-
Telehealth Research and Evaluation: Implications for Decision Makers
J. Michael Fitzmaurice
Agency for Health Care Policy and Research
U.S. Department of Health and Human Services, Rockville, Maryland 20852
E-mail: M$tzmau@ahcpr.gov
ABSTRACT
Society must answer questions about health information
technology applications, or telehealth, that lead to the best
allocation of resources for maintaining and improving the
health status of our population. These questions deal with
the adoption and deployment of telehealth for improving the
health and well-being of the members of society compared
with alternative means, From the less than overwhelming
response to the “build it and they will come” approach, we
clearly have insuf$cient evidence of the medical
effectiveness, cost effectiveness, and patient and provider
satisfaction with telehealth solutions.
The Agency for Health Care Policy and Research
(AHCPR) is a federal research agency that supports
research to find out what is effective in improving the quality
of and access to health services in the community, what is
the impact on patient outcomes, and what is the cost of
obtaining those outcomes, Telehealth decision makers need
studies of telehealth technologies that focus on spect$c
clinical conditions in narrowly concentrated applications
and that use scienttfk methods to compare outcomes and
treatment costs for patients and physicians who do and those
who do not receive telehealth services under controlled
circumstances. AHCPR-funded studies are presented as
examples of methods of scient@ investigation into the use
and acceptance of computerized decision support and
telehealth services.
1. Introduction
This paper defines telehealth as the use of information,
computing, and telecommunications technologies to provide
medical information and health services when the provider
of care and patient are separated by distance. Telemedicine
has been defined as “the use of modern telecommunications
and information technologies for the provision of clinical
344
O-8186-8667-7/98 $10.00 0 1998 IEEE
Authorized licensed use limited to: The University of Hong Kong Libraries. Downloaded on February 05,2021 at 00:38:21 UTC from IEEE Xplore. Restrictions apply.
care to individuals at a distance and the transmission of
information to provide that care [ 11, p. 3961.” In this sense,
telehealth is equivalent to the broad use of the term
telemedicine and both terms will be used interchangeably.
Telehealth has been widely proclaimed as a solution to
many of the nation’s health care needs, yet telemedicine
solutions face significant barriers to widespread
implementation.
1.1 Telehealth as a solution to existing needs
Although still at an early stage of development and
diffusion, telemedicine has often been advocated as a means
to address many health system needs. A shortage of
professional health providers exists in rural areas. As a
result, rural residents do not have as much access to health
care as their urban cousins and may have to go far for proper
care. Telemedicine can give rural patients access to medical
specialties that compliment the level of medical diagnosis
and treatment found in their rural communities. It can also
lower costs of reaching health care by reducing the necessity
for patients or providers to travel long distances to obtain
radiology, pathology, dermatology, and mental health
services, for example. Telehealth can help with better triage
decisions about patients when it is not clear if they should be
transported to a specialist who is miles away. Sometimes
when no physician is locally available, remotely located
patients and their caregivers might need to be directed by a
physician to assist him or her in making a diagnosis and care
management decision while aided by telehealth technology,
e.g., in the placement of sensing instruments and description
and visual display of responses to physician-directed stimuli.
As our population ages, we expect the nation’s health care
expenditures to rise more rapidly than they are today.
Telehealth technologies that support remote monitoring of
and provider interaction with nursing home patients and
 elderly patients in their homes hold promise to provide some
relief from rising costs and reductions in patient mobility.
Telehealth conferencing to maintain continuing medical
education of physicians can keep rural providers up-to-date
about the most recent advancements in their field at lower
cost. All health providers and patients have had to wait for
each other at some time. To the extent that telehealth can
improve scheduling and continuity of care, it allows more
efficient planning of productive time.
For most civilian telemedicine projects, the emphasis has
been on helping rural populations access medical care.
Patients in underserved inner-city areas, on the other hand,
can find getting to physicians only two miles away to be just
as difficult as for rural persons to go 50 miles for
professional care and, therefore, can benefit from access to
the same kinds of technological support.
1.2 Telemedicine use
From a survey of all 2472 nonmetropolitan U.S. hospitals
conducted in January 1996, 499-hospitals responded to a
follow-up survey of telemedicine users. Of the 499, 340
used only teleradiology applications, with two-thirds of the
other telemedicine users (159) being users for two years or
less. These other users had an average of 10 clinical
consults per month (with a median of two visits per month)
[6]. The survey was undertaken by Abt Associates, Inc., and
funded by the U.S. Health Resources and Services
Administration (HRSA), Office of Rural Health Policy [7].
