TOMORROW’S TELEMEDICINE TODAY

The Changing Face of Medical Practice

AMIA TUTORIAL

Los Angeles, CA

PRESENTERS

Julie McGowan, PhD, Professor of Knowledge Informatics and Director, Ruth Lilly Medical Library, Indiana University School of Medicine

Michael Kienzle, MD, Professor of Medicine and Associate Dean, Clinical Affairs and Biomedical Communications

TOPICS

Telemedicine Concepts/History

Telecommunications Technologies

Provider Impact and Practice Patterns

Cost and Benefit

Licensure, Legislation and Liability

Lessons Learned in Iowa

Evaluation of Telemedicine

What Lies Ahead?

TELEMEDICINE CONCEPTS AND HISTORY

TELEMEDICINE DEFINED

“...the use of electronic information and

communications technologies to provide

and support health care when distance

separates the participants...”

from: Institute of Medicine: Telemedicine: A Guide to Assessing Telecommunications in Health Care

Brief History of Telemedicine

1955 Nebraska Psychiatric Institute usedclosed-circuit TV

1964 Institute linked to hospital 112 milesaway

1967 Mass. General Hospital & Logan Int.Airport linked with 2-way audiovisualmicrowave circuit

1971 Alaska Satellite BiomedicalDemonstration Project linked 26 sitesusing NASA satellite technologies

1972 Space Technology Applied to RuralPapago Advanced Health Care: Acollaboration of NASA & PapagoIndian Reservation in Arizona

Brief History of Telemedicine (cont.)

1990s Coaxial cable and fiberoptics leadto growth and development oftelemedicine (200 + programs,world-wide)

1996 Telecommunications Act of 1996lowers rural rates –potentiallypositive impact on telemedicine

1997 Balanced Budget Act mandatesreimbursement via HCFA forMedicare patients

History of Telemedicine in Iowa

1991 Construction of Iowa CommunicationsNetwork (600+ sites now connected)

1993 Midwest Rural TelemedicineConsortium established – 38 medicalsites connected

1994 Governor signs bill to allow healthfacilities on ICN

19941996

UI receives $14 million intelemedicine awards from theNational Library of Medicine

1997 Iowa General Assembly appropriatesfunding for Medicaid TelemedicinePilot Program

1999 Iowa Telehealth Directory created

Video

Store & ForwardDesktop Videoconference

Electronic Patient Record

Digital Libraries, Databases

Internet, World Wide Web, E-mail

Intranets, Local Area Networks, Internal

Application Pyramid

DELIVERY APPROACHES

Tele-Consultation- most resembles office visit

Tele-Monitoring- most resembles visiting nurse care

Store-and-Forward- most resembles the curbside consult, radiology/pathology service

VIDEOCONSULTATIONVIDEOCONSULTATION

Home Care

HOME MONITORING

www.healthhero.com

HEALTH BUDDY®

TELERADIOLOGYTELERADIOLOGY

STORE-AND-FORWARD

STORE-AND-FORWARD

Content Provider

Physician

Nurse

Disease Management

Care Setting

Family

Home

Patient

CareLink Community

Bedside Bedside TerminalTerminal

VC UnitHome Station

Telemedicine and Telecommunications Technologies:

High End Equipment vs. Low End Equipment;

High Speed vs. Low Speed:

Optimizing Costs and Care

Telemedicine & Equipment Choice

Video Conferencing Distance Learning

Clinical Telemedicine Applications Store and Forward Provider to Patient with Provider Provider to Patient

Critical Questions

Is the image quality [resolution] high enough to make a clinical decision?

If appropriate, is the audio quality satisfactory to have an effective clinical encounter?

Is the transmission speed of the image and/or sound appropriate to the application?

Basic Hardware

Telephone Off the Shelf Analog Systems PC’s & the Web for Store and Forward Desktop Systems with Cameras and

Teleconferencing Software Room Size Systems !!! Standards !!!!!! Standards !!!

