Telemedicine A Guide to Assessing Telecommunications for Health Care (1996) / Chapter Skim
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3 THE TECHNICAL AND HUMAN CONTEXT OF TELEMEDICINE
3 THE TECHNICAL AND HUMAN CONTEXT OF TELEMEDICINE
Pages 55-82
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From page 55... ...
Nonetheless, they must still be dealt with site by site and application by application as clinical uses of telemedicine are planned, implemented, evaluated, and redesigned. This chapter considers elements of the technical and human infrastructures that support clinical applications of telemedicine and that are often identified as the source of application failures or disappointments.
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From page 56... ...
For example, expensive digital cameras produce the high resolution images needed for teledermatology, but some features, which were designed with newspaper and magazine photographers in mind, may be of marginal clinical value (Van Riper, 1996~. Furthermore, manufacturers may abandon technologies useful for some telemedicine applications because the total market is too limited to justify continued support of the product or because corporate realignments have shifted business priorities.
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From page 57... ...
. Organizations Medical information resources Telemedicine conferences/training Other SOURCE: Adapted from Telemedicine Today: Telemedicine Buyer's Guide and Directory, Winter 1996 special issue.
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From page 58... ...
For telemedicine and for health care generally, computer-based patient records, clinical information systems, and clinical decision support systems all of which involve management judgments as much as technical factors are critical items on the list. Variation in User Needs and Circumstances Rural emergency departments, primary care clinics, public health facilities, correctional institutions, home care programs, and managed care plans may each need somewhat different technologies or combinations of technologies to fit their particular objectives and circumstances.
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From page 59... ...
The equipment, which is employed in different kinds of consultations between the center and Naval Medical Clinic in Annapolis, Maryland, includes clinical and administrative work stations, communications and storage devices, and a variety of peripherals such as video cameras. Variety and Complexity of Technologies The variety and complexity of advanced technologies makes formidable demands on those responsible for planning, deploying, sustaining, and evaluating information and telecommunications systems and programs (see, e.g., IOM, 1991; OTA, 1995; NRC, 1996~.
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From page 60... ...
Key aspects of the technical infrastructure of telemedicine that affect its feasibility, utility, and cost are briefly described immediately below. The discussion minimizes the use of more technical terminology, but the report's glossary provides definitions of some basic terms.
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From page 61... ...
and "network" may be used and defined differently in different sectors of the Nil (NRC, 1996~. Information Carrying Capacity The capabilities of telemedicine are constrained by the information carrying capacity the bandwidth of the communications media on which they depend (e.g., copper telephone wires, coaxial cable)
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From page 62... ...
.............................................. TELCON Film/EKG Digitizer Admin WS T1 Transmission via landline National Naval Medical Center Bethesda, Maryland Telemedicine Workstation .
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From page 63... ...
; TEL CON = clinical video teleconferencing workstation; TELCON Admin WS = teleconferencing administrative workstation; TEL RAD = teleradiology workstation; TELRAD Archive = Picture Archiving and Communications Systems (PACS) ; T1 line = communications line capable of transmitting 1.544 Mbps of electronic information; VTC = video teleconferencing workstation; 2GB Server = two gigabyte server; 1K = standard resolution 1024 x 768 monitor; 2K = high resolution (for diagnostic imaging)
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From page 64... ...
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From page 65... ...
Information Transmission Media Several different transmission media, with different capacities and costs, are available for telemedicine applications. Many telemedicine transmissions rely on telephone lines because they are so widely distributed and relatively inexpensive.
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From page 66... ...
the 1mpilcatlons for short-term and long-term advances in bandwidth options and their stability are likely to be significant. Information Restructuring and Digital Technologies Limitations on the carrying capacity of different transmission media can be overcome, in part, by restructuring or manipulating information before it is sent.
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From page 67... ...
The trend toward consolidation in health care delivery including mergers of hospitals or health care systems and insurers, and purchase of physician practices and home care programs by hospitals further complicates the information management picture as different information and telecommunications systems have to be understood and meshed. What two observers call the "hype associated with medical computing and telecommunications technologies" is, on the one hand, alluring to
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From page 68... ...
