Telemedicine in Hospitals

Issues in Implementation

Sherry Emery

• Publisher: Routledge
• Year: 2015
• Print ISBN: 9780815332237
• eBook ISBN: 9781317733188
• Edition: 1
• Topic: Politics & International Relations
• Subtopic: Politics
• Index: Politics & International Relations

This book looks at the history and development of telemedicine and its effect on the medical profession. It includes advances in telecommunications and medical technologies that greatly have increased the reliability, resolution, and speed of transmitting medical images, changes that are have been affected by changes in the national and global economies and the support to rural hospitals during the 1990s.

CHAPTER 1

Introduction

telemedicine \tel-I-med-.-s.n\ n: technologies that allow for medical consultation between health care providers in geographically separate locations, ranging from telephone consultations to interactive video sessions using state-of-the-art technologies.

In 1968, Dr. Kenneth D. Bird solved a problem for Massachusetts General Hospital. The hospital had been responsible for staffing the medical station at Boston’s Logan International Airport. Emergencies demanded an immediate, highly skilled response even though the expertise of a physician was rarely required. Therefore, during most of the staffed time at the medical station, the physician’s time and labor were underutilized—a significant expense to the hospital and airport. In response to this problem, Dr. Bird developed a system for remote transmission of voice and images. Using this system, doctors working remotely from Massachusetts General Hospital performed physical examinations, made diagnoses, and even delivered limited treatments to ailing travelers using the airport’s medical station (New York Times, February 16, 1991).

Dr. Bird was not the first innovator of telemedicine, but in the 1960s and early 1970s, his project was among the few that used microwave television technologies to transmit medical images and educational materials. For rural areas, these new telemedicine technologies promised to change how health care and medical education were accessed and delivered. Some of the pioneering telemedicine projects were very successful in achieving such promises. Yet, in its early applications, telemedicine failed to diffuse widely or to change health care dramatically. Now, more than 25 years later, the original telemedicine innovations are being transformed by advances in medical and telecommunications technologies. Once again, telemedicine holds promise as a partial solution to the health care crisis in many urban centers and rural areas of the United States.

Telemedicine, literally medicine across distance, has captured the attention of legislators, policy makers, scholars, and practitioners in the fields of health services, rural development, and telecommunications. Telemedicine combines two dynamic policy areas, health care and telecommunications, using emerging technologies to create imaginative solutions to previously intractable problems. The application of these technologies potentially improves access to health care in underserved areas and, by doing so, enhances prospects for economic development in these underserved communities. The combination of health care and telecommunications has potential that even the most jaded policy maker could not overlook. In fact, several states, including North Carolina, have cited telemedicine as a partial justification for public investment in telecommunications infrastructure, or “the information superhighway.” (Raleigh News & Observer, May 11, 1993).

The increase in active telemedicine projects in the United States is evidence of its potential. In 1993, fewer than 30 active telemedicine programs existed nationally (Wyman 1994). By 1996, over 40 telemedicine linkages existed in North Carolina alone. Despite the phenomenal growth rate and the high visibility of telemedicine in the popular press and in the national policy arena, acceptance and financing of these technologies are uncertain. Doubt remains as to whether telemedicine will become an important component of health care at the turn of the millennium and whether telemedicine can fulfill the expectations that these technologies inspire.

What is different in the 1990s that would make telemedicine a more viable medical technology than it was in earlier decades? First, advances in telecommunications and medical technologies have increased the reliability, resolution, and speed of transmitting medical images between remote locations. Thus, telemedicine is simply more medically useful. Second, these same advances in telecommunications technologies are part of, and have fostered, changes in the national and global economies. Telecommunication technologies have intensified competition in many industries, including health care, by diminishing geographical barriers to competition. In concert with information systems, telecommunications has become a tool used by managed care corporations and hospital networks to establish competitive advantage (Coopers and Lybrand 1994, Neuberger 1995). As smaller, rural hospitals depend increasingly on telecommunications for survival (Size 1995), it is not difficult to imagine how telemedicine could become a component of these competitive strategies (Neuberger 1995).

Another difference in the 1990s that adds viability to telemedicine technology is the imperative to bolster rural hospitals, both financially and medically. During the 1980s, rural hospitals suffered because of sweeping changes in payment systems, a declining patient base due to rural out-migration, and declining inpatient utilization (Halpern et al. 1992, OTA 1990). State and federal policy makers, as well as some rural hospital administrators and larger hospital networks, see telemedicine as one way to increase rural access to health care, to augment the range of medical specialties available in rural areas, and to retain patients in rural hospitals safely.

