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--> Telemedicine A Guide to Assessing Telecommunications in Health Care Committee on Evaluating Clinical Applications of Telemedicine Marilyn J. Field, Editor Division of Health Care Services INSTITUTE OF MEDICINE NATIONAL ACADEMY PRESS Washington, D.C. 1996
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--> National Academy Press 2101 Constitution Avenue, N.W. Washington, D.C. 20418 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This report has been reviewed by a group other than the authors according to procedures approved by a Report Review Committee consisting of members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of the appropriate professions in the examination of policy matters pertaining to the health of the public. In this, the Institute acts under both the Academy's 1863 congressional charter responsibility to be an adviser to the federal government and its own initiative in identifying issues of medical care, research, and education. Dr. Kenneth I. Shine is president of the Institute of Medicine. Support for this project was provided by the National Library of Medicine and the Health Care Financing Administration, U.S. Department of Health and Human Services, under Contract No. N01-OD-4-2139. Additional support for dissemination of the report was provided by GTE. The views presented are those of the Institute of Medicine Committee on Evaluating Clinical Applications of Telemedicine and are not necessarily those of the funding organizations. Library of Congress Cataloging-in-Publication Data Institute of Medicine (U.S.). Committee on Evaluating ClinicalApplications of Telemedicine. Telemedicine: a guide to assessing telecommunications in health care / Committee on Evaluating Clinical Applications of Telemedicine, Division of Health Care Services, Institute of Medicine; Marilyn J. Field, editor. p. cm. Includes bibliographical references and index. ISBN 09-309-05531-8 1. Telecommunications in medicine—Evaluation. 2. Telecommunications in medicine—United States—Evaluation. I. Field, Marilyn J. (Marilyn Jane) II. Title. [DNLM: 1. Telemedicine—standards—United States. 2. Program Evaluation—methods. W 84 AA1 I4828t 1996] R119.9.I56 1996 First Printing, October 1996 362.1'028—dc20 Second Printing, November 1997 DNLM/DLC for Library of Congress 96-30101 CIP Additional copies of this report are available from National Academy Press, 2101 Constitution Avenue, N.W., Box 285, Washington, D.C. 20055. Call 800-624-6242 (or 202-334- 3313 in the Washington metropolitan area). http://www.nap.edu. The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The image adopted as a logotype by the Institute of Medicine is based on a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. Copyright 1996 by the National Academy of Sciences. All rights reserved. Printed in the United States of America
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--> COMMITTEE ON EVALUATING CLINICAL APPLICATIONS OF TELEMEDICINE JOHN R. BALL, M.D., J.D.,* Chair, President and CEO, Pennsylvania Hospital, Philadelphia MICKEY S. EISENBERG, M.D., Ph.D.,* Director, Emergency Medicine Service, University of Washington Medical Center, Seattle MELVYN GREBERMAN, M.D., M.P.H., Associate Director for Medical Affairs Division of Small Manufacturers Assistance, Food and Drug Administration, U.S. Department of Health and Human Services, Rockville, Maryland MICHAEL HATTWICK, M.D., President, Woodburn Internal Medicine Associates, Annandale, Virginia SUSAN D. HORN, Ph.D., Senior Scientist, Institute for Clinical Outcomes Research, Salt Lake City, Utah PETER O. KOHLER, M.D.,* President, Oregon Health Sciences University, Portland NINA W. MATHESON, M.L.,* Director Emerita, William H. Welch Library, Professor of Medical Information, Johns Hopkins University, Baltimore, Maryland DAVID B. NASH, M.D., Director of Health Policy and Clinical Outcomes, Thomas Jefferson University Hospital, Philadelphia JUDITH OZBOLT, Ph.D., R.N., Professor, University of Virginia School of Nursing, Charlottesville, Virginia JAMES S. ROBERTS, M.D., Senior Vice President, Clinical Leadership, VHA, Inc., Irving, Texas JAY H. SANDERS, M.D., Director of Telemedicine Center, Professor of Medicine and Surgery, Medical College of Georgia, Augusta JOHN C. SCOTT, M.S., President, Center for Public Service Communications, Arlington, Virginia JANE E. SISK, Ph.D., Professor, Division of Health Policy and Management, Columbia University School of Public Health, New York * Member, Institute of Medicine.
