1

Introduction

In 1996, the Institute of Medicine (IOM) released its report Telemedicine: A Guide to Assessing Telecommunications for Health Care (IOM, 1996). In that report, the IOM Committee on Evaluating Clinical Applications of Telemedicine found

Telemedicine is similar in most respects to other technologies for which better evidence of effectiveness is also being demanded. Telemedicine, however, has some special characteristics—shared with information technologies generally—that warrant particular notice from evaluators and decision makers. Most notably, telemedicine is not a single technology or a discrete set of related technologies; it is, rather, a large and very heterogeneous collection of clinical practices, technologies, and organizational arrangements. In addition, widespread adoption of effective telemedicine applications depends on a complex, broadly distributed technical and human infrastructure that is only partly in place and is being profoundly affected by rapid changes in health care, information, and communications system. (IOM, 1996, p. 208)

Since that time, attention to telehealth1 has continued to grow in both the public and private sectors. Peer-reviewed journals and professional societies are devoted to telehealth, the federal government provides grant funding to promote the use of telehealth, and the private technology industry continues to develop new applications for telehealth. However, barriers

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1 See later in this chapter as well as Appendix A for more on definitions of telehealth, telemedicine, and other relevant terms.



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1 Introduction In 1996, the Institute of Medicine (IOM) released its report Tele medicine: A Guide to Assessing Telecommunications for Health Care (IOM, 1996). In that report, the IOM Committee on Evaluating Clinical Applications of Telemedicine found Telemedicine is similar in most respects to other technologies for which better evidence of effectiveness is also being demanded. Telemedicine, however, has some special characteristics--shared with information tech- nologies generally--that warrant particular notice from evaluators and decision makers. Most notably, telemedicine is not a single technology or a discrete set of related technologies; it is, rather, a large and very hetero- geneous collection of clinical practices, technologies, and organizational arrangements. In addition, widespread adoption of effective telemedicine applications depends on a complex, broadly distributed technical and human infrastructure that is only partly in place and is being profoundly affected by rapid changes in health care, information, and communications system. (IOM, 1996, p. 208) Since that time, attention to telehealth1 has continued to grow in both the public and private sectors. Peer-reviewed journals and professional societies are devoted to telehealth, the federal government provides grant funding to promote the use of telehealth, and the private technology indus- try continues to develop new applications for telehealth. However, barriers 1Seelater in this chapter as well as Appendix A for more on definitions of telehealth, tele- medicine, and other relevant terms. 1

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2 THE ROLE OF TELEHEALTH remain to the use of telehealth modalities, including issues related to reim- bursement, licensure, workforce, and costs. Also, some areas of telehealth have developed a stronger evidence base than others. WORKSHOP STATEMENT OF TASK The Health Resources and Services Administration (HRSA) sponsored the IOM in holding a workshop in Washington, DC, on August 8-9, 2012, to examine how the use of telehealth technology can fit into the U.S. health care system. HRSA asked the IOM to focus on the potential for telehealth to serve geographically isolated individuals and extend the reach of scarce resources while also emphasizing the quality and value in the delivery of health care services. Specifically, the charge to the planning committee was to discuss the evolution of telehealth since 1996, including the increas- ing role of the private sector, policies that have promoted or de- layed the use of telehealth, and consumer acceptance of telehealth; discuss the current evidence base for telehealth, including available data and gaps in data; discuss how technological developments, including mobile tele- health (mHealth), electronic intensive care units, remote monitor- ing, social networking, and wearable devices, in conjunction with the push for electronic health records, is changing the delivery of health care in rural and urban environments; and discuss actions that the U.S. Department of Health and Human Services (HHS) can undertake to further the use of telehealth to improve health care outcomes while controlling costs in the current health care environment. Overall, the workshop speakers were asked to meet the following workshop objectives: delineate the evidence base for telehealth; highlight special implications for rural populations; discuss the actions HHS can undertake; and identify what in particular warrants further study. The planning committee's role was limited to planning the workshop, and the workshop summary has been prepared by the workshop rapporteur as a factual summary of what occurred at the workshop. Statements, rec- ommendations, and opinions expressed are those of individual presenters

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INTRODUCTION 3 and participants, and are not necessarily endorsed or verified by the IOM, and they should not be construed as reflecting any group consensus. DEFINITIONS In 1996, the IOM defined telemedicine as "the use of electronic infor- mation and communications technologies to provide and support health care when distance separates participants" (IOM, 1996, p. 1). (See Ap- pendix A for more definitions related to telehealth and telemedicine.) In his keynote address at this workshop (see Chapter 3), Dr. Thomas S. Nesbitt of the University of California, Davis, Health System noted that while the terms telehealth and telemedicine both describe the use of technology to exchange information to improve a patient's health status, they are often interchanged. He stated that telemedicine has typically been used more to describe direct clinical services, whereas telehealth has been used to define a broader scope of health-related services (e.g., patient education, remote monitoring). Similarly, the American Telemedicine Association (ATA) states, Telemedicine and telehealth both describe the use of medical informa- tion exchanged from one site to another via electronic communications to improve the patients' health status. Although evolving, telemedicine is sometimes associated with direct patient clinical services and telehealth is sometimes associated with a broader definition of remote health care services. (ATA, 2012a) Many of the presenters at the workshop itself interchanged the use of the terms, and this summary does not attempt to regularize the usage of either term. Appendix A defines some telehealth-relevant terminology, as defined by the ATA. ORGANIZATION OF THE WORKSHOP SUMMARY In this summary, the presentations at the workshop have been orga- nized into 13 chapters. Following this introduction, Chapter 2 presents the opening remarks of the planning committee chair and the workshop sponsor. Chapter 3 provides an overview of the past, present, and future of telehealth. Chapter 4 considers some of the overarching challenges in telehealth, especially for rural communities. Chapter 5 delves into the issues surrounding the challenges of payment for telehealth. Chapter 6 examines the use of telehealth by a variety of providers in different settings across the health care continuum. Chapter 7 reviews the observations and discussions of the planning committee members as well as other workshop participants at the end of the first day of the workshop. Chapter 8 discusses the evidence base of telehealth, including challenges

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4 THE ROLE OF TELEHEALTH with research design and how evidence can help change policy. Chapter 9 explores the development of newer telehealth technologies. Chapter 10 examines how telehealth is being embraced at the state level. Chapter 11 considers the experiences of the federal government in providing telehealth care. Chapter 12 presents perspectives from the representatives of several stakeholder organizations. Finally, Chapter 13 provides final observations made by planning committee members and workshop participants at the conclusion of the workshop. Appendix A offers some key definitions for telehealth. Appendix B includes a list of acronyms. Appendix C provides the workshop agenda.