The need for cost-effectiveness studies in telemedicine

Telemedicine has the potential substantially to improve the delivery of health care. However, cost-effectiveness studies are needed to help define the appropriate scope and application of telemedicine in different settings. Reports on the evaluation of telemedicine are dominated by technical and feasibility studies. Such studies may be very helpful for initial decision making. However, any cost information at this level tends to be very preliminary and often concerned with making a case to proceed further. Decision makers will wish for further information as the telemedicine application is introduced, to consider its effectiveness - its performance under routine conditions. Without information on the costs and effectiveness of telemedicine services, decision makers run the risk of supporting telemedicine systems that are not responsive to health-care needs or which do not provide cost-effective services. The most immediate needs seem to be improvements in the conduct and reporting of studies, and additional information on the performance of telemedicine in routine practice. Investigators need to provide transparent accounts of their studies, describing in detail the approaches taken, sources of data and assumptions made, and indicating the reliability of their results. Decisions may have to be made on the basis of limited studies, but sufficient detail must be made available to decision makers.     

Approaches to economic evaluation in telemedicine

External validity or generalizability is a major challenge in the economic evaluation of telemedicine. There are two possible ways of increasing generalizability: the first is to use a pragmatic trial design so it better reflects normal patient caseload and everyday practice. The second is to use existing data from the literature and decision modelling to estimate the expected costs and outcomes of different alternatives. The first will increase generalizability to other patients than those in the trial and the second will increase generalizability from place to place. The objective and role of the evaluation will decide the most appropriate evaluation approach. Pragmatic trials should be used in studies where the objective is to provide measurements of costs and outcomes for a specific group of patients in a particular setting. This approach is highly relevant in telemedicine evaluations where the objective is to support local investments strategies and reimbursement systems. Decision modelling provides an overall structure for a decision problem and a formal analysis of the implications of different decisions. Modelling can simulate a trial or mimic a current system or a system that decision makers would like to use. Modelling is a useful approach when decisions need to be made about whether to invest in telemedicine within a broader context.     

The reality of applying an assessment guideline to a telemedicine mental health programme

A guideline for assessment of telemedicine applications was used by the Alberta Mental Health Board (AMHB) in its evaluation of a telemedicine mental health (TMH) service. Many attributes referred to in the guideline were well covered in the AMHB evaluation. However, there were limitations on the assessment of outcomes and cost-effectiveness. From the perspective of the AMHB, the guideline was helpful, although more so in the earlier stages of the TMH service than for its appraisal as it reached maturity. The measures of performance suggested by the guideline did not fully match local operational conditions. Constraints on the assessment of the mature TMH service included the complexity of the network, the limited resources available for evaluation and the routine administrative demands of decision makers. This experience points to the usefulness of standardized assessment approaches to telemedicine, but also to their limitations.     

Study quality and evidence of benefit in recent assessments of telemedicine

We carried out a systematic review of recent telemedicine assessments to identify scientifically credible studies that included comparison with a non-telemedicine alternative and that reported administrative changes, patient outcomes or the results of an economic assessment. From 605 publications identified in the literature search, 44 papers met the selection criteria and were included in the review. Four other publications were identified through references cited in one of the retrieved papers and from a separate project to give a total of 48 papers for consideration, which referred to 42 telemedicine programmes and 46 studies. Some kind of economic analysis was included in 25 (52%) of the papers. In considering the studies, we used a quality appraisal approach that took account of both study design and study performance. For those studies that included an economic analysis, a further quality-scoring approach was applied to indicate how well the economic aspects had been addressed. Twenty-four of the studies were judged to be of high or good quality and 11 of fair to good quality but with some limitations. Seven studies were regarded as having limited validity and a further four as being unacceptable for decision makers. New evidence on the efficacy and effectiveness of telemedicine was given by studies on geriatric care, intensive care and some of those on home care. For a number of other applications, reports of clinical or economic benefits essentially confirmed previous findings. Although further useful clinical and economic outcomes data have been obtained for some telemedicine applications, good-quality studies are still scarce.     

