Financial analysis of telemedicine in a prison system.

OBJECTIVE: To quantify the costs and benefits of medical care under a telemedicine agreement. METHODS: Two telemedicine contracts between the North Carolina Central Prison (NCCP) and the East Carolina University School of Medicine were analyzed, first from the point of view of the prison using break-even analysis and second from the societal point of view examining whether the arrangements were positive for the taxpayers of North Carolina. RESULTS AND CONCLUSIONS: While the prison system never broke even with the first contract, the break-even was attainable, as it would have required an average of only one consultation per day. The prison system attained break-even status in the latest year of the second contract, and simple forecasts indicate a good chance that usage will grow beyond the break-even point. From the societal point of view, the contracts are merely transfers of funds from one state agency to another. Therefore, the differences in them are irrelevant. What is relevant is a measure of average fixed and variable spending for telemedicine and what this expenditure buys in terms of avoided costs. Thus, we examined the average full cost per visit, as determined from the actual or estimated expenditures, and concluded that the program paid back its cost during year 4.     

An Ohio telemedicine system for prison inmates: a case report.

BACKGROUND: A project was established by The Ohio State University Medical Center (OSUMC) and the Ohio Department of Rehabilitation and Corrections (ODRC) to investigate the use of telemedicine in providing health care to Ohio's prison inmates. OBJECTIVES: To determine the effects of telemedicine on continuity of inmate care, the sense of isolation experienced by health care providers at remote institutions, the security risks incurred when transporting inmates to outside facilities, and the overall cost of care. In tracing the initial adoption and implementation of the project, the authors describe health care in Ohio's prisons and the unique nature of providing that care. METHODS: The project was conducted over a 1-year period, from November 1994 through December 1995, using a variety of methods: direct observation of inmate consultations; participation in task force meetings; unstructured interviews with physicians, prison administrators, ancillary health care personnel, and security guards; and initial collection of survey data. RESULTS: Telemedicine enables Ohio's inmates to receive health care in a more timely fashion than before. Physicians and inmates were generally satisfied, and the costs of providing inmate medical care were reduced by lessening or eliminating the need for additional security guards, vans, chase vehicles, and travel time for physicians. CONCLUSIONS: Some initial hurdles in using the system, such as scheduling and triage, are being overcome as new methods are devised, and additional incentives for specialty physicians to use the system are being investigated. The OSUMC/ODRC project suggests that the advantages of using telemedicine in prison settings are immense, and the ODRC plans to expand the network to include two more remote sites early in 1996.     

User satisfaction with asynchronous telemedicine: a study of users of Santa Catarina's system of telemedicine and telehealth

User satisfaction analyses in synchronous telemedicine and teleconsultation environments have been widely performed and generally show satisfied users. In the field of asynchronous telemedicine, however, satisfaction studies were performed only in one single location or with a restricted set of users. With the aim of offering an exemplar evaluation of the impact of the statewide use of a large-scale asynchronous telemedicine network on the satisfaction of the involved users, this study presents the results obtained from a survey of the perceived quality of the service by both patients and healthcare staff. For this purpose, a survey with satisfaction questionnaires was performed with 564 patients from seven upstate municipalities and 56 healthcare professionals from 46 municipalities, using a methodology from the process improvement field. The collected data were quantified and underwent statistical analysis, which showed a clear perception of the improvement in the quality of service by both patients and healthcare professionals. The present findings also showed that both patients and healthcare professionals felt that introducing these new technologies was a positive step, even in upstate areas and when they involved great changes in the usual processes of primary care.     

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.     

Diffusion of telemedicine: a knowledge barrier perspective.

Telemedicine, broadly defined as the use of information technology (IT) to deliver medical services over distances, is one proposed solution to problems of accessibility, quality, and costs of medical care. Although telemedicine applications have proliferated in recent years, their diffusion has remained low in terms of the volume of consultations. In this study, we extend Attewell's theory of knowledge barriers to explain why diffusion of telemedicine remains low. A longitudinal, embedded multiple case study of telemedicine programs in three medical centers in Boston, Massachusetts, reveals that, in addition to technical knowledge barriers, as suggested by Attewell, there are economic, organizational, and behavioral knowledge barriers that inhibit the diffusion of telemedicine. The lowering of these barriers entails intensive learning efforts by champions of applications within adopter organizations. They need to develop technically feasible, medically valid, reimbursable, and institutionally supported applications in order to justify the value of telemedicine and engender consistent and frequent use by physicians.     

The clinician's view of diagnostic electron microscopy.

From the clinician's standpoint, it has become increasingly evident that use of the electron microscope should no longer be confined to research institutes, but should be applied as an adjunct to clinical diagnosis, a guide to therapy, and a means of elucidating pathogenetic mechanisms. The usefulness of electron microscopy is stressed in relation to hematology, nephrology, virology, gastroenterology, and the study of miscellaneous metabolic conditions such as the storage diseases.     

Parent-child concordance for separation anxiety: a clinical study.

There is tentative evidence supporting a familial basis for separation anxiety. The present study aimed to examine parent-child concordance for that subtype of anxiety. Fifty-four children diagnosed with anxiety disorders and their parents (54 mothers and 29 fathers) were recruited from two juvenile anxiety clinics. Sixty-three percent of children diagnosed with juvenile separation anxiety disorder had at least one parent who suffered from the putative adult variant of the disorder (odds ratio = 11.1) (P < 0.001). Affected parents reported high levels of separation anxiety in their own childhoods. Juvenile separation anxiety disorder in children was not associated with any other parental diagnosis. The small sample size and other potential biases caution against definitive conclusions being drawn, but the present data add to existing evidence that separation anxiety may aggregate in families.     

Health systems evaluation of telemedicine: a staged approach.

Telemedicine promises greater access to health care of higher quality, potentially at lower cost. The diverse applications of telemedicine technology developed to date have not been evaluated systematically in terms of their ability to achieve these goals. Furthermore, the great variety in telemedicine applications and the far-reaching consequences of new information systems for health care delivery pose challenges to traditional methods of technology assessment. Methods appropriate for mature technologies may not be suitable for emerging ones and, indeed, may risk stifling their development with premature negative conclusions. The staged approach to technology assessment proposed here matches the analysis to the technology's stage of development. It focuses on access, quality, and cost and considers the communication pathway employed in the telemedicine application. A staged approach to technology assessment can inform and foster the development of new telemedicine technology while allowing health care delivery systems to make rational decisions about adopting telemedicine.     

Exploring medication use to seek concordance with ''non-adherent'' patients: a qualitative study.

BACKGROUND: 'Concordance' has been proposed as a new approach towards sub-optimal medication use; however, it is not clear how this may be achieved in practice. AIM: To develop a strategy for understanding sub-optimal medication use and seek concordance during primary care consultations. DESIGN: A developmental qualitative study using a modified action research design. SETTING: Three Scottish general practices. METHOD: Patients using treatment sub-optimally and having poor clinical control were offered extended consultations to explore their situation. Their authority to make treatment decisions was made explicit throughout. Clinicians refined a consultation model during ten 'Balint-style' meetings that ran in parallel with the analysis. The analysis included all material from the consultations, meetings, and discussion with patients after the intervention. RESULTS: Three practitioners recorded 59 consultations with 24 adult patients. A six-stage process was developed, first to understand and then to discuss existing medication use. Understanding of medication use was best established using a structured exploration of patients' beliefs about their illness and medication. Four problematic issues were identified: understanding, acceptance, level of personal control, and motivation. Pragmatic interventions were developed that were tailored to the issues identified. Of the 22 subjects usefully engaged in the process, 14 had improved clinical control or medication use three months after intervention ceased. CONCLUSIONS: A sensitive, structured exploration of patients' beliefs can elucidate useful insights that explain medication use and expose barriers to change. Identifying and discussing these barriers improved management for some. A model to assist such concordant prescribing is presented.     

Prevalence and density-related concordance of three diagnostic tests for malaria in a region of Tanzania with hypoendemic malaria

Accurate malaria diagnosis has dual roles in identification of symptomatic persons for effective malaria treatment and also enumeration of asymptomatic persons who contribute to the epidemiologic determinants of transmission. Three currently used diagnostic tests, microscopy, rapid diagnostic tests (RDTs), and real-time PCR, all have different sensitivities and specificities, which are parasite density dependent. Here, we compare their concordance among 451 febrile episodes in a cohort of 2,058 children and adults followed over 6 months in a region in central Tanzania with hypoendemic malaria. Microscopy, a histidine-rich protein-based RDT, and two different real-time PCR gene probes detected Plasmodium falciparum in 20, 54, 41, and 78 episodes of fever, respectively. They had complete concordance in only 9 episodes. Real-time PCR with an 18S probe was more sensitive than with a mitochondrial probe for cytochrome b despite higher copy numbers of mitochondrial DNA. Both PCR yields were increased 4-fold by glycogen/acetate precipitation with low-speed centrifugation. Duplicate PCR increases low-density malaria detection. RDT had the highest number of unique positives, presumably from persistent antigen despite the absence of parasites, although RDT did not detect 3 parasitemias with over 1,000 parasites/μl. In a latent class analysis, real-time PCR had significantly higher sensitivity than did microscopy or RDT. Agreement between real-time PCR, RDT, and microscopy was highest in March and April, when both the P. falciparum parasite rate and parasite densities are highest. Real-time PCR is more sensitive and specific than RDT and microscopy in low-prevalence, low-parasite-density settings.     

Comparison of direct and indirect enzyme immunoassays with direct ultracentrifugation before electron microscopy for detection of rotaviruses.

A direct and an indirect enzyme immunoassay (EIA) were evaluated against a standard of electron microscopy after direct ultracentrifugation of the specimen for their performances in detecting rotaviruses. The indirect EIA had variable background activity which influenced test specificity. The indirect EIA control (test system without the detector antibody) plus a regression line (which reflected background noise) improved test specificity. However, the results of direct EIA (Rotazyme; Abbott Laboratories, North Chicago, Ill.) sensitivity (86%) and specificity (96%) were better than those of the indirect EIA in tests on 73 rotavirus-positive and 78 rotavirus-negative specimens. Endpoint titrations of purified SA-11 rotavirus showed greater sensitivity of the direct EIA test. Electron microscopy, performed after direct ultracentrifugation, and direct EIA were approximately 2 log10 more sensitive in the detection of purified SA-11 rotavirus than was electron microscopy with standard methods of unconcentrated specimen preparation. Direct EIA test are potentially sensitive, specific, and practical for the rapid detection of rotaviruses from human clinical specimens. Further studies are needed before EIA methods for detection of human rotaviruses can be equated with the level of reliability of results obtainable with sensitive electron microscopy techniques.     

Implementation and evaluation of a multifunctional telemedicine system in NTUH

In this article, we proposed a multifunctional telemedicine system supporting both telediagnosis and teleconsultation services. We attempted not only to insure that the implementation of this system satisfied most requirements, but also to evaluate the impact of the system. With regard to system architecture, we designed a unified multimedia database to store all types of data and used two kinds of network (ATM and ISDN) for different possible applications. As for data transmission, the REFRESH and PREFETCH mechanisms were implemented to enhance data transfer efficiency. A total of 1107 consultations employing the telemedicine system were performed during the past 3 years. This technology was used most frequently for radiology consultation (32.7%, n = 362) and ultrasonic examination (19.5%, n = 216). An evaluation of the impact on diagnosis (507 valid cases) indicated that the diagnosis in 80 cases (15.78%) were altered on the basis of second opinions from a medical center; and the number of patients transferred to the medical center was reduced from 24 (4.7%) to eight cases. Most of the rural-site physicians (97%) thought that they did benefit from specialists' experience and knowledge via the telemedicine system. Based on 431 valid questionnaires, the number of the patients with confidence in the telemedicine system at their local healthcare center increased from 72.6% to 87.5%. Overall, more than 90% of patients and physicians believed that the system was valuable and provided satisfactory services.     

Cost-minimization analysis: A follow-up study of a telemedicine program.

OBJECTIVE. To present the follow-up findings to a cost-benefit analysis of telemedicine subspecialty services provided between the Powhatan Correctional Center (PCC) of the Virginia Department of Corrections and the Medical College of Virginia Campus of Virginia Commonwealth University (MCV Campus). METHODS. Costs included those of operating the telemedicine system, transportation, litigation avoidance, and the medical care itself. RESULTS. Over a 12-month study period, the total number of consults completed through telemedicine was 290. The cost per visit of treating inmates at the MCV Campus clinics was $401. The cost per visit of treating inmates at PCC via telemedicine was $387, a net saving of $14 per visit with the use of telemedicine. CONCLUSION. As a result of implementing telemedicine, the Department of Corrections for the State of Virginia was able to achieve a cost saving of $14 per visit. Nonmonetary cost savings, such as greater security and increased access to care, should be considered a net benefit as well.     

Real-time emergency telemedicine system: prototype design and functional evaluation

In this paper, an emergency telemedicine system was designed for the transmission of real-time multimedia for remote consultation, including radiological images, patient records, video-conferencing, full-quality video, ECG, BP, respiration, temperature, SpO(2), systolic and diastolic pressures and heart rate. The standardized, modular, software-based design architecture, without resorting to external hardware compression boards, enables the low-cost implementation of the telemedicine system, using the unified, systematic and compact integration of multimedia on general personal computers. Experimental tests on local networks analyze the technical aspects of designed systems, and inter-hospital experiments demonstrate its clinical usefulness.     

Efficiency analysis of a multi-specialty telemedicine service.

OBJECTIVE: The goal of this project was to assess case turn-around times for store-and-forward and real-time video consultations in the Arizona Telemedicine Program. MATERIALS AND METHODS: Five components contributing to total case turn-around time were analyzed. Each parameter was submitted to statistical analysis and compared for store-and-forward and real-time sessions. RESULTS: Turn-around for real-time are longer than for store-and-forward sessions. Real-time sessions take longer, from when the consulting clinician is contacted to the time the case is reviewed. This is compounded by the fact that real-time sessions sometimes need to be rescheduled. For both types of consults, the time to deliver the final report is the longest segment of the total turn-around time. CONCLUSION: Several factors contribute to case turn-around times. By identifying and analyzing each contributing factor, it is possible to revise consult protocols to improve efficiency.     

Histologic fixatives suitable for diagnostic light and electron microscopy.

The merits of formaldehyde, formaldehyde-glutaraldehyde combinations, and glutaraldehyde in phosphate buffers have been compared as fixatives that will give easy and satisfactory preservation of tissues for routine automated histologic processing and yet keep them suitable for electron microscopical studies after prolonged storage at room temperature. We recommend a combination of 4% commercial formaldehyde and 1% glutaraldehyde in a buffer of 176 mOsm/liter. Tissue sections should not exceed 3 mm in width, and tissues to be examined by electron microscopy should be taken from the outside of the tissue sections. All special stains performed at light microscopical level gave satisfactory results. The fixative should be stored at 4 C and is stable for at least three months. The superior cross-linking features of glutaraldehyde are retained, while the concentration of glutaraldehyde is low enough not to substantially obscure the PAS reaction.     

Widespread neuroendocrine malignancy within the central nervous system: a diagnostic conundrum.

A 75 year old female presented with a sellar tumour, and was subsequently found also to have a cauda equina tumour, a parietal dural tumour, a pontine tumour, an intradural spinal tumour, and several vertebral body tumours. Histological examination revealed a neuroendocrine tumour forming cell nests surrounded by reticulin. There was moderate nuclear pleomorphism, prominent mitoses, and focal necrosis. Immunohistochemistry showed diffuse positive staining with cytokeratins, chromogranin and 5-hydroxytryptamine, and focal positive staining with S100. This case is an unusual and ultimately insoluble, diagnostic problem; however, the differential diagnoses include pituitary carcinoma, malignant paraganglioma, and atypical carcinoid.