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--> PAUL C. TANG, M.D., Associate Professor of Medicine, Northwestern University Medical School, and Medical Director, Information Systems, Northwestern Memorial Hospital, Chicago ERIC TANGALOS, M.D., Associate Professor of Medicine, Mayo Clinic, Rochester, Minnesota Technical Advisory Panel to the Committee RASHID L. BASHSHUR, Ph.D., Professor, Department of Health Management and Policy, School of Public Health, The University of Michigan, Ann Arbor DOUGLAS D. BRADHAM, Dr.P.H.,** Associate Professor, Bowman Gray School of Medicine, Department of Public Health Sciences, Section on Social Sciences and Health Policy, Wake Forest University, Winston-Salem, North Carolina LINDA H. BRINK, Ph.D., Chair, U.S. Department of Defense Testbed Telemedicine Evaluation Working Group, U.S. Army Medical Research and Materiel Command, Walter Reed Army Medical Center, Washington, D.C. JIM GRIGSBY, Ph.D., Associate Professor, University of Colorado Health Sciences Center, and Senior Researcher, Centers for Health Policy and Health Services Research, Denver CAROLE L. MINTZER, M.P.A., Senior Finance Analyst, Office of Rural Health Policy, Rockville, Maryland DOUGLAS A. PEREDNIA, M.D., Director, Telemedicine Research Center and Oregon State Health Sciences University Advanced Telemedicine Research Group, Portland Study Staff MARILYN J. FIELD, Ph.D., Study Director KARLA R. SAUNDERS, Administrative Assistant ELINOR C. GRAY, Research Assistant ** As of July 1996, Director, Section on Medical Outcomes and Policy Analysis, and Associate Professor, University of Maryland School of Medicine, Department of Medicine, Division of Gerontology, Baltimore, Maryland.
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--> JERRARD R. SHEEHAN, Staff Liaison, Computer Sciences and Telecommunications Board KATHLEEN N. LOHR, Ph.D., Director, Division of Health Care Services (through February 2, 1996) CLYDE J. BEHNEY, Director, Division of Health Care Services (after February 5, 1996) NINA H. SPRUILL, Financial Associate
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--> Acknowledgments Many individuals and groups assisted the study committee and staff in the development of this report. We particularly benefited from the experience and wisdom of the Technical Advisory Panel (listed after the committee), both as a group and as individuals. A number of those involved with the federal Joint Working Group on Telemedicine provided information and advice throughout the project. Dena Puskin, Sc.D., chair of the working group and Deputy Director of the Office of Rural Health Policy, was unfailingly helpful with her time and insights. Linda Brink, Ph.D., Chair of the Department of Defense Telemedicine Evaluation Working Group, contributed generously from her evaluation experience. She also arranged an on-site visit to the telemedicine center at Walter Reed Army Medical Center and provided periodic updates on the military's development of evaluation tools and processes. Michael Ackerman, Ph.D., was a pleasure to work with, both as project officer for this study for the National Library of Medicine (NLM) and as a participant in many key information infrastructure activities. Donald Lindberg, M.D., Director of the NLM and Betsy Humphreys, M.L.S., Deputy Associate Director of NLM Library Operations provided important direction early in planning the study. William England, Ph.D., the project officer from the Health Care Financing Administration, was also very helpful. From the early
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--> days of the study, Colonel Joan Zajtchuk and Brigadier General Russ Zajtchuk of the U.S. Army provided information and other assistance, including invitations to several military telemedicine meetings. Committee members and staff met with representatives of many organizations and visited several telemedicine projects. Joseph Gitlin, D.P.H., graciously helped to organize our visit to the University of Maryland Medical System and the Baltimore Veterans Affairs Medical Center (VAMC). (He also worked with Melvyn Greberman, a committee member, to arrange discussions with participants at annual meetings of the Radiological Society of North America and the Society for Computer Applications in Radiology.) In Baltimore, we especially appreciated the time Eliot Siegel, M.D., of the VAMC spent with us, providing a very helpful review of their decision to adopt filmless radiology and their internal assessments of the effects