Peripheral Equipment

Digital Cameras Data Collection Devices [Glucose monitors] Sound Devices [Digital Stethoscopes] Visual Scoping Devices [Endoscopes] Radiologic Devices [Ultrasound] Wireless & Handheld

Telecommunications Formats & Issues

Asynchronous Store & Forward Time is the Variable; Image is the Constant

Synchronous Speed for viewing comfort Speed for diagnostic quality Speed vs. Cost

Synchronous Telecommunications Primer

Circuit Switch H.320 ITU Standard for formatting video & audio

Packet Switch H.323 ITU Standard for formatting video & audio

Codec Compression & Decompression of Video Image

Multi-point Control Unit [MCU] Equalization of multiple sites

Telecommunications Links and Speeds [Land-based]

POTS 20+ Kbps ISDN 128 Kbps T1 1.54 Mbps Cable Modem 1-27 Mbps [One Way] T3 44 Mbps ATM 155 Mbps Frequently mixed

Telecommunications Systems and Speeds [Wireless]

Small Footprint Satellite Dish 400 Kbps –[Low Orbiting Satellite] 6 Mbps [Asyn]

14 Kbps –

2 Mbps [Syn]

Wireless terrestrial 1-26 Mbps

[Asyn & Syn]

Minimum Application Standards

Asynchronous TelePathology High Resolution; Low Speed

TelePsychiatry Medium Resolution; Interactive video at 384

Kbps [3 ISDN lines]

Camera Placement TeleEndoscopy

High Resolution; Medium to High Speed

Other Applications

Synchronous Nursing Home Care Low Resolution; Low Speed [Audio]

Asynchronous Data Transmission – Home Health Monitoring POTS

Exercise

List one to three telemedicine applications

Choose hardware; note resolution; include peripheral equipment

Select appropriate telecommunications speed

Telemedicine: Licensure, Litigation and Legislative Mandates

OR

How do I keep from being sued?

JCAHO: Telemedicine Credentialing Standards

“If a telemedicine practitioner prescribes, renders a diagnosis, or otherwise provides clinical treatment to a patient, the telemedicine practitioner is credentialed and privileged*by the organization receiving the telemedicine service.

JCAHO: Telemedicine Credentialing Standards, cont.

An organization may use credentialing information from another Joint Commission accredited facility, so long as the decision to delineate privileges is made at the facility that is receiving the telemedicine service.”

Effective 1 Jan 2001

AMA: Telemedicine Goals

To evaluate relevant federal legislation To urge HCFA to fund demonstration projects To urge specialty societies to develop practice

guidelines To encourage CPT to develop or modify codes To provide appropriate CME credit To work with FSMB for cross-state licensure

Licensure Issues

States want to protect their health care providers In addition to state licensure for those areas served

by telemedicine, a growing number of states require telemedicine licensure

Telemedicine may fall under the Commerce Clause of the Constitution which prohibits states from erecting barriers against interstate trade.

No litigation to date!

Licensure Solutions

Consulting without an implied contract State agreements

Endorsement [2/3 of states] Registration [time] or limited licensure [scope] State Compacts

Federal Licensure Exemptions for image and data transfer

Malpractice Issues

Where does consultation take place and is relationship between physician & patient or physician to physician in the consultation?

Who is liable – referring or consulting physician?

Which site determines standards of care?

What about technology?

Malpractice Solutions

As a consulting provider, refuse payment ? JCAHO defines telemedicine consultation as

taking place at the referring institution [standards of care]

Define risk before beginning / insurance Failure to use technology is also a risk What about manufacturer’s liability?

Where to we go from here?

Legislation may help to define the environment

Litigation will determine the nuances of telemedicine practice

Physicians and other health care providers must be proactive to shape policy

Group Exercise

If you use a laptop to consult over the web, where does the telemedicine consult take place?

If you are mentoring a tele-endoscopy procedure who is liable if the connection is lost and the bowel perforates?

PROVIDER PRACTICE

CHALLENGES OF RURAL PRACTICE SETTING

Complex population of patients

Health delivery system under stress

Supporting programs lacking

Rural practitioners isolated

RATIONALE FOR TELEMEDICINE

Access to care Enhanced efficiency of

care provision Shorten time to

treatment Enhance professional

communication Cost savings

ELEMENTS OF ACCESS

Geography/Distance Availability of Health Facilities Complexity of Illness Transportation System Social/Cultural Norms Income Health Insurance

