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29
Proposal for an Evaluation of Health Care Applications on the NII

Joseph Gitlin
Johns Hopkins University

Statement of the Problem and Issues

Telemedicine is being advocated as a process of delivering health care to all segments of the population with the potential of reducing the cost of care while maintaining its quality. However, little is known about the efficacy and cost-effectiveness of the technology in routine diagnostic and therapeutic practice. A well-designed evaluation based on stringent criteria is needed to determine the merits of telemedicine in utilizing the national information infrastructure (NII) in the environment of health care reform. Within this context, some of the more important concerns related to the realization of telemedicine are the following:

The lack of "bandwidth on demand" to provide data rates when they are needed at affordable costs to the health care community;

The lack of availability of high-density, low-cost, digital storage and related software for efficient access by authorized users; and

The lack of standards and interfaces for both health care data acquisition and for the effective use of such information. This is particularly applicable to integration with heterogeneous legacy systems used by a wide variety of health care providers.

Projections Regarding the Problem and Related Issues

Assuming the telecommunication "tariff" issue under the jurisdiction of federal, state, and local authorities can be resolved, it is anticipated that the technical barriers to bandwidth on demand will be overcome in the next 5 to 7 years. The efforts under way to develop a reliable storage and retrieval system that is suitable for medical images and other health care data should be realized before the year 2000. Though improved interfaces and system integration techniques are expected to be available shortly, the accommodation of heterogeneous legacy systems may be delayed by economic and cultural factors for several years.

Status of Key Developments

Recent developments in information technology and the recognition of the need for reform provide a unique opportunity for health care decisionmakers to capitalize on the availability of the NII. If, for example, medical imaging advances are to be available to all patients regardless of situation or geography, the storage, transmission, and retrieval of large volumes of data must be accommodated in all areas of the country. Also, access by secondary users to clinical information for teaching, research, and management (within appropriate security and privacy restrictions) requires that the information be readily available to medical students, research investigators, and health care policymakers.



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Page 233 29 Proposal for an Evaluation of Health Care Applications on the NII Joseph Gitlin Johns Hopkins University Statement of the Problem and Issues Telemedicine is being advocated as a process of delivering health care to all segments of the population with the potential of reducing the cost of care while maintaining its quality. However, little is known about the efficacy and cost-effectiveness of the technology in routine diagnostic and therapeutic practice. A well-designed evaluation based on stringent criteria is needed to determine the merits of telemedicine in utilizing the national information infrastructure (NII) in the environment of health care reform. Within this context, some of the more important concerns related to the realization of telemedicine are the following: • The lack of "bandwidth on demand" to provide data rates when they are needed at affordable costs to the health care community; • The lack of availability of high-density, low-cost, digital storage and related software for efficient access by authorized users; and • The lack of standards and interfaces for both health care data acquisition and for the effective use of such information. This is particularly applicable to integration with heterogeneous legacy systems used by a wide variety of health care providers. Projections Regarding the Problem and Related Issues Assuming the telecommunication "tariff" issue under the jurisdiction of federal, state, and local authorities can be resolved, it is anticipated that the technical barriers to bandwidth on demand will be overcome in the next 5 to 7 years. The efforts under way to develop a reliable storage and retrieval system that is suitable for medical images and other health care data should be realized before the year 2000. Though improved interfaces and system integration techniques are expected to be available shortly, the accommodation of heterogeneous legacy systems may be delayed by economic and cultural factors for several years. Status of Key Developments Recent developments in information technology and the recognition of the need for reform provide a unique opportunity for health care decisionmakers to capitalize on the availability of the NII. If, for example, medical imaging advances are to be available to all patients regardless of situation or geography, the storage, transmission, and retrieval of large volumes of data must be accommodated in all areas of the country. Also, access by secondary users to clinical information for teaching, research, and management (within appropriate security and privacy restrictions) requires that the information be readily available to medical students, research investigators, and health care policymakers.