Clearly, most U.S. telemedicine sites are at the early parts
of their learning curves. Their viability is an issue to be
closely tracked.
1.3 Telemedicine barriers
The 1997 Telemedicine Report to Congress [14] of the
Department of Commerce, with the Department of Health
and Human Services (HHS), covers a plethora of key
telemedicine barriers including evaluation, licensure, legal
issues, regulatory issues, professional liability, payment
issues for public (Medicare and Medicaid) and private
payers, safety and standards, telecommunications
availability and cost issues, and privacy, confidentiality and
security issues.
The executive summary of the 1997 Telemedicine Report
to Congress states, “Lack of solid evaluative information is
a significant barrier to the deployment of telemedicine [ 14,
Executive Summary, p. 21.” At the time of the Report, most
federally-funded telemedicine projects were only three or
fewer years old. Yet, some early lessons were presented that
345
Authorized licensed use limited to: The University of Hong Kong Libraries. Downloaded on February 05,2021 at 00:38:21 UTC from IEEE Xplore. Restrictions apply.
enhance the success of telemedicine projects. They included
preparing a business plan that assesses the requirements for
telemedicine, obtains input from users at an early stage, and
shows a full understanding of the health system. Additional
lessons were selecting low-cost and simple technology that
meets the clinical needs, emphasizing human factors,
adopting open architecture, leasing rather than purchasing
equipment, bargaining for low telecommunication rates, and
obtaining widespread local support. Other requirements
presented were for evaluation with early and proper data
collection, coordination of training and technical assistance,
and development of standards, protocols, and guidelines [ 13,
pp. 7-S].
Bashshur describes four major sets of telemedicine issues
[3, pp. 114-1151. First is technological dilemmas--the
tendency to view telemedicine as a hammer in search of a
nail, a screwdriver in search of a screw, rather than starting
with the health problem and searching for the best solution--
telemedicine or not and the delay between advances in
technological and our ability to use them efficiently.
Second, evaluation dtfficulties in telemedicine applications
have hindered the ability to conduct assessments like those
of other medical technologies. Third is contextual hazards,
such as limiting telemedicine’s focus on rural areas. Fourth
is the need for professional maturation that leads to self-
regulation and control.
In writing about implementation of telemedicine
applications, Sanders and Bashshur [ 121 note the challenges
of
l Licensing and credentialing of professionals engaged in
telemedicine across state borders
l Legal liability and litigation
l Individual autonomy and the right to privacy
l Reimbursement
l Knowledge about the benefits of telemedicine
l System design and infrastructure
Two key issues important to this paper are among them--
reimbursement and knowledge of telemedicine benefits (and
costs). First, additional reimbursement for telemedicine is
often said to be critical for viability of providing beneficial
services, assuming the services provided are beneficial.
However, payers fear the “unreasonable use of telemedicine”
where it has not been proven to be safe, efficacious,
medically effective, and cost effective. Further, where
telemedicine may meet all these criteria, payers are still
cautious of the risk of higher and rapidly rising expenditures
if they grant consumers insurance coverage of telemedicine
services. Even if unit service prices are lower under
telemedicine, the feared increase in volume of services may
drive health expenditures upward. In remote areas, access to
needed care will increase with telemedicine coverage by,
 say, Medicare and can result in rural payments much greater
than the federal program is prepared to finance. Private
insurers certainly have the same concern.
Second, lack of knowledge about telemedicine benefits
results from the lack of results from well-designed empirical
studies of telemedicine projects. There are problems of
accurate data collection, different telemedicine system
designs and environment, resource mix, and clinical
applications. In the words of Sanders and Bashshur, “what
is required, therefore, is scientifically valid research on
optimally designed
systems that are operating at a normal steady-state level that
reflects the true potential of telemedicine systems [12, p.
1221.”
Combing through these and other analyses [2, 5, 6, 7, 8,
131 yields the following list of telehealth barriers:
l Not knowing what is the optimal mix of teleheahh
technologies (e.g., real-time video versus store-and-
forward techniques)
l Not knowing what is the legal liability of health
professionals and institutions when they deliver care
across state borders?
l Defining malpractice responsibility
l Defining privacy requirements
l Different state licensing requirements for physicians
engaged in telemedicine
l Lack of knowledge about the clinical efficiency of
telemedicine
l Lack of qualification of the benefits of telemedicine,
including travel costs and time costs
l Low current volumes of clinical telehealth treatments
l Lack of relevant evaluation study findings
l Lack of standards for telemedicine data exchange and for
telemedicine communication equipment
Another barrier is the fear that “increased clinical
sophistication” of rural primary care providers (PCP)
engendered by telemedicine consults could increase PCP
services and reduce referrals to specialists [3, p. 1241. (The