12-11-98

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Osceola

O'Brien Clay

Emmet

Palo Alto

Kossuth

Winne-bago

Hancock

Worth

CerroGordo

Mitchell Howard

Chickasaw

Fayette

Allamakee

Clayton

PlymouthCherokee

BuenaVista

Pocahontas

Woodbury Ida Calhoun

Crawford

Wright

Webster Hamilton

Butler

Bremer

Buchanan

BentonTama

Black HawkGrundy

Clinton

ScottCedar

Johnson

Muscatine

Louisa

Des Moines

Henry

Van Buren

Jefferson

Washington

Davis

Wapello

Keokuk

IowaPoweshiek

Mahaska

Appanoose

Monroe

Marion

MarshallStory

Wayne

Linn

Sac

Sioux

Polk

Lyon

Adair

Jasper

Mills

Floyd

Hardin

Carroll

Jackson

Union Lucas

Dubuque

LeeDecaturRinggold

WarrenMadison

Clarke

Taylor

Adams

Cass

AudubonDallasGuthrie

Jones

BooneGreene

Delaware

FranklinHumboldt

Page

Montgomery

Pottawattamie

Shelby

Dickinson

Fremont

Harrison

Monona

Winneshiek

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DesignationGovernor's HPSAFederal MUAFederal HPSAGovernor's HPSA & Federal MUAGovernor's HPSA & Federal HPSAFederal HPSA/MUAGovernor's HPSA/Federal HPSA/MUANo Designation

ÊÚ 130 Rural Health Clinics 9-98

Iowa Shortage Areas & Rural Health ClinicsHealth Professional Shortage Areas (HPSA) & Medically Underserved Areas (MUA)

Source:Iowa Department of Public HealthBureau of Rural Health and Primary Care

Contact:Carl Kulczyk(515) 281-7223ckulczyk@idph.state.ia.us

Note: Locations of RHCs are approximated by Zip Code.

TELEHEALTH SITES, 1999

10-14--98

Osceola

O'Brien Clay

Emmet

Palo Alto

Kossuth

Winne-bago

Hancock

Worth

CerroGordo

Mitchell Howard

Chickasaw

Fayette

Allamakee

Clayton

PlymouthCherokee

BuenaVista

Pocahontas

Woodbury Ida Calhoun

Crawford

Wright

Webster Hamilton

Butler

Bremer

Buchanan

BentonTama

Black Hawk

Grundy

Clinton

ScottCedarJohnson

Muscatine

Louisa

Des Moines

Henry

Van Buren

Jefferson

Washington

Davis

Wapello

Keokuk

IowaPoweshiek

Mahaska

Appanoose

Monroe

Marion

MarshallStory

Wayne

Linn

Sac

Sioux

Polk

Lyon

Adair

Jasper

Mills

Floyd

Hardin

Carroll

Jackson

Union Lucas

Dubuque

LeeDecaturRinggold

WarrenMadison

Clarke

Taylor

Adams

Cass

AudubonDallasGuthrie

Jones

BooneGreene

Delaware

FranklinHumboldt

Page

Montgomery

Pottawattamie

Shelby

Dickinson

Fremont

Harrison

Monona

Winneshiek

Designation

Federal HPSA

Federal Health Professional Shortage Areas

Contact:Carl Kulczyk(515) 281-7223ckulczyk@idph.state.ia.us

Primary Care HPSA

Source:Iowa Department of Public HealthBureau of Rural Health and Primary Care

SPECIALTY CARE IN RURAL IOWA

Access to many specialties limited

Over 2 decades of providing care through visiting consultant clinics

Care limited by frequency of visits

TELECARDIOLOGY LOGIC

Time and distance play a key role in patient outcomes (e.g.,acute MI, ventricular arrhythmias).

Much of the key information needed for patient evaluation is historical and visual.

In some settings, cardiovascular specialists must travel to remote clinics.

Managed care is changing referral relationships.

IOWA CARDIOLOGY VCC, 1989-1994

0

50

100

150

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250

300

1989 1994 % change

#Towns#Arrange>1 VCCDays (x10)

Wakefield, Tracy, Kienzle, Fieselmann

VCC SHORTCOMINGS

Travel time for consultant may be considerable

Weather is a big factor Inherent inefficiency of

VCC may alter diagnostic and therapeutic approach

Clinics (by themselves) rarely financially sound; case finding and “down-stream” revenue provide rationale

Intermittent nature limits ability to provide more urgent levels of care

PEDIATRIC ECHO NET

Courier170 mi

Courier25 mi

DS3Line

ISDNLine

Time toReport(minutes)