偏远及农村地区卫生人力留用计划成本分析技术框架

背景：通过加强卫生人力留用以提高偏远和农村地区卫生人力的可及性,对于人口健康至关重要。然而,此类干预措施有关成本方面的信息往往零散、不全面、甚至缺失。政策措施的成本分析对于政策的选择、规划、实施和评估至关重要,但是由于缺少成本分析的系统方法,为卫生政策制定和决策带来了严峻的挑战。方法：本文提出了提高偏远及农村地区卫生人力可及性政策干预措施的成本分析实施框架,旨在为卫生政策决策者提供帮助。同时,该框架也强调了确定财政的主要来源和财政资金可持续性的重要性。文章对加强边远农村地区卫生人力留用相关政策措施的成本分析进行了文献综述,为此类干预措施的成本分析提供了指导框架,并进一步调查分析了成本分析在整个卫生人力规划与管理中的角色与重要意义。结果：尽管对于人力留用相关政策措施效益的争论得到越来越多的关注,但如何对此类政策措施进行成本分析,目前仍缺乏相关的知识与证据。为了解决这个问题,文章提出了实施成本分析框架的关键要素,并对此进行讨论分析。结论：这些关键要素能够帮助决策者对政策措施有更加深入的了解,明晰与理解财政来源和运行机制,同时确保财政资金的可持续性。     

Biotechnology: a special case for health technology assessment?

Many substances produced naturally in a wide range of living organisms have been identified to be of benefit in the treatment of human disease. Current health biotechnologies recreate DNA-recombinant cellular processes in laboratory settings to produce 'natural' therapeutics: these are potentially a step forward from traditional pharmacology which has developed synthetic analogues or sought to extract products from donor material. However, with increasing financial pressures, decision makers require evidence that the benefits of biotechnologies justify their costs. The challenges experienced when evaluating the cost-effectiveness of biotechnologies are explored with reference to three examples: HA-1A human monoclonal antibody, erythropoietin and DNase. Difficulties in economic evaluation are similar to those experienced with conventional pharmaceuticals: use of short-term clinical endpoints rather than meaningful health outcomes, the artificial nature of clinical trial protocols, and uncertainty about the applicability of economic data. However, early clinical and economic assessments are required by decision-makers, particularly where biotechnology products fill major gaps in therapy. The financial structure of biotechnology companies may limit movement towards adequate clinical and economic research for health technology assessment. Governments should negotiate with the industry to promote more relevant studies, and develop policies for the managed introduction of products as evidence on effectiveness and cost expands. New technologies often present additional costs requiring reallocation of existing resources. Careful resource planning is required so that cost-effective innovation are not denied to patients.     

Transaction costs economics as a conceptual framework for the analysis of barriers to the diffusion of telemedicine

Telemedecine has been talked about for more than 20 years, without it entering daily use with any success. Based on transaction costs economics, the present analysis of the exchange relationships between health care producers highlights certain characteristics of the current technical and legislative context, which leads to transaction costs. It also demonstrates that the introduction of telemedicine shifts the costs associated with agents' opportunism from patients to health-care producers themselves. All these costs may be considered nowadays to thwart the use of telemedicine. It is argued here that the Public Authorities and professionals of health care could act upon telemedicine in two fields: (1) intervention in the institutional environment aims notably at better defining the property rights of telemedicine, and so constitutes an unavoidable means of encouraging health-care producers to invest in new technology; and (2) implementation of organisational forms and mechanisms susceptible to regulating such telemedical relationships between health care producers-given the present institutional environment-constitutes an essential means for overcoming the immediate barriers blocking the diffusion of telemedicine.     

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.     

荷兰卫生技术评估体系分析及对我国的启示*

目的：介绍荷兰卫生技术评估体系和政策转化现状，为完善我国价值医疗体系、提高卫生改革决策水平提供借鉴。方法：通过查阅国内外相关文献，描述荷兰的卫生技术评估体系，分析其常规应用的转化特点，综合评价其在新冠肺炎疫情中急性护理服务的网络构建特点。结果：荷兰卫生体系被称为“欧洲最佳医疗体系”，卫生技术评估在荷兰卫生系统决策中发挥了重要作用，特别是在降低医疗成本层面。相比荷兰，我国卫生技术评估政策转化成果相对较少。结论：我国需要完善卫生技术评估机构体系，加强研究人员与政策制定者的沟通，提升决策科学性及加快卫生技术评估转化效率。同时，筑牢分级诊疗体系，提升卫生技术评估综合性评价标准，进而推动实践价值医疗，促进我国卫生健康事业发展。     

基于Web服务的远程医疗会诊系统研究

针对全军远程医疗会诊系统存在的不足,结合全军远程医学信息网建设现状,设计了基于Web服务的远程医疗会诊系统,并对其体系结构、协作关系及各子系统的功能进行了详细的阐述。基于Web服务构建远程医疗会诊系统,不仅实现了与医院信息系统的良好集成,更重要的是全面提高了远程医疗会诊质量。     

