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1 INTRODUCTION AND BACKGROUND
Pages 16-33

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From page 16...
... On the commonplace side of the spectrum are familiar uses of the telephone for consultations between patients and clinicians and the use of radio to link emergency medical personnel to medical centers. On the other end of the telemedicine spectrum are largely experimental innovations such as telesurgery in which a surgeon receives visual and tactile information to guide robotic instruments to perform surgery at a distant site.
From page 17...
... by the scarcity of careful evaluations of patient care applications of telemeclicine. It presents a broac!
From page 18...
... The prospect of a physician surplus coupled with declining personal income has become a real concern for many physicians, particularly specialists (Pew Health Professions Commission, 1995; IOM, 1996~. Nurses likewise are facing pressures from decreasing hospital utilization and a reordering of nursing practices in managed care, although these may be offset to some degree by more options in
From page 19...
... In these contexts, the information and telecommunications technologies that constitute telemedicine have the potential to radically reshape health care in both positive and negative ways. In particular, over time, the widespread adoption of clinical applications of telemedicine could fundamentally alter the personal, face-to-face relationship between patient and practitioner that has been the mode!
From page 20...
... Academic medical centers, community hospitals, and other institutions have created World Wide Web pages that serve both as information sources and as marketing tools. To meet internal needs and external demands, offices and hospitals are being remodeled to better accommodate information technologies that require differently configured space for people and equipment.
From page 21...
... 3~. The technical base for telemedicine applications will also continue to be affected by innovations spurred by consumer electronics, the entertainment industry, and defense department investments.
From page 22...
... The commonly cited sources of this demand include the sharp escalation in health care costs during the 1970s and 1980s, the documentation of wide variations in clinical practice, the proliferation of expensive medical technologies, and the publication of studies questioning the appropriateness of a variety of health care pract~ces. In response, a number of public and private initiatives have been launched to extend the evidence base for health care and to improve the use of such knowledge by clinicians, patients, and other decisionmakers (see, e.g., TOM, 1985, 199Oa, 1992a; Ball, 1990; PPRC, 1989; OTA, 1994~.
From page 23...
... and credible analysis and presentation of data; · build computer-based patient records and other electronic information systems that provide relatively easy and fast access to large databases and that permit the application of powerful statistical methods for analyzing and displaying those data; · create decision support tools and learning systems that assist clinicians and patients in evaluating information, preferences, and options; formulate strategies for providing information to patients, clinicians, and others in ways that promote informed decisions and stimulate desired changes in behaviors and outcomes; and . assess the effect of information and decision-support strategies on behaviors and outcomes.
From page 24...
... The evaluative focus was to be on the quality, accessibility, and cost of health care, not on technical hardware and software issues. To undertake the requested study, the TOM appointed a 15member committee of experts in telemedicine, medical informatics, health care delivery, health services research, quality assurance, economics, and public policy analysis.
From page 25...
... , and clinical practice guidelines (1992b)
From page 26...
... TERMS AND DEFINITIONS As more and more people use computers and advanced telecommunications technologies at work and at home, the arcane language of these technologies bits and bytes, analog and digital signals, pixels and bandwidths is slowly diffusing, but it remains far from common parlance in most medical settings. Reflecting its dependence on these technologies, the field of telemedicine is replete with highly technical terms and abbreviations.
From page 27...
... The committee viewed the degree of system integration not as a defining characteristic but, rather, as a major variable or factor to be considered in planning, implementing, evaluating, and redesigning telemedicine programs to achieve desired outcomes. Thus, as cited on the first page of this report, telemedicine is defined as the use of electronic information and communications technologies to provide and support health care when distance separates the participants.4 Several elements of this definition warrant comment.
From page 28...
... Clinical applications of telemedicine, the focus of this report, involve the first category patient care, including diagnostic, treatment, and other medical decisions or services for particular patients. Nonclinical uses of telemedicine, such as continuing medical education and management meetings, do not involve decisions about care for specific patients.
From page 29...
... . monitoring; triage or emergency patients Continuing medical education programs; online information and education resources; individual mentoring and instruction On-line help services for patients with chronic health problems Aggregation of data from multiple sites; conducting and coordinating research at multiple sites , .
From page 30...
... use of remote information and decision analysis resources to support or guide care for specific patients. This classification scheme includes a mix of several different dimensions related to the clinical problem, the process of care, and the kind of clinical information involved in a particular clinical application of telemedicine.
From page 31...
... , telemedicine routinely transmits only the first two, but these two provide most of the core sensory information for clinical decisionmaking. The transmission of tactile data, which is important for many diagnostic, management, and treatment purposes, is largely experimental (e.g., the "virtual glove" that would allow remote palpation of patients)
From page 32...
... The committee focused on the set of basic concerns about the quality, accessibility, and cost of health care that lie at the core of most health services research and technology assessments. Because a comprehensive presentation of specific criteria appropriate for the heterogeneity of telemedicine applications was beyond the committee's resources, this report sets forth criteria in the form of questions with examples of the kinds of measures or standards that would be applied to particular telemedicine applications.
From page 33...
... Chapter 3 considers the technical and human infrastructure of telemedicine, and Chapter 4 discusses policy issues with an emphasis on professional licensure, malpractice, medical privacy, payment for services, and telecommunications law. Chapter 5 reviews telemedicine evaluation frameworks and selected evaluation projects identified by the committee.


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