reader is encouraged to examine the sources noted above for
further analyses of these important barriers and
considerations.)
Of all these barriers, this paper emphasizes the lack of
good evidence and the need for careful evaluations of the
medical and cost effectiveness of telehealth applications.
2. Evaluation of telehealth applications
A systematic literature review of clinical trials “on the
efficacy of distance medicine technologies in clinical
practice and health care outcome” showed that “significantly
346
Authorized licensed use limited to: The University of Hong Kong Libraries. Downloaded on February 05,2021 at 00:38:21 UTC from IEEE Xplore. Restrictions apply.
improved outcomes were demonstrated in studies of
preventive care, management of osteoarthritis, cardiac
rehabilitation, and diabetes care [2, p. 1.521.” However,
there was not enough evidence to judge the cost
effectiveness of these telemedicine applications. Overall,
there is little evaluation research with findings on the
medical and cost effectiveness of telehealth technology
applications.
2.1 Why are telehealth evaluations needed?
Sound evidence of where telehealth applications can
improve the quality of care, especially the patient outcomes
of care, at a reasonable cost or with cost savings is needed
for clinical, resource allocation, and health policy decisions.
Some of these decisions fall outside the health arena, but
will rely on health effects to add to the benefit and the cost
sides of the ledger used for guiding technology development
decisions.
Clinical efficacy, does the technology work under ideal or
controlled circumstances, is important for treatment
decisions. Whether telehealth is medically effective under
the less-than-ideal conditions often found in the community
is also important knowledge to have. The lack of scientific
research findings about the effect of telehealth applications
on patient outcomes is a major factor in decisions not to pay
a differential for medical services delivered with the
assistance of telehealth technology.
Resource allocation and coverage decisions within health
plans are being affected more and more by evidence of what
the costs are for the benefits received. With the lack of
positive findings and great uncertainty about both the costs
and the benefits of telehealth, these decisions are generally
not to invest in or provide coverage for telehealth.
For policy purposes, research findings are needed to
address such issues as:
l Telehealth payment policy, for both the government and
private sector payers
l National investment in high bandwidth service on demand
l National subsidies for high bandwidth access for rural
areas
l Scope of regulatory coverage by FDA for telehealth
applications to ensure safety and efficacy
2.2 What are the barriers to undertaking good
telehealth evaluations?
Good evidence for making clinical decisions has its basis
in sound scientific methods. The types of study methods
leading to good evidence may be described as follows:
 testimony or theory, case reports and anecdotes, case series,
observational studies (cross-sectional, case control, and
cohort), narrative review articles, nonrandomized controlled
trials, meta-analyses, and randomized controlled trials [9].
The method yielding the strongest evidence is the
randomized controlled trial. The method is especially
convincing when the patient and the physician are blinded to
which intervention is being used, e.g., whether the drug
under study, the drug considered the next best alternative, or
a placebo is being given to the patient.
There are, however, insufficient resources to conduct
randomized controlled trials on every health care decision.
Some decisions involve patients with more than one
condition or involve situations with other factors influencing
patient outcomes, rendering such methods problematic or
inappropriately applied to many real-world treatment
decisions. Evaluating telemedicine projects by aggregating
patients with many different clinical conditions makes it
hard to define outcomes consistently and relevantly.
Sometimes the scientific hypothesis to be tested can be so
narrowly defined as to be of low usefulness to a decision
maker who needs answers to very complex questions.
Accordingly, there is a need for researchers to understand
the barriers to adoption of telehealth solutions and the
difficulties of conducting telehealth evaluations, and for
researchers to carefully apply appropriate methods of
scientific evaluation [3].
Some specific difficulties are that telemedicine programs
may have different goals, outputs, and measures. For
example, the objectives may be to demonstrate a “proof of
concept,” to offer a small or a large set of specialty services
via telemedicine, to apply telehealth to a variety of clinical
conditions, to educate facility staff, to serve remotely or
densely populated areas, to reduce the costs of prisoners’
health care, to conduct administrative business, or a mix of
these aims. Therefore, generalizing accurately across
evaluations of different telemedicine projects may be hard.
Additional difficulties are that:
l Many telemedicine projects are not operating at “normal”
levels of patient flow or output due to their newness and
lack maturity and knowledge about what the expected
“normal” levels are.
l Cost analyses and comparisons are jeopardized by the
small number of patients usually found in new
telemedicine projects and by changes in equipment costs
and transmission costs, and rate of equipment
obsolescence.
l Data collection for evaluation is not planned well at the
beginning of telemedicine demonstrations.
