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Some of the program information listed on the TIE was provided by the Association of Telemedicine Service Providers (ATSP) from their Annual Survey of Active Telemedicine Programs.

The Steering Committee on Telehealth and Healthcare Informatics met on Capitol Hill on 5/21/03 to discuss Effective Disease Management. The session looked at chronic illnesses in terms of the economic costs in providing healthcare.

Scott Nystrom Ph.D Senior Policy Advisor, U.S. Senate Special Committee on Aging pointed out that Medicare was not designed to care for persons with chronic illnesses, but to treat acute illnesses. The 1965 legislation also did not provide a prescription drug benefit, provided poor preventive coverage and as a result, the country now faces a fragmented delivery system to treat chronic illnesses.

Almost half of Medicare beneficiaries have 3 or more chronic conditions that could be greatly helped with effective disease management and reduce Medicare spending. With effective disease management, total health costs could be reduced by 20% with patients that have CHF (Congestive Heart Failure). Disease management can also improve all clinical outcomes by reducing costs by 17%.

Disease management, coordinated care, and telehealth could improve the quality of Medicare for seniors. Unfortunately seniors are less likely to have access to modern integrated health care plans that provide disease management, coordinated care, and telehealth services. If Medicare provided higher quality integrated health care services, then many of these needs could be met.

William Rollow, Office of Clinical Standards and Quality, CMS said that disease management strategies should identify patients with chronic illnesses, make information available, support patients in self management, and encourage patients to obtain medical services on a regular schedule.

To make disease management efficient from the physician's viewpoint, doctors should build a database to identify and manage patients. This system could support reminders and alerts that doctors could look at while they are seeing patients.

CMS (Medicare and Medicaid Services) is working on a number of demonstration projects. Demonstration projects results will be announced in a couple of years, but some of the early demonstration projects have already produced reports.

Betty Levine M.S. ISIS Center, Georgetown University Medical Center talked about the Internet Diabetes Management Program at Georgetown University and the enormous cost to treat diabetes in this country. She mentioned how trends are being studied and pilot projects have been done to look at the costs. Now the university is doing a study to look at the problem in Native American communities.

Karen Fox, Assistant Dean College of Medicine at the University Of Tennessee Health Sciences Center said that according to the Robert Wood Johnson Foundation, health care expenditures for patients with chronic conditions represent nearly 70% of the national healthcare expenditures. Many of these expenses are associated with patients with chronic conditions that could be avoided if patients received proper care.

Large numbers of enrollees in TennCare, the Medicaid System in Tennessee, have expensive chronic conditions. Hospital costs for the top 5 chronic conditions exceed $95 million per year. Fifty per cent to seventy percent of the hospitalizations for Medicaid recipients with chronic conditions could be avoided with appropriate outpatient care in the month prior to admission.

The University of Tennessee experience shows that patients are seeing primary care doctors 4 to 6 times for specific symptoms related to chronic conditions. Patients referred to specialists using telehealth with chronic illness symptoms have the condition controlled within 1 to 2 visits. Telehealth can reduce hospitalizations for chronic conditions by 50-70% and obtain $47 to $66 million in potential savings.

This study was conducted to better understand the trends affecting the use of telemedicine. The widespread adoption of telemedicine, like virtually all high technology innovations, is particularly dependent on meeting the needs of end-users. More than 500 members of The Science Advisory Board's Clinical Panel participated in this project and offered their opinions and insights on a technology undergoing great transformation.

Although the definition of telemedicine may vary, the concept is not new. From its inception, the goal of telemedicine has been to overcome the time and distance barriers that separate the caregiver from the patient. While the proponents of telemedicine have promoted its potential to revolutionize healthcare, widespread adoption of the technology has been hampered by a number of technological, regulatory and other barriers. Interest in telemedicine, however, has been re-ignited by remarkable developments in computers and telecommunications. Until very recently, text, sounds, pictures, and video have been disseminated independently of each other over separate media, and have been controlled by separate industries. Due to the phenomenon known as digital convergence previously distinct industries and technologies are evolving, interconnecting, and merging in completely new ways.

