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5 PAST AND CURRENT EVALUATIONS OF TELEMEDICINE
Pages 116-136

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From page 116...
... Evaluations that will help identify acceptable "low-cost, fowtechnology" strategies are particularly important in an environment dominated by cost concerns. Most clinical applications of telemedicine in common, it must be recognized, with many other clinical practices have not been subject to rigorous comparative studies to assess their effects on the quality, accessibility, cost, or acceptability of health care.
From page 117...
... EVALUATION EFFORTS IN TELEMEDICINE Recognizing the limited evaluative base for telemedicine applications, a number of government and private organizations have moved to support improved evaluation strategies and frameworks, to fund evaluation research, or to require demonstration project grantees to conduct their own internal evaluations and participate in related activities. These organizations include the National Library of Medicine, the Health Care Financing Administration, the Agency for Health Care Policy and Research, and the Office of Rural Health Policy in the U.S.
From page 118...
... Evaluation initiatives fall into three broad categories: frameworks for evaluation; actual evaluations; and training or technical assistance in evaluation. Those involved in these efforts are aware of the problems encountered by the demonstration projects funded in the 1970s, including the small numbers of patients, high cost per patient served, less than satisfactory equipment, and inattention to the organizational, behavioral, and financial conditions for sustaining programs beyond the grant period.
From page 119...
... The goal was not a single evaluation strategy for all agencies but rather a document and a discussion process that would strengthen evaluation designs and promote comparable evaluations to build a stronger base of knowledge about telemedicine. As discussed with the committee, the working group approach identified three "operative goals" for evaluations under the joint framework.
From page 120...
... Another initiative concentrates on complex software to provide information and medical decision support. ARPA and the Department of Health and Human Services are also cooperating to promote civilian uses of advanced technologies (Zajtchuk and Sullivan, 1995; Telemedicine Monitor, 1995.)
From page 121...
... For example, this chapter cites activities involving the VA Medical Centers in Baltimore and Palo Alto. The committee learned that a task force had proposed a coordinated telemedicine evaluation strategy for the Department of Veterans Affairs but that no decision had been made to adopt and implement it.
From page 122...
... . Health Care Financing Administration As part of a continuing initiative to evaluate telemedicine and inform Medicare coverage policies, the Health Care Financing Administration (HCFA)
From page 123...
... , even the first category applications that are judged effective may raise additional questions about implementation and economic impacts that warrant pilot tests designed to guide explicit .
From page 124...
... Telemefdicine Research Center One of the problems in evaluating telemedicine applications is the small number of cases generated by most demonstration or pilot projects (Crump and Pfeil, 1995; Perednia, 1995~. The Telemedicine Research Center, an independent, nonprofit organization located in Portland, Oregon, has created a Clinical Telemedicine Cooperative Group (CTCG)
From page 125...
... These limits have been discussed in the context of growing use of formal meta-analyses (see, e.g., Eysenck, 1994; Greenland, 1994; Bailar, 1995~. The Telemedicine Research Center also sponsors an on-line computer information service, collaborates with other researchers, and develops tools to support telemedicine evaluations.3 One of these tools is the Evaluation Question Hierarchy and associated software, which are designed to generate specific questions tailored to particular research problems, to streamline the process of questionnaire 3The Telemedicine Information Exchange (TIE)
From page 126...
... with few addressing effects on health outcomes, process of care, access, or costs. The literature reviews consulted by the committee include extensive reviews conducted by the Center for Health Policy Research under its contract with the Health Care Financing Administration (Grigsby et al., 1993, 1994a,b,c; Grigsby et al., 1995)
From page 127...
... Studies to Compare Digital versus Conventional Images Perhaps the largest quantity of systematic comparative telemedicine research has dealt with medical images viewed on electronic workstations compared to conventionally viewed images (e.g., radiology films, glass pathology slides) or direct patient examination, for example, of skin lesions.
From page 128...
... The results indicated that although it took a radiologist about 40 percent more time to use a computer work station rather than a conventional viewing system set up by technicians, overall productivity increased by about 25 percent. The investigators attributed this increase to several factors, including better workload sharing, home access to images, fewer interruptions, quicker and more organized access to previous images and reports, and elimination of time spent waiting for film to be developed.
From page 129...
... The committee heard anecdotes about physicians worried about the pale color of patients seen in video consultations who discovered the problem was with their color monitor. In a study reported in 1977 that compared on-site physician diagnoses with remote physician diagnoses using telephone, still-frame black-and-white television, black-and-white television, and color television, few differences were found among the telemedicine options (Dunn et al., 1977)
From page 130...
... It has already accumulated considerable practical experience in telemedicine consultations involving a number of its major medical centers. The experience with deployed troops was recently described in an article by Walters (1996~.
From page 131...
... One was the problem of sustaining telemedicine consultations over time because the initial group of trained participants left, because the technology was awkward, or because participants at distant sites learned enough during initial consultations to handle subsequent patients. It also demonstrated the difficulty of conducting prospective studies and, even with retrospective studies, of tracking patient outcomes.
From page 132...
... Phone companies have not been eager to extend improved telecommunications technologies to rural areas, where even basic phone service is sometimes hard to obtain.5 Competition and other financial pressures are leading health care providers to reduce funding of continuing medical education for staff and withdraw from participation in the telecommunications network that was also to be used for telemedicine. Three Research Initiatives on Effectiveness and Cost-Effectiveness The committee discovered several research projects that were intended to apply more rigorous methods to the evaluation of telemedicine and to extend the focus beyond description and feasibility assessments to effectiveness and cost-effectiveness.
From page 133...
... Information collection will involve abstraction of information from patient records, telephone interviews with patients, Medicare records, and other sources. In a second, experimental phase of the study, CHPR will randomly assign patients to one of four interventions: telephone consultation only; still images with audio or text; interactive video; and face-to-face consultation.
From page 134...
... They often emphasize what some call the proof or test of concept (referred to above) , that is, the basic operational feasibility of an application with which users have little relevant experience.
From page 135...
... has developed a demonstration project involving diverse rural sites and a university-based specialty consultation network. It employs a multisite pretest, posttest research design to assess the feasibility, acceptability, and cost-effectiveness of a telemedicine network (WAMI, unpublished project description, 1995~.
From page 136...
... . CONCLUSION For the series of early demonstration projects funded in the 1970s, the awkward equipment, feasibility oriented projects, small numbers of patients, and high cost per patient served discouraged a sustained program of systematic development and research in telemedicine and apparently contributed to the disappearance of most of these projects.


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