Telemedicine Technology-An Overview

H.S.Sheshadri,A.Kandaswamy,
Department of ECE, PSG College of technology, Coimbatore-641004.

Abstract.Technology has been used to deliver health care at a distance for many years. Early technologies included telephone, radio, television, and telemetry. More recently, microwave transmission, audio and visual teleconferencing, fax, and computer networks are being used. Telemedicine technologies may be synchronous simulations. Asynchronous methods include a popular "store-and-forward" computer technology that(real time, interactive) or asynchronous (off-line, batch). Examples of synchronous technologies are interactive full-motion video, robotics, and virtual reality uses high-resolution video and high-fidelity audio to transmit patient information. Telemedicine involves teleconsultation, telediagnosis, telemonitoring, and delivery of continuing medical education. Some examples of telemedicine applications include teleradiology, telecardiology, teledermatology, telepsychiatry, telepathology, telesurgery, and teleneurology. Telemedicine is used in a variety of locations including rural and urban areas, battlefields home care, prisons, and outerspace.In this paper we have made an attempt to discuss an overall view of the application of telemedicine and its major issues with respect to Indian context.
Keywords.
Telemedicine, remote consultation, teleradiology, patient satisfaction
 

Introduction
Telemedicine Issues
Telemedicine poses many practical issues that are currently being addressed. Technology issues include transmission speed (bandwidth), standards for hardware and software, and protocols for transmission. The effectiveness of telemedicine is being investigated for cost-benefit analysis and compared with traditional medical practices. The safety of telemedicine as a "medical device", and the patient and physician acceptance of the technology including the human interface, logistics, and delivery of health care, are being addressed. Licensure, credentialing, malpractice liability, privacy, confidentiality and security are major issues that are still unresolved in telemedicine. In addition, financial aspects including costs of technology and reimbursement of services are major issues. Telemedicine is a growing part of medical practice and its future is being shaped by physicians, patients, government agencies and third-party payers Telemedicine is coming up as an alternative in the provision of particular health care services, being the field of neurosurgical emergencies one of its most frequent applications. Despite the potential advantages of telemedicine, such as the improvement of access and quality of care, as well as the decrease in costs of some services, the lack of scientific evidence on its efficacy, effectiveness and efficiency is currently important. Also, the validity of traditional methods in its evaluation is questioned.
Technology Assessment in Teleneuromedicine (TASTE) is an European project within the Telematic Applications Programme (TAP), which was started in 1996 and has been completed in 1999. Assistance Publique-Hôpitaux de Paris, the Irish Southern Board (Ireland), the TNO-Prevention and Health (The Netherlands) and the Catalan Agency for Health Technology Assessment participate in this project.

The main objectives of the TASTE project were:
1. to develop a methodology to assess the impact of these technologies in terms of quality and organisation of health care, patients outcomes and costs, and
2. To advise decision-makers in the assessment of teleneuromedicine services.
This project has different stages:
1. assessment of information needs when implementing a telemedicine service;
2. guidelines for priority setting;
3. design and elaboration of an assessment project of two teleradiology networks for the co-ordination of neurosurgical emergencies, and
4. Elaboration of guidelines for the assessment of telemetric initiatives in this field.
This report includes a review and synthesis of the clinical benefit of telemedicine, and economic evaluation implications. These reviews are part of an assessment currently being performed.

CLINICAL BENEFIT OF TELEMEDICINE
To review the current knowledge on the clinical benefit of telemedicine, regarding these measures related to the process of care and to outcomes measures.

METHOD AND DATA COLLECTION
A bibliographic search has been performed in the main databases: MEDLINE, Health STAR, Current Contents, and the Cochrane Library, during the period 1989-1997. Inclusion criteria were:
1. applications of telemedicine in clinical services,
2. studies of primary data with a minimum of 10 subjects,
3. incorporation of some process measures and outcomes measures
Exclusion criteria were:
1. clinical case,
2. telemedicine applications in training and education,
3. The studies referred exclusively to technical, legal and ethical aspects.

RESULTS
Out of about 200 studies identified in the search, 50 met the inclusion criteria. Clinical applications of telemedicine considered were: neurosurgery, emergencies, ophthalmology, cardiology, obstetrics, psychiatry, otorrhinolaryngology and home care. One of the most frequent applications of telemedicine is the management of skull traumatism (ST) patients, which shows the highest amount of literature available. Other applications, such as home care, are more recent, so the published papers report pilot studies.