2700 1200 720 190

THE COST PERSPECTIVES

SHORT-TERM

LONG-TERM

DOCTOR Up Neutral/Down

HOSPITAL Up Up/Neutral

PAYER Neutral/Up Neutral/Up

PATIENT Down Down

PRISON TELEMEDICINE

BARRIERS TO SUCCESS

Human Factors- local politics, relationships

Cost- capitalization, operations, sustainability

Technical- network design/management

Interoperability- silos

Reimbursement- will improve eventually

Licensure- opportunity and threat

Liability- unique vulnerabilities

Evaluation- difficult to control study variables

CONSULTATIONS 1997-99

DISTRIBUTION

VISIT TYPE

Frequency of New vs. Return Clinic Visits

44%

56%

New

Return

DIAGNOSES

COMPLEXITY

CONSULTATION RESULTS

Follow-up Actions by Category

Frequency Action Category

198 Diagnostic Procedure(s) Ordered

109 Lab(s) Ordered

288 Continued/Unchanged Medication

118 New Medication Ordered

59 Medication Change/Stoppage

175 Other Therapy Ordered

41 Surgical Procedure(s) Ordered

26 Non-Surgical Therapy Ordered

265 Return to UIHC Specialty Clinic

133 Return to Telemedicine

138 Return PRN

12 Schedule for Hospitalization

PROVIDER SATISFACTION

0 1 2 3 4 5

Video Useful for diagnosis?

Video Useful for Treatment Plan?

Medical Problem Appropriate for Video?

Quality of Transmission Adequate?

Consult Met Standards of Adequate Care?

Satisfied with Consultation?

Consultant Average

Referral Average

SPECIALTY SATISFACTION

0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5

Surgery

Orthopedics

GMed

GU

GI

Dermatology

Cardiology

Consultant

Referral

Telemedicine Cost Models for ROI

Will Telemedicine Make You Rich? Reality Check - Reimbursement Update

Categories of Support

Cost of Doing Business Managed Care Cost-shift Third Party Payers

Mode of health care delivery vs. procedure Image transmission

HCFA Guidelines for Reimbursement 1997 Balanced Budget Act [4/1/99]

Medicare

Only Interactive Consultations Only in Rural HPSA’s

Patient Residency or Site of Consultation

Reimbursed at 75% of live consult 25% of amount must go to referring provider

Referring providers can only be: MDs, NPs, PAs, MSN Clinical Nurse Specialists, Nurse Anesthetists, Nurse

Mid-Wives, Social Workers, Clinical Psychologists. NOT Nurses & Other Allied Health Staff

Medicaid

States may reimburse for telemedicine based on scope and coverage determinants

Issues include: Types and quality of equipment Types of reimbursable services Location of eligible providers

Proposed Legislation

Senators Jeffords (R-VT) & Bliley (R-VA) Eliminates the fee split requirements New $20 facility fee for institutions

providing service Expansion of CPT fee codes Eligibility to include both rural HPSAs &

non urban Metropolitan Statistical Areas

Proposed Legislation also includes:

Clarification on how home care agencies can use tele-home care in fulfilling requirements under Medicare’s home health program!

4 Ways to Look at $$$

Managed Care Environment

Multi-Payer Environment

Alternative Savings [Training, Patients]

Cost-Plus in Captive Patient Populations

Calculating ROI:Prospective Model in Managed Care

Telemedicine and Managed Care Principles

It is less expensive to perform procedures at referral sites when appropriate.

Repetitive procedures should be avoided. Patient-centered care requires use of

telemedicine when appropriate because of quality of life issues.

Telemedicine mitigates cost of specialist travel and missed appointments.

Tele-Endoscopy Cost Study

Six Months Chart Review of Endoscopic Procedures in FAHC

Determination of Preferable Locus of Procedures in Fully Capitated Market Appropriately referred to FAHC Initially done at FAHC; Could be done at local

site Unnecessary repetition of procedure at FAHC

Tele-Endoscopy Study Design Cont.

Determination of Cost of Procedure FAHC (tertiary medical center) Rural site (PC office or local hospital)

Cost of Telecommunications Amortization of Equipment Endoscopist Time

Mentoring time Savings on travel time; Missed appointment

Formula for Projected Savings For Tele-Endoscopy

Actual Current Endoscopy Costs Less: Cost savings from procedures done locally Cost savings from procedures not repeated Cost savings of endoscopy specialist time

Travel Missed appointments

Add Costs of Telemedicine - Equipment; Line Charges; Endoscopist time

Tele-EndoscopySix Months Projected Savings

$27,381 savings on locally done procedures $44,438 savings on single procedures $5,563 savings on travel & missed appts. $9,930 costs of telecommunications $4,775 costs of equipment amortization $9,625 costs of endoscopist time 6 mos. Projected savings of $68,962

Calculating ROI: Retrospective Model with Multi-Payers

Telemedicine and Multi (3rd Party) Payer Principles

Few procedures are covered for reimbursement. Follow-up visits included in single payment

surgical procedures can frequently be done as efficiently and effectively using telemedicine.

