Chapter  131:  Telemedicine for the Medicare Population: Update

Overview

Telemedicine is the use of telecommunications technology for medical diagnostic, monitoring, and therapeutic purposes where distance and/or time separates the patient and health care provider. Both federal and private health insurers are now covering some telemedicine services, despite the fact that the benefits and costs of providing many of these services have not been well studied.

This report assesses the peer-reviewed literature of specific telemedicine study areas, with a focus on those that substitute for face-to-face medical diagnosis and treatment of the Medicare population. Thus, this report targets face-to-face clinical specialties (as opposed to radiology and pathology) and the Medicare population. It does not evaluate studies examining populations that usually are not covered by Medicare, such as children and pregnant women. The report identifies health care services that could be provided using telemedicine and describes existing programs in three categories of telemedicine: store-and-forward, home-based and office/hospital-based services.

Introduction

This evidence report provides an update on the state of telemedicine, following the 2001 publication of Telemedicine for the Medicare Population.¹ It identifies whether there has been significant progress in the number and types of telemedicine studies being conducted. More specifically, we searched for well-designed studies that evaluated telemedicine services in three technological categories described below.

Methods

The Oregon Evidence-based Practice Center (EPC) team that developed this report sought to identify peer-reviewed literature in the three study areas. We searched the peer-reviewed literature using the Ovid MEDLINE® electronic bibliographic database. We also searched through telemedicine reports and compilations, including their reference lists.

The inclusion criteria for the evidence report update were that the study was relevant to at least one of the three study areas, addressed at least one key question in the analytic framework for that study area, and contained reported results. Exclusion criteria for the evidence report update were that the study did not address a key question, lacked reported results, had a study population that was not relevant to the Medicare population (i.e., children and pregnant adults) or substituted for a service that did not historically require face-to-face encounters (e.g., diagnostic services in radiology or pathology).

We categorized the included articles by the key question(s) they addressed. The included studies for each study area and key question were critically appraised to determine the strengths and limitations of the most important studies following a detailed rationale for the appraisal of study characteristics related to quality.

For each study area, we constructed an evidence table summarizing the strength of the evidence for each key question. We then constructed summary tables for clinical specialties or domains. For studies of diagnosis and management decisions, we explicitly noted whether studies assessed concordance (without a diagnostic gold standard) or accuracy (with a gold standard) of the telemedicine system when compared to conventional care.

Results

Discussion

This update on evidence about the efficacy of telemedicine for the Medicare population covered published peer-reviewed literature for the five years between 2000 and 2004. Similar to the findings of our original report a half-decade ago, there are still serious gaps in the evidence base for telemedicine. While this situation is hardly unique to telemedicine, having a solid evidence base is essential given that there is increased advocacy for health care payers, especially Medicare, to provide coverage for its use.

The best evidence for the effectiveness of telemedicine is in medical specialties for which verbal interactions are a key component of the patient assessment, such as psychiatry and neurology. Various psychiatric and neurological assessments can be administered effectively via interactive videoconferencing. Likewise, treatments administered in these specialties via telemedicine appear to achieve comparability with face-to-face care.

Our systematic review also identified several studies, a few of them of high methodologic quality, showing benefits of home-based telemedicine interventions in chronic diseases. These systems appear to enhance communication with health care providers and provide closer monitoring of general health, but the studies of these techniques were conducted in settings that required additional resources and dedicated staff. With ongoing improvements in telecommunications technology, particularly broadband connections to the home, further research, including larger clinical trials, will likely be informative.

The specialty with the largest number of studies is dermatology, and most studies of teledermatology have evaluated store-and-forward techniques. The body of evidence summarized in this report is consistent with the findings of the earlier report. There continues to be highly variable rates of interobserver and intraobserver agreement in diagnoses. This issue can only be resolved by high-quality studies that compare not only the concordance of telemedicine versus face-to-face diagnosis, but also the concordance of face-to-face versus face-to-face diagnosis in the same situation.

Of course, rates of concordance in a vacuum, i.e., without a clinical context of how the patient fared, are also limited from an evidence standpoint. What we ultimately need to know is the patient outcome. In other words, did the teledermatology encounter at least provide comparable care for the patient? A corollary question that must be answered is whether teledermatology resulted in harm from any missed diagnoses or other consequences of the telemedicine encounter. These questions can only be answered in studies of clinical outcomes, none of which were identified in this report. In general, advocacy for an expanded role for teledermatology will require further studies that examine rates of missed diagnoses, incorrect treatments, and when the technology is insufficient to avoid in-person encounters.

