices that are owned by patients for everyday use, rather than installing special-purpose devices for telemedicine. Provider-side telemedicine capabilities, specifically for upload, storage, and display of medical data, will improve as technology develops. How clinicians will process the large amount of data made available by telemedicine is a clinical issue, but it is likely that software will emerge to aid in this task.

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