The combination of dramatically improved medical efficacy, a changing health care marketplace, and a growing crisis in rural health care makes a compelling case for the resurgence of telemedicine in the 1990s. Two central questions emerge: (1) Does telemedicine improve rural health care delivery? and (2) Does telemedicine play a role in transforming the economic organization of the health care industry? These questions, in turn, prompt many subsidiary questions: What types of social and economic benefits does telemedicine offer? Who benefits from telemedicine technologies—hospitals, health care corporations, or communities? How do we account for or measure these benefits? How are benefits distributed and are costs and benefits balanced? What is the appropriate level of government involvement in promoting telemedicine adoption and its continued use?

Because we are only in the early stages of this new round of telemedicine diffusion, providing definitive answers to these questions is like shooting at a moving target. Published information that would answer these questions exists in anecdotal form, at best, and consists largely of logical deductions. As one researcher aptly explains, “The problem with telemedicine is that there is very little good information about it.” (Perednia, quoted in Scott 1994).

In order to obtain the necessary information to address these issues, a mail survey was conducted of all general hospitals in North Carolina, South Carolina, and Georgia to explore (1) whether and when they adopted telemedicine, (2) the clinical purposes for using telemedicine technologies, (3) the business purposes for adopting these technologies, (4) how much money is invested in these technologies and the sources from which these funds originated, (5) the perceived barriers to adopting telemedicine, and (6) their level of experience with other information technologies. In order to create a working data base, the results from this mail survey were combined with data obtained from the American Hospital Association (AHA) Guide to Hospitals in the U.S. and the Area Resource Files (ARF). In addition, hospital administrators in the region were interviewed by telephone to obtain a richer understanding of individual telemedicine projects, general attitudes toward and beliefs about telemedicine, and the relationship between managed care and telemedicine.

With this information, a model of the diffusion of telemedicine was constructed. The theoretical underpinnings of the model represent a synthesis of sociology, management, and economic theories. The modeling begins with the assumption that adopting telemedicine is a result of combined, observable hospital and market characteristics. The functional relationship used in this research is as follows:

Probability of adopting telemedicine = f (hospital location, teaching status, size, ownership, affiliations, technological sophistication, competition from other hospitals, HMO penetration, and local population and per capita incomes).

The probability of adopting telemedicine is a function of hospital and market characteristics. By establishing the relationships between these characteristics and adoption, we are able to make inferences about the types of benefits telemedicine technologies offer and the strategic role of telemedicine technologies in a hospital’s mission.

The research in this study represents a critical first step in understanding the many and complex policy questions that have emerged in the 1990s, the second round of telemedicine development. Using diffusion modeling techniques, this study describes and explains adoption of telemedicine technologies by hospitals in three states in the southeastern United States. The diffusion model used in this research makes it possible to predict what types of hospitals will adopt telemedicine and to relate that information to the types of benefits telemedicine confers and to whom. By examining the economic and policy context in which telemedicine is diffusing in this region, along with the characteristics of the hospitals adopting telemedicine, this research provides the foundation for understanding the role of telemedicine in the changing health care marketplace. This research is a snapshot of a dynamic process, providing feedback for current policy initiatives about the types of hospitals adopting telemedicine, their location, their experience with other information technologies, and their current status in the evolving market.

The findings from this study have important policy implications. Telemedicine holds great promise for improving the financial viability and quality of health care of rural hospitals; however, this research shows that rural areas are not realizing these benefits. Despite federal and state programs aimed at improving rural health through the use of telemedicine, rural hospitals are not adopting these technologies at the rate of their urban counterparts. At the same time, urban hospitals are finding ways to use telemedicine as a powerful marketing tool. Urban hospitals are also envisioning ways in which telemedicine will reduce hospital costs in a managed care environment by enhancing patient management and resource utilization. These findings suggest unrealized potential for public benefit from telemedicine and uncover substantial private—or internalizable—benefits from these technologies as well.

Such results imply a mismatch between the objectives of federal and state policies and the adoption and use of telemedicine technologies by hospitals. By identifying this incongruity, this research will help policy makers target their efforts to encourage telemedicine where it is most needed, to take advantage of market forces, and to evaluate the efficacy and necessity of current efforts. Furthermore, this research provides some of the first empirical data about telemedicine, forming the building blocks for future research in the field. This work also represents the first exploration into the relationship between telemedicine and managed care.

The remainder of this study is divided into seven chapters. By describing advances in telecommunications and telemedicine technologies and describing the federal and state policies directed to promoting telemedicine, chapter 2 provides the background of telemedicine in the 1990s. Chapter 2 also explains the major public policy issues surrounding the extensive government involvement in telemedicine development. Finally, it explores the complexities of the financial management of telemedicine in North Carolina. Chapter 3 provides a review of the relevant theoretical literature on technology diffusion, including sociological and economic approaches. Chapter 4 lays out the conceptual framework for the empirical research, including research hypotheses, modeling issues, specification of functional form, and operationalizing the diffusion model. Chapter 5 details the research design and methods, describing the survey and interviewing techniques. Chapter 6 presents the descriptive statistics, characterizing the data and the research setting. Chapter 7 analyzes the data, using the diffusion modeling techniques described in Chapter 4. Finally, Chapter 8 summarizes the research and identifies policy implications.