Other widely studied domains include ophthalmology and wound care. Teleophthalmology appears to result in high rates of diagnostic concordance and accuracy, but only for some eye conditions. It appears to be particularly efficacious in assessment of diabetic retinopathy. Studies of wound care show potential, but are limited by small sample sizes, use of only one assessor, and lacking comparison to other in-person examiners when assessing concordance.

There may be situations when the use of telemedicine is warranted even if the evidence is lacking. For example, there may be situations when care would be otherwise impossible to deliver except via telemedicine. This could include remote rural areas or other locations where medical care is not available locally and the patient is for whatever reason unable to travel to a setting where it can be obtained. However, even in these instances it is important to understand the efficacy of telemedicine so that any clinical shortcomings can be anticipated.

The present evidence base provides guidance on the clinical areas in which future research is most likely to be useful. It now is clear that continued small or methodologically weak studies are unlikely to add to the evidence base for telemedicine. In teledermatology, larger and more comprehensive analyses that assess key patient outcomes are needed. Likewise, there is a need for similar studies of clinical outcomes using office/hospital-based telemedicine in fields such as psychiatry and neurology. Well-designed randomized controlled trials will likely provide valuable information on the potential of these clinical applications. Longitudinal observational studies and demonstration projects also will be useful. Studies of home-based telemedicine should carefully address the independent contributions of technology and human resources in the complex delivery models for patients with chronic diseases.

Goal of the Report

The goal of this report is to present an overview of the scientific evidence on diagnosis and management decisions, clinical outcomes, and access to services through the use of three categories of telemedicine services: store-and-forward, home-based, and office/hospital-based. The report is intended to provide an update on the evidence for the efficacy of telemedicine services in the Medicare population. Consequently, the scope of this report is limited to telemedicine programs and clinical settings that have been used for, or are likely to be applied to, Medicare beneficiaries.

This report provides an update on the state of telemedicine, following the 2001 publication of Telemedicine for the Medicare Population (AHRQ Publication No. 01-E012).¹ Our initial report found that while telemedicine was in widespread use, the evidence of efficacy for those uses was lacking. But even more problematic was the quality of evaluative studies. Many studies were performed using poor methodologies and small sample sizes. Indeed, our major conclusion was not that telemedicine was not efficacious, but rather that the quality of the studies evaluating it prevented one from making that determination at all. Another goal of the current report is to determine whether there has been progress in the number and quality of telemedicine studies that have been conducted since then.

We note that this report only presents a view of telemedicine from the standpoint of the peer-reviewed medical literature. This does not represent the sum of all experience with telemedicine. Indeed, telemedicine continues to be widely used. According to the 2004 TRC Report on Telemedicine Activity (Telemedicine Research Center and Telemedicine Information Exchange),² 48,194 non-radiology teleconsultations took place in 2003 in 46 states. Mental health, cardiology, dermatology, orthopedics, and neurology represent some of the clinical specialties most actively utilizing telemedicine services. This report also identified a number of barriers to telemedicine services. The most significant of these barriers are the difficulty associated with integrating telemedicine services into health care delivery, lack of long-term funding, and lack of reimbursement for the provision of telemedicine services.²

Despite the peer-reviewed literature representing only a subset of all telemedicine experience, it is important to analyze telemedicine using an evidence-based approach, especially when the goal is to inform decisions about coverage. As such, this report undertakes a systematic if limited review of the efficacy for the telemedicine services and usages described above.

Definitions

Telemedicine is the use of telecommunications technology for medical diagnostic, monitoring, and therapeutic purposes when distance and/or time separates the participants. Some descriptions use the broader term telehealth to indicate care beyond that provided in medical encounters (e.g., health education, health-related Web sites, etc.). Other descriptions use narrower terms focused on medical specialties, such as teledermatology or teleradiology. A telemedicine encounter is the event where clinical services are provided using telemedicine. The narrower term teleconsultation is used when a traditional specialist medical consultation is performed using telemedicine.

Telemedicine Study Areas

This report examines telemedicine services in three areas: store-and-forward, home-based, and office/hospital-based services. Each of these three services are evaluated for their efficacy in three functions: diagnosis and management decisions, clinical outcomes, and access to care. Because the decision to use telemedicine is only predicated on it performing comparably to face-to-face care, studies are assessed from the standpoint of telemedicine to perform comparable to, but not necessarily better than, conventional care.

