Telemedicine A Guide to Assessing Telecommunications for Health Care (1996) / Chapter Skim
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7 EVALUATING THE EFFECTS OF TELEMEDICINE ON QUALITY, ACCESS AND COST
7 EVALUATING THE EFFECTS OF TELEMEDICINE ON QUALITY, ACCESS AND COST
Pages 162-193
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From page 162... ...
This chapter focuses on questions about the quality, accessibil~ty, cost, and acceptability of telemedicine services. Additional questions will, however, be relevant for some organizations, some communities, and some evaluations.
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From page 163... ...
Policymakers may, for example, be interested in the effects of telemedicine on the survival of rural health care providers and the implications of such effects for the overall economic health of rural areas, including their ability to attract or maintain business, educational, and other resources IOTA, 1991; Council on Competitiveness, 1994; GAO, 1996~. For any specific evaluation, the selection of measures and criteria will depend on the telemedicine application, the alternatives to which it is compared, the target clinical problems and populations, the setting, and similar factors.
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From page 164... ...
The human and policy issues identified in Chapters 3 and 4 likewise warrant attention so that evaluation planning casts a wide net for possible benefits and costs of an application. Some telemedicine evaluations will focus less on individual patients than on populations, including but not limited to those enrolled in managed care plans.
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From page 165... ...
. For example, a telemedicine application might target a high-risk group to test whether surveillance and early intervention could reduce hospitalization and net costs.
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From page 166... ...
In capitated environments, the worry has been that financial incentives might lead to underuse of appropriate face-to-face consultations or other services and to poorer performance in the interpersonal aspects of patient care, including good communication between clinician and patient. For purposes of this discussion and consistent with past usage in TOM reports, appropriate care is defined as care for which "the expected health benefit Lexceeds]
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From page 167... ...
In principle, several kinds of process and outcomes measures might be relevant for any specific telemedicine application. For example, in North Carolina, researchers studying an emergency medicine project involving rural emergency departments and four medical schools plan to collect process of care, utilization, and outcomes data on "patient flow, time to diagnosis, effectiveness of spe
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From page 168... ...
2~. Questions about Quality of Care and Patient Outcomes As explained above, the committee concluded that it would identify basic questions about quality of care to guide evaluators in devising questions and criteria specific to their telemedicine project, its objectives, and its context.
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Was the application associated with differences in the interpersonal aspects of care? What were the effects of the telemedicine application on immediate, intermediate, or long-term health outcomes compared to the alternativetsJ?
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From page 170... ...
(Brenner et al., 1995~. Because patient outcomes data are often difficult to obtain for longer-term outcomes and outcomes that occur outside the hospital, immediate or intermediate clinical results (e.g., physiological signs such as blood pressure or postoperative complications)
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. Adjustments for Patient Risk or Severity of IlIness Proper interpretation of patient outcomes data requires good information on patient characteristics, in particular, their health status.
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From page 172... ...
Other Quality of Care Issues AS noted elsewhere in this report, primary care physicians or nurse practitioners who participate with patients in telemedicine consultations may learn more about clinical problems that they once referred to specialists and, thereby, become more proficient at identifying and managing repeat problems on their own. Telemedicine may, in this respect, be analogous to the informal "curbside" consultation about a specific patient, a process that clinicians may value more highly than consulting a journal or undertaking formal continuing medical education.
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From page 173... ...
More generally, what kind of procedures, if any, are appropriate for training and then certifying proficiency in a particular telemedicine application? How the volume-outcome hypothesis might apply for telemedicine is largely unexplored.
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From page 174... ...
Today, telecommunications and information technologies permit greater access to health information and thereby allow patients, potential patients, and families to learn more about health problems, care options, and prevention strategies. For those without computers or even telephones, however, access to these information resources is more a promise than a reality.
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From page 175... ...
Both formal and informal conceptualizations of access imply that the evaluative focus ought to be on people's ability to get appropriate care rather than on their ability to get any service, whether appropriate or not. Although this point is easy to make, it is more difficult to translate into operational measures, in part because of disagreement about what constitutes appropriate care for specific problems and in part because of the difficulty of data collection or interpretation.
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From page 176... ...
That is, does a telemedicine application affect access only when it directly involves the patient (e.g., as does an interactive video consultation for a psychiatric problem) or does it also affect access when mediated through a clinician (e.g., as in the typical teleradiology consultation)
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From page 177... ...