CHAPTER 2

Background and Foundation of Research

Telemedicine captures the imagination. These technologies suggest possibilities that justify state and federal policies for both the telecommunications and health care arenas. This seemingly simple connection of technology to policy initiatives raises some very complex economic and public policy issues. In this chapter, the technologies and range of telemedicine are described. The chapter identifies the federal and state programs that promote telemedicine and explains the public policy questions that telemedicine raises. This chapter discusses the difficulties of answering directly with quantitative data the public policy questions concerning the cost effects of telemedicine. To illustrate this point, this chapter describes three examples of prototypical telemedicine projects and suggests that diffusion modeling can begin to address these complex public policy issues.

2.1 Telemedicine: The range of possibilities

Telemedicine technologies represent a broad range of ideas and technological applications. Telemedicine can include relatively low-technology applications that are almost universally available. Some examples of low-technology applications include telephone calls or electronic-mail exchanges between medical practitioners in separate locations, facsimile transmission of fetal monitor outputs or electrocardiogram (EKG) printouts (Yamamoto and Wiebe 1989), and two-way radio transmission of medical information. More often, telemedicine describes the transmission of medical images between remote sites. In the case of teleradiology, telepathology, or teledermatology, telemedicine involves transmitting still-images between consulting physicians in distant locations: sending X rays, computerized tomography (CT) images, magnetic resonance images (MRIs), images of pathology slides, or digitized pictures of dermatological conditions. Other applications include using peripheral devices, such as electronic stethoscopes, otoscopes, or ophthalmoscopes, which are attached to audio and/or visual media for transmitting medical information between locations. In many cases, telemedicine refers to some combination of these applications. Using full-motion interactive video conferences, medical practitioners are conducting nearly every type of medical consultation that would take place in-person, including telepsychiatry (Preston, Brown, and Hartley 1992), neurology, rehabilitation, emergency medicine, as well as medical education. The most exciting, albeit currently least practical, telemedicine technologies use virtual reality and robotics technologies to enable surgeons to operate remotely (Satava 1993, 1995). The Department of Defense has developed technologies that allow surgeons, who are safely ensconced away from the battlefield, to operate on soldiers near the front lines of battle.

The key element, which is often the limiting factor in many rural areas (Puskin 1992, McCaughan 1995), to each of these applications is the conduit over which the medical information travels. Advances in communications technologies have brought about dramatic progress in the types of telemedicine consultations that are possible, making the technology more feasible and affordable. Narrowband media, such as the twisted-pair copper wires that still extend to many homes and businesses, are capable of carrying many types of telemedical information; however, the constraint of this technology is the length of time required to transmit information over a narrowband conduit. In the age of digitization, all information—from printed documents to voice messages to video images—can be represented as binary code, a string of zeros and ones. A facsimile image or voice message represents a substantially smaller quantity of information than contained in an X-ray or moving picture. Advanced communications technologies, such as broadband media (fiber optics, coaxial cable, or satellites) accommodate greater quantities of information in a given increment of time. The difference between narrowband and broadband communications media is often compared to the difference between a garden hose and a fire hose: both are able to deliver the same amount of water, but delivery takes much more time with a garden hose. Thus, the recent and rapidly expanding availability of broadband media has dramatically increased the quantity and variety of medical information that can be delivered in a timely fashion.

Advances in compression technologies¹ allow narrowband media to resemble broadband technologies more closely (Witherspoon, Johnstone, and Wassem 1993). Areas with limited access to broadband technologies are often able to bridge the technological gap with compression technologies; these areas gain access to many telemedical applications without large public or private investments in telecommunications infrastructure.

During the past decade, not only have the technological possibilities burgeoned, but also the costs of telecommunications and telemedicine technologies have steadily decreased, effectively making these technologies more accessible. For example, the price of CODEC² units has decreased over 70% in recent years (Puskin 1992). Similarly, computer prices continue to fall steadily, and telecommunications expenses have decreased in many regions of the country as a result of the trend toward deregulation (Egan and Waverman 1991).

2.2 Government involvement in telemedicine

As a function of the interrelated trends of increased medical applications, growing access to broadband communications, and declining technology and telecommunications costs, telemedicine has evolved into a very practical means of delivering health care. Te...

Table of contents

• Cover
• Title Page
• Copyright Page
• Table of Contents
• Tables
• Figures
• Acknowledgments
• Abbreviations
• Symbols
• Chapter 1. Introduction
• Chapter 2. Background and related literature
• Chapter 3. Review of the diffusion literature
• Chapter 4. Conceptual framework
• Chapter 5. Research Design and Methods
• Chapter 6. Characteristics of the Survey Population and Descriptive Statistics
• Chapter 7. Data Analysis, Findings, and Discussion
• Chapter 8. Conclusions and Policy Implications
• Appendix
• Bibliography and References Cited