Patient-centered care requires use of telemedicine when appropriate because of quality of life issues.

Telemedicine and Multi (3rd Party) Payer Cost Study Assumptions

Patient Savings (travel, child care, lost work time) not accounted for in model

Costs such as mileage and indirect costs not included in analyses

Savings not equivalent to revenue generated

Vascular Surgery Cost Study: Telemedicine Costs

System Cost $11,000 each Monthly ISDN (VT) $375 per site Monthly ISDN (NY) $ 90 per site Tel-Comm Charges ~$50 per hour Tech Support ~$35,000 per year Provider Time $50-150 per hour Outreach Travel Time~1-4 hours

Vascular SurgeryTelemedicine Findings

26 months 107 Telemedicine Uses

Educational Conferences…… 4 ( 3.7%) Clinical Uses…………………. 103 (96.3%)

8 External Sites (4 NY/4 VT), 1 FAHC Site 14.2% of All Telemedicine System Uses 30.6% of All Clinical Uses

Vascular SurgeryTelemedicine Clinical Use

Vascular Access F/U 45 (42.1%)Follow-Up Visits 42 (39.3%)X-Ray Review 10 ( 9.3%)Consults 3 ( 2.8%)Emergency Evaluation 2 ( 1.9%)Real-time Surgery 1 ( 0.9%)

Vascular Surgery26 Months Cost Analysis

Expenses 103 clinical uses of telemedicine (14% of total) $33,976 (telecommunications, equipment, etc.)

Savings 87 clinical visits; 3 consultations $35,413 (personnel costs)

Vascular SurgeryTelemedicine Summary

Savings accrue primarily as a result of decreased need for physician travel.

“Break-even” for vascular surgery use of telemedicine at ~ 2 years.

Surgical follow-ups do not generate additional revenue, thus savings may be more appropriate evaluation tool.

Calculating ROI: Alternative Savings

Telemedicine and Alternative Savings Principles

Patient-centered care requires use of telemedicine when appropriate because of quality of life issues.

Patient costs need to be calculated into the ROI equation.

Alternative uses of telemedicine equipment can reduce overall system costs.

Tele-Dialysis Cost Study:Environmental Overview

2 external dialysis units, 1 FAHC site 9 uses in a one-month audit period

Educational / Administrative… 4 Technical Troubleshooting… 3 Clinical Uses… 2

16% of all telemedicine systems uses Telemedicine baseline costs are constant.

TeleDialysis Cost Study: Telemedicine Costs

System Cost $11,000 each Monthly ISDN (VT) $375 per site Tel-Comm Charges ~$50 per hour Tech Support ~$35,000 per

year Provider Time $50-150 per hour Outreach Travel Time~1-2.5 hours

Tele-Dialysis Projections

3 external dialysis units in rural areas Extrapolated use to one-year period

Educational / Administrative… 72 Technical Troubleshooting… 54 Clinical Uses… 36

Without telemedicine system, each of the above would require in-person visits to each of three sites.

Tele-Dialysis12 Month Cost Analysis

Expenses 162 uses of telemedicine (16% of total) $38,020 (telecommunications, equipment,

etc.)

Savings $34,200 (personnel costs)

Tele-DialysisPatient Savings

External dialysis units save patient travel 3 times weekly.

Savings in gas ($1.15 per gallon) is $182.85 per week or $9,508 per year.

Additional savings for patients accrued in lower food costs, less loss of work time.

Tele-DialysisTelemedicine Summary

Projected “break-even” point for tele-dialysis with three external dialysis units is ~ 14 months.

Dialysis care is capitated by Medicare so revenues are not generated by in-person visits or lost by telemedicine use.

Telemedicine time and travel savings allow more efficient delivery of care.

Tele-DialysisTelemedicine Summary Cont.

Provider training and support costs can be minimized through telemedicine use.

