Introducing telemedicine within a health informatics curriculum.

Abstract

Telemedicine, defined as the use of advanced telecommunications technologies to bridge distance and support health care delivery and education, is an essential part of health informatics. The current U.S. market for telemedicine is growing rapidly and its growth rate is predicted to increase even more in the following years. A telemedicine course becomes an essential part of a medical informatics training program. This paper discusses the introduction and integration of telemedicine into a medical informatics curriculum and proposes a framework for the course design that covers the following sections: definitions, introduction to technical aspects of telemedicine, history of telemedicine and its impact on health care delivery, success criteria, legal and ethical issues, a tool for literature review and practical exposure to products and applications. The challenge for the instructor becomes to keep the course material up-to-date given the constant telecommunication developments while equipping students with the knowledge and the tools they will need in their future role as decision makers to detect a need for, design, implement, maintain or evaluate a telemedicine application.

Introduction

John is a 67 year old rural home care patient. Lately he has changed his morning routine. As soon as he wakes up, he sits at the desk near the television where a "system" has been installed by his home care agency that allows him to fill out an online questionnaire reporting symptoms, problems and medication compliance and measure his blood pressure with an attached device. Twice a week a "virtual visit" by his home care nurse is scheduled where he can see her on his TV screen. Although he emails questions at a regular basis, there is always so much more to discuss. When John became home bound, he was concerned that his house in the middle of the forest would not be easily accessible. Thanks to telemedicine technology his house does not seem so distant any more.

Telemedicine is a general term that refers to a wide range of technologies and applications. In a broad sense it is defined as the use of medical information "exchanged from one site to another via electronic communications for the health and education of the patient or health care provider and the purpose of improving patient care [1]." The rapid expansion of telemedicine internationally reflects the growth of technological innovations. High-capacity digital networks, powerful and affordable computer hardware and software, compressible, high-resolution digital images and the Internet have had a great impact on the process of health care delivery. A survey by US Healthcare Information and Systems Society (HIMSS) found that 34% of the responding health care executives reported that their organizations currently use telemedicine, 10% plan on using telemedicine within the next year, and 28% are investigating its use in the future [2].

The use of telecommunications technology in the health care field has been established and the concept of telemedicine is no longer considered an innovation. Telemedicine applications have become part of the care routine for several urban and rural areas across the country. Telemedicine is an essential part of the field of health informatics and should be integrated into a graduate health informatics curriculum. The challenge is to introduce the concept of telemedicine and its applications to a group of students who in their future positions as system designers, chief information officers or chief executive officers, have to understand the notion of utilizing telemedicine to support care delivery and education. They also have to be in a position to evaluate its effectiveness, detect a possible need for such application in a specific setting and determine the design principles that would make it successful.

In the following section, the introduction and integration of telemedicine into a medical informatics curriculum is discussed and a framework for the design of a course is being presented. This framework includes a set of topics that constitute the outline for the course and ways to approach them, a tool for reviewing telemedicine literature and aspects of academic training that are of importance specifically to telemedicine.

Course Framework

The proposed course should include following sections: Definitions, Introduction to technical aspects of telemedicine, History of Telemedicine, Telemedicine's Impact on Health Care Delivery, Success Criteria, Legal and Ethical Issues, Reviewing the Literature, Site Visits.

Definitions

Telemedicine is defined as the use of information technology and telecommunications to bridge geographical distances and improve health care delivery and education. Due to the continuous advancements of telecommunications telemedicine's application areas are evolving and new terms arise. Students should be introduced to formal definitions of telemedicine, "telecare", "telehealth" and "e-health."

The general use of the term "telemedicine" by medical doctors and administrators often does not cover the wide variety of significantly different technologic methods, devices and procedures necessary for correctly performing specific tasks of telemedicine applications. Frequently one term is used to describe different tasks (for example, in some studies the term "teleconsultation" is used to describe an interaction between a health care provider and a clinical expert at a remote site utilizing videoconferencing technology, but there are cases in mental health settings where this term is used to describe the interaction between patient and provider). It is important for students to be equipped with a definitions list that can function as a "dictionary." The proposed list should include the items of the Telehealth and Telemedicine Manifesto proposed by Pinciroli [3] and should be expanded to incorporate specific terms that are currently widely used and refer to telemedicine in a specific clinical area (e.g., teleradiology, teleoncology, telehomecare) as well as the mode of care delivery (e.g., virtual visit, remote monitoring, teleconsultation). In addition, students should be introduced to the wealth of resources related to telemedicine such as the major journals of the field, the sites of national and international associations and online databases.

