TELEMEDICINE REPORT TO CONGRESS
January 31, 1997
This report provides a snapshot of the Federal government's activities in the area of telemedicine. Telemedicine, in one form or another, has actually been practiced for over thirty years. At the most simple level, a nurse providing clinical advice over the telephone is telemedicine. The focus of the most recent activity, however, has been on telemedicine applications that generally employ advanced image as well as audio capabilities. These technologies can range from high resolution still images (e.g., x-rays) to sophisticated interactive teleconferencing systems.
Although interest and investment in these advanced systems is rapidly growing, significant skepticism about telemedicine remains. This skepticism is fueled by concerns about the current low use of telemedicine systems and about continued sustainability once Federal, state, or private subsidies disappear. At the heart of much of this concern is uncertainty as to what the Federal government might do or not do to advance telemedicine.
It is important to remember, however, that telemedicine and the technology associated with it,
is fast changing and still in its early development stages. Telemedicine is a rapidly evolving field,
requiring flexibility and creativity to respond to its challenges. Moreover, telemedicine encompasses
many legal, technical and political issues that must be resolved before it can proliferate. Thus, it will
become all the more critical that the Federal government have a vehicle for coordinating its
telemedicine policies and programs. The JWGT provides an important forum to accomplish this task.
However, eventhough the JWGT will undertake to support the cost-effective deployment of
telemedicine, Federal government agencies cannot resolve all the issues discussed in this report,
alone. Congress, the states, health professionals and associations, and the private sector must come
together to make telemedicine a viable health care delivery option for the United States. The
following discussion outlines areas for further action over the coming year but should be viewed
mainly as a work-in-progress.
As a beginning step in its evaluation of telemedicine, the JWGT created an inventory of Federal
telemedicine activities. The Telemedicine Gateway should be viewed as a prototype that
demonstrates the usefulness of using the World Wide Web for maintaining distributed data bases
across Federal agencies. The basic design of the inventory could be very useful to other initiatives
that need to be tracked across Federal agencies. The inventory will undergo further refinement and
updating throughout the coming year.
Much has been written about the barriers to telemedicine and the policies and programs needed to overcome those barriers. Yet, these writings are generally more likely to agree on the nature of the problems than on the solutions. As noted by the Institute of Medicine (IOM) and by others, the lack of quality, scientific evaluations is a major barrier to the adoption of telemedicine. The JWGT has undertaken a number of actions to stimulate the development of such studies. Last winter, it published an evaluation framework that outlined the major questions that needed to be answered in order to adequately assess telemedicine. Members of the JWGT played an active role advising the IOM on its telemedicine evaluation and several member agencies have been active in supporting evaluation studies which have been described in earlier chapters. Over the coming year, the JWGT and its member agencies will be pursuing the following activities to promote better knowledge about what works and what does not in telemedicine.
Uniform Evaluation Tool Development. Building upon its previous study with Abt Associates and the evaluation frameworks of both the JWGT and the IOM, the Office of Rural Health Policy has awarded a grant to the Telemedicine Research Center to develop and evaluate instruments for creating a common data set for application across all agencies. Emphasis will be on collecting common data elements on clinical encounters, costs, and the structure of telemedicine provider organizations, wherever possible. The instruments will be first used in ORHP's 20 demonstration projects. The ORHP efforts will be closely coordinated with those of other JWGT agencies, including the NLM and the Health Care Financing Administration (HCFA ). The National Telecommunications and Information Administration and the Rural Utilities Service are also coordinating their evaluation efforts with other agencies through the JWGT. It is hoped that this effort will result in data collection tools that would allow for analyses of data across projects.
Evaluation of Medicaid Telemedicine Programs. Currently, 10 states offer some telemedicine coverage under their Medicaid programs, but there is no general evaluation effort or opportunity for them to share their experiences, successes, and failures. The JWGT will assess the current level of evaluation activity in the Medicaid program and work with selected states to promote better evaluation. In particular, the JWGT will work with HCFA and ORHP to develop strategies for using state offices of rural health and HCFA regional offices to develop an ongoing mechanism to track Medicaid activities.
Evaluation of Telemedicine in Managed Care Settings. Evaluation studies of telemedicine need to be expanded to managed care settings, and in particular, to rural managed care settings. Currently, there is very little penetration of managed care in rural settings, but several managed care plans, most notably in Minnesota and California, believe that telemedicine might provide a more cost-effective way for the plans to reach rural communities with needed services. A question to examine is whether telemedicine technologies will be beneficial to rural communities in the long-run through the provision of specialty care that would otherwise not be available, or will they result in reduced access and availability of care because specialists are no longer visiting these communities to provide care? The JWGT will be coordinating efforts among the agencies to develop some specific evaluations of telemedicine in managed care settings.
Quality and Efficacy of Care. Very little current research systematically evaluates the quality and efficacy of telemedicine services. This is a very complicated area of research that needs to be pursued over the next two years if we are to be credible leaders in telemedicine. DoD and the Agency for Health Care Policy and Research (AHCPR) are working together to develop strategies for assessing the clinical efficacy of telemedicine for specific specialty applications. This work may serve as a foundation for other agencies to build upon. State-funded initiatives are also beginning to establish research and demonstration efforts to assess the clinical efficacy of telemedicine services provided in different specialties. The JWGT plans to actively broker partnerships between these state and Federal efforts.