The impact of convergence is forcing radical rethinking and restructuring of many traditional paradigms in the practice of telemedicine. Convergence is presenting both practitioners and vendors with a vast array of new opportunities. Innovations such as computer-based patient records, remote consultations, hospital information systems, computer-based decision support tools, community health information networks, and new ways of distributing health information to professionals and consumers are supported by, and in some cases reliant on, the widespread use of networked telemedicine technologies. Exploiting the opportunities of convergence, however, will require close collaboration between visionary healthcare professionals and innovative companies to creatively combine new and existing technologies to produce cost-effective solutions.

Among the study's major findings:

Supporting "Continuing Medical Education" is the most common way in which telemedicine is used, followed closely by "clinical consultations".

"Text documents" are the most frequently transmitted type of medical information transmitted between locations, while "real-time motion video" is transmitted least frequently.

A desire to "deliver quality care to rural/under-served areas" was cited by users as the most important reason their organizations decided to implement a telemedicine, but non-users claim the "availability of affordable technology" would be their primary motivation.

"Access to medical databases" was considered the most valuable clinical telemedicine application cited by users.

87% of those using telemedicine report that their organization provides them with access to the Internet.

Slightly more than a third of those using telemedicine report that their organization "occasionally" uses telemedicine to assess a patient at a remote location, while almost half "occasionally" use an interactive technology to consult with a remote caregiver.

"Lack of funding" was by both users and non-users as the greatest impediment to the growth of telemedicine.

Budgets for the majority of new telemedicine programs (less than one year old) appear to have increased by 50% or more from 1997 to 1998. However, budgets for the majority of older telemedicine programs (5 years or more), have remained the same for the majority of the respondents.

Non-users indicated that having access to medical databases and the ability to transmit medical images would be the two most valuable telemedicine capabilities.

75% of the participants are located in North America, 14% in Europe, and the remaining 11% in Australia/New Zealand, Latin America, Asia and Africa. 54% of the participating members work in hospitals, 24% in academic medical centers, 10% in private practice, and the remainder in a variety of commercial, government and private institutions.

Two different questionnaires were completed by members of the Clinical Panel. One questionnaire was designed for those with "hands-on" experience with telemedicine, while the second was designed to measure the perceptions of those professionals who have yet to use the technology. The results of this study show an overwhelmingly positive disposition toward telemedicine and a remarkable similarity between the experiences of "users" and the perceptions of "non-users."

Patient Satisfaction with Telemedicine

Abstract:

Overall patient satisfaction with telemedicine applications was found to be a high 98.3%. Patients were highly satisfied with consultations through telemedicine, and reported that care was easier to obtain.

Telemedicine Center of the East Carolina University School of Medicine

The University of East Carolina (ECU) School of Medicine recently published a report entitled "Patient Satisfaction with Telemedicine" in the Telemedicine Journal (Vol. 5, Num.1). In this report, the authors review other non-telemedicine studies that look at patient satisfaction as well as 12 studies of patient satisfaction in telemedicine applications. They also report their own findings about patient satisfaction based on data collected and evaluated from 495 real-time interactive telemedicine clinical consultations associated with their Telemedicine Center at the School of Medicine. ECU's Telemedicine Center is the hub to eight spoke sites, including six hospitals, one rural health clinic and one maximum-security prison.

ECU's review of 12 telemedicine studies showed patient satisfaction ranging between 71% to 100%. And similar to the Oregon Health Sciences University's review of 18 telemedicine studies, above, ECU found that the 12 telemedicine studies they reviewed tended to have small sample sizes, ranging from 21 to 292 patients. Also similar to the DHHS studies was the focus on one clinical specialty or particular setting, such as a prison.

In contrast to the reviewed studies, the ECU study has a much larger data sample size (495 responses) and looks at patient satisfaction across telemedicine specialties. ECU studied a wide variety of clinical specialists including dermatology (33.5%), allergy (21%), cardiology (17%), psychiatry (5.1%), endocrinology (4.2%) and rehabilitation medicine (4.0%).