Introduction to technical aspects of telemedicine

Informatics students are traditionally being introduced to theory and design of networks, data transfer and communication within other undergraduate and/or graduate courses related to computer science. However, a brief review of telecommunications technologies and protocols that are being utilized for telemedicine applications is a necessary component of a telemedicine course. This section is not designed to provide expertise in the technical aspects of telemedicine but rather familiarize students with the terminology and different types of technology and networks, their features, limitations and cost. Students' awareness of technology limitations (e.g., in image quality or data transfer speed) and cost ranges facilitates the understanding of telemedicine evaluation studies. This task becomes a challenge for the instructor who needs to ensure that the material is complete and up-to-date given the constant developments in telecommunications.

History of telemedicine

There has been great interest in telemedicine over the last ten years, but of course, the concept is not new. Even in 1924, at a time radio had just started reaching American homes, the magazine Radio News had a cover showing a "radio doctor" linked to a patient not only by sound but also by live image [4]. One of the first references to telemedicine that appeared in medical literature was an article published in 1950, that described the transmission of radiologic images by telephone between West Chester and Philadelphia, Pennsylvania, a distance of 24 miles [5]. Other landmarks in the history of telemedicine include the closed-circuit television system at the Nebraska Psychiatric Institute that was used to provide a link with a state hospital 112 miles away in 1964 [6]. More advanced telemedicine applications were developed in the seventies such as the STARPAHC Project (Space Technology Applied to Rural Papago Advanced Health Care) that delivered medical care to the Papago Indian Reservation in Arizona [7] and the Alaska ATS-6 Satellite Project [8]. An introduction to the history of telemedicine will help students understand the diffusion and development of this innovation as well as the permanent need to bridge time and geographical gaps in health care delivery. Finally, students need to be introduced to the Telecommunications Act of 1996 which has had a great impact on the number and nature of telemedicine initiatives. This should lead to a discussion of the Congress's attempt to ensure that the country's historic universal service communications policy be applied to advanced telecommunications.

Telemedicine's Impact on Health Care Delivery

1. Cost of care The cost of telemedicine should be analyzed in relation to how it improves the health of a population by preventing or treating a disease through access to information and communication. On of the learning objectives of this section should be to make clear that the measurement of potential cost savings associated with a telemedicine application depends upon the interest group (e.g., patient, health maintenance organization, provider, society). It is a general assumption, for example, that telemedicine decreases the opportunity costs for patients in seeking care (by reducing, for instance, travel expenses to visit a specialist). On the other hand, cost savings that might be accomplished by unit price decreases may be offset by an increase in volume. That is, increasing access to health services could lead to increased demand.

For the context of the proposed course emphasis should be given on the societal perspective, which is most relevant for public policy decisions and encompasses the total costs of resources used to provide a service through telemedicine compared to alternative means [9]. Thus, use of examples could clarify the learning objective further. For example, a scenario can be studied where an analysis is based on a private insurer's perspective that incorporates costs only for health care benefits or services covered by the insurance plan. Such an analysis would exclude uncovered medical expenses (e.g., transportation) borne by the insured. In relation to the issue of cost several studies should be studied by the students and discussed within groups (e.g., studies that have found teleradiology to cost less than alternative delivery systems [10,11,12], detection of potential cost savings from teledermatology [13], a cost analysis of a teleoncology practice [14]).

2. Quality of care Bashshur [15] suggests that the quality of care provided by telemedicine can be evaluated either on a biomedical/ bioengineering basis (clinical performance, clinical efficacy, effectiveness, safety) or health services basis (appropriateness of the treatment chosen, policy adapted to improve health status). Fineberg et al. distinguished several process and outcomes dimensions that might appropriately be assessed when evaluating the quality of care [16] and should be discussed within the context of the proposed course. These dimensions include:

* Technical capacity that addresses whether a technology is safe, accurate and reliable

* Diagnostic accuracy that addresses whether a technology contributes to a correct diagnosis

* Diagnostic impact that addresses whether a technology provides diagnostic information that is useful in making a diagnosis)

* Therapeutic impact that demonstrates whether/ how a technology influences patient management or therapy

* Patient outcome that addresses whether a technology improves patients' health and well-being.

A discussion of telemedicine's impact on quality of care can be enhanced with the review of published studies that have examined several aspects of this concept. O'Sullivan et al. [17], for example, compared digital image quality (used in a teleradiology application) with original radiographic films used to detect urinary calculi and came to the conclusion that a highly affordable teleradiology system is effective and accurate compared to plain films. Other studies have investigated the diagnostic accuracy of advanced video-capturing systems [18, 19, 20].

