A cost-minimization study of telemedicine. The case of telemonitored polysomnography to diagnose obstructive sleep apnea syndrome.

OBJECTIVES: In a context where sleep laboratories are overwhelmed by a growing demand to diagnose obstructive sleep apnea syndrome (OSAS), efficient substitutive solutions to in-laboratory polysomnography should be found. To compare the effectiveness and costs of home unattended polysomnography (Hpsg) and telemonitored polysomnography (TMpsg), a cost minimization study was performed. METHODS: In a crossover trial, 99 patients underwent on two consecutive nights TMpsg and Hpsg according to a randomized order. A legibility recording criterion was retained to measure effectiveness. A microcosting study of TMpsg and Hpsg was performed. The risks to adopt home strategy or telemonitored strategy, according to different scenario chosen to reach the diagnosis in case of failure of Hpsg or TMpsg, were analyzed. RESULTS: The recording was considered to be ineffective in 11.2% of TMpsg (95% CI, 4.9-17.4) and in 23.4% (95% CI, 19.12-27.68) of Hpsg. The effectiveness differential was 12.2% (95% CI, 1.8-22.6) (p = .02). Assuming that in case of failure PSGs would be re-realized in the same condition to reach the diagnosis, then TMpsg could be selected if Hc/TMc (cost of Hpsg/cost of TMpsg) > 0.97; Hpsg could be selected if Hc/TMc < 0.76. If 0.76 < or = Hc/TMc < or = 0.97, the choice of TMpsg would be ambiguous. TMc was estimated to be $244, while Hc was $153 (Hc/TMc = 0.63). CONCLUSION: Unless some specific geographical situations generate significant transport costs, the implementation of a strategy based on unattended polysomnography at home is cost-saving compared to a telemonitoring strategy.     

Implementation of telemedicine: the problem of evaluation

In the UK, few telemedicine applications have endured beyond the trial phase. It is commonly said that lack of evidence is responsible for the lack of implementation. This assumes that evidence will lead to implementation. Studies show that this is naive, especially in organizations like health-care systems, which are characterized by professional dominance. Furthermore, other research indicates that the nature of the changes experienced by clinicians in telemedicine experiments is sometimes limiting compared with conventional practice. This presents a dilemma for evaluation since it cannot reliably take place until a particular technique has become stable and accepted into the daily routine. A programme of selected case studies is recommended to develop knowledge of how telemedicine can become a taken-for-granted part of medical care.     

A review of telemedicine cost-effectiveness studies

As interest in telemedicine grows, many of its proponents and vendors increasingly suggest that it is now time to move to full-scale implementation of telemedicine services in a variety of contexts throughout the world, and question the need for further evidence of its utility and cost-effectiveness. We have reviewed the published literature relating to cost-effectiveness studies in telemedicine and have identified some important weaknesses. Ten recommendations regarding the design of economic evaluations of telemedicine are suggested.     

Social networks for teaching and learning: the case of the telemedicine laboratory

This article analyzes the possibility of using social networks for teaching and learning telemedicine. The Telemedicine Laboratory is presented as a case study that offers a learning model supported by the development of a social network in a higher education environment. We performed a qualitative research study through an anonymous survey and participant observation. The results show that the Telemedicine Laboratory allows the generation of new knowledge from a holistic approach to reality, through communication and information technology, supported by the development of a social network. The presence of "invited experts" in the teaching and learning process and the linking of this process to problematic situations that members can "recognize" and perceive as true for their domain increase motivation and constitute success factors in the learning and teaching process.     

An evaluation of the west Surrey telemedicine monitoring project

We conducted a three-month pilot study of a home monitoring service for patients with chronic obstructive pulmonary disease. Fifty-five patients were recruited. They transmitted physiological data to a monitoring centre once a day. During the period of the study, 36 escalations were reported to have occurred. Of these, 29 (81%) were managed at home; the other 7 (19%) resulted in acute admission after emergency telephone calls. Although only a small number of patients were involved for a relatively short period of time, there was evidence of a substantial (approximately 50%) decrease in rates of hospital admission. The service was highly acceptable to the patients.     

Success and failure: a case study of two rural telemedicine projects

We studied two rural telemedicine projects in the state of Michigan: one that enjoyed success and steady growth in activity, and one that experienced frustration and a lack of clinical utilization. Multiple data collection strategies were employed during study periods, which lasted approximately one year. Both projects enjoyed a grassroots approach and had dedicated project coordinators. However, the more successful project benefited from resources and expertise not available to the less successful project. In addition, the more successful project possessed a more formalized organizational structure for the telemedicine application. A comparison of the two projects leads to a simple conclusion. Telemedicine programmes are positioned within larger health organizations and do not operate in a vacuum. It is crucial that the organization in which it is intended to launch telemedicine is examined carefully first. Each organization operates within a larger environment, which is often constrained by fiscal, geographical and personnel factors. All these will affect the introduction of telemedicine.     

Economic impact of ergonomic intervention—Four case studies

The economy of ergonomic improvements is reported as case studies from four Swedish companies. Poor workplace ergonomics and related musculoskeletal problems were already known and had caused repeated sick- leave periods at these workplaces. Expenses associated with certain preventive activities were accounted for and financial effects were estimated based on interviews with representatives at the companies. When costs were compared to gains, the improvements appeared to be highly profitable.     

An evaluation of a telemedicine fracture review clinic

Telemedicine is being widely used in the treatment of patients with minor injuries in north-east Scotland. A telemedicine fracture review clinic has been developed. During a one-month study period there were a total of 67 review appointments and 88 new patients. Fifty individual patients were reviewed and 10 were seen on more than one occasion. The mean number of reviews for all patients was 2.3. Thirty-six patients had initially been seen by telemedicine, six of whom (17%) had to come to Aberdeen for part of their treatment. Fourteen patients reviewed by telemedicine had initially been seen in person. All patients were safely managed and normal guidelines were followed. There is scope for significant expansion of this service, since 131 patients were seen in a fracture clinic in Aberdeen who lived close to a minor injury unit with telemedicine and X-ray facilities. The majority of these patients were likely to have had injuries suitable to be followed up using telemedicine.     

基于DRGs的医疗服务绩效评估方法与案例应用研究

介绍了医疗服务绩效评价的特点及科学评价医疗服务绩效的策略选择,系统描述了基于DRGs评估医疗服务绩效的条件和方法,从医疗服务提供者的产能、效率和医疗安全3个方面,列举了6个评估指标,并详细介绍了这些指标的计算过程.通过案例应用,认为病案首页数据的完整性和准确性,是应用DRGs进行医疗服务绩效评估的基础条件.     

Preliminary evaluation of the use of a CDMA-based emergency telemedicine system

We have conducted a preliminary evaluation of the use of a code division multiple access (CDMA)-based emergency telemedicine system to be used by emergency rescuers providing first-aid treatment for patients. The prototype system included five instrumentation modules for measuring non-invasive arterial blood pressure (NIBP), arterial oxygen saturation (SpO(2)), six-channel electrocardiogram (ECG), blood glucose concentration and body temperature. The patient data were transferred to a doctor's PC through CDMA and TCP/IP networks using an embedded personal digital assistant (PDA) phone. Performance tests in the laboratory showed that the system provided reliable values with error ranges within +/-1% for heart rate, +/-5 mmHg for NIBP, +/-2% for SpO(2) and +/-1% for glucose. The feasibility of the prototype system was then evaluated with 15 real emergency patients on Jeju Island over a two-month period. Measured data were transmitted from a moving ambulance to the emergency medical centre without significant CDMA connection loss or transmission errors. The average transfer time was 8 min. Four emergency doctors and 11 rescuers completed a questionnaire. There were favourable reviews from the users.     

A systematic review of research methodology in telemedicine studies

We conducted a systematic review of 15 relevant databases for articles about telemedicine. After eliminating articles that did not meet the inclusion criteria, 1615 remained for analysis. Three raters coded the articles to assess various theoretical and methodological variables. Only 5% (n = 85) of the telemedicine articles made mention of any theory or paradigmatic approach. Studies commonly reported the objectives (96%) but rarely stated a research question or hypothesis (11%). Randomized selection of the subjects was reported in 11% of patient studies and 4% of studies where providers were the subject. There was a wide range in the number of subjects employed, although the majority of studies were based on sample sizes of less than 100. Only 26% of the studies reported a time frame. Until the telemedicine field adheres to agreed standards of reporting methodological details it will be difficult to draw firm conclusions from review studies.     

Transcending the technology of telemedicine: an analysis of telemedicine in North Carolina

This study investigated the telemedicine program at East Carolina University School of Medicine. In-depth interviews, organizational texts, and archival records provided data for a case study that sought to understand what telemedicine is to organizational members and how they came to create this contextual reality. The goal of this study was to apply interpretive paradigmatic assumptions in the privileging of telemedicine as the very context of the organization. The findings explain how organizational members make sense of this new way of providing health care. Organizational members' talk revealed that telemedicine is multifaceted: It is access, an economic tool, education, technology, and a grant activity. With the single exception of technology, these themes emerged equally, regardless of whether the telemedicine provider was located at the urban hub site or the rural spoke site. Interestingly, members at both locations talked about critical events in relation to receipt of grant or financial support for new projects. Implications for future research are advanced.     

Teleradiology: a case study of the economic and legal considerations in international trade in telemedicine

Growth in the global market for telemedical services is being driven by economics. Two operational models are already recognizable. "Nighthawk" providers are virtually indistinguishable from their domestic counterparts with respect to medical malpractice liability and price for service. Indian providers, in contrast, offer deep price discounts on services, but jurisdictional loopholes are likely to allow these providers a method to avoid medical malpractice liability. Hospitals that outsource their radiology services need to be aware of these differences, because hiring Indian telemedical providers will likely result in a shift of medical malpractice liability from providers to hospitals.     

An evaluation of satisfaction with telemedicine among health-care professionals

A survey was conducted among non-doctor health-care professionals in six rural counties in Missouri. The purpose of the survey was to establish baseline data to evaluate the effect of changes in the health-care sector, especially technology changes, on the job satisfaction, career satisfaction, relationships and communication activities of health professionals. The survey included three rural counties in which integrated telecommunication and interactive video telemedicine services were being installed, but before significant activities had begun, and three comparator counties without substantial integrated telecommunications infrastructure and telemedicine services. During a one-month study period, 1108 questionnaires were distributed. The total response rate was 50.1% (n = 555). Of the respondents, 30.3% indicated that technology in health-care was having a large effect on their work, although only 18.2% indicated that telemedicine and telecommunications were having a large effect. No systematic differences were found among the health professionals in the two communities at the time telemedicine equipment was being installed.     

Economic evaluation of diagnostic tests. A review of published studies

OBJECTIVES: The purpose of this review was to examine whether studies from the medical literature focusing on efficiency of diagnostic facilities reported economic evaluation methods appropriately, following guidelines for conducting and reporting economic evaluations. METHODS: A Medline search was conducted, and studies that concerned a diagnostic technology and fulfilled the Drummond criteria were selected for methodological review. The reliability of selection and methodological review based on the abstracts was determined by scoring a random sample of both abstracts and full articles. Interrater reliability was determined by scoring a random sample of abstracts by both authors. Kappa values were calculated. Nine methodological aspects were reviewed: study design, the type of economic evaluation, the comparison made, the study's perspective, the cost-effectiveness ratio used, the definition of cost-effective, the types of costs analyzed, the cost calculation method, and the use of sensitivity analysis. RESULTS: Two hundred fifty studies published between 1992 and 1997 were found regarding efficiency of diagnostic facilities; 134 studies fulfilled the Drummond criteria and were selected for methodological review. Kappa values showed reliability of selection and methodological review and interrater reliability. The existing literature on the economic evaluation of diagnostic facilities does not adhere well to guidelines for economic evaluation. In 95%, no perspective was mentioned, in 50% of the cases no ratio was given, in 82% the cost calculation method was not mentioned, and in 66% no sensitivity analysis was reported. CONCLUSIONS: Our review suggests that to improve the quality of reporting economic evaluations, editorial boards could issue and enforce guidelines for standard reporting of such studies.     

Implementation and evaluation of a low-cost telemedicine station in the remote Ecuadorian rainforest

A clinical workstation was developed to provide basic telemedicine services in a medical clinic in rural Ecuador. The unit cost was less than $1000. The system provided videoconferencing and a Spanish language electronic medical record (EMR) for clinic consultations. All partners participated in the development of the EMR. Over a six-month period, almost all new patient encounters and ultrasound studies were entered into the EMR. Of 2387 patient encounters, 572 were recorded in electronic format and 80% were transmitted over the Internet for consultation. Four hundred and eight ultrasound studies were filed with the EMR and 90% were transmitted over the Internet for shared evaluation. During the six months of the study, there were no serious software or hardware problems. The doctor in Ecuador was initially trained at the laboratory in the USA. The two sites were in contact by email almost daily. Without such interaction, the performance of the software and hardware would probably have been worse. When a structured programme of instruction, protocols, EMR and technology support is in place, telemedicine can support remote rural practice.     

Feasibility and outcome evaluation of a telemedicine application in speech-language pathology

This evaluative study assessed the feasibility and outcome of delivering speech-language services from a distance to children and adolescents who stutter. All six patients who formed the first cohort seen in the telespeech programme were included in the study. The results demonstrated that interactive videoconferencing can provide a feasible and effective care delivery model. Patient attendance was maintained throughout the intervention. All participants showed improved fluency. Stuttering ranged from 13% to 36% before treatment and 2% to 26% after treatment. All participants maintained at least part of their improved fluency during the six-month follow-up, when stuttering ranged from 4% to 32%. The study demonstrates that full assessment and treatment of stuttering in children and adolescents can be accomplished successfully via telemedicine.     

Economic evaluation of services for a National Health scheme: the case for a fairness-based framework

In this paper we argue that the usual framework for evaluating health services may need modification in the context of a National Health Scheme (NHS). Some costs and benefits may need to be ignored or discounted, others included at face value, and some transfer payments included in the decision algorithm. In contrast with the standard framework, we argue that economic evaluation in the context of an NHS should focus on 'social transfers' between taxpayers and beneficiaries, and that the nature and scope of these transfers is determined by the level of social generosity. Some of the implications of a modified framework are illustrated with a re-examination of (i) costs and transfer payments, (ii) unrelated future costs, (iii) moral hazard, and (iv) the rule that marginal costs should equal marginal benefits. We argue that an explicitly 'fairness-based' framework is needed for the evaluation of services in an NHS. In contrast, the usual welfare economic theoretic framework facilitates the sidelining of issues of fairness.