The terminology used in this update varies from the terminology used in the 2001 report. The term self-monitoring/testing has been replaced with home-based, and the term clinician-interactive has been replaced with office/hospital-based. The updated terms more accurately reflect the services that they describe and match the terminology used in subsequent publication of the findings of the 2001 evidence report in the peer-reviewed literature.^{3, 4}

Store-and-forward telemedicine services collect medical data, store them, and then forward them to be interpreted later. Store-and-forward systems provide the ability to capture and store digital still or moving images of patients, as well as audio and text data. A store-and-forward system eliminates the need to have the patient and the specialist available at the same time. Store-and-forward is therefore an asynchronous, non-interactive form of telemedicine. It is usually employed as a clinical consultation (as opposed to an office or hospital visit).

Home-based telemedicine services enable physicians and others to monitor physiologic measurements, test results, images, and sounds, usually collected in a patient's residence or a nursing facility. Post-acute-care hospital patients, patients with chronic illnesses, and patients with conditions that limit their mobility often require close monitoring and follow-up. These patients also may be taking medications that require testing and/or titration of dosage.

Telemedicine systems use a variety of strategies to accomplish this monitoring. For example, several technologies allow patients to upload monitoring data directly to a health care system or to enter it into a home computer, whereby it can be transferred to a provider. Others make use of high-bandwidth phone or cable television infrastructure to apply two-way interactive video, audio, and medical diagnostic instrumentation. The close monitoring afforded by these approaches may allow better health care through early detection of problems or more precise dosing of medications and biologic agents, potentially reducing costs.

Some common forms of home-based telemedicine services are blood pressure measurement and blood glucose measurement performed by a diabetic patient and used by a clinician to evaluate the patient's glycemic control and to recommend changes in management. Other medical conditions for which home-based telemedicine services have been developed include asthma (in which spirometry is measured), congestive heart failure (weights, symptoms, blood pressure), cardiac arrhythmias (electrocardiography), anticoagulation therapy (prothrombin time), and post-acute hospital care. Monitoring may facilitate preventive measures to be taken before problems get so severe that hospitalization becomes necessary. Telemetry devices could also provide a more cost-effective method of care, by reducing medical visits for conditions that are not severe. Home-based telemedicine systems also may enhance patient-provider communication.

Office/hospital-based telemedicine services are real-time, clinician-patient interactions that conventionally would require face-to-face encounters between a patient and a health professional. Examples of office/hospital-based services that might be delivered by telemedicine include office visits, hospital visits, consultations, and home visits, as well as a variety of specialized examinations and procedures.

Telemedicine is commonly used to make diagnosis or management decisions, often by a specialist located remotely from the patient. Because many diagnostic decisions in medicine are not made definitively, it is often adequate to demonstrate that telemedicine results in concordant as opposed to accurate decisions. This is particularly true in specialties like dermatology, where diagnoses are made by visualizing skin lesions and not confirmed with definitive testing before treatment is begun. Making accurate decisions usually requires more definitive testing, such as biopsies, which are not routinely done for many conditions, especially those that are not life-threatening.

For this reason, we distinguish in this report between concordance and accuracy in making diagnoses. We note other dimensions of concordance, such as the measure used (usually either percent agreement or Cohen's kappa measure for categorical data and correlation for continuous data), comparison to the same diagnostician (intraobserver) versus a different one (interobserver), and whether concordance of telemedicine versus face-to-face diagnosis is compared to face-to-face versus face-to-face diagnosis. Studies of the highest quality must include the latter as a reference to the comparison of telemedicine. In our original report, few studies made this important comparison. Accuracy is usually measured by comparison with some gold standard using sensitivity and specificity.

The clinical outcomes assessed in this study are limited to measures of clinical care, such as health status, improvement in clinical parameters (e.g., blood glucose or blood pressure), and recovery from disease. We do not focus on utilization or economic outcomes.

This review has a number of limitations of scope. Our gathering of evidence is limited to the peer-reviewed literature. Only studies assessing populations relevant to Medicare (non-pregnant adults) are assessed. Studies focusing on non-clinical care (teleradiology and telepathology) are excluded, as are those focusing on economics as well as patient or provider satisfaction. We also do not look explicitly at telemedicine from the context of changes in the health care system or implementation of wider information technologies unless such aspects were specifically assessed in peer-reviewed studies.