Patient satisfaction was examined in relation to patient age, gender, race, income and insurance. Overall patient satisfaction with telemedicine applications was found to be a high 98.3%. Patients were highly satisfied with consultations through telemedicine and reported that care was easier to obtain.

ECU suggests several reasons for the high patient satisfaction rate. For example, travel time can be a factor in patient satisfaction. Travel distances for patients seen over the telemedicine link were on average 81 percent shorter, when compared to the distance to the School of Medicine clinics. The overwhelming majority of patients indicated that telemedicine had made it easier for them to obtain medical care. For example, scheduling a time to see a telemedicine specialist was easier than trying to schedule an appointment with a traditional specialist at ECU's clinics. The amount of time the telemedicine specialist spent on a patient's interview, physical examination and discussion of treatment options was greater and more satisfying to the patient. Part of the reason was that the telemedicine physician received patient information several days prior to the consultation and spent less time gathering information about medical history and more time on the problem at hand. According to the ECU study, although the telemedicine consult usually takes longer than a traditional exam, "it is plausible that these factors make the patient feel more involved in the consultation and increase(s) satisfaction in the process."

Improving Drug Prescribing Practices in the Outpatient Setting

E-Prescribing Technologies May Improve Efficiency and Safety While Lowering Costs [of] 3 Billion Prescriptions a Year, California HealthCare Foundation (CHCF) press release, November 12, 2002

Excerpt: A CHCF analysis concludes that several products show capability to quickly, inexpensively, and easily help physicians. The potential for technology to significantly reduce the costs and medical errors associated with physician drug prescribing habits is still largely untapped, but a handful of companies have started to make inroads, according to a new report commissioned by the California HealthCare Foundation.

Doctors must deal with a staggering amount of drug information. More than 17,000 pharmaceutical brands are currently sold in North America, and 1,500 new products and indications are slated for FDA approval over the next three years. More than 10,000 articles are published annually on randomized clinical trials and, on average, doctors have more than 16 managed care contracts with their related formularies.

Until now, physicians were buried in more paper than they could handle or lacking key information when they were away from their offices and reference materials. New technology allows doctors to carry prescribing information into the clinical setting, in handheld products that hold thousands of pages of up-to-date drug information.
Despite turmoil in the technology sector, electronic tools continue to hold promise in addressing problems related to health care costs, safety, and care, particularly in the area of drug-prescribing practices.

Currently, the lack of accurate, easy-to-access drug reference and formulary information at the point of care, and a reliance on handwritten prescriptions, leads to prescribing problems in several areas:

This report examines e-prescribing products and organizes the technologies into four categories based on functionality: (1) electronic drug references; (2) integrated drug reference and formulary tools; (3) e-prescribing solutions; and (4) integrated electronic medical records (EMR) and e-prescribing systems.
Each of the four categories is rated as low, moderate, or high on efficiency, lowering costs, improving patient safety, ease of implementation, affordability, and stability and use in the market. The results provide potential buyers with an easy way to assess the range of options and implementation considerations.

IT use for administrative functions remained stronger than for clinical use, according to the survey. While 98% of respondents said computers were present in at least one administrative location, 68% reported having computers in clinical areas. In clinical areas, computers are most frequently located in laboratories, followed by radiology departments and examining rooms.

Nearly 70% of respondents said they access pharmaceutical information using handheld computers, the technology's most popular application. Forty-one percent use handhelds for scheduling purposes, but only 12% use handhelds to access hospital data and 9% download lab information to their handhelds.

Physician e-mail and EMR use are less popular. Only 20% of physician offices are using e-mail to communicate with patients about medical concerns. EMR adoption varies widely among medical specialties, with internal medicine practices outpacing other specialties by 42%. One-third of multispecialty practices report using an EMR system, followed by about 30% of family practices and 27% of other specialty practices, including dermatology and gastroenterology. Only 8% of pediatrics practices reported using EMRs.

Respondents indicated that they would continue to purchase IT applications throughout the next year. Although nearly 10% said their practice would spend more than $500,000 on IT next year, most reported more modest IT purchases; 57% expected their IT spending to total $50,000 or less.

The survey was based on responses from 453 physicians and administrators in outpatient settings in August 2002