As per the literature survey made by students of a research center in India, it has been found that most of our telemedicine projects are addressed to assessing the impact of telemedicine in the process of care. A 33-80% decrease in the transfer of patients with ST among centers was found. In infants with congenital cardiopathies, decrease of transfers was 80%, and 75% in ophthalmologic emergencies. For elective obstetrics consultations, the decrease was 86%. Other measures included in the studies are the frequency of therapeutically interventions prior to the transfer, with a 21.4% increase in ST patients. Decreases in the transfer time, and in the time of stay in neonatal intensive care units connected telemetrically with a similar unit in a reference hospital were also mentioned. On the other hand, only one study was identified on the use of a teleradiology network for the management of patients with ST, which reported outcomes measures (mortality and the Glasgow Outcomes Scale [GOS]). In this study, results were inconclusive, given the low number of patients. Another aspect measured was patients' satisfaction with the teleconsultations performed by different specialists (ophthalmology, otorrhinolaryngology, ultrasound monitorisation of pregnancies) for acute conditions. In these studies, satisfaction with telemedicine was higher than the usual consultations. When these applications were studied in patients with serious diseases (cancer), teleconsultation for some follow-up visits was considered as satisfactory.Most studies regarding clinical applications of telemedicine are case series, with different size, follow-up time and stage of technology development. In two studies, which used a control group, the number of patients was very small. Therefore, the results of these studies should be cautiously interpreted.Despite the important diffusion of telemedicine in recent years, in different specialities and services, the lack of studies assessing its efficacy and effectiveness, as well as the quality of the currently available desings, hamper the evaluation of the potential advantages that this technology may bring.

Economic issues
In an era of limited resources devoted to health care, providers and purchasers at all levels in the health care sector must justify technology decisions on a value for money basis. Although in many cases and applications telemedicine is already underway, most experts in the field agree that their cost-effectiveness is still to be studied in depth. This report has aimed at reviewing the literature on the topic as regards their implications for cost and economic assessments in telemedicine.To review the literature on economic evaluation studies of telemedicine applications according to the most important steps in economic evaluation methods. A systematic search was performed in the different bibliographic databases of biomedical journals (MEDLINE, Health STAR, Current Contents and The Cochrane Library, period 1989-97), using specific descriptors for the technology assessed and for economic and cost implications. The selected studies were reviewed following the economic evaluation methods. Studies comparatively assessing the costs and/or the costs and effects of the application of telemedicine in one or more intervention alternatives were include for review.
No full economic evaluation study was found among those selected for review. Indeed, the focus on costs is predominant and the need to comparatively examine costs and benefits is encouraged. However, the following considerations should be carefully looked into when performing a full cost-effectiveness or cost-utility analysis in the future.
Both the economic evaluation studies reviewed and the recommendations of economic evaluation methods, strongly advocate for the selection of comparators to telemedicine to be justified on the grounds of existing operating systems within the context of the study. Further, some assessment proposals also reviewed here back up this need. Accordingly, any future assessment proposals would consider as the most adequate comparator to teleneuromedicine that delivery of care systems teleneuromedicine would substitute or has already replaced.

In terms of time horizon and perspective of analysis, the review of the literature focuses on selecting, first, an adequate time horizon so as to capture all relevant costs and consequences of our interventions, and second, a widest perspective as possible, disaggregate it according to relevant sub-perspectives, those associated to the main actors in the system. Relevant perspectives for an economic analysis of teleneuromedicine would then include the health care systems, receivers, senders, and patients'. All economic evaluation studies reviewed here consider differences between sender and receiver only in an indirect way when selecting the alternatives for comparison.

All economic evaluation studies reviewed here insist on the importance of distinguishing between fixed and variable costs in telemedicine. Indeed, this is outlined as an important distinction given the fact that although telemedicine may imply higher fixed costs, especially investment costs, the per patient and per consultation costs will go down as patient workload and consultation increase. An additional comment should be made regarding fixed costs and its annihilation accounting for discount rates. Large investments tend to be difficult to justify. Discount periods appear here as an important variable together with the upgrading of the equipment and the choice of discount rate. Telecommunication rental line is also included under the heading of fixed cost. Further, maintenance costs are commonly calculated on the bases of investment costs (10-15%). Variable costs usually include labor costs, overheads, telephone charges and other items including consumables and occasionally insurance.

No separate account is given for costs of training the personnel to use the network. It is generally assumed these costs would be included in the personnel costs. Only one study points to the need to measure indirect costs as a result of productivity losses of both patients and relatives traveling unnecessarily to the referred centre.
The type of costs and items included vary according to the characteristics of the alternative to which telemedicine is compared. There is, however, a major source of distinction between non-telemedicine and telemedicine services, and that is travel costs resulting from unnecessary transfers of patients. In general terms, the particularities of each setting and set of alternatives considered will determine the type of costs and cost items finally included in the analysis. Although there are studies that mention the fact that there are important cost-saving sources as a result of implementing a telemedicine network, none of the studies included in this review attempted to measure them in their totality. (See cost-savings below).

In order to perform an incremental analysis both costs and consequences of competing options should be reported. In the absence of measures of health outcomes, and when only results on costs are given then an analysis exploring savings or potential savings of one option over the others can be done and that is what some authors account for in their studies. In terms of future assessments it becomes necessary to account for a proper incremental analysis. Results should therefore be also reported on an incremental basis, considering both costs and medical benefits of telemedicine and the selected comparator.

Sensitivity analysis is mandatory in the face of uncertainty. In economic evaluation of telemedicine there are numerous variables whose values are uncertain. This may come as a consequence of variables being highly context specific for which we find a wide range of values, or variables whose true value is unknown. Since all studies reported here concentrate mainly on costs, the variables they include in sensitivity analyses relate only to costs, not to health outcomes or medical benefits. Therefore, his implications we may draw from sensitivity analyses in these studies would only refer to variables affecting total costs of competing alternatives. The results point to final costs and relative costs being dependent on variables such as the number of patients, the useful life of investment, travel costs, leisure time, and discount rates applied, among other.

The studies referred to in this report outline the importance of other factors such as equity of access and quality besides those affecting costs. Indeed, the improvements in access to quality care as a result of the implementation of a telemedicine network should not be neglected. Equity and access are two important criteria in deciding whether a telemedicine system is finally implemented. Even in the case the system may firstly be seen as not as cost-effective as its alternative in a particular setting, investment decisions could be justified on equity of access grounds. Accordingly the benefits side of implementing such as network should count on increased equity as an additional component.

Costs savings are relevant implications of telemedicine networks that ought to be looked upon. Not accounting for them will certainly lead to a less favorable judgment of the potential of telemedicine in containing costs. Certainly, an adequate and not delayed transfer of the patient would improve both the health outcomes and the cost to the system in terms of reduced resource allocated as a result of better and earlier diagnosis and treatment. Further costs are saved as a consequence of avoiding unnecessary transportation of patients in terms of reduced hospitalizations, and transportation costs. Although not mentioned in the articles reviewed in this report an additional, albeit important, source of savings to the system would stem from the reduced future costs to the system as results of better final patients outcomes.

Conclusions.
An evaluation activity is highly dependent on the assessment methods used, the characteristics of the technology under assessment, and the particularities of the context where the evaluation takes place. Such an activity is therefore context specific in many ways, including data sources applications, organization, epidemiological data, social values, and so on. Economic evaluation practices should account for context variations in issues such as the choice of comparators, data sources available, values on costs and consequences, or the financing perspectives considered, among others.
In India telemedicine is being slowly developed and there are lot of research activities being held .But still the scope of this area depends mostly on the economic issues and status of the people at large. In this context we appeal to our budding scientists and engineers to come forward and take up some challenging research in the field of telemedicine. Also some developments in the field of indigenous product development related to telemedicine has to be taken up so as to become self sufficient.

References
1. Field MJ, ed. Telemedicine: a guide to assessing telecommunications in health care. Washington, DC: National Academy Press; 1996.
2. 2. Grigsby J, Sanders JH. Telemedicine: where it is and where it's going. Ann Intern Med. 1998; 129:123-127.
3. Telemedicine report to Congress. NTIA, 1997.