What were the attitudes of attending and consulting physicians and other personnel about the · timeliness of care · burden of providing care · appropriateness of care? NOTE: Each question assumes that an analysis of results will control for or take into account severity of illness, comorbidities, demographic characteristics, and other relevant factors.
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From page 178... ...
Furthermore, information on the use of telemedicine services is not routinely available in major national databases so that it would not now be possible to link the availability of telemedicine in different areas to differences in access measures. The kinds of routine and specialized surveys and other data collection instruments used to obtain information for the databases described in the IOM report on access may, however, provide useful models for those devising measurement and data collection strategies for telemedicine projects employed by health systems that serve well-defined populations.
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From page 179... ...
These include efforts to increase competition in health services, to change methods for paying clinicians and institutions, to make patients more conscious of costs, and to identify and discourage overuse of health services. In this environment, the costs and cost-effectiveness of telemedicine applications compared to conventional health services are understandably central concerns of decisionmakers.
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From page 180... ...
other health professionals delivering care to people at a distance. Within traditional fee-forservice payment anc!
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From page 181... ...
For example, the potential economic benefits of digital radiology networks include increases in the average number of images read per radiologist per week and reductions in the number of retaken or mislaid images, the times for image location and retrieval, and the physical space required for storage (Vanden and Strauss, 1995~. Such benefits may be highly dependent on the technical characteristics and scope of an installation, for example, whether digital imaging is used on an institution-wide rather than supplemental or incremental basis or whether any major infrastructure costs are shared with other applications.
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From page 182... ...
For a telemedicine application that requires an infrastructure with sizable fixed costs that cannot be legitimately shared or assigned in part to other users, the application of these principles implies a higher per unit cost. Similarly, during the start-up period of a program, spreading costs over a small number of cases will also result in high per unit costs.
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From page 183... ...
Parts of the system might be used to support emergency medical services, radiology consults, interactive patient counseling sessions, and monitoring of patients in their homes. A1though each application may have costs specific to its use, such as certain personnel and supplies, all the applications may share other costs related to certain equipment and perhaps certain personnel and supplies.
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From page 184... ...
As noted elsewhere in this report, the longer the interval that should be tracked in an evaluation, the more difficult become the problems in collecting and properly attributing relevant data. Decision Rules for Analyzing Cost-Effectiveness Results For some patterns of cost-effectiveness results, the findings strongly suggest certain decisions.
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Was an application associated with differences in total health care costs, the cost per service, per episode of illness, or per capita? How did the costs of the application relate to the benefits of the telemedicine application compared to the alternativetsJ?
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From page 186... ...
This chapter has noted patient perceptions as a factor to be considered in evaluating quality, access, or cost-effectiveness. They are also important in their own right to the extent that successful telemedicine applications depend on patient and cli .
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From page 187... ...
In several telemedicine evaluations, patient satisfaction data appear to be the only patient-level data collected (ORHP, 1995~. The committee considers this evaluative focus far too limiting, although it agrees that evaluators should consider patient and clinicianviews.
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. Telemedicine applications potentially offer an unusual opportunity to explore patient satisfaction data in more depth.
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NOTE: Each question assumes that analysis of results will control for or take into account prior patient experiences with the health care system, severity of illness, comorbidities, demographic characteristics, and other relevant factors.
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From page 190... ...
NOTE: Each question assumes that analysis of results will control for or take into account severity of illness, comorbidities, demographic characteristics, and other relevant factors. how much time was lost to such problems.
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From page 191... ...
For example, terms like "moderate bleeding" or "persistent TABLE 7.7 Desirable Attributes of Evaluation Criteria Reliability/Reproducibility An evaluation instrument or criterion is reliable if repeated use under identical circumstances by the same or different users produces the same results. Validity An evaluation instrument or criterion is valid if it measures the properties, qualities, or characteristics it is intended to measure.
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From page 192... ...
CONCLUSION This chapter has reviewed issues in measuring and evaluating critical outcomes for telemedicine and proposed general evaluation questions in four key areas: quality, access, cost, and patient and clinician perceptions and satisfaction. Depending on the application and clinical problem, the setting and patient population, the objectives of the program, and other factors, evaluations will differ in the outcomes of greatest interest and relevance.
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From page 193... ...
EVALUATING THE EFFECTS OF TELEMEDICINE 193 alternatives. Judgments are typically based on a balancing of objectives that is contingent on a given evaluation's mix of effects on quality, access, and cost.
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