Other Telemedicine Research Summaries

Several other reports have analyzed the quality of telemedicine studies, some of which are systematic reviews. These include:

Bashshur R, Shannon G, Sapci H. Telemedicine evaluation. 2004. In: Proceedings of the Second International Symposium on the Future Directions for Telemedicine; 2004 May 22–24; Ann Arbor, MI.

Brantley D, Laney-Cummings K, and Spivack R. Innovation, Demand and Investment in Telehealth. 2004, Department of Commerce: Washington, DC. http://www.technology.gov/reports/TechPolicy/Telehealth/2004Report.pdf.

Currell R, et al., Telemedicine versus face-to-face patient care: effects on professional practice and health care outcomes, in The Cochrane Database of Systematic Reviews. 2000, Update Software: Oxford, UK. CD002098.

Grigsby J, Brega A, DeVore P. Health services research and evidence of telemedicine. In: Proceedings of the Second International Symposium on the Future Directions for Telemedicine; 2004 May 22–24; Ann Arbor, MI.

Hailey D, Ohinmaa A, Roine R. Study quality and evidence of benefit in recent assessments of telemedicine. J Telemed Telecare 2004 10(6):318–24.

Heinzelmann P et al. A review of clinical outcomes in telemedicine/telehealth. In: Proceedings of the Second International Symposium on the Future Directions for Telemedicine; 2004 May 22–24; Ann Arbor, MI.

Hersh W, Wallace J, Patterson P, et al. Telemedicine for the Medicare Population. Evidence Report/Technology Assessment No. 24. Rockville, MD: U.S. Department of Health and Human Services, Agency for Health Care Quality and Research. 2001 Jul. AHRQ Publication No. 01-E102.

Jennett P, Scott R, Hailey D, et al. Socio-Economic Impact of Telehealth: Evidence Now for Health Care in the Future: Volume One: State of the Science Report. 2003, Health Telematics Unit, University of Calgary: Calgary, AB.

Analytic Framework and Key Questions about the Efficacy of Telemedicine Services

Figure 1. Analytic framework

   Figure 1. Analytic framework

Figure 1

We then made explicit the key questions for each of the three study areas. For studies of diagnosis and management decisions and of clinical outcomes, the key questions were assessed from the standpoint of determining whether the telemedicine system provided comparable care, since telemedicine can be deemed efficacious when the quality of clinical care provided is as good as, but not necessarily better than, in-person care.

• A

  Store and forward

  • 1

    Does store-and-forward telemedicine result in comparable diagnostic decisions and recommendations for clinical management?

  • 2

    Does store-and-forward telemedicine result in comparable health outcomes?

  • 3

    Does the availability of store-and-forward telemedicine services improve access to care?

• B

  Home-based

  • 1

    Does home-based telemedicine result in comparable diagnostic decisions and recommendations for management?

  • 2

    Does the use of home-based telemedicine result in comparable health outcomes?

  • 3

    Does the use of home-based telemedicine improve access to care?

• C

  Office/hospital-based

  • 1

    Does office/hospital-based telemedicine result in comparable diagnosis and appropriateness of recommendations for management?

  • 2

    Does office/hospital-based telemedicine result in comparable health outcomes?

  • 3

    Does the availability of office/hospital-based telemedicine improve access to care?

Literature Search Strategy

We searched the literature for information about ongoing telemedicine programs, activities, and services. This search focused on obtaining English-language journal articles and reports pertaining to the three study areas. We identified programs from the following:

Electronic bibliographic database. The search strategy was similar to that used in the prior report. It was designed to find any publications about telemedicine and was used to search the MEDLINE® database using Ovid, version 19.2.0. The key MeSH terms associated with the search include telemedicine, remote consultation, telecommunications and delivery of health care. Appendix A ^* details the complete search string. The initial search, which identified telemedicine articles published between January 2000 and June 2004, resulted in 3,848 citations. An update of the same strategy in November 2004 yielded 224 additional citations. Other databases, such as EMBASE® and CINAHL®, were not searched, since their coverage tends to duplicate MEDLINE® for telemedicine.

Reference lists. Reference lists of previously published telemedicine systematic reviews were searched, resulting in the inclusion of 11 studies to those identified by our search strategy. Of these 11 studies, six were subsequently included following application of the inclusion criteria. Reference lists of included studies also were searched.

Selection of Abstracts and Full-Text Articles

Figure 2. Results of literature search and abstract (more...)