In chronic disease, quality of life issues, including cost savings to patients, must be weighed against actual cost of telemedicine use.

Calculating ROI:Captive Patient Populations

Prisons Nursing Homes Emergency Rooms

Military

Prison Telemedicine

Captive patient population Contracts negotiated on:

Personnel, Out-of-pocket, and Amortized costs Quality of program Reasonableness of offering based on needs of

contracting institution Ability to garner “extra” benefits for both

offering agency and contractors.

Nursing Home Telemedicine

On-demand patient population support Contracts negotiated on:

Personnel, Out-of-pocket, and Amortized costsOften minimal staffing, technology requirements

Quality of program – value-added Reasonableness of offering based on needs of

both offering and contracting institutions

Emergency Room Telemedicine

On-demand, captive patient patient Contracts negotiated on:

Personnel, Out-of-pocket, and Amortized costs Offering based on linking emergency rooms

specialists to off-site patients Ability to garner “extra” benefits for EMS

Offer emergency critical care Stabilize patients prior to / during transport

Military Telemedicine

Captive patient population Refer to Prison Telemedicine No Contracts – Federally funded and

directed [pushing frontiers – in space, under oceans, on battlefield]

Same basic precepts – provide remote patients with highest quality medical care

The Future?

A Prediction:

Telemedicine will become a ubiquitous technology to improve care and quality of life. Because telemedicine will be viewed as a tool to enhance patient care, all care provided using telemedicine will be fully reimbursable.

??? QUESTIONS ???

IOWA EXPERIENCE

UI TELEMEDICINE PROGRAMS

Federal Contracts

Correctional Facilities

Home Health Care

Continuing Medical Education

TELEHEALTH SITES, 2000

National Laboratory for the Study of Rural Telemedicine

16 hospitals 10 programs Telecommunications infrastructure Telemedicine Resource Center April, 1994 - March, 2000 Over $14 million to date

APPLICATIONS DEVELOPED

Virtual Hospital® Virtual Library Radiology Consult 3-D Chest CT Trauma Consult

Disability Consult Psychiatry Consult Peds Echo Network MI/CVA Consult Home Diabetes

Education

TELEMEDICINE RESOURCE CENTER

Administration/Coordination

Equipment Purchases

End-User Training

Data Collection

Reports, Documentation

Information & Referral

Troubleshooting

Grant Writing

SUPPORT TOOLS

800 Number System-Wide email Administrative

Videoconferences On-Site and Virtual

Support/Training Special Events Media Support

DEPARTMENT OF CORRECTIONS

•Highest volume of service nationally

•All 9 Iowa Prisons now Connected

•540 UI teleconsults Mar. 1997-Feb, 99

•1,768 outpatient telepsychiatry consultations FY ‘99

HOME CARE

resourceLink™ of Iowa

University of University of Iowa Iowa

Health SystemHealth System

HELP HELP Innovations, Innovations,

Inc.Inc.

Joint-VentureJoint-Venture

of Iowaof Iowa

ADMISSIONS TO RLI

0

510

1520

2530

3540

4550

1997 1998 1999 (Oct)

Patients

SAVINGS COMPONENTS

Home Care 62%

Length of Stay17%

Readmissions17%

Emergency Room4%

INITIAL EXPERIENCE: UTILIZATION

0

50

100

150

200

250

300

350

400

450

ER visits Hospital Days ECF Days MD Visits Total

Type of Encounter

Nu

mb

er

of

Enco

un

ters

Before

After

INITIAL EXPERIENCE: COST

Total cost of Care

283,200

126,400

0

50,000

100,000

150,000

200,000

250,000

300,000

Before After

Telemedicine and Report Cards:

Evaluation to Promote and Support

Telemedicine Initiatives

WHY PROGRESS TO TELEMEDICNE?

[or if it works fine now…]

The Rationale

Just-in-time Care Improved Quality Enhanced Efficiency Better Professional Communication Patient Satisfaction Enlarged Catchment Area Cost Savings?