The added value of thorough economic evaluation of telemedicine networks

This paper proposes a thorough framework for the economic evaluation of telemedicine networks. A standard cost analysis methodology was used as the initial base, similar to the evaluation method currently being applied to telemedicine, and to which we suggest adding subsequent stages that enhance the scope and sophistication of the analytical methodology. We completed the methodology with a longitudinal and stakeholder analysis, followed by the calculation of a break-even threshold, a calculation of the economic outcome based on net present value (NPV), an estimate of the social gain through external effects, and an assessment of the probability of social benefits. In order to illustrate the advantages, constraints and limitations of the proposed framework, we tested it in a paediatric cardiology tele-expertise network. The results demonstrate that the project threshold was not reached after the 4 years of the study. Also, the calculation of the project’s NPV remained negative. However, the additional analytical steps of the proposed framework allowed us to highlight alternatives that can make this service economically viable. These included: use over an extended period of time, extending the network to other telemedicine specialties, or including it in the services offered by other community hospitals. In sum, the results presented here demonstrate the usefulness of an economic evaluation framework as a way of offering decision makers the tools they need to make comprehensive evaluations of telemedicine networks.     

Guidelines for preoperative assessment: impact on clinical practice and costs.

OBJECTIVE: To describe preoperative evaluation in the San Giovanni Battista Hospital in Turin and to forecast the economic impact when preoperative assessment guidelines are implemented. DESIGN: We enrolled, in a month, 702 consecutive patients, excluding cardiac, thoracic, neuro- and vascular surgery, as well as emergency operations. Preoperative assessment data were collected individually, followed by simulating various applications of guidelines based on: (i) preoperative tests relying on full medical history and physical examination to discriminate preoperative risk patients; (ii) organization of a preoperative evaluation unit and tests before patient hospitalization. MAIN MEASURES: Mean number of tests prescribed, preoperative assessment cost per patient. RESULTS: The application of preoperative guidelines would decrease the mean number of tests prescribed from 20 laboratory and 1.9 instrumental to, respectively, 3 and 1.4 per patient. Tests deemed inappropriate by guidelines did not add any relevant clinical information to our study. Economic analysis estimates a reduction of 63% in cost per patient for preoperative tests by introducing guideline criteria (from 69 euros to 26 euros). As regards the cost per patient for preoperative evaluation and hospital stay (115 euros considering only variable costs, 580 euros including all costs), the application of the guidelines would reduce costs by 41-52% according to different cost evaluation approaches for hospital stay. CONCLUSION: Preoperative guidelines fully introduced in practice could notably increase efficiency without affecting the quality of care.     

Design,implementation and preliminary evaluation of a telemedicine system for home haemodialysis

A telemedicine system for home haemodialysis was designed using a systems approach and a feedback model to produce the hardware and software specifications. Preliminary clinical trials at four European locations involved 29 patients and 305 sessions of haemodialysis. The evaluation included an evaluability assessment and formative evaluation. Central to the methodology was the detailed specification of a stakeholder/evaluation criterion matrix. Preliminary results indicated that the telemedicine system was capable of satisfying the requirements of formative evaluation as a precursor to evaluating its overall worth.     

Benefits and drawbacks of telemedicine

Telemedicine is a vast subject, but as yet there are limited data on the clinical effectiveness and cost-effectiveness of most telemedicine applications. As a result, objective information about the benefits and drawbacks of telemedicine is limited. This review is therefore based mainly on preliminary results, opinions and predictions. Many potential benefits of telemedicine can be envisaged, including: improved access to information; provision of care not previously deliverable; improved access to services and increasing care delivery; improved professional education; quality control of screening programmes; and reduced health-care costs. Although telemedicine clearly has a wide range of potential benefits, it also has some disadvantages. The main ones that can be envisaged are: a breakdown in the relationship between health professional and patient; a breakdown in the relationship between health professionals; issues concerning the quality of health information; and organizational and bureaucratic difficulties. On balance, the benefits of telemedicine are substantial, assuming that more research will reduce or eliminate the obvious drawbacks.     

Designing Web-based telemedicine training for military health care providers

BACKGROUND: The purpose of the study was to ascertain those learning objectives that will initiate increased use of telemedicine by military health care providers. Telemedicine is increasingly moving to the center of the health care industry's service offerings. As this migration occurs, health professionals will require training for proper and effective change management. The United States Department of Defense (DoD) is embracing the use of telemedicine and wishes to use Web-based training as a tool for effective change management to increase use. This article summarizes the findings of an educational needs assessment of military health care providers for the creation of the DoD Web-based telemedicine training curriculum. METHODS: Forty-eight health care professionals were interviewed and surveyed to capture their opinions on what learning objectives a telemedicine training curriculum should include. RESULTS: Twenty learning objectives were found to be needed in a telemedicine training program. These 20 learning objectives were grouped into four learning clusters that formed the structure for the training program. In order of importance, the learning clusters were clinical, technical, organizational, and introduction to telemedicine. FINDINGS: From these clusters, five Web-based modules were created, with two addressing clinical learning needs and one for each of the other learning objective clusters.     