   Figure 2. Results of literature search and abstract review

Note: Articles may fit into more than one key question category.

Figure 2

Table 1

Inclusion/exclusion criteria

Table 1

Inclusion/exclusion criteria

Code #	Explanation
	Inclusion
1	KEY QUESTION AND DATA
	Addresses a key question on one of the service areas and contains data (results)
	Exclusion
2	NO KEY QUESTION
	Does not address a key question
3	KEY QUESTION, NO DATA
	Addresses a key question, but does not contain data
4	WRONG POPULATION
	Addresses key question and contains data, but population of study is outside our scope
5	GOOD BACKGROUND MATERIAL and/or REVIEW
	However, does not meet inclusion criteria
6	OTHER
	Indicate reason

Table 2

Inter-rater reliability

Table 2

Inter-rater reliability

Reviewers	Percent agreement	Kappa value
WRH, SMS	89.5	.56
WRH, TLD	91.9	.59
DHH, SMS	85.8	.40
DHH, TLD	91.2	.42

Data Abstraction

All studies rated as relevant on the basis of review of titles and abstracts were retrieved, photocopied, and distributed to one of the investigators (WRH or DHH). Studies judged to have evidence about a key question were then abstracted. For each key question, data from each study were abstracted using electronic abstraction forms (Appendix B ¹), and entered into an evidence table. Evidence tables are presented in full in Appendix C.* A second investigator reviewed all studies included in evidence tables to verify the evidence table content. The study quality ratings of all included studies were assigned at this time (see further details in the next section). A complete list of excluded studies appears in Appendix D.^*

Assessment of Study Quality

Table 3

Classification of evidence for studies of clinical (more...)

Table 3

Classification of evidence for studies of clinical outcomes

Study Class	Characteristic
I	Properly designed random controlled trials
II	Random controlled trials that contain design flaws preventing specification of Class I
	Properly designed trials with control groups not randomized
	Multi-center of population-based longitudinal (cohort) study
	Case control studies
III	Descriptive studies (uncontrolled case series)
	Clinical experience
	Expert opinion
	Case reports

Table 4

Classification of evidence for diagnostic and management (more...)

Table 4

Classification of evidence for diagnostic and management decisions

Study Class	Characteristic
I	Case series of consecutive patients from relevant population of individuals who would use telemedicine; using an objective gold standard with blinded interpretation of results; with inter-observer analysis
II	Case series of patients from relevant population of individuals who would use telemedicine; using an objective gold standard
III	Case series not from relevant population or not using appropriate methodology for diagnostic test evaluation

In appraising studies addressing access to care, we adapted criteria described by the Institute of Medicine (IOM)¹⁰ as applied to the use of telemedicine. The model of access to care incorporated three types of indicators: barriers (structural, financial, and personal); utilization; and outcomes (mortality, well-being, or functionality). The IOM has recommended that studies of access to care measure both utilization and outcomes, and our criteria included both measures. Studies that examined only outcomes of care were assigned to the Outcomes category rather than to the Access category.

The definition of access that we used had originally been proposed in a report by the IOM published in 1993⁷ and had been widely disseminated prior to the period of time covered by the studies reviewed for the current report. Other models of access to care have been described,^{11, 12} but these models include elements of staff deployment and scheduling strategies that have rarely been addressed in studies of telemedicine. Thus, we found the IOM model to be best suited to the published literature in this domain.

Table 5

Classification of strength of evidence for studies (more...)

Table 5

Classification of strength of evidence for studies of access to care

Study Class	Characteristic
I	Appropriately comparable comparison group not exposed to telemedicine services; valid measures of utilization and outcomes
II	Appropriately comparable comparison group not exposed to telemedicine services; valid measure of utilization
III	Comparison group absent or not comparable in some respects; valid measure of utilization; outcomes may also be measured

Table 6

Classification of direction of effect

Table 6

Classification of direction of effect

A	Strong improvement or clearly comparable
B	Weak improvement or probably comparable
C	Conflicting evidence for improvement or comparability
D	Negative effect (evidence that technology does not provide comparability or improvement)

Because of the larger evidence base for studies of diagnosis/management and clinical outcomes, we excluded Class III studies from the analysis in these categories. Class III studies were included in the evidence tables for access to care. We included tallies of Class III studies in all summary tables that show the number of studies and their class and effect for each specialty.