Evaluation of Telemedicine in Post-Acute Care (Home and Long-Term Care) and in Non-Health Care Settings. Based on phone inquiries from the health care industry, this is clearly
a priority area. One study in Ohio suggests that over 30 percent of emergency hospital
readmissions of Medicaid patients from nursing homes might be prevented by timely
teleconsulting triage with the patient's primary care practitioners. The JWGT will work with
agencies currently funding projects in post-acute and non-health care settings to develop
standard evaluation tools.
The lack of technical, educational, and clinical practice standards, guidelines and protocols in telemedicine can affect the safety and efficacy of telemedicine provision and has been a handicap in developing cost-effective programs. Lack of technical standards can result in equipment that cannot communicate with one another or do not provide adequate images for clinical decision-making. All too often, lack of objective technical advice has led to inappropriate purchases and poorly performing systems that hinder the cost-effective application of telemedicine technologies. One of the most frequent questions posed to Federal agencies is: "Where can I get some objective advice on setting up my system?" Currently, the VA operates a laboratory to assess the efficacy and technical reliability of new health care technologies. Similarly, the Open Systems Laboratory at Lawrence Livermore Laboratories provides objective assessment of computer equipment and the Department of Commerce's National Institute on Standards and Technology also provides testing.
In the coming year, the JWGT will explore the economic and logistic feasibility of expanding these and similar efforts in the private and public sectors to provide a technical assessment capability of telemedicine technologies that would be available to all Federal agencies and their grantees. In addition, the Working Group will continue to work with the FCC and other appropriate bodies to promote greater uniformity of standards in both telecommunications and telemedicine equipment. In addition, the JWGT will continue to work of the FDA in its activities to develop guidelines for defining its role in the regulation of medical devices. In addition to the standards question, questions of monitoring telecommunications service quality and reliability should be addressed.
Lack of standards or guidelines, however, goes beyond telemedicine equipment to issues of
guidelines for clinical training and practice. With the exception of guidelines for radiology, there are
no specialty-generated standards, protocols or guidelines for providing services through
telemedicine. Several groups, however, are in the process of generating such guidelines. For
example, the American Academy of Ambulatory Care Nurses is developing practice standards for
telephone-based nursing practice. The American Nurses Association is also in the process of
developing general standards and guidelines for professional nurses practicing telehealth. Over the
next 12 months, the JWGT will be working with Federal agencies, specialty associations, and
industry groups to support the development of an agenda for establishing standards or guidelines for
telemedicine.
Although broader than telemedicine, concerns about the lack of privacy and security standards
impact several of the legal challenges facing telemedicine (e.g., malpractice) and have profound
implications for the acceptance of telemedicine services. This is particularly of concern in the use
of telemedicine technologies for treating mental illness, substance abuse, and other conditions that
carry a social stigma. Although issues of privacy and security in telemedicine have much in common
with those regarding medical records, the use of live, interactive video introduces certain technical
dimensions that must be very carefully evaluated. For example, maintenance of secure transmission
lines is critical. Moreover, unlike standard medical record documentation, in which the practitioner
has discretion to selectively record his or her findings, most interactive telemedicine consultations
are recorded in toto. This record usually is maintained as part of the documentation of the
consultation. Practitioners have less discretion to remove sensitive items that they might otherwise
not record. The JWGT will provide assistance in addressing these and other related issues in the
context of the broader privacy initiatives of HHS's Privacy Advocate and its Data Council. The
Working Group will bring in representatives from various consumer and professional groups to
discuss their views on privacy and security issues in telemedicine. Finally, it will examine available
results from various demonstrations and pilot projects that may provide insights into privacy
concerns in telemedicine and compile its results in a briefing paper.
This report contains a full discussion of the licensure issues raised by telemedicine and highlights several of the options for addressing these issues. The JWGT will follow-up the report by convening interested parties, including representatives from the Federation of State Medical Boards, the National Council of State Boards of Nursing, the AMA, the Center for Telemedicine Law, the Western Governors Association and the National Governors Association, to explore next steps, including the development of regional compacts or agreements, to ease the licensure barriers between states. In addition, the JWGT will convene several of the specialty associations and credentialing bodies (e.g., Joint Commission on Accreditation of Healthcare Organizations, AMA, APA, ANA) to explore issues in credentialing of health professionals in telemedicine.
The current high costs of using advanced telemedicine applications can be prohibitive in many
areas of the nation because of the high transmission costs. Part of the problem lies in the widening
gap between those who have access to modern telecommunications systems and those who do not.
The Telecommunications Act of 1996 seeks to ameliorate the inequity between the telecommunications infrastructure "haves and have nots." The JWGT and its members will be working with the
FCC over the coming 6 months to assist in developing the necessary information to allow the agency
to make decisions that would significantly assist rural and urban underserved health care providers
obtain access to affordable advanced telecommunications services that support telemedicine
applications.
Although primarily focused on telemedicine in its first year, the interests of the JWGT go
beyond telemedicine to encompass several aspects of telehealth. The terms telemedicine and
telehealth are often confused and used interchangeably. Telemedicine is the use of telecommunications and information technologies for the provision and support of clinical care to individuals at a
distance and the transmission of information needed to provide that care. Telehealth includes clinical
care but additionally encompasses the related areas of health professionals education, consumer
health education, public health, research, and administration of health services. The JWGT is
particularly interested in addressing the opportunities for distance learning in health care delivery
settings for both health professionals and patients. Moreover, the global implications of telehealth
are of increasing concern to the group. As the activities of the Working Group progress over the
coming months, more and more attention will be paid to the broader applications inherent in
telehealth.