Telemedicine A Guide to Assessing Telecommunications for Health Care (1996) / Chapter Skim
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8 FINDINGS AND RECOMMENDATIONS
8 FINDINGS AND RECOMMENDATIONS
Pages 194-208
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From page 194... ...
Conversely, telemedicine applications may also languish for lack of good evidence documenting their relative value compared to alternative services or for lack of evaluation research identifying the obstacles standing in the way of useful and sustainable programs. This final chapter builds on the preceding seven chapters.
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From page 195... ...
THE TECHNICAL, HUMAN, AND POLICY CONTEXT FOR TELEMEDICINE EVALUATIONS Telecommunications and information technologies are evolving to provide and support medical care at a distance. Some of these technologies involve incremental improvements in the way familiar tools, such as the telephone, are used; others, such as telesurgery, involve devices and procedures that are still experimental.
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From page 196... ...
Varied and restrictive state licensure laws have attracted attention from those interested in or worried about the interstate practice of telemedicine, and differences in state laws about medical liability create additional anxieties. A range of advances in information and telecommunications technologies are intensifying concerns about the inadequacies of state and federal laws to protect the privacy and confidentiality of personal medical information.
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From page 197... ...
First, the rapid advance of information and telecommunications technologies makes evaluations vulnerable to obsolescence as key hardware and software components move from being state of the art to being out-of-date. This prospect sometimes discourages or delays investments in technologies; once an investment is made, it may also discourage more rigorous and often more expensive research designs, including experimental clinical trials and quasi-experimental clinical studies.
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From page 198... ...
A preoccupation with glamorous technologies may also interfere with efforts to distinguish the conditions under which a telemedicine application is likely to become a sustainable element of day-to-day health care delivery in an environment dominated by cost concerns. Fifth, evaluators in rural and even urban sites have found it particularly difficult to design and then recruit appropriate comparison groups, to generate a sufficient number of cases from both experimental and comparison sites for reliable comparisons, and to assure compliance with the research protocol when multiple institutions and investigators are involved.
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From page 199... ...
in many areas, anc! they may be reluctant to shift even moclest resources from the core activities of grant programs to evaluation research on their actual consequences.
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From page 200... ...
The second presents the case for careful evaluation planning to establish objectives and priorities well in advance of implementation. The third describes the key elements of an evaluation, and the fourth outlines the primary questions about quality, access, cost, and patient and clinician perceptions that will form the starting point for most evaluations of specific clinical applications of telemedicine.
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From page 201... ...
Moreover, a project that serves as an early "test of concept" or demonstration of basic technical and procedural feasibility for a new application will generally call for a different research strategy than one intended to help decisionmakers determine whether to adopt a more developed application as part of its routine operations. In addition, somewhat different evaluation strategies may be appropriate depending on whether the purpose is to inform decisions at the clinical or patient care level, the level of institutional strategy, and the system or societal level.
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From page 202... ...
The intent is to underscore the importance of practical evaluations of telemedicine, particularly for applications that are beyond the "test of concept" stage. A business plan explicitly states how the evaluation will provide information to help decisionmakers determine whether a telemedicine application is useful, consistent with the overall strategic plan, and sustainable beyond the test phase.
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From page 203... ...
For public organizations that depend on government appropriations and that do not generate significant revenues, the business plan would still include some estimate of start-up and operating costs, but projections would link expected net costs against expected budgets.
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From page 204... ...
The committee commends researchers and research sponsors that attempt collaborative trials of telemedicine involving independent institutions. Budgetary constraints notwithstanding, the committee encourages all federal agencies providing grants for demonstration projects to strengthen the provisions for formal evaluation of individual projects and encourages agencies to provide technical support and fund innovative research and methodology development activities.
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From page 205... ...
Given the large number of possible quality, access, cost, and acceptability measures for different clinical applications of telemedicine and the difficulty of stipulating many of them in the abstract, the committee did not present application-specific measures and criteria. Instead, they identified several sets of basic questions to guide the selection of evaluation criteria or measures for particular telemedicine evaluation projects (see Box 8.2~.
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From page 206... ...
Proper interpretation of patient outcomes data requires good information on patient characteristics, in particular, the severity of their health problem and any comorbid conditions. The methods for adjusting for differences in patient severity and other patient factors are not completely satisfactory and remain the subject of some disagreement, but evaluators should make an effort to identify and adjust for differences in patient characteristics.
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From page 207... ...
Most notably, telemedicine is not a single technology or a discrete set of related technologies; it is, rather, a large and very heterogeneous collection of clinical practices, technologies, and organizational arrangements. In addition, widespread adoption of effective telemedicine applications depends on a complex, broadly distributed technical and human infrastructure that is only partly in place and is being profoundly affected by rapid changes in health care, information, and communications systems.
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From page 208... ...
208 TELEMEDICINE individual telemedicine projects and evaluation approaches will vary, general adoption of an evaluation framework that includes the elements specified here would strengthen the rigor and cumulative value of telemedicine evaluations and results. As noted at the beginning of this chapter, more rigorous evaluations of some telemedicine applications will produce positive findings that will, in turn, encourage wider adoption of these applications.
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