For managers at central telemedicine sites, some of the most frustrating aspects of telemedicine technologies involve how well the components operate together, work in different settings without extensive adaptation, and accommodate change (Bashshur et al., 1994; OTA, 1995~. Phrased as questions, the issues are .
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From page 69... ...
The HL7 standard covers the interchange of computer data about patient admissions, discharges, iThe term HL`7 derives from the seven-part classification scheme for computer communications established by the International Standards Organization. The first level involves physical connections for equipment and the seventh involves messages.
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From page 72... ...
and the National Electrical Manufacturers Association (NEMA) have cooperated to produce initial standards for exchanging digital radiological images and then to revise them in the face of changing technologies and user needs (ACR, 1994; OTA, 1995~.
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From page 73... ...
In addition, those directly involved in telemedicine will ordinarily be linked to other personnel involved in financial administration, information systems management, research, and a myriad of patient care activities. Getting these human components both individuals and organizations to work well together and with complex and changing technologies is a never-ending challenge.
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From page 74... ...
The issues raised and the strategies proposed by human factors engineers can inform designers and evaluators of telemedicine projects. Growing Recognition of Human Factors A recent overview of telemedicine technologies by two experienced telemedicine researchers argued that "most failures of telemedicine programs are associated with the human aspects of implementing telemedicine" (Allen and Perednia, 1996, p.
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From page 75... ...
They also identified factors that may slow acceptance and adoption of telemedicine, including lack of documented benefit for clinicians; difficulty of incorporating telemedicine into existing practice; problems related to equipment; concerns about professional image; inadequate assessment of needs and preferences; lack of societal readiness; and health care restructuring (Scott and Neuberger, 1996~. To incorporate an examination of human factors, evaluators may in some cases be able to use program logs, debriefing interviews, or questionnaires to detect how these factors may have shaped the effects of telemedicine application.
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From page 76... ...
Further, most product specifications and proposed technology solutions refIect the perspective of the technology vendor rather than the user of the product. More attention to applications-driven design, human factors engineering principles, and business process re-engineering might help to alleviate many of the problems identified here.
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From page 77... ...
The widespread availability of practical and affordable desktop work stations should make it easier to employ telemedicine and a variety of other applications, such as patient record, clinical information, and decision support systems. Whether telemedicine or other applications are cost-effective for any specific user and situation still, however, would need to be assessed.
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From page 78... ...
Many health care institutions and most clinicians have not yet adopted computer-based patient records systems, but even those who have done so may find it difficult to integrate them with telemedicine applications. Barriers include the lack of common definitions and clinical vocabulary, inadequate standards for sharing and protecting the confidentiality of electronic data, and inconvenient documentation and data retrieval procedures.
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From page 79... ...
without such accommodation, financial considerations will undoubtedly affect the extent to which decisionmakers are willing to accommodate user preferences. One pressing challenge is to develop methods and tools for assessing potential users' needs and for matching characteristics of particular telemedicine technologies to these needs.
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From page 80... ...
Lack of Documented Benefit The scarcity of rigorous evaluations of clinical telemedicine the stimulus for this report may also discourage clinicians and other decisionmakers. Little information is available to document how telemedicine can help health care organizations or clinicians improve health outcomes, promote better quality of care, manage costs, attract patients, reduce administrative hassles, or otherwise be of benefit.
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From page 81... ...
Practitioners and administrators are acutely concerned about protecting their patient base in the face of cost-driven reductions in the use of many services and changes in referral patterns. Advanced telecommunications technologies stand to alter further the relationships between health care organizations and professionals and between the practitioners and their patients.
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From page 82... ...
CONCLUSION Those responsible for creating, sustaining, and evaluating information and telecommunications systems and programs face a bewildering and constantly changing array of hardware and software options, many of which are not tailored to health care uses. Assessing the utility of advanced information and telecommunications technologies is difficult, particularly given the need to consider options in combination, not just individually.
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