l Appropriate skill mixes may not be known or achieved in
the short term
347
Authorized licensed use limited to: The University of Hong Kong Libraries. Downloaded on February 05,2021 at 00:38:21 UTC from IEEE Xplore. Restrictions apply.
The validity of telemedicine evaluations may be
influenced by:
l Low volumes of patients, reducing the yield of statistical
tests
l Difficulty of blinding patients to the use of telemedicine
services or keeping telemedicine services from people
who want them. It is likely that in some telemedicine
evaluations, patients and physicians cannot be blinded and
that randomization should be on providers rather than on
patients.
l Subject (physician or patient) selection bias, such at that
resulting from the healthiest patients being chosen or not
chosen for the telemedicine study groups
l Implementation bias from badly implemented programs
l Changes in the telemedicine system during the evaluation
period [3, p. 12 l]
All of the above can harm the ability of a telemedicine
evaluation study to yield unbiased, valid, and generalizable
scientific findings about patient outcomes and resource
useful that are useful for guiding telehealth adoption and
implementation decisions.
The professional maturation of telemedicine requires,
among other things, professional acceptance, cost
containment, and specification of professional requirements,
including appropriate triage, a code of ethics, quality
assurance with outcome-based criteria and standards, and
certification of qualified personnel. Such maturity has not
yet come to telemedicine [3, 124-51.
2.3 Research domains in telehealth
A telemedicine evaluation framework has been proposed
by Puskin, et al.[l 1, p. 3971, containing the following six
domains for study:
0 Clinical outcomes
l Technical acceptability
l Health systems interface
l Costs and benefits
l Patient and provider acceptability
l Access to care
The medical effectiveness of telehealth is best investigated
under the clinical outcomes domain. Some intermediate
outcome measures suggested are to examine the ability of
telemedicine to facilitate faster diagnoses and more accurate
and effective treatment plans than if there were no such
interaction with a specialist. Other outcome measures
include speed of return to work. Independent functioning,
levels or rates of morbidity and mortality and function al
status, speed of patient evacuation when necessary, and rates
of hospital admissions, readmissions, or repeat clinical visits
 for unresolved problems.
A crucial component should be the use of good scientific
methods to describe the telemedicine use and acceptance and
more. Hypotheses need to be tested with a sufficient number
of study observations to reduce the possibility that the results
were found just by chance. This argues that rural
telemedicine projects to be pooled for study must be alike
for producing valid, generalizable research findings. Urban
telemedicine projects are likely to attract more patients for
study. Some hypotheses are needed to focus on the optimal
mix of telehealth resources to get the best results and on the
human behavior changes engendered by new ways to access
and deliver health care.
3. Role of the government
When activities have large risks and long payoff periods,
very low costs of producing an extra unit but high start-up
costs, are subject to the free-rider problem of not being able
to ration user access to a good or service once it is produced
except at very high cost, or a combination of these attributes,
there is a role for government action. Even when the
benefits will be greater than the costs in the long-run, the
marketplace often fails to provide sufficient incentives for
short-run development. For example, many consumers
would not have the benefit of public utility services if not for
a strong government role. As the demand for the service
grows and service exchange networks grow, the marketplace
can often reclaim efficient operation of this service, e.g.,
airline and telephone services. The role for government is
to take action where the market fails.
3.1 Technology growth
Accelerating technology growth enables consumers to
enjoy a richer quality of life all the sooner. It is the role of
the government to assess the future benefits and costs of
technology advancement and to promote technology growth
wisely when the private market fails to do so. Investing in
accurate assessments helps guide both public and private
investments in technology. With health care lagging behind
other industries in investment in information technology,
and with the potential for information technology to support
improved health decisions, a case can be made for
government support of basic and applied research,
demonstrations, and evaluations in health information
technology. The key is to obtain an accurate assessment of
the expected benefits and costs so that there is a high
prospect of developing good things with public promotion
and public-private partnerships.
348
Authorized licensed use limited to: The University of Hong Kong Libraries. Downloaded on February 05,2021 at 00:38:21 UTC from IEEE Xplore. Restrictions apply.
3.2 Safety and Efficacy
The government has a responsibility for assuring the
safety and efftcacy of medical pharmaceutical and devices.
This responsibility is part of the mission of the Food and
Drug Administration (FDA). The FDA’s role is to guard the
safety and efficacy of health products for consumers,
especially when private market interests may lean in the
opposite direction. This role needs information about the
medical effectiveness of telehealth applications. Products
that support telemedicine, such cameras, video monitors, and