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Page 234 Key developments in telecommunications essential to meeting the demand generated by health care activities include the availability of high-speed communication networks in sparsely populated areas. The economic and cultural aspects of the telemedicine applications can then be identified, demonstrated, and evaluated. Technology related to high-density storage and retrieval of medical images and related patient data is immature. Much work remains to be done to achieve reliable and cost-effective systems that will support patient care, medical research and education, and health care administration. The proliferation of personal computers and the increase in computer literacy are major factors in user acceptance of telemedicine and related technology. Interaction Between Technical and Nontechnical Factors The regulatory authority of federal, state, and local agencies to set tariffs has resulted in barriers to the economic reality of telemedicine. If the quality of health care is to be maintained in a cost-effective manner using the NII, clinical data must be transmitted promptly within cost constraints. Other legal and regulatory issues that must be addressed include the privacy of patients and health care providers, and the security of data against unauthorized access. Many questions need to be answered regarding the "ownership" of medical information and the responsibility for retention of medical records. The differing state medical licensure requirements must be rationalized to permit access, when needed, to specialists across state boundaries, and malpractice regulations need to be modified to eliminate unnecessary medical procedures that are performed solely to reduce the threat of litigation. In the area of administration, the adoption of a uniform claims data set would substantially reduce current processing activities related to reimbursement. Though health care costs in the United States amount to approximately 15 percent of the gross domestic product, health care information requirements alone cannot support the development and deployment of the NII. However, health care is an important contributor to the information community and is one of many large economic segments that must be included in the utilization of the NII. If the cost of the NII is shared among a large number of major segments of the economy, the application of telecommunications will be facilitated. Further advances in storage and retrieval technology are largely dependent on government agencies and sectors of the economy other than health care. The special requirements of health care can then be met by modifying the basic developments designed to meet other needs. The current trend of health care reform emphasizes the restructuring of the delivery system toward managed care corporations. The driving force behind this restructuring is the recognized need for cost containment. Today, the decisions to adopt new technology for use in health care are predominantly made by corporate managers rather than by individual practitioners. Since health care is a labor intensive activity, in this new climate technology that increases efficiency is more favorably received. Increased access to quality care by patients regardless of situation or geography is the primary justification for telemedicine and for health care reform. To some extent, this implies "patient acceptance" of the NII and related technology; however, health care provider acceptance is pivotal to adoption of telemedicine in practice. The acceptance of new technology requires many cultural and procedural changes by physicians, nurses, and allied health care workers. These changes have already occurred in health care financial activities such as billing and reimbursement and in medical research but are lagging in patient care delivery functions. Contingencies and Uncertainties The investment in and deployment of new technologies applicable to health care are partly dependent on the success of health care reform. "Many of the political imperatives driving telemedicine derive from the anticipated use of managed care incentives to provide accessible low-cost health care to all Americans."1 It is expected that the information infrastructure will be deployed because of impetus by government agencies and industries other than health care. The implementation of the NII for the delivery of health care is dependent on the cost-effectiveness of the technology as perceived by the decision makers within health care reform.

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Page 235 Other contingencies and uncertainties related to investment and deployment of the NII and its use in health care include the following: • Availability of appropriate network connections throughout the country; • Willingness by health care providers to share new technologies; • Resolution of security and privacy issues; • Cost-effective solutions to integration of legacy systems; • Resolution of telecommunications tariff issues, particularly bandwidth on demand; • Adoption of a uniform claims data set; • Acceptance by physicians of "compressed" data, especially in medical imaging; and • Completion of the comprehensive computer-based patient record. Key Applications, Enabling Technologies, and Capabilities Several recent technological developments make it possible for health care to take advantage of many of the capabilities offered by the NII. The following are among the more important developments available to health care providers: • A range of workstations accommodates the spectrum of needs of health care providers, particularly the high-resolution and luminance requirements of radiologists, as well as the needs of other specialists and primary care physicians. • Several standards have been developed for health care data interchange. These include the Digital Imaging Communication in Medicine (DICOM), HL7, and MEDIX P1157. However, it is necessary to identify and develop other standards that will facilitate further use of the NII by health care providers. • Preliminary results of the large-scale effort to develop a comprehensive computer-based patient record are available, and there is momentum to complete the task. • Various technical approaches have made "electronic signature" available. However, some legal questions remain to be answered before broad acceptance can be achieved. • Recent advances in "speech recognition" technology are most important to health care provider input to medical records. This is especially applicable to medical imaging, where interpretation of examinations is basic to the specialty. • The use of compression algorithms to decrease data volume has proved cost-effective and reduces transmission time. However, there is concern about the loss of pertinent information when "destructive" compression is applied. This is especially true of medical images, where radiologists require all of the original data for detecting subtle abnormalities. Classes of Users In health care, there are several types of users to be considered when access to the NII is planned. Among those users who are relatively easy to accommodate and who may adapt quickly to the new technology are the following: • Computer-literate health care providers, researchers, educators, and students in academic settings; • Computer-literate health care providers and other personnel in managed care settings; and • Government and insurance agencies concerned with reimbursement. There are also a large number of potential health care users of the NII that will require substantial training and education, as well as appropriate hardware and software to be capable of using the infrastructure:

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Page 236 • Older health care providers in small groups and solo practices, and • Health care providers in remote locations. If the technology proves to be cost effective, the increase in managed care organizations should expedite the use of the NII for patient care, medical research and education, and health care administration. Though the primary factors relative to ramp-up expectations and determinants are outside the health care environment, government actions regarding Medicare and Medicaid will affect investments in technologies intended for health care markets. Public and Private Sector Responses Since health care is uniquely the purview of both the public and private sectors, such an application of NII technology is affected by government and industry. Acceptance by health care providers and related organizations in terms of cost-effectiveness and utility is affected by both political and economic considerations. Recommendations A comprehensive evaluation based on a realistic demonstration should be conducted to identify the factors related to the utilization of the NII by health care providers and related organizations. The evaluation should be based on stringent criteria that focus primarily on patient care issues such as quality and access, and that measure selected key parameters related to technology, economics, and legal/regulatory and social/cultural factors. The project will require the participation of industry, academia, and government in cooperation with health care providers to develop the evaluation criteria, design the study, and conduct the demonstration of cost-effective systems that will support telemedicine, medical research and education, and health care administration. It is intended that this white paper will provoke serious consideration of health care applications on the NII. Reference 1. Perednia, D.A., and A. Allen. 1995. "Telemedicine Technology and Clinical Applications," Journal of the American Medical Association 273:483–488.