Perceptions of Local Health Care Quality in 7 Rural Communities with Telemedicine

CONTEXT: Rural health services are difficult to maintain because of low patient volumes, limited numbers of providers, and unfavorable economies of scale. Rural patients may perceive poor quality in local health care, directly impacting the sustainability of local health care services. PURPOSE: This study examines perceptions of local health care quality in 7 rural, underserved communities where telemedicine was implemented. This study also assesses factors associated with travel outside of local communities for health care services. METHODS: Community-based pretelemedicine and posttelemedicine random telephone surveys were conducted in 7 northern California rural communities assessing local residents' perceptions of health care quality and the frequency of travel outside their community for health care services. Five-hundred rural residents were interviewed in each of the pretelemedicine and posttelemedicine surveys. Between surveys, telemedicine services were made available in each of the communities. FINDINGS: Residents aware of telemedicine services in their community had a significantly higher opinion of local health care quality (P =.002). Satisfaction with telemedicine was rated high by both rural providers and patients. Residents with lower opinions of local health care quality were more likely to have traveled out of their community for medical care services (P =.014). CONCLUSIONS: The introduction of telemedicine into rural communities is associated with increases in the local communities' perception of local health care quality. Therefore, is it possible that telemedicine may result in a decrease in the desire and need for local patients to travel outside of their community for health care services.     

What is the least costly strategy to evaluate cervical abnormalities in rural women? Comparing telemedicine, local practitioners, and expert physicians.

OBJECTIVE: This study establishes the least costly strategy for evaluation of rural women in need of colposcopy among 3 alternatives: telemedicine, local practitioners, and referral experts. METHODS: Women in rural Georgia who needed colposcopy were examined by an expert colposcopist on site, by a local practitioner, and by a distant expert colposcopist linked by telemedicine. Independent determinations of biopsy intent were used to model the differing biopsy costs of the 3 methods. Record review determined the average total cost of telemedicine. Reports of average cost in year 2000 dollars from societal perspective include medical costs and pain and suffering due to additional biopsies and curettage, telemedicine costs, and costs of potential diagnostic delay for a 1-year time horizon. RESULTS: From the societal perspective in the baseline case, the average cost per patient evaluated was dollar 270 for patients seen by referral experts. The cost was dollar 38 less (e.g., dollar 232) for patients seen by local practitioners, and dollar 35 more (e.g., dollar 305) for patients seen by telemedicine. From the societal perspective, local practitioners were less costly than referral experts because of lower travel costs for patients, but from the medical perspective, their average cost was dollar 32 higher than referral experts because they performed more biopsies and curettage procedures than experts. Telemedicine assistance would have lowered the number of biopsies performed by local practitioners, but as of year 2000 the costs of this technology could not be justified by the savings. CONCLUSION: From the societal perspective, local practitioners performing colposcopy are the least costly way to evaluate cervical abnormalities in rural patients with substantial time and travel costs.     

E-health and the Universitas 21 organization: 2. Telemedicine and underserved populations

Telemedicine activities in underserved communities were reviewed as part of the Universitas 21 (U21) e-health project. A SWOT analysis (strengths, weaknesses, opportunities, threats) was conducted on 12 articles identified in a literature review, supplemented by expertise from U21 members. The analysis showed that threats include the reluctance of populations to use telemedicine services, and a general absence of infrastructure and resources to sustain them. Opportunities centre around potential research, including cost-effectiveness analyses and quantitative assessments of existing telemedicine services. The great strength of telemedicine is that it can improve access to health services among those most in need. However, its greatest weakness is the lack of evidence supporting its clinical and cost advantages relative to traditional services. This represents an important opportunity for research on telemedicine initiatives among underserved populations.     

Physician perceptions of the effect of telemedicine on rural retention and recruitment

We conducted a postal survey of 140 family and community specialist physicians in a predominantly rural area which had received clinical telemedicine services and videoconferenced continuing medical education (CME) for two years. The questionnaire contained 46 items. The response rate was 47%. Most respondents (83%) reported having attended videoconferenced CME sessions and 45% reported having referred patients for teleconsultation. Physicians in more rural areas used these services more frequently. Ratings of two statements assessing the value of telemedicine in community support were significantly and positively correlated with the number of videoconferenced CME sessions attended and the number of telemedicine services used. In relation to their decision to stay in their community for at least one year, respondents rated telemedicine lower in importance than all but one of 17 other factors expected to influence physician recruitment and retention in rural communities. The influences on physician rural recruitment and retention are complex. However, telemedicine was used more frequently by the more rural physicians, and there was a relationship between higher usage and higher ratings of its value as a community support.     