3. Access to care Access has geographic, social, financial and psychological components which makes a precise definition difficult. As Bashshur [15] defines it, access to health services reflects the "fit" between health care resources (including hospitals, clinics, doctor's offices) and the health care needs of the people they serve. Students should identify and discuss the three primary types of barriers to access [21] in relation to telemedicine:

* Structural barriers, these are impediments to medical care directly related to the number, type, concentration or location of health care providers [21].

* Financial barriers, these are factors that inhibit patients to pay for needed medical services or discouraging providers from offering such services to patients of limited means.

* Personal or cultural barriers, these are factors related to personal previous experiences, religious beliefs or cultural issues, that inhibit people who need medical attention from seeking it, or once they obtain care, from following post-treatment guidelines [21].

Success criteria

Most telemedicine projects in the 1970s and 80s were unable to achieve a market niche. Scientists have offered many different explanations for the limited adoption of telemedicine. The most often listed reasons for the failure of telemedicine to achieve a market niche in the 70s and 80s include:

* people's unfamiliarity and limited experience with technology [22]

* limitations in the technology at the time

* the absence of long-term institutional funding commitments. According to Reid [15], the single most influential factor was the programs' dependence upon external- usually federal- funding.

* poor planning and design which affected the stability of the systems [22].

In the nineties the number of telemedicine applications started to expand rapidly. One report by Perednia and Allen [22] estimated that the number of programs using interactive television had reached 50 in 1996, with growth doubling each year between 1990 and 1995. The report [22] also suggests that teleradiology installations have been growing at a similar pace. Students should study literature that demonstrates the success or failure of telemedicine interventions and identify common patterns that could be listed as success predictors or lessons learned from past applications. This is significant as they will in their future professional positions be in charge of converting data from past practice into information to support decisions about future practices

Legal and Ethical Issues

Although telemedicine applications have been growing and expanding, the legal and regulatory environment has not progressed as rapidly, A series of legal and ethical issues that are associated with the utilization of telemedicine should be introduced to students in a way that stimulates them to think of and analyze matters some of which still remain to be addressed. These issues should include:

* Licensure Interstate telemedicine raises licensure questions, such as whether physicians can be practicing (tele)medicine in a remote state where they don't have a practicing license.

* Accreditation Is there a need for separate standards for "virtual" practice? What should be the regulations for a "remote physician" who wants to admit patients? Should the "host" site continuously monitor "remote" physicians' competence to the same extent it does with its own medical staff members?

* Privacy of the electronic medical record Students will be familiar with the issues of privacy and confidentiality of medical data from other informatics courses. It should be emphasized that telemedicine applications often require that electronic medical records are shared across state lines (and this could become an issue when confidentiality and privacy laws have been enacted on a state basis without consistency across state lines), physical examinations are being broadcasted within the videoconferencing network, interactions are being taped and integrated into the medical record.

* Malpractice liability Some argue that although the legal system aims to ensure that health care agencies and systems supervise and monitor their own staff members providing services, it does not account for the case where a network of independent physicians and remote experts participate in "telemedicine" activities.

* Reimbursement Telemedicine services are in some states for the most part not reimbursed by Medicare, Medicaid and private/third-party payers (except for the cases of federal grant funding for research). The type and amount of evidence demonstrating telemedicine's impact required to enforce reimbursement for telemedicine activities can be discussed.

Reviewing the Literature

The articles reviewed within the course should be summarized in a chronological order following an expanded version of the Matrix Method and Matrix Indexing System for conducting and organizing literature reviews [23]. This method provides a plan for organizing references and reprints and managing this information on an ongoing basis enabling an efficient and thorough search of the literature using electronic databases and an organized review of published studies. The specific format proposed for the literature review in this context includes following columns:

* the year the studies were published

* instruments used to collect data

* study subjects

* clinical area the study focused on

* results as presented by the author(s)

* technology used.

The matrix method holds a distinct significance for reviewing telemedicine literature for two reasons:

* Reviewing the matrix one can study it "horizontally" (examine one study at a time) or "vertically" (scan each column to have an overview of the technology trends over time, changes in the methods or result). This structure supports the detection of clinical areas that have been unexplored, and research questions that have remained unanswered. This is of importance for a field that is relatively new and rapidly growing.

* Unlike other medical literature and due to the innovative nature of the field, telemedicine literature is lacking of a great number of clinical trials, data collection instruments that have been tested for reliability and validity and in some cases sound statistical methods. It is therefore of importance to encourage students to be critical of the generalizability of methods and results and incorporate their remarks into the matrix. This literature matrix should be an ongoing project maintained and updated by and accessible to all students.

Site visits

Several vendors can be invited to present their products for different application areas. In addition, site visits to clinical settings where telemedicine is being practiced, can be of benefit to students who will get exposed to a practical implementation of the concepts they have been introduced to throughout the course. During these visits students will have the opportunity to assess health care providers' perceptions of and attitudes toward telemedicine applications and discuss their impact on daily care delivery.