telecommunications systems, when put together to supply
medical services fall under the category of medical devices.
Although the FDA does not currently require approval of
telemedicine systems, it has the authority to do so. Just as
new drug approvals require convincing scientific evidence
that they are safe and have beneficial effects on health when
used in ideal, controlled circumstances, FDA approval of
telemedicine systems could well require the same level of
scientific evidence.
3.3 Research
Research is an example of a public good, where once the
findings are produced, many people can learn from them
with no or low additional cost, and keeping the knowledge
from those unwilling to pay for it is difficult. Consequently,
the private market will underinvest in research. When they
do invest, private companies have incentives to hold the
research findings closely to themselves--for private gain.
Private research investments must be encouraged and profits
provide this encouragement. Since publicly available
information can make markets work more efficiently, it is to
the advantage of consumers that additional research findings
be developed and widely and rapidly distributed.
Consumers benefit from government-supported research that
would not be done or widely shared in the private sector.
A key government goal is to promote the well-being,
safety, and security of its population. Growth in technology
and its uses promotes consumer well-being, when the long-
run benefits exceed the costs (see 3.1 above). There is a role
for government to support basic and applied research that
leads to development and efficient use of technology. With
information and telecommunications technology, the federal
government has supported basic research leading to
advances in computing speed, network capacity, security,
human development, and other areas, through its High
Performance Computing and Communications Program. It
continues similar support through the Computing,
 Information, and Communications Program coordinated in
the White House, including the Next Generation Internet
program. We need to bring the benefits of investment in
basic science to practical applications in the health sector.
There is a need for well-designed research, demonstrations
and evaluations, technology roadmaps (showing what
advances are needed to make telehealth applications good
investments), consumer and physician education in the use
of health information systems, and for health information
infrastructure building.
3.4 Government recognition
The need to build an information infrastructure into rural
areas has been recognized. In the Telecommunications Act
of 1996, Congress directed the Federal Communications
Commission to put forth and carry out a plan that supports
access to high bandwidth telecommunications’ services in
rural areas. The expectation is that making available a
universal services pool of funds for reducing rural
telecommunications costs will spur a growth of demand for
products and services in such areas as health and education
that eventually will sharply reduce the per unit rural
telecommunication cost of these services through
economies of scale.
In the Balanced Budget Act of 1997 (Public Law 105- 191)
[lo], Congress directed the Secretary of Health and Human
Services to (a) make payments from the Medicare Trust
Fund “for professional consultation via telecommunications
systems with a physician . . . or a practitioner furnishing a
service” to Medicare beneficiaries in rural health
professional shortage areas even when the consulting
provider and servicing provider are not at the same location
and (b) to undertake a four-year, $30 million demonstration
project to use health care provider telemedicine networks to
349
Authorized licensed use limited to: The University of Hong Kong Libraries. Downloaded on February 05,2021 at 00:38:21 UTC from IEEE Xplore. Restrictions apply.
improve primary care to Medicare beneficiaries with
diabetes mellims who are residents of medically underserved
rural or inner-city areas. Congress recognizes the need for
information by requiring a report under a) about the access,
clinical efficacy and cost effectiveness, and quality of
telehealth services delivered and a report under b) evaluating
“the use of telemedicine and medical informatics on
improving access of Medicare beneficiaries to health care
services on reducing the cost of such services and on
improving the quality of life of such beneficiaries [ 10, BA97
11 1 Stat. 377-3811.”
No funds or staff, however, were provided to the Secretary
for conducting such evaluations or producing the required
reports. Nevertheless, this section of the Balanced Budget
Act of 1997 is recognition that disease-specific results are
needed to focus on where telehealth applications can be
medically and cost-effective for improving the health care
quality and consumer well-being in both rural and urban
areas.
4. Agency for Health Care Policy and Research
AHCPR is a federal research agency created in 1989 to
undertake scientific research that produces findings about
our health care system that show what works in the practice
of medicine in the community and how much it costs. This
agency conducts and supports health services research that
investigates quality of care, patient outcomes, and
organization, cost, financing and access issues. With a
budget of $146 million in FY 1998, AHCPR has developed
and extended tools that assist consumers and providers in
making choices about clinical treatments and health plans,
 Table 1 .--AHCPR’s Computerized Clinical Decision Support for Health Providers Proaram