Telemedicine Screening for Diabetic Retinopathy

Diabetic eye disease is the most common cause of new cases of blindness in the Western world. If the disease is detected early then proper treatment can be provided to prevent loss of vision. Regular screening can reduce the incidence and prevalence of blindness due to diabetic retinopathy. Health personnel, optometrists and primary care providers can perform the screening using digital nonmydriatic fundus cameras. Digital data can be archived, stored, manipulated and sent via telecommunication networks, e.g. the Internet, to ophthalmologists for diagnosis and second opinions.Easy-to-operate, low cost and portable digital fundus cameras and intuitive software are necessary to perform cost-effective screening of rural, remote and underserved communities using trained lay personnel. Several feasibility studies of telemedicine screening for diabetic retinopathy have been reported. These studies demonstrate the enormous usefulness of this technology for communities living in rural and remote areas. Further studies are needed to prove the cost benefit of telemedicine technology for diabetic retinopathy screening.     

A cost analysis of a tele-oncology practice in the United States

Oncology services have been provided by telemedicine from the University of Kansas Medical Center (KUMC) for almost 10 years. We have analysed the costs associated with providing tele-oncology clinics to a rural Kansas town for two fiscal years, 1995 and 2000. The aim was to compare recent tele-oncology costs with those of the first year of tele-oncology practice. A study conducted in 1995 showed that the average cost was $812 per telemedicine consultation. Data from fiscal year 2000 showed that the average cost was $410 per telemedicine consultation, a decrease of almost 50%. As the tele-oncology practice in Kansas continues to grow, it can be expected that the costs associated with providing tele-oncology services will continue to decline.     

Telepsychiatry: Challenges in Rural Aging

A significant health care dilemma for older individuals living in rural areas is that at a time in life when there is, predictably, a greater need for medical services, the ability to access those limited services is markedly reduced. Telepsychiatry presents an innovative and cost-effective strategy for the provision of improved local access to quality mental health services for the underserved rural elderly. Telepsychiatry has demonstrated the potential to improve access to mental health services, provide those services in an affordable and cost-effective manner and deliver those services at a quality nearly equal to traditional face-to-face services. Advances in telepsychiatry technology allow a core group of skilled mental health providers in a central location to provide timely local access to quality services for the rural elderly over a broad geographic area.     

A method for identifying comparison counties: application to a rural telemedicine evaluation project

The evaluation of telemedicine activity in rural communities is complicated by the fact that most telemedicine sites are chosen because of their existing telecommunications infrastructure and institutional relationships, not by a random selection process. In addition, it is difficult to draw conclusions about the effects of telemedicine without a careful analysis of parallel changes in communities which do not have access to telemedicine services. We have developed a method of identifying comparable counties based on an aggregate measure of health status. A set of 66 variables was collected in a previous project to develop a model to evaluate the relative health status of the population in Missouri. A stepwise regression was used to identify a subset of 15 variables that had the highest predictive value for the health status of a county. Distance measures were then used to identify six counties which were most similar to three telemedicine counties. The method can be used with any study set chosen non-randomly, to identify similar objects that can be used for comparative purposes.     

Patient-centered medical homes: will health care reform provide new options for rural communities and providers?

Many are calling for the expansion of the patient-centered medical home model into rural and underserved populations as a transformative strategy to address issues of access, efficiency, quality, and sustainability in the delivery of health care. Patient-centered medical homes have been touted as a promising cost-saving model for comprehensive management of persons with chronic diseases and disabilities, but it is unclear how rural practitioners in medically underserved areas will implement the patient-centered medical home. This article examines how the Patient Protection & Affordable Care Act of 2010 will enhance rural providers' ability to provide patient-centered care and services contemplated under the Act in a comprehensive, coordinated, cost-effective way despite leaner budgets and health workforce shortages.     