Culture – Medical &

Re-engineering practice Crossing referral lines Comfort with and understanding of Technology as

a Tool

“REPORT CARD” OFTELEMEDICNE EFFECTIVENESS

Report Card andThe Educational Model

Define Desired Outcomes Quality Improvement Reduced Costs Referring Provider Satisfaction Patient Satisfaction

Develop Evaluation to Assess Desired Outcomes

Report Card andThe Educational Model

Disseminate Findings Select appropriate recipients Combine findings with marketing strategy

Be Willing to Modify Program as Necessary

Re-Evaluate Frequently

EVALUATING TELEMEDICINE

Need for Evaluation

Administrative Justification Sociological

Consulting and Referring Providers Patients

Political Public - CON Competitive Health Care Marketplace

Types of Evaluation

Technology

Provider and Patient Satisfaction

Economic Issues

Technology

Image vs. Use Store and Forward Human Interaction

Patient / Provider ConsultationPsychiatry; Orthopedics

Image QualityColor ReliabilityMovement Artifacts

Technology

Reliability of Technology Connections

Ease and Reliability of ContactInterface Standards

Peripheral EquipmentQuality – Digital vs. DigitizedTransmission Protocols

Provider Satisfaction

Referring Providers – assess: Comfort level with technology Comfort level with process Comfort level with patient communication Comfort level with consulting provider

interaction Unanticipated Benefits Unanticipated Problems

Provider Satisfaction

Consulting Providers – assess: Comfort level with technology Comfort level with process Comfort level with patient communication? Comfort level with referring provider interaction Unanticipated Benefits Unanticipated Problems

Patient Satisfaction

Patients Follow ImagesThe Value EquationHome is Where…

Comfort issues Environmental issues Economic issues

Economic Analysis of Telemedicine

4 Ways to Look at $$$

Managed Care Environment

Multi-Payer Environment

Alternative Savings [Training, Patients]

Cost-Plus in Captive Patient Populations

??? QUESTIONS ???

FUTURE DIRECTIONS

TELEMEDICINE TRENDS

Migration to Internet Focus on home as site of care Development of biosensors and elimination

of role of physical location

How are you most likely to use the Internet for health concerns?

62.1% Research an illness or disease62.1% Research an illness or disease 20.0% Look for nutrition and fitness information20.0% Look for nutrition and fitness information11.6% Research drugs and drug interactions11.6% Research drugs and drug interactions3.7% Look for a doctor or hospital3.7% Look for a doctor or hospital2.3% Look for online medical support groups2.3% Look for online medical support groups

July 10, 1998

RATING HEALTH SUPPORT

0

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60

70

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90

Attributes

Pe

rce

nt

Po

sit

ive

Re

sp

on

se

On-Line

Specialist

Primary Care

The Ferguson Report, Jan/Feb 1999

INTERNET HEALTH

Health Information Administrative & Financial

EDI Medical E-Mail Online Health Records Pharmaceutical & Supply

Sales Online CME & Training

Source: Industry Standard

WHAT ABOUT MY MOTHER?

Afraid of unfamiliar technologyAfraid of unfamiliar technology Doesn’t type wellDoesn’t type well Limited budgetLimited budget No technical support availableNo technical support available Understands appliances Understands appliances (single purpose device)(single purpose device)

WEB TV

INTERNET APPLIANCE

GRAY HAIR AND BLUETOOTH

WHY THE HOME?

Health system trends Target of multiple

industries Fundamental change in

patient-provider relationship

Natural development of bandwidth, wireless technology

HOW WILL PROVIDERS USE THE INTERNET?

Information Online Continuing Education Electronic Claims Submission Purchasing Prescribing Communicating with Patients

Source: Industry Standard

Source: Industry Standard

DEAR DOCTOR…

Medical electronic mail will be the transforming application

Critical mass will change physician practice

Striking impact on reimbursement model

THINKING BIG

Determine user requirements

Design prototype from known components

Test prototype at community level

Business planning and wide-scale roll-out

YOU CAN TAKE IT WITH YOU

Wireless technologies GPS Micro-computers Nanotechnology Bio-sensors Convergence will mean

a health system that is always on

TELEMEDICINE ON THE WEB

http://telemed.medicine.uiowa.edu/ (UI TRC) http://tie.telemed.org/ (Telemedicine Information

Exchange) http://www.nlm.nih.gov/research/telemedinit.html (NLM

National Telemedicine Initiative) http://www.tmgateway.org/ (Federal Telemedicine

Gateway) http://www.atsp.org/charter/charter.htm (ATSP) http://www.atmeda.org (ATA) ftp://nlmpubs.nlm.nih.gov/bibs/cbm/telembib.txt (Biblio)

SLIDES AVAILABLE

http://telemed.medicine.uiowa.edu