Grant Title and Number Principal Investigator Institution

Computerized Decision Support for Keith M. Sullivan, M.D. Fred Hutchinson Cancer
Post-Transplant Care. (Grant Research Center, Seattle, WA
No .HWQ4fl7)
Family Linkages Supporting Charles J. Homer, M.D., Children’s Hospital
Hyperbilirubin Guidelines. (Grant No.: Boston, MA
HS09390)

Depression Care Using Computerized Bruce L. Rollman, M.D. University of Pittsburgh

Decision Support. (Grant No.: HS09421) Pittsburgh, PA

Evaluating Computer Decision Support Stephen M. Downs, M.D. University of North Carolina
for Preventive Care. (Grant No.: Chapel Hill, NC
HS09507)

Interactive, Guideline-Based Decision David F. Lobach, M.D., Ph.D. Duke University Medical Center
Support on the Web. (Grant No.: Durham, NC
HS09436)

Computerized Decision-Support Mark Frisse, M.D Barnes Jewish Hospital

Deployment in Diverse Clinical Settings St. Louis, MO

and improved understanding about how health services are delivered, organized, and financed. Since the early 1970’s, AHCPR
(as did its predecessor the National Center for Health Services Research) has devoted a varying portion of its resources to
investigating how information technology can improve health outcomes, reduce costs, and improve access to and care, and
that support continues today.