Data Synthesis

Results of the evidence report update are presented in full in the evidence tables (Appendix C ²). The investigator for each key question constructed separate evidence tables for each of the three study areas. In general, the evidence tables include author/date, key research question(s), study design/level, population, sample/selection, measures, results, quality rating, and limitations.

For the study areas with more than two studies, we constructed a summary table of specialties or domains and the strength of the evidence for each key question and type of telemedicine. The efficacy for telemedicine can therefore be gleaned from the number of studies that have a “positive” direction of effect, i.e., are rated A or B. For those procedures or services that have evidence, the summary tables show which analytic framework links are supported by evidence. We also interpret our synthesis and discuss the limitations of our approach to this evaluation.

Peer Review Process

Thirteen peer reviewers were selected based on their expertise in the field of telemedicine and their availability to review the draft report. Refer to Appendix E ³ for the list of peer reviewers. The draft report was submitted to the peer reviewers along with a peer review form. The review form was developed by the research team and was based on one used in our original study and those used by other research teams at the Oregon Evidence-based Practice Center. The peer reviewers had three weeks to respond. The comments from the peer reviewers were received and distributed to the investigators for their consideration and response. A spreadsheet was prepared that contained the comments of the peer reviewers and our response to them. The peer review comments aided in creating this improved, comprehensive final document.

Overview of Peer-reviewed Studies

Table 7

Summary of included studies

Table 7

Summary of included studies

	UPDATE				ORIGINAL REPORT
Modality	Diagnosis and management	Access	Outcomes	Total	Diagnosis and management	Access	Outcomes	Total
Store and forward	30	5	0	35	22	2	0	24
Home-based	2	0	25	27	4	2	19	25
Office/hospital-based	20	9	9	38	33	7	6	46
Total	52	14	34	100	59	11	25	95

Table 8

Summary of studies by key questions and results

Table 8

Summary of studies by key questions and results

Summary by key question	Total	I-A	I-B	I-C	II-B	II-C	II-D	III-B	III-C
Diagnosis and management store-and-forward	30	2	3	2	21	2	0
Diagnosis and management home-based	2	0	0	0	0	2	0
Diagnosis and management office/hospital-based	20	1	3	1	13	2	0
Diagnosis and management total	52	3	6	3	34	6	0
Outcomes store-and-forward	0	0	0	0	0	0	0
Outcomes home-based	25	6	2	0	17	0	0
Outcomes office/hospital-based	9	2	0	0	6	1	0
Outcomes total	34	8	2	0	23	1	0
Access store-and-forward	5	0	1	0	1	0	0	2	1
Access home-based	0	0	0	0	0	0	0	0	0
Access office/hospital-based	9	0	1	1	3	1	0	3	1
Access total	14	0	2	1	4	1	0	5	2
All total	100	11	10	4	61	8	0	5	2

Another problem with many of these studies concerns a statistical issue. As noted earlier, the goal of most telemedicine studies is only to show that telemedicine is “comparable” to in-person care, not necessarily “better,” especially when it can provide that care with decreased cost, increased convenience, and/or access to care when none was previously available. One way to determine whether two approaches are comparable is to show there is no statistically significant difference between them. However, lack of statistical significance can also occur even when there is a difference, but the study lacks adequate statistical power to detect it. For this reason, studies with small sample sizes should compute, in addition to an alpha value (the well-known p value), the value of beta. This value estimates the probability that a difference between two comparison groups truly exists when the study results fail to show a difference (also known as a type 2 error). Virtually none of the studies we reviewed assessed beta error, and as such, the “statistical comparability” may exist because there was inadequate statistical power to show otherwise.

In assessing diagnostic and management decision studies, a Class I study had to include not only a comparison of the telemedicine and in-person decisions but also one of the following:

• In the case of concordance studies, a comparison of a “baseline” concordance between two or more face-to-face examiners,

• In the case of accuracy studies, have measurement against a suitable “gold standard” with measures such as sensitivity and specificity.

Therefore, when there was just a comparison of telemedicine and in-person concordance, the study was rated as Class II. Studies were also rated as Class II when the diagnostic assessment did not include a definitive gold standard consisting of an objective test (e.g., biopsy) or a commonly accepted clinical judgment (e.g., visual findings on gastrointestinal endoscopy or of diabetic retinopathy). Class III studies were excluded from our analysis of diagnosis and management decisions.

For the strength of evidence, a grade of A or B was given when the study set out to demonstrate comparability and did so. Class II studies were not graded higher than B, since studies with this level of methodology do not have the quality of evidence to provide convincingly strong results.