Conclusion

Telemedicine has the potential to provide access to high quality medical care for isolated populations, empower patients to play active role in their disease management and could in some cases decrease the cost of care. Health informatics students need to be equipped during their training with the knowledge and skills required to develop and evaluate action plans for telemedicine research and development at the state, national and international level.

Although the selection of published studies and parts of the material should be updated frequently due to the constantly evolving nature of telemedicine, the proposed framework can constitute the outline of a graduate course in telemedicine for informatics students that will provide them with an overview of the field and equip them with telemedicine related knowledge and skills required for their future role as decision makers.

References

[1] American Telemedicine Association http://www.atmeda.org

[2] Siwicki B. HIMSS Survey: Attention shifts from Y2K to HIPAA. Health Data Management 2000;8(6): 12-16.

[3] Pinciroli FL. Journal of the American Medical Informatics Association 2001;8:349-350

[4] Radio News, April 1924 Ed. By H. Gernsback

[5] Gerson-Cohen J, Colley A. Telediagnosis. Radiology 1950;55:582-587.

[6] Benschoter R, Garetz C, Smith P. The use of closed circuit TV and videotape in the training of social group workers. Social Work Education Reporter 1967;15(1):18-20.

[7] Bashshur R, Armstrong P. Telemedicine: a new mode for the delivery of health care. Inquiry 1976;13(3):233-244.

[8] Foote D, Hudson H, Parker E. B. Telemedicine in Alaska: the ATS-6 satellite biomedical demonstration. Springfield, VA: National Technical Information Service (NTIS) U.S. Department of Commerce; 1976.

[9] Committee on evaluating clinical applications of telemedicine; Field MJ (ed) Telemedicine; A guide to assessing telecommunications in health care. Washington DC: National Academy Press; 1996.

[10] Bergmo TS An economic analysis of teleradiology versus a visiting radiologist service. Journal of Telemedicine and Telecare 1996;2(3):136-142.

[11] Stoeger A, Strohmayr W, Giacomuzzi S, Dessl A, Buchberger W, Jaschke W. A cost analysis of an emergency computerized tomography teleradiology system. Journal of Telemedicine and Telecare 1997;3(1):35-39.

[12] Bailes J, Poole C, Hutchison W, Maroon J, Fukushima T. Utilization and cost savings of a wide-area computer network for neurosurgical consultation. Telemedicine Journal 1997; 3(2):135-139.

[13] Linder B, Adams G. Assessing the utility of telemedicine with Kaiser Permanente. Third Annual Meeting of the American Telemedicine Association, April 5-8, Orlando FL, 1998.

[14] Doolittle G. Practicing oncology via telemedicine. Journal of Telemedicine and Telecare 1997;3(2):63-70.

[15] Bashshur R, Sanders J, Shannon G. Telemedicine: Theory and Practice. Springfield, IL: Charles C. Thomas; 1997.

[16] Fineberg H, Bauman R, Sosman M. Computerized crasial tomography: Effect on diagnostic and therapeutic plans. Journal of the American Medical Association 1997; 238:224-230.

[17] O'Sullivan DC, Averch TD, Cadeddu JA et al. Teleradiology in urology: comparison of digital image quality with original radiographic films to detect urinary calculi. The Journal of Urology 1997; 158:2216-2220.

[18] Kvedar J, Edwards R et al. The substitution of digital images for dermatologic physical examination. Archives of Dermatology 1997;133:161-167.

[19] Notes J, Malone FD, Athanassiou A, Craigo SD, Simpson LL, D'Alton ME. Validation of first trimester telemedicine as an obstetric imaging technology: A feasibility study. Obstetrics & Gynecology 1997; 90(3):353-356.

[20] Larson A, Lynch DA, Zeligman B et al. Accuracy of diagnosis of subtle chest disease and subtle fractures with a teleradiology system. American Journal of Roentgenology 1998; 170(1):19-22.

[21] Millman M. Institute of Medicine: Committee on Monitoring Access to Personal Health Care Services. Washington D.C.: National Academy Press; 1993.

[22] Allen A, Perednia D. Telemedicine and the Health Care Executive. Telemedicine Today 1996;Winter:4-23.

[23] Garrard J. Health sciences review made easy: The Matrix Method. Gaithersburg, Maryland: Aspen Publishers; 1999.

George Demiris, University of Missouri-Columbia

Dr. Demiris is an Assistant Professor at the Department of Health Management and Informatics. He received his Master's degree in Medical Informatics at the University of Heidelberg, Germany and his PhD degree in Health Informatics at the University of Minnesota.