Using Telemedicine to Avoid Transfer of Rural Emergency Department Patients

Access to emergency treatment in rural areas can often mean the difference between life and death. Telemedicine technologies have the potential of providing earlier diagnosis and intervention, of saving lives and of avoiding unnecessary transfers from rural hospital emergency departments to urban hospitals. This study examined the hypothetical impact of telemedicine services on patients served by the emergency departments of two rural Missouri hospitals and the potential financial impact on the affected hospitals. Of the 246 patients transferred to the hub hospital from the two facilities during 1996, 161 medical records (65.4 percent) were analyzed. Using a conservative approach, only 12 of these cases were identified as potentially avoidable transfers with the use of telemedicine. Of these 12, 5 were admitted to the hub hospital after transfer. In addition to this conservative estimate of avoidable transfers based on current availability of resources in the rural hospitals, two more aggressive scenarios were developed, based on an assumption of increased service availability in the rural hospitals. Economic multipliers were used to estimate the financial impacts on communities in each scenario. This evaluation study demonstrates the potential value of telemedicine use in rural emergency departments to patients, rural hospitals and rural communities.     

Title VII Funding and Physician Practice in Rural or Low-Income Areas

CONTEXT: Whether Title VII funding enhances physician supply in underserved areas has not clearly been established. PURPOSE: To determine the relation between Title VII funding in medical school, residency, or both, and the number of family physicians practicing in rural or low-income communities. METHODS: A retrospective cross sectional analysis was carried out using the 2000 American Academy of Family Physicians physician database, Title VII funding records, and 1990 U.S. Census data. Included were 9,107 family physicians practicing in 9 nationally representative states in the year 2000. FINDINGS: Physicians exposed to Title VII funding through medical school and residency were more likely to have their current practice in low-income communities (11.9% vs 9.9%, P< or =.02) and rural areas (24.5% vs 21.8%, P< or =.02). Physicians were more likely to practice in rural communities if they attended medical schools (24.2% vs 21.4%; P =.009) and residencies (24.0% vs 20.3%; P =.011) after the school or program had at least 5 years of Title VII funding vs before. Similar increases were not observed for practice in low-income communities. In a multivariate analysis, exposure to funding and attending an institution with more years of funding independently increased the odds of practicing in rural or low-income communities. CONCLUSIONS: Title VII funding is associated with an increase in the family physician workforce in rural and low-income communities. This effect is temporally related to initiation of funding and independently associated with effect in a multivariate analysis, suggesting a potential causal relationship. Whereas the absolute 2% increase in family physicians in these underserved communities may seem modest, it can represent a substantial increase in access to health care for community members.     

Primary Care Providers'' Perceptions of Home Diabetes Telemedicine Care in the IDEATel Project

CONTEXT: Few telemedicine projects have systematically examined provider satisfaction and attitudes. PURPOSE: To determine the acceptability and perceived impact on primary care providers' (PCP) practices of a randomized clinical trial of the use of telemedicine to electronically deliver health care services to Medicare patients with diabetes in federally designated medically underserved areas of upstate New York, primarily those in rural areas and small towns with limited access to primary care. METHODS: A longitudinal phone survey was completed by 116 PCPs with patients with diabetes in the treatment arm of the trial, and conducted 12 and 24 months after a PCP's first patient was randomized to the home telemedicine arm of the trial. The 36-item survey included measures of acceptability (to PCPs, time required), impact (on patient knowledge, confidence, perceived health outcomes), and communication. Six open-ended questions were analyzed qualitatively. RESULTS: The quantitative data indicated positive responses in terms of acceptability of the telemedicine intervention to the PCPs and of the impact on the PCPs' patients. This was most evident in issues critical to good control of diabetes: patient knowledge, ability to manage diabetes, confidence, and compliance in managing diabetes. Key qualitative themes, on the positive end, were more patient control and motivation, helpfulness of having extra patient data, and involvement of nurses and dieticians. Negative themes were excessive paperwork and duplication taking more PCP time, and conflicting advice and management decisions from the telemedicine team, some without informing the PCP but none involving medications. CONCLUSIONS: Telemedicine was reported to be a positive experience for predominantly rural PCPs and their Medicare-eligible patients from medically underserved areas; several inefficiencies need to be refined.     