For outcomes studies, a Class I study had to be a randomized controlled trial (RCT). RCTs with clear and obvious flaws were rated as Class II, as were cohort, pre-post, and observational studies. For the strength of evidence, a grade of A or B was given when the study set out to demonstrate comparability and did so, or when the study set out to show superiority of telemedicine and did so. Similar to diagnostic and management efficacy studies, Class II studies of outcomes were also not graded higher than B.

Store-and-Forward Telemedicine

Table 9

Summary of studies of store-and-forward telemedicine (more...)

Table 9

Summary of studies of store-and-forward telemedicine for diagnosis and/or management decisions

UPDATE	Total	I-A	I-B	I-C	II-B	II-C	II-D	III-B	III-C
Dermatology	13		2		9	2
Gastroenterology	2				2
Gynecology	3			2	1
Ophthalmology	5	2	1		2
Plastic Surgery	7				7
Total	30	2	3	2	21	2	0
ORIGINAL	Total	I-A	I-B	I-C	II-B	II-C	II-D	III-B	III-C
Ambulatory Care	1					1
Dentistry	1					1
Dermatology	9		2		5			2
Neonatology	1							1
Ophthalmology	5				2	1	1	1
Otolaryngology	2				1			1
Wound Care	1				1
Total	20	0	2	0	9	3	1	5

The most commonly assessed aspect of teledermatology was interobserver concordance.¹³–¹⁹ The range of concordance varied widely, from 41 percent to 87 percent for complete agreement to 51 percent to 96 percent for disease-category agreement. Unfortunately, all of these studies were limited by the lack of measurement of concordance among more than one face-to-face examiner. In other words, none of the studies compared face-to-face versus telemedicine agreement with face-to-face versus face-to-face agreement. As such, none of the studies could be rated as Class I. In our previous report, two studies did assess concordance of face-to-face examiners.^{20, 21} Concordance studies assessing management decisions typically looked at decision to biopsy. While one study found complete agreement,²² others found lesser concordance.^{13, 23}–²⁵

The studies of diagnostic accuracy typically compared the telemedicine diagnosis to some sort of gold standard, often a biopsy of a pigmented lesion.^{13, 23, 26, 27} Most of these studies did not calculate statistical significance, but some did show a trend towards less accuracy for telemedicine.

Store-and-forward applications of teledermatology have generally used commonly available digital cameras and varying techniques for storing and transmitting the digital photographs. Teledermoscopy is a technique by which a low-power lens is used to generate a magnified image of a discrete skin lesion. This methodology was tested in two studies of store-and-forward techniques and found to be comparable to face-to-face diagnosis of pigmented lesions.^{26, 27}

The second most frequently studied clinical area was wound care. Seven studies, all Class II, demonstrated that some characteristics of skin wounds and ulcerations could be assessed effectively using store-and-forward telemedicine. However, most of these studies had small numbers of patients and very small numbers of clinicians, raising the statistical power issues described above.

Five studies provide data on store-and-forward applications in ophthalmology. Four of these studies show that a high accuracy of diagnosing diabetic retinopathy (DR) could be obtained.²⁸–³¹ One of them found, however, that concordance was lower for severity of DR and specific abnormalities.³¹

Other specialties studied include gynecology and gastroenterology. The gynecology studies assessing colposcopy were hindered by the limitations of that procedure even when done in person.^{32, 33}

Table 10

Summary of studies of the effects of store-and-forward (more...)

Table 10

Summary of studies of the effects of store-and-forward telemedicine on access to care

UPDATE	Total	I-B	II-B	III-B	III-C
Dermatology	2	1			1
Ophthalmology	1			1
General Surgery	1			1
Multiple Specialties	1		1
Total	5	1	1	2	1
ORIGINAL	Total	I-B	II-B	III-B	III-C
Dermatology	2		1		1

The studies of access provide information about how telemedicine systems have been deployed in real-world situations and thereby provide an estimate of the actual clinical impact of the systems. All of the studies measured utilization of traditional (non-telemedicine) clinical services following the telemedicine intervention, and all reported the proportion of patients for whom the telemedicine service was the only care received in the index clinical episode. However, two of the studies^{34, 35} collected no data to assess whether the care provided by the telemedicine service was adequate.