on productivity. Richard Alcorta, M.D., and Gene Bidun of the Maryland Institute of Emergency Medical Services System gave us an overview and tour of the organization's headquarters. Deborah Finkelsen, Stephen Schimpff, M.D., Colin MacKenzie, M.D., and Robert Allman, M.D., of the University of Maryland contributed to our education about their activities. Douglas Perednia, M.D., arranged for the committee to hear from him, Dan Filiburti, Nancy Brown, M.L.S., Tamara Hayes, Ph.D., Jim Wallace, and others about the activities of the Telemedicine Research Center and the research being undertaken at Oregon Health Sciences University. He also arranged for a "televisit" with Catherine Britain of RODEO NET, which provided an unplanned opportunity to experience some of the technical problems that can complicate interactive audio-video conferencing. Peter Kohler, M.D. (a committee member), and Carol Reinmiller kindly enabled the committee to get a broader view of telemedicine in Oregon by arranging meetings with those involved with state telecommunications policy and with educational uses of telemedicine. Participants included Donald Girard, M.D., Paula McNeil, R.N., Lesley Hallick, Ph.D., James Walker, James Elert, John Saultz, M.D., Mark Dodson, Deana Molinari, R.N., M.S.N., and Hersch Crawford. At the University of Washington, Tara Cannava, M.H.A., arranged a discussion with those evaluating the WAMI Rural Telemedicine Network including Gary Hart, M.D., Peter House, M.H.A.,
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--> Mike Pirani, Ph.D., and Peter West, M.D. Alan Rowberg, M.D., demonstrated some of the technical and practical issues in integrating digital radiology with traditional film-based operations in radiology departments, emergency departments, and intensive care units. Chris Barnard, M.D., Medical Director of the Stanford Telemedicine Program, showed us the medical center side of some of the University's telemedicine activities and also took us to two of their "remote" sites. Rodney Hawkins, M.P.A., Purna Prasad, M.S., Linda Cook, R.N., Rick Kong, Gerry Shebar provided insights into the strategic, business, engineering, and management aspects of their program. At the Lytton Gardens Health Care Center, we met with Vera Goupille, M.P.H., Peter Pompei, M.D., and Linda Hibbs, R.N., M.P.A. At Drew Health Foundation, we met with administrator Manfred Hayes, M.B.A., Dana Knoll, M.B.A., Bertha Price, L.V.N., and others. An attempt to arrange a video link with the San Jose Medical Group failed because severe storms disrupted telephone communication in the Bay Area, but this experience, again, was instructional. William Goodall, M.D., of Allina Health System; Ed Hinman, M.D., of Total Health care; and John Santa, M.D., Joanne Zamorra, and Eric Livingston, all of Blue Cross/Blue Shield of Oregon talked with us about telemedicine in different kinds of managed care environments. Robert Thompson, M.D., invited staff to participate in a meeting of the American College of Radiology and National Electrical Manufacturers Association that illuminated some of the difficulties of building on and extending their experience in developing the DICOM standards for radiology. Francoise Gilbert, J.D., of Altheimer & Gray, Chicago, and Leo J. Whelan, J.D., Legal Counsel, for Mayo Clinic, Rochester, Minnesota, reviewed drafts of the policy chapter, which greatly benefited from their suggestions (although they bear no responsibility for any errors). In addition to helping draft a background paper for the committee, Neil Neuberger provided numerous information resources and contacts. Among others who were helpful in a variety of ways were Richard Bakalar, M.D., U.S. Navy; Roger Shannon, M.D., Veterans Health Administration; Gloria Jones of East Carolina University; Donna Farley, M.H.A., now of the Rand Organization; Suzanne Tichenor of the Council on Competitiveness; Alice Meyer at
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--> md/tv; Barry Rome at VTEL; Sharon Cauchi of Telemedicine and Telehealth Networks; and Ace Allen, M.D., of Telemedicine Today. Staff within the Institute of Medicine provided assistance in many different ways. Some of those we especially thank include Claudia Carl, Nina Spruill, Mary Lee Schneiders, Mike Edington, Donna Thompson, Richard Julian, and Molla Donaldson. At the Computer Sciences and Telecommunications Board of the National Research Council, first Louise Arnheim and then Jerry Sheehan were the staff liaisons for this project.