Technology decision making. A constructive approach to planning and acquisition will require a paradigm shift

Technology should be viewed as an integrating rather than a divisive element in hospital planning. In the past, technology decision-making responsibility has often been diffused throughout hospitals, but providers are beginning to take a more considered and coherent approach. The process of making decisions about technology has four key elements: assessment, planning, acquisition, and management. The most important aspect of the assessment phase is the formation of a technology advisory committee to review and evaluate requests for new and emerging technology; review capital budget requests for new and replacement technology; and set mission-based and strategic priorities for new, emerging, and replacement technologies. Technology planning allows hospitals to set long-term goals for technology acquisition. The process involves an audit of existing technologies, evaluation of other hospitals' technologies, and review of technology trends. A well-defined technology plan will, in turn, facilitate the acquisition and management process, allowing hospitals greater flexibility in negotiating costs and budgeting for training, spare parts, service, upgrades, and support. By pooling resources with other providers in their region, hospitals can further enhance the effectiveness of their use and acquisition of technology. Collaboration allows providers to share the risks of technologically volatile and intensive services and avoid costly duplication of equipment and facilities.     

Evaluating computerized health information systems: hardware, software and human ware: experiences from the Northern Province, South Africa.

Despite enormous investment world-wide in computerized health information systems their overall benefits and costs have rarely been fully assessed. A major new initiative in South Africa provides the opportunity to evaluate the introduction of information technology from a global perspective and assess its impact on public health. The Northern Province is implementing a comprehensive integrated hospital information system (HIS) in all of its 42 hospitals. These include two mental health institutions, eight regional hospitals (two acting as a tertiary complex with teaching responsibilities) and 32 district hospitals. The overall goal of the HIS is to improve the efficiency and effectiveness of health (and welfare) services through the creation and use of information, for clinical, administrative and monitoring purposes. This multi-site implementation is being undertaken as a single project at a cost of R130 million (which represents 2.5 per cent of the health and welfare budget on an annual basis). The implementation process commenced on 1 September 1998 with the introduction of the system into Mankweng Hospital as the pilot site and is to be completed in the year 2001. An evaluation programme has been designed to maximize the likelihood of success of the implementation phase (formative evaluation) as well as providing an overall assessment of its benefits and costs (summative evaluation). The evaluation was designed as a form of health technology assessment; the system will have to prove its worth (in terms of cost-effectiveness) relative to other interventions. This is more extensive than the traditional form of technical assessment of hardware and software functionality, and moves into assessing the day-to-day utility of the system, the clinical and managerial environment in which it is situated (humanware), and ultimately its effects on the quality of patient care and public health. In keeping with new South African legislation the evaluation process sought to involve as many stakeholders as possible at the same time as creating a methodologically rigorous study that lived within realistic resource limits. The design chosen for the summative assessment was a randomized controlled trial (RCT) in which 24 district hospitals will receive the HIS either early or late. This is the first attempt to carry out an RCT evaluation of a multi-site implementation of an HIS in the world. Within this design the evaluation will utilize a range of qualitative and quantitative techniques over varying time scales, each addressing specific aims of the evaluation programme. In addition, it will attempt to provide an overview of the general impact on people and organizations of introducing high-technology solutions into a relatively unprepared environment. The study should help to stimulate an evaluation culture in the health and welfare services in the Northern Province as well as building the capacity to undertake such evaluations in the future.     

Cost effectiveness scenario analysis for a proposed trial of hormone replacement therapy

Whereas evaluation of resource implications and quality of life are often incorporated into assessments of health technology, the decision to undertake the assessment is still mostly driven by interests in the clinical outcomes alone. A systematic approach to evaluating expected returns to health technology assessment has not been readily taken up by research funders or assessors. This paper sets out a specific methodology for ex ante evaluation or triage and proposes a decision procedure, using alternative outcome scenarios and the associated policy changes and costs and benefits, against a background of likely clinical practice in the absence of the assessment. The methodology is used to consider implications of a proposed major clinical trial to assess the long term costs and benefits of hormone replacement therapy.     

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.