5. Computerized decision support systems

During the 1996-99 period, AHCPR is funding its Computerized Decision Support System (CDSS) Program by investing
approximately $4.5 million over the three-year period (see Table 1 above) in six investigator-initiated research grants. These
grants use scientific methods to study how to incorporate CDSSs into computer-based patient records (CPR), addressing the
“1) use of clinical practice guidelines in decision support systems while maintaining security and confidentiality of patient care
data in different patient care settings, 2) the impact of CDSS on the effectiveness of the private care process, patient outcomes
of care, and/or cost impact on patient care, and 3) identification and testing of factors that influence practitioner use of CDSS
[l, p. I].” Adverse drug event detection and drug dose-checking, newborn jaundice, primary care treatment of major
depression, pediatric care, preventive services guidelines, and post-bone marrow transplant follow-up are the clinical
conditions and therapies addressed by these studies. These are basically controlled trials with randomization across physicians.
They use web-based technology to link clinical practice guideline information with the patient’s medical record under
conditions that protect the confidentiality of the patient’s information. AHCPR hopes to learn the effects of these computerized
decision supports on clinical practice, how large the effects are, and lessons to be shared with others faced with decisions about
implementing computerized decision supports for improving quality of care.

6. Telehealth studies

Two AHCPR-supported grants devoted to telehealth are presented here. The first one is being undertaken at the University
of Georgia and studies the efficacy of telemedicine colposcopy (or telecolposcopy) on predominantly minority, rural, poor
women. The other one is funded through Texas A&M University, studying the adoption and use of telecommunications for

350

Authorized licensed use limited to: The University of Hong Kong Libraries. Downloaded on February 05,2021 at 00:38:21 UTC from IEEE Xplore. Restrictions apply.
 rural health. The first study is a controlled trial; the second is a descriptive and survey study of nine telemedicine sites of care.

6.1 Telecolposcopy

In a study currently underway, AHCPR is funding researchers at the University of Georgia to study the barriers to quality
health care and the efficacy of telemedicine colposcopy (or telecolposcopy) on predominantly minority, rural, poor women
in the prevention, diagnosis, and treatment of cervical cancer. These three characteristics--rural location, poorness, and
black/minority status--are positive predictors of cervical cancer. This study will compare same-case results across rural
clinicians, an expert in-person colposcopist, and an expert using telecolposcopy, and will analyze the use of real-time versus
off-line telecolposcopic image transmission.
This study addresses three basic questions. First, does telecolposcopy deliver care at least as equivalent to in-person
traditional care in diagnostic accuracy and in determining clinically appropriate management of care. Second, does real-time,
compared with off-line, telecolposcopy provide greater diagnostic accuracy and more effective patient management decisions?
Will patients accept telecolposcopy and will acceptance of telecolposcopy depend on the patient’ attitude and the patient’s
perception of her cancer risk?

6.2 Telehealth adoption and use

AHCPR has funded another study at Texas A&M University to investigate the factors influencing the adoption and continued
use or disuse of telecommunications for rural health educational and clinical consultations. The method is a case-study
approach using interviews with decision makers, telecommunications users, and nonusers, and secondary data from committee
meeting notes, correspondence and newspaper coverage of events. The researchers will interview both telemedicine user and
nonuser patients, health professionals, decision makers, and continuing education users in this investigation of the adoption
and use of telecommunications for health care. The study covers six rural communities and nine sites of care and examines
the impact of the telecommunication network attributes, such as composition, size, population density, resources used, and
goal-achievement gaps found.
These studies illustrate two different methods for obtaining research findings to improve clinical and societal understanding
and to guide decisions about the medical and cost effectiveness of telehealth applications.

7. Summary and conclusion

To develop implications for decision makers, this paper has examined the barriers to information and telecommunications
technology applied to health care at a high level. The level is high because the kinds of scientific inquiries needed to support
investment, clinical application, and public policy decisions have not been readily forthcoming in the private sector. Quite
possibly telehealth is too complex, it is too immature, social organizations are not prepared to adopt telehealth solutions to
medical problems, or technology has not sufficiently advanced that the benefits exceed the costs. Yet, with the advances in
the past ten years that have improved the infrastructure, increased computing speed, widened the bandwidth with which we
share digital information, and reduced the storage costs for this digital information, we would expect the health sector to adapt
and adopt technology applications used in industries that are not as complex as medicine and invent new applications pertinent
to health care.
The major implication is that decision makers do not have enough good information about telehealth effects. As a result of
this review of telehealth research and evaluation barriers, some suggestions are in order:
l We need an inventory of telehealth service and information delivery projects, a snapshot in time that leads to a continually

updated web site of such information.

l We need inventory of telehealth evaluation projects with an assessment of the quality of the evidence they bring to decision

making.
l We need a follow-up to the HRSA-Abt Associates, Inc., study of telemedicine projects to determine how steep the learning

curve is and to assess telehealth viability in today’s marketplace.

l We need to support telehealth demonstration and evaluation projects that can be scientifically evaluated.

l We need the development of a roadmap showing what specific information infrastructure and telecommunication technology

351

Authorized licensed use limited to: The University of Hong Kong Libraries. Downloaded on February 05,2021 at 00:38:21 UTC from IEEE Xplore. Restrictions apply.
 advances are required to apply telehealth solutions productively.
l We need to keep the goals of improving health outcomes, costs, and access in front of us and remember that telehealth is
but another tool for addressing these problems, not the end result.
As technology changes rapidly, and as providers and patients become more educated in using these technologies, we must
continually assess the case for wider use of telehealth solutions to address society’s health and resource allocation challenges.

7. References

[I] Agency for Health Care Policy and Research, “Computerized Decision Support Systems for Health Providers,” Agencyfor Health Cure
Policy and Research Grant Announcement, Rockville, Maryland, AHCPR Pub. No. 96-R061, 1996.

[2] Balas, A.E., Jaffrey, F., Kuperman, G.J., Boren, S.A., Brown, G.D., Pinciroli, .F, Mitchell, J.A., “Electronic Communication with
Patients,” Journal of the American Medical Association, 1997, 277(2): 152- 159.

[3] Bashshur, R.L. “Critical Issues in Telemedicine,” Telemedicine Journal, 1997, 3(2): 113-I 26.

[4] Preston, J. The Telemedicine Handbook, Austin, Texas: Telemedical Interactive Consultative Services, 1993.

[5] Gelman, R. ‘Confidentiality and Telemedicine: The Need for a Federal Legislative Solution,” Telemedicine Journal, 1995, l(3): 189-I 94.

[6] Hassol, A., Irvin, C., Gaumer, G., Puskin, D., Mintzer, C., and Grigsby, J., “Rural Applications of Telemedicine,” Telemedicine Journal,
1997, 3(3):215-225.

[7] Office of Rural Health Policy, Exploratory Evaluation of Rural Applications of Telemedicine, Rockville, MD: U.S. Department of Health
and Human Resources, Health Resources & Services Administration. 1997.

[S] Perednia, D.A. and Allen A. “Telemedicine Technology and Clinical Applications,” Journal of the American Medical Association, 1995,
273(6): 483-488.

[9] Powe, N., “The Contributions of Meta-analysis to Effectiveness Research,” Presented to the Translating Evidence into Practice ‘98
Conference, Washington, D.C. Agency for Health Care Policy and Research, July 27, 1998.

[IO] Public Law 105-33, “Balanced Budget Act of 1997,” August 5, 1997

[I I] Puskin, D.S., Brink, L.H., Mintzer, CL., and Wasem, CJ .“Letter to the Editor: Joint Federal Initiative for Creating a Telemedicine
Evaluation Framework,” Telemedicine Journal, 1995, 1(4):395-399.

[12] Sanders, J.H., and Bashshur, R.L., “Challenges to the Implementation of Telemedicine,” Telemedicine Journal 1995, 1(2):115-123.

[13] Telemedicine: A guide to Assessing Telecommunications in Health Care, ed.: Marilyn Field, Institute of Medicine, Washington, D.C.:
National Academy Press, 1996.

[14] Telemedicine Report to Congress, Washington, D.C.: U.S. Department of Commerce in conjunction with the Department of Health and
Human Services, January 3 1, 1997.

352

Authorized licensed use limited to: The University of Hong Kong Libraries. Downloaded on February 05,2021 at 00:38:21 UTC from IEEE Xplore. Restrictions apply.