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--> Contents SUMMARY 1 1 INTRODUCTION AND BACKGROUND 16 Telemedicine in Context 18 The Demand for Evidence of Effectiveness 22 Study Origins and Approach 24 Terms and Definitions 26 Structure of the Report 33 2 EVOLUTION AND CURRENT APPLICATIONS OF TELEMEDICINE 34 Evolution of Distance Communication 34 Development of Telemedicine 35 Current Applications of Telemedicine 40 Conclusion 53 3 THE TECHNICAL AND HUMAN CONTEXT OF TELEMEDICINE 55 The Technical Infrastructure 55 Human Factors and the Acceptance of Telemedicine 73 Conclusion 82
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--> 4 THE POLICY CONTEXT OF TELEMEDICINE 83 National Communications and Information Infrastructure Policy 84 State Programs and Initiatives 87 Professional Licensure and Distance Medicine 89 Malpractice Liability 96 Privacy, Confidentiality, and Security 100 Payment Policies for Telemedicine 107 Regulation of Medical Devices 113 Conclusion 115 5 PAST AND CURRENT EVALUATIONS OF TELEMEDICINE 116 Evaluation Efforts in Telemedicine 117 Evaluation Frameworks 118 Examples of Individual Research Strategies 126 Conclusion 136 6 A FRAMEWORK FOR PLANNING AND IMPROVING EVALUATIONS OF TELEMEDICINE 137 Planning for Evaluation 138 Elements of an Evaluation 144 Evaluation and Continuous Improvement 154 Conclusion 156 Addendum: Experimental, Quasi-Experimental, and Nonexperimental Designs 156 7 EVALUATING THE EFFECTS OF TELEMEDICINE ON QUALITY, ACCESS, AND COST 162 Evaluation Criteria and Questions 163 Quality of Care 165 Evaluating Access 173 Evaluating Costs and Cost-Effectiveness of Telemedicine 179 Patient and Clinician Perceptions 186 Desirable Attributes of Evaluation Criteria 191 Conclusion 192 8 FINDINGS AND RECOMMENDATIONS 194 The Technical, Human, and Policy Context for Telemedicine Evaluations 195
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--> Challenges and Progress in Evaluating Telemedicine 197 Framework for Evaluating Telemedicine 200 Conclusion 207 REFERENCES 209 APPENDIXES A Examples of Federal Telemedicine Grants 229 B Glossary and Abbreviations 239 C Committee Biographies 253 INDEX 259 Tables, Figures, And Boxes Tables 1.1 Categories and Examples of Telemedicine Applications 29 1.2 Dimensions, Subdimensions, and Examples of Patient Care Relevant to Telemedicine Applications 31 3.1 Types of Telemedicine Service Providers, Related Services, and Other Resources 57 3.2 Key Information Technologies for Health Care 60 4.1 Categorization of 28 State Telemedicine Programs in 1995 with Examples 88 7.1 Categories of Evaluation Questions for Comparing Telemedicine to Alternative Health Services 164 7.2 Evaluating Quality of Care and Health Outcomes 169 7.3 Evaluating Access to Care 177 7.4 Evaluating Health Care Costs and Cost-Effectiveness 185 7.5 Evaluating Patient Perceptions 189 7.6 Evaluating Clinician Perceptions 190 7.7 Desirable Attributes of Evaluation Criteria 191
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--> Figures 2.1 Telemedicine circa 1924 37 2.2 Telemedicine work station 50 2.3 Telemedicine consultation from the patient's perspective 51 3.1 Schematic representation of the telemedicine center at the National Naval Medical Center in Bethesda, and the satellite Naval Medical Clinic in Annapolis, Maryland 62 3.2 Relationship between the complexity of telemedicine applications and bandwidth requirements 64 3.3 Messaging standards for electronic exchange of different kinds of hospital medical information 70 Boxes S.1 Elements of an Evaluation Plan 6 S.2 Categories of Evaluation Questions for Comparing Telemedicine to Alternative Health Services 9 3.1 Human Factors, Telemedicine, and the Telephone Analogy 77 6.1 Threats to the Internal Validity of Evaluations 158 8.1 Elements of an Evaluation Plan 203 8.2 Categories of Evaluation Questions for Comparing Telemedicine to Alternative Health Services 206
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