All of the studies that included data on access to care examined the deployment of store-and-forward telemedicine systems for screening patients referred for medical or surgical specialty services following referral by clinicians in primary care or general practice settings. One study³⁶ used only text information submitted by electronic mail, while the other four studies all were based on the collection of digital photographs, usually to supplement conventional clinical information submitted in a text format. The effect on utilization of specialty services was generally modest. In the two studies of teledermatology, more than 80 percent of patients were recommended to have subsequent face-to-face evaluations by dermatologists.^{37, 38} In a randomized trial of all specialty consultation requests in a rural Finnish community, the electronic mail-based store and forward system had no effect on the proportion of patients who received follow-up care in the local community rather than at the regional centers providing specialty services.³⁶ The two other studies^{34, 35} used photography-based screening systems by which the majority of patients were recommended not to have specialty follow-up. However, these studies were of relatively low quality and did not collect any follow-up information on the screened patients.

The only study of access to care that was given a Class I rating evaluated a store-and-forward technique for screening primary care patients referred for dermatologic consultation in a Veterans Affairs medical center.³⁸ That study was a randomized trial that included a measure of the time to completion of the consultation. Dermatologists evaluating the patients randomized to teledermatology could determine the time interval to a face-to-face dermatology appointment, while patients randomized to the conventional care group had only a routine appointment scheduled. Patients randomized to the teledermatology group had significantly shorter time intervals until the face-to-face appointment. We judged this to be an unfair comparison, because the study design itself favored improved access to care for the teledermatology group. Since it is likely that the hospital in which the study was conducted had a fixed number of appointment slots for the dermatology clinic, scheduling sooner appointments for patients in the teledermatology group would tend to reduce the pool of available appointments and cause the appointments available to the patients randomized to the conventional care group to be, on average, further distant in time.

Home-Based Telemedicine

Table 11

Summary of studies of home-based telemedicine for clinical (more...)

Table 11

Summary of studies of home-based telemedicine for clinical outcomes

UPDATE	Total	I-A	I-B	I-C	II-B	II-C	II-D	III-B
Congestive Heart Failure	6	1	1		4
Chronic Disease	3	1			2
Coronary Artery Disease	2	1			1
Diabetes Mellitus	5	1	1		3
Hypertension	3	1			2
Lung Transplantation	1				1
Multiple Sclerosis	1				1
Spinal Cord Injury	1	1
Obesity	1				1
Psychiatry	1				1
Pulmonary Medicine	1					1
Total	25	6	2	0	17	0	0
ORIGINAL	Total	I-A	I-B	I-C	II-B	II-C	II-D	III-B
AIDS	2	1	1
Alzheimer’s	1		1
Cardiology	1				1
Chronic Disease	3		1		1			1
Diabetes Mellitus	10	1	1		8
Hypertension	2	1	1
Neonatology	1		1
Pulmonary	1							1
Total	21	3	6	0	10	0	0	2

A common characteristic of the studies of home-based telemedicine was that the intervention included dedicated staff (usually nursing staff) that monitored the data recorded in the home and developed clinical management plans. Some of the studies were randomized controlled trials that compared such systems (technology and dedicated staff) to conventional care (such as visiting nurse services). These studies found improved outcomes with the telemedicine-based interventions, but the design of the studies made it difficult to discern the benefit of the dedicated program staff from the telemedicine intervention.

While a small number of the studies were well-designed RCTs,³⁹–⁴³ the rest were limited by either small sample sizes and/or control groups of dubious value. In addition, while all of the studies assessed achieved at least comparable benefits in clinical outcomes, and thus obtained an effect rating of A or B, the value of such comparability (e.g., same but not better blood sugar control or weight loss) was not clear.

Three studies of chronic disease in the elderly showed benefit of the dedicated programs in both patient functional status and reduced emergency department visits and hospital admissions.⁴⁰–⁴⁴ Some interventions tailored for specific diseases were found to be effective in congestive heart failure (CHF), hypertension, and pulmonary disease.^{39, 42}–⁴⁵ Other home-based interventions, such as blood sugar measurements intended to improve management of diabetes mellitus, were not found consistently superior to usual care.⁴⁶–⁵⁰ Interventions in other domains, such as obesity⁵¹ and lung transplantation,⁵² also failed to show benefit over usual care.

While two studies were identified in the original report that examined the effect of home-based telemedicine systems on access to care, no studies were identified in the 2000-2004 period. Home-based systems have nearly always been used to enhance the care of patients who already receive conventional clinical services, either through clinic visits or via home care agencies. The primary rationale for home-based telