Rural applications of telemedicine.

OBJECTIVES: To describe the status of telemedicine in rural America, the characteristics of health care facilities using telemedicine technologies to serve rural patients, the volume and scope of services delivered, the costs associated with this care, and the funding sources. METHODS: A screening survey was mailed to all 2472 nonfederal U.S. hospitals located outside metropolitan areas. Nonrespondents were interviewed by telephone. Those who reported some form of telemedicine capability, and all the telemedicine affiliates they named, became the sample for a detailed follow-up survey (N = 558) in January 1996. RESULTS: Ninety-six per cent of all rural hospitals responded to the screener survey, and 89% of the 558 identified telemedicine facilities responded to the detailed follow-up survey (total respondents = 499). In this cross-sectional study, two thirds of the telemedicine respondents (340) were using only teleradiology. Of the 159 telemedicine programs pursuing other clinical applications, 67% had been using telemedicine for 2 years or less. Telemedicine facilities have tried many clinical specialty applications, the most common being radiology, cardiology, and orthopedics. At this early stage of technology diffusion, reported utilization of the telemedicine systems for both clinical and nonclinical applications was very low, and the unit costs of equipment acquisition and operating expenses were corresponding high. Programs most commonly used hospital financial resources and federal grants and contracts for support. Telemedicine networks planned to grow from an average of nine facilities to an average of 13 facilities during 1996. CONCLUSIONS: Investment has been rapid in telemedicine, and the installed base reported in this survey was large, sophisticated, and growing rapidly. Nonclinical uses of the technology (e.g., meetings, training sessions, continuing medical education) were more common than clinical consultations, although the volumes of both were quite low. Investment and expansion to new sites were occurring in the absence of a favorable payor reimbursement environment and in spite of low volume at most operating sites, demonstrating optimism about the future of telemedicine and the potential for nonclinical applications.     

Implementation and evaluation of a telemedicine course for physician assistants.

Clinical telemedicine uses interactive video technologies and telecommunications networks to deliver medical consultations to distant patients and their primary care providers. Telemedicine provides real-time access to specialists whose services might not otherwise be available in rural or medically underserved areas. While recently there has been dramatic growth in the use of telemedicine, there is little evidence that telemedicine as a patient care delivery system has been incorporated into the medical school curriculum. The authors describe the current status of telemedicine in medical curricula and report on efforts at the University of Iowa to incorporate telemedicine into the curriculum of its Physician Assistant Program.     

Teleradiology at the tertiary-level Women's and Children's Hospital in South Australia.

This article relates to a teleradiology trial undertaken in 1998-1999 at the Women's and Children's Hospital (WCH) in Adelaide, the capital of South Australia. The trial involved linking the hospital to a range of rural and remote sites in South Australia and the Northern Territory. The main aim of the project was to evaluate the advantages, limitations, benefits, and costs of a teleradiology service provided by WCH. The major finding from the study is that for a tertiary hospital providing second opinions in complex medical cases, a new form of business justification is required for teleradiology. The justification would include an emphasis on the range of high-level services that a subspecialist hospital such as the WCH can provide. The justification would also include the range of benefits to different parties, particularly the patient, and the intangible nature of many of the benefits.     

Telemedicine and rural health care applications

Telemedicine has the potential to help facilitate the delivery of health services to rural areas. In the right circumstances, telemedicine may also be useful for the delivery of education and teaching programmes and the facilitation of administrative meetings. In this paper reference is made to a variety of telemedicine applications in Australia and other countries including telepaediatrics, home telehealth, critical care telemedicine for new born babies, telemedicine in developing countries, health screening via e-mail, and teleradiology. These applications represent some of the broad range of telemedicine applications possible. An overriding imperative is to focus on the clinical problem first with careful consideration given to the significant organisational changes which are associated with the introduction of a new service or alternative method of service delivery. For telemedicine to be effective it is also important that all sites involved are adequately resourced in terms of staff, equipment, telecommunications, technical support and training. In addition, there are a number of logistical factors which are important when considering the development of a telemedicine service including site selection, clinician empowerment, telemedicine management, technological requirements, user training, telemedicine evaluation, and information sharing through publication.     

Rural telemedicine: a national snapshot.

OBJECTIVES: To estimate the use of telemedicine in rural hospitals in the U.S. and to identify and describe those rural hospitals that are active in telemedicine. MATERIALS AND METHODS: Nationwide mailed survey, with telephone follow-up, to all hospitals not located in a Metropolitan Statistical Area. RESULTS: The overall response rate was 95% of all rural hospitals. Of these, 416 (17.55%) reported having telemedicine, and more than 530 more have plans to begin telemedicine programs during the next few years. Rural hospitals of all sizes and in all regions of the country are initiating telemedicine programs, but there is significant variation by region. Specifically, hospitals located in more populous rural counties near metropolitan areas are less likely to have telemedicine than are hospitals located in less populous rural counties in more remote areas. Conservatively, more than 4000 teleconsults per month are estimated among rural hospitals nationwide in 1995, including all forms of telemedicine. CONCLUSIONS: Telemedicine is becoming an important means of providing specialty medical services in rural areas. This screening survey generated information about the extent of telemedicine use in rural communities, but it also raised many new questions. These questions are being pursued through a detailed follow-up survey.     

The comparative impact of video-consultation on neurosurgical health services

This study evaluated the impact of telemedicine technology on the provision of neurosurgical health services. We focused on the differences between the use of real time audio-visual teleconferencing and teleradiology versus conventional telephone consultations in the referral of neurosurgical patients from a large district general hospital. All patients requiring emergency neurosurgical consultation were included for randomization into telephone consultation only (Mode A), teleradiology and telephone consultation (Mode B) and video-consultation (Mode C). Measures of effectiveness included diagnostic accuracy and adverse events during the transfer and Glasgow Outcome Score. In a 10-month period, 327 patients were recruited and randomized into the study: the male/female ratio was 2:1 and the number of patients required to be transferred to the neurosurgical unit was 125 (38%). There was a trend towards a more favourable outcome in the video-consultation mode (44%, Mode C), versus teleradiology (31%, Mode B), versus telephone consultation (38%, Mode A). The interim data of this prospective randomized trial suggests that video-consultation may have a favourable impact on emergency neurosurgical consultations.     

Public knowledge, perception, and expressed choice of telemedicine in rural West Virginia.

OBJECTIVE: It is doubtful that any new health care delivery system that requires as much adjustment as telemedicine does will be sustained if its users do not fully support it. We sought to determine the familiarity with, perceptions of, and attitudes toward telemedicine among rural adults in West Virginia. METHODS: Data were collected in a statewide telephone survey of 461 non-institutionalized rural adults. The survey contained questions about familiarity with telemedicine, perceptions about its attributes and benefits, and willingness to use it for routine, specialty, and emergency care. Responses were examined in relation to the subjects' age, sex, socioeconomic status, access to care, and insurance coverage. RESULTS: Despite mass media coverage of the subject, only one third of the respondents had heard of telemedicine. Nearly two thirds thought patients would find it less satisfactory than seeing a physician in person. Male subjects, younger subjects, and those with higher incomes were more likely to think telemedicine would be as satisfactory as a face-to-face meeting. There was a general consensus on the benefits of telemedicine, such as greater convenience and easier contact with specialists. For chronic conditions, 47% of the respondents would use telemedicine if no physician was available locally, whereas 27% would go out of town to see another physician in person, and 25% would wait for their own physician. For emergency care, these figures were 41%, 58%, and 0. Three fourths of the respondents were somewhat or very willing to use telemedicine for routine or specialist care. CONCLUSION: More work needs to be done to demonstrate the efficacy of telemedicine and disseminate this knowledge to the public.     

Telegenetics in Maine: Successful clinical and educational service delivery model developed from a 3-year pilot project.

PURPOSE: The goal of this 3-year pilot project was to increase accessibility to genetics educational and clinical services in Maine. METHODS: Southern Maine Genetics Services, Foundation for Blood Research in collaboration with Maine Telemedicine Services established telemedicine capacity to link with rural health care centers located in Northern, Central, and Southern Maine and public health nursing statewide for the provision of genetics clinical and educational services. Core partners included a rural family practice residency program, a rural pediatric practice in northern Maine, and public health nurses statewide. The telegenetics model created was based on development and implementation of a preventive and medical management technology solution, conducting a pilot study to collect data, and approaching insurance companies for reimbursement. Evaluation included surveys on the quality, acceptability, and usefulness of genetics services delivered via telemedicine, telephone interviews, and decision-making confidence evaluations. RESULTS: During the project period, 24 rural clinical sites participated. In total, 93 presentations were given, and 125 patients were evaluated. Sixty-four percent of patients evaluated were pediatric. Despite site coordinator efforts to complete satisfaction surveys, the provider and patient response level was low (18% and 25%, respectively). Of those evaluations received, provider and patient response to telegenetics was positive. Decision-making confidence for genetics and neurology consultants was high. Our experience contributes to the development of telegenetics models that can be used in other rural states.     

Primary-care delivery for sickle cell patients in rural Georgia using telemedicine.

BACKGROUND: Advances in newborn screening and pediatric management of sickle cell disease have resulted in patients living well into adulthood. For adults, preventive care and medication monitoring are crucial for optimal health maintenance. The Medical College of Georgia (MCG) in Augusta provides consultative services and comprehensive medical care to about 1200 sickle cell patients residing in middle and southern Georgia. An increase in the demand for clinical services in this patient population has resulted in expansion of sickle cell outreach efforts throughout the state. OBJECTIVE: A telemedicine clinic for adult sickle cell patients was established in order to meet the growing clinical demands. METHODS: An on-site outreach clinic was introduced in the target area. After 10 months of operation, a monthly telemedicine clinic was offered to patients as an option for routine medical follow-up. A clinic model was used, with scheduled appointments and a public health nurse assisting at the remote site. Phlebotomy and laboratory services enhanced the telemedicine encounter. RESULTS: Over a 12-month period, 52 encounters for 28 patients from 17 medically underserved counties were completed. All patients were African-American, and 89. 3% had Medicaid or Medicare insurance coverage or both. The clinic encounter time was 24 +/- 7.9 minutes (mean +/- SD), comparable to that for all telemedicine clinic encounters during the same period. CONCLUSIONS: The adult sickle cell population in rural Georgia accepts innovative health care delivery using telemedicine. Thus, the telemedicine sickle cell clinic has increased access to care for rural patients in underserved areas. For providers, it has allowed greater clinical productivity and diminished travel time to outreach clinics.     

Telemedicine across borders: A systematic review of factors that hinder or support implementation

PurposeInnovative technologies to deliver health care across borders have attracted both evangelists and sceptics. Our aim was to systematically identify factors that hinder or support implementation of cross-border telemedicine services worldwide in the last two decades.MethodsTwo reviewers independently searched ten databases including MEDLINE and EMBASE, in June 2011 including citations from 1990 onwards when at least an abstract was available in English. We also searched ELDIS and INTUTE databases and Internet search engines to identify grey literature. We included studies which (a) described the use of telemedicine to deliver cross-border healthcare and, or (b) described the factors that hinder or support implementation of cross-border telemedicine services. All study designs were included. Two reviewers independently assessed titles and abstracts of articles identified. Papers were allocated to one of four reviewers who extracted relevant data and validated it. We took a qualitative approach to the analysis, conducting a narrative synthesis of the evidence.Results6026 records were identified of which 5806 were excluded following screening of titles and abstracts. We assessed 227 full text articles, excluding 133 because they were fatally flawed or did not meet the inclusion criteria, producing a final sample of 94. They involved 76 countries worldwide, most involving collaborations between high and low or middle income countries. Most described services delivering a combination of types of telemedicine but specialties most represented were telepathology, telesurgery, Emergency and trauma telemedicine and teleradiology. Most link health professionals, with only a few linking professionals directly to patients. A main driver for the development of cross-border telemedicine is the need to improve access to specialist services in low and middle income countries and in underserved rural areas in high income countries. Factors that hinder or support implementation clustered into four main themes: (1) legal factors; (2) sustainability factors; (3) cultural factors; and (4) contextual factors.ConclusionsNational telemedicine programmes may build infrastructure and change mindsets, laying the foundations for successful engagement in cross-border services. Regional networks can also help with sharing of expertise and innovative ways of overcoming barriers to the implementation of services. Strong team leadership, training, flexible and locally responsive services delivered at low cost, using simple technologies, and within a clear legal and regulatory framework, are all important factors for the successful implementation of cross-border telemedicine services.     

Telemedicine to Iowa's correctional facilities: initial clinical experience and assessment of program costs.

OBJECTIVE: To evaluate the costs and benefits of a prison telemedicine program for the institutions involved and to assess early provider satisfaction. MATERIALS AND METHODS: A survey of primary care and consulting providers from four prisons and an academic tertiary care facility in Iowa was conducted during the first year of telemedicine service linked with the state's correctional facilities, from March, 1997 to February, 1998. Data were evaluated from 247 completed telemedicine encounters. Cost estimates were made for (1) 1997 cost data for the 4,396 Iowa prisoners who were transported to The University of Iowa Hospitals and Clinics (UIHC) for their health care, and (2) the equipment, circuitry, and personnel costs necessary on both ends of the network to provide comparable telemedicine service to remote patients and providers. A formula for estimating the cost of implementing a telemedicine service is presented. It includes a projection for determining at what point the cost of the telemedicine visit approaches the average cost of an on-site visit (breakeven point). There was also a brief survey administered to presenting and consulting physicians to determine their overall satisfaction with the telemedicine system for diagnosis, treatment planning, and follow-up. RESULTS: The average cost to the prisons for an on-site inmate visit to the University of Iowa Hospitals and Clinics (UIHC) was $115 during our study period, from March 1997 to February 1998. Using a formula that specifies a number of fixed and variable costs for implementing telemedicine, we were able to determine that the breakeven point for Iowa's correctional facilities would require 275 teleconsultations per year, per site (total of 1,575 consultations a year). Given the higher equipment investment at the UIHC hub, the breakeven point would be around 2,000 teleconsultations annually. Cost studies did not include medical care, which is assumed to be relatively comparable for both on-site and telemedicine interactions. Overall, referring physicians expressed a higher rate of satisfaction with telemedicine than specialists (4.19 to 3.45, respectively, on a scale of 1 to 5 - 5 representing the highest ranking). Both consulting and referring physicians ranked the quality of transmission the highest among all questions regarding satisfaction with the telemedicine system. CONCLUSIONS: No one should anticipate instantaneous cost-effectiveness with telemedicine. However, with careful planning, implementing a telemedicine program can be "cost-acceptable" initially. Telemedicine ultimately becomes cost-effective as the volume of teleconsults increases.     

Beyond adoption to sustained use: telemedicine for rural communities.

The objective of this paper is to identify factors that affect the sustained use of telemedicine in rural communities and to suggest possible ways to improve such utilization. We draw on innovation and network theory to develop hypotheses about conditions that will hinder or facilitate sustained use of telemedicine. Telemedicine systems are expected to achieve sustained use in communities with higher physician-to-population ratios, greater availability of nonphysician providers, and greater consumer knowledge of and support for telemedicine. Additionally, telemedicine is more likely to be used in settings where hospital medical staff structures use contractual arrangements that encourage the use of telemedicine or reimburse through capitated systems. Rural physicians are more likely to use telemedicine if they have previous experience in facilities that serve as telemedicine hubs and if they have strong relationships with physicians in a hub location or with local physicians who are supportive of telemedicine. Physicians whose primary offices are geographically closer to the remote telemedicine installation are more likely to order telemedicine consultations for their patients than are their counterparts further away. Also, telemedicine systems that are well managed and easy to use are more likely to achieve sustained utilization by rural physicians. These hypotheses should be considered by supporters, providers, and managers of telemedicine. A proactive approach to managing telemedicine networks, with an emphasis on the issues raised here, should help telemedicine achieve its potential, namely, improved access and enhanced quality and efficiency of health services in rural communities.     

Minimum technical requirements and evaluating effectiveness of teleradiology.

Teleradiology, the electronic transmission of radiological images for the purposes of interpretation and consultation, has successfully entered routine health services. It is, therefore, currently one of the single largest applications of telemedicine. This technology is predicted to play a significant role in improving service access to rural and remote areas. However, teleradiology services are currently characterized by a compromise between expense and quality of digital images. This paper reviews minimum equipment requirements and the technical issues and limits that are experienced when utilizing current teleradiological technology. Categories of service evaluation, including measures of user satisfaction, clinical outcome and financial benefit, are discussed in relation to facilitating a radiology service of the highest quality possible.     

Design of a high-speed,high-resolution teleradiology network

A teleradiology system acquires radiographic images from one location and transmits them to one or more distant sites where they are displayed and/or converted to hard-copy film recordings. The long-term goal of teleradiology research is to show that teleradiology systems can provide diagnostically equivalent results when compared with conventional radiographic film interpretation. If this hypothesis is proven, provision of the following radiology services will be improved: (1) providing for primary interpretation of radiological images for patients in underserved areas as well as in other medical facilities; (2) integration of radiological services for multihospital/clinic health care provider consortiums; (3) improving emergency service and intensive care unit coverage; (4) offering consulting-at-a-distance with subspecialty radiologists; and (5) providing radiologists in the community or in rural areas with immediate access to large academic centers for help in the interpretation of difficult and problematic cases. We are designing a high-speed, high-resolution teleradiology network that will communicate between our level 3 medical center and several outlying medical centers within the metropolitan area. Computed tomography (CT), magnetic resonance (MR), and screen-film examinations will be digitized to 2,000 x 2,000 or 4,000 x 4,000 pixels at the remote sites, transmitted to the central referral facility, and sent to a laser film printer, replicating the original film. This film may then be used for primary diagnosis, overreading/consultative purposes, or for emergency department preparation. Inherently digital modality data (eg, MR and CT) can be sent without digitization of the multiformat film if desired.     

An automated system to monitor imaging equipment service and billing information

Numerous writers have commented on barriers to the growth and progress of telemedicine. Among these barriers are reimbursement concerns, professional liability exposure, licensing restrictions, hospital credentialing questions, and other problems. A legal threat not generally described in the literature to data is the possibility that products liability claims could be brought against manufacturers and distributors of hardware, software, and peripherals used in providing telemedicine services. Several of these concerns extend to picture archiving and communication systems (PACS), including, of course, teleradiology. This article considers that possibility in the context of several potential plaintiffs’ theories, discusses currently applicable law, and proposes approaches to diminishing the magnitude and severity of this potential threat.     

面向家庭的远程健康监护医疗系统探讨

本文探讨了面向家庭健康监护的远程医疗系统的系统结构，主要技术及其应用模式与发展前景。面向家庭的远程健康监护医疗是一种利用计算机，电子监护设备和互联网，将用户和医院紧密联系起来，实现预防和保健、监护、诊断、康复的综合治疗方式。它是远程医疗应用中跟人群联系最紧密的一种方式，相信它将成为现代医疗方式的一种新的必然趋向。     

卫星远程医学信息网站点建设与应用

随着通信技术的不断发展,卫星通信远程医学系统的应用领域正在逐步拓展。我院卫星站点开通运行以来,不断健全组织管理,加强机构建设,加大宣传力度,提升业务能力,拓展应用领域,使远程医学工作形式更加多样,服务内容更加丰富,服务质量不断提高。     

Domestic and peer violence in secondary school among adolescents: can telemedicine help?

Domestic and peer violence in Macedonia is similar to other developed nations. It is present among adolescents and their families. A study was conducted on 664 secondary school students throughout Macedonia. The results indicated that 11.2% male and 16.54% female students often face different kinds of family violence. Peer violence of different forms is marked as "often" in 8.04% male respondents and 5.63% female respondents. One of possibilities in preventing this negative phenomenon is the application of telemedicine. There is a growing body of evidence that the use of telemedicine offers a good tool for mental healthcare in underserved communities, and that these services are as effective as face-to-face work with adolescents. By building an effective telemedicine network in Macedonia, both victims (adolescents) and their parents could be given a chance to contact proper institutions for help with more confidence and less stress.     

A cost-effectiveness analysis of shipboard telemedicine.

BACKGROUND: The U.S. Navy is considering the installation of telemedicine equipment on more than 300 ships. Besides improving the quality of care, benefits would arise from avoiding medical evacuations (MEDEVACs) and returning patients to work more quickly. Because telemedicine has not yet been fully implemented by the Navy, we relied on projections of anticipated savings and costs, rather than actual expenditures, to determine cost-effectiveness. OBJECTIVES: To determine the demand for telemedicine and the cost-effectiveness of various technologies (telephone and fax, e-mail and Internet, video teleconferencing (VTC), teleradiology, and diagnostic instruments), as well as their bandwidth requirements. METHODS: A panel of Navy medical experts with telemedicine experience reviewed a representative sample of patient visits collected over a 1-year period and estimated the man-day savings and quality-of-care enhancements that might have occurred had telemedicine technologies been available. The savings from potentially avoiding MEDEVACs was estimated from a survey of ships' medical staff. These sample estimates were then projected to the medical workload of the entire fleet. Off-the-shelf telemedicine equipment prices were combined with installation, maintenance, training, and communication costs to obtain the lifecycle costs of the technology. RESULTS AND CONCLUSIONS: If telemedicine were available to the fleet, ship medical staffs would initiate nearly 19, 000 consults in a year-7% of all patient visits. Telemedicine would enhance quality of care in two-thirds of these consults. Seventeen percent of the MEDEVACs would be preventable with telemedicine (representing 155,000 travel miles), with a savings of $4400 per MEDEVAC. If the ship's communication capabilities were available, e-mail and Internet and telephone and fax would be cost-effective on all ships (including small ships and submarines). Video teleconferencing would be cost-effective on large ships (aircraft carriers and amphibious) only. Teleradiology would be cost-effective on carriers only. Telemedicine's bandwidth requirement is small-1% of a month's time. However, if the ships' medical departments need to resort to a commercial satellite, E-mail and Internet would be the only telemedicine modality generating enough monetary benefits to offset the costs.     

Teleradiology for remote diagnosis: A prospective multi-year evaluation

Teleradiology has been used for nearly 3 years at our institution to provide urgent radiologic interpretations for two outpatient clinics and an affiliated hospital. The purpose of this study was to evaluate the clinical reliability of the existing system. Teleradiology images were interpreted using 1600×1200 pixel display stations. The original films from the same cases were subsequently interpreted, usually by another radiologist. The initial and final interpretations were compared. Discrepancies were rated and adjudicated by another senior radiologist. These data were compared to peer review interobserver discrepancy rates. Among the 2688 teleradiology examinations evaluated, there were major discrepancies in 31 (1.15%). In three instances teleradiology rather than film interpretation was considered correct. Abnormalities missed on teleradiology were apparent in all but two at adjudication. Among the 628 peer-review cases, there were 6 (0.96%) major discrepancies. Major teleradiology diology discrepancy rates are statistically similar to film-based peer review discrepancy rates. Teleradiology is suitable for providing radiologic services to remote medical facilities.