A Rural Cancer Outreach Program Lowers Patient Care Costs and Benefits Both the Rural Hospitals and Sponsoring Academic Medical Center

The Rural Cancer Outreach Program (RCOP) between two rural hospitals and the Medical College of Virginia's Massey Cancer Center (MCC) was developed to bring state-of-the-art cancer care to medically underserved rural patients. The financial impact of the RCOP on both the rural hospitals and the MCC was analyzed. Pre- and post-RCOP financial data were collected on 1,745 cancer patients treated at the participating centers, two rural community hospitals and the MCC. The main outcome measures were costs (estimated reimbursement from all sources), revenues, contribution margins and profit (or loss) of the program. The RCOP may have enhanced access to cancer care for rural patients at less cost to society. The net annual cost per patient fell from $10,233 to $3,862 associated with more use of outpatient services, more efficient use of resources, and the shift to a less expensive locus of care. The cost for each rural patient admitted to the Medical College of Virginia fell by more than 40 percent compared with only an 8 percent decrease for all other cancer patients. The rural hospitals experienced rapid growth of their programs to more than 200 new patients yearly, and the RCOP generated significant profits for them. MCC benefited from increased referrals from RCOP service areas by 330 percent for cancer patients and by 9 percent for non-cancer patients during the same time period. While it did not generate a major profit for the MCC, the RCOP generated enough revenue to cover costs of the program. The RCOP had a positive financial impact on the rural and academic medical center hospitals, provided state-of-the-art care near home for rural patients and was associated with lower overall cancer treatment costs.     

The effect of information technology on the physician workforce and health care in isolated communities: the Canadian picture

The ratio of physicians to population in Canada peaked in the mid-1990s and is now falling. The decrease in the number of family physicians has had a disproportionate effect on rural and remote communities, and surveys have indicated that the availability of physicians and services is likely to deteriorate in rural and remote communities. Telemedicine is increasingly evident in every Canadian province and territory, and it could assist in more effective use of workforce resources by linking appropriate experts at central sites to patients and practitioners at remote sites. Positive effects on recruitment and retention of health providers and morale of the local workforce can be expected. In spite of national interest, evidence for the effect of telemedicine on staff distribution, roles and recruitment, use of health resources, health management and system integration is very limited. Telephone interviews were therefore conducted to collect information from 12 telehealth projects in Canada, one from each province or territory. The responses confirmed observations in the literature that telemedicine has positive outcomes for the workforce.     

A proposed model for telemedicine to supplement the physician workforce in the USA

Maldistribution of physicians is the norm in much of the USA. This paper explores the effect that the integration of telemedicine into the health system could have on physician workforce requirements in the USA. The analysis is based on preliminary evidence suggesting that telemedicine is an effective and efficient means of delivering a broad spectrum of health services to medically under-served rural and inner-city communities. While the emphasis here is on interactive, video-based telemedicine services, other telemedicine modalities, such as store-and-forward techniques and remote monitoring, are likely to have a parallel effect. As these new technologies become a normal part of health care, they will reshape the medical workforce and exert a profound influence on physician workforce requirements in the USA. This paper presents a potential model for this reshaped workforce that emphasizes an expanded role for mid-level health-care providers.     

Economic Effects of the Outmigration of Obstetric Services in a Rural County

Obstetrical health care resources have been declining in rural areas since 1980, resulting in reduced prenatal care that can result in higher medical costs. Loss of health care services is known to have negative economic consequences for rural communities. This article illustrates how hospitals and other providers of medical services can be used as vehicles for local economic development. Provision of medical services is an important component of the economic base of all communities and especially of small rural communities with hospitals. When a community loses medical services to another community, it loses both direct and indirect economic benefits. The research presented here analyzes the economic effects of outmigration of obstetric services from a rural "perimeter" community in Wyoming. The combined direct and indirect economic losses are shown to be significant. Annual revenue losses to the local hospital were estimated as high as 12 percent. It is important to make explicit the economic losses that result from reductions in health care. Such research, combined with knowledge of negative health and social factors can provide community leaders with additional motivation to find solutions to declining health care in rural areas.     

对发展我国HIS技术市场的调研与思考

为规范我国ＨＩＳ市场的发展提供决策参考,对医院信息系统开发市场及行业发展的整体情况进行调开,综合调查结果显示：全国的ＨＩＳ发展情况基本处在同一水平,整个ＨＩＳ产品正处于更新换代阶段,市场竞争激烈。对此,建议从整体上强调政府宏观指导,利用市场规律,主张强强联合,注重对国有资产设备的调配和充分利用,加强企业内部管理是ＨＩＳ成功的基本保证。     

A tele-obstetric broadband service including ultrasound, videoconferencing and cardiotocogram. A high cost and a low volume of patients

We established a tele-obstetric service connecting the Department of Obstetrics and Gynaecology at the Nordland Hospital in Bod? to the delivery unit at the Nordland Hospital in Lofoten. The telemedicine service included a videoconferencing link (3 Mbit/s) for transmission of ultrasound scans and a low-speed data link (telephone modem) for transmission of cardiotocograms (CTGs). One hundred and thirty pregnant women entered the antenatal clinic in Lofoten during the eight-month study period. A total of 140 CTGs were recorded. The tele-ultrasound service was used in five cases (4%). The cases were serious malformation, Down's syndrome, breech presentation, vaginal bleeding during pregnancy and triplets. Analysis showed that the cost of patient travel was NOK 2460 per transfer. The variable cost of videoconferencing was NOK 250 per consultation. However, the total investment costs for the telemedicine service, including the broadband infrastructure, was NOK 1.7 million (Euro 212,000). The telemedicine service was not cost saving at annual workloads below 208. We conclude that the installation has to be used by other medical specialities to make it cost-effective.     

Cost-effectiveness of family planning and maternal health service delivery strategies in rural Bangladesh

Two alternative service delivery strategies to improve the effectiveness and efficiency of the Bangladesh national Family Planning and Maternal and Child Health programme have been tested: (1) service delivery at cluster spots, a centrally located neighbourhood spot, rather than at the client's home, and (2) increased frequency of outreach clinics merged with immunization spots. The cost-effectiveness of these strategies was compared with baseline estimates of the cost of providing services. The data were collected in two rural sites of Bangladesh, Mirsarai Thana of Chittagong and Abhoynagar Thana of Jessore, in August 1996. The results of this analysis indicate that cluster service delivery of contraceptive services in their present form are not more cost-effective than home delivery services. The cost per birth averted was lower in only one out of three services in each of the field sites. When the cost-effectiveness of increasing the frequency of SCs combined with EPI services was examined, the service delivery was found to be more cost-effective for all services in one thana and for two out of three services in the higher performing thana, Abhoynagar. This implies that the provision of a wider range of services is improving overall cost-effectiveness.     

Introducing telemedicine technology to rural physicians and settings

OBJECTIVE: The researchers investigated rural health providers' perceptions of telemedicine, developed a framework for assessing their readiness to adopt this type of technology, and offered a guide for its implementation. STUDY DESIGN: Qualitative data were collected from semistructured interviews with thematic analysis. POPULATION: The study population included physicians, nurses, and administrative personnel located in 10 health care practices in 4 communities in 3 rural Missouri counties. OUTCOMES MEASURED: The researchers measured how often health providers used telemedicine technology and their perceptions of the advantages, disadvantages, barriers, and facilitators involved in adopting it. RESULTS: Participants varied widely in their perceptions of telemedicine. Providers in practices affiliated with the university's tertiary center were more likely to use it than were those in private practice. Interviews and other data yielded 6 themes related to a provider's receptivity to technological change: These themes were turf, efficacy, practice context, apprehension, time to learn, and ownership. Each theme applies to the computer and videoconferencing components of telemedicine, and each may operate as a perceived barrier or facilitator of change. CONCLUSIONS: Care providers and administrators consider a range of factors, including economic ramifications, efficacy, social pressure, and apprehension, when deciding whether and how fast to adopt telemedicine. Since adopting this technology can be a major change, agencies trying to introduce it into rural areas should take all these factors into account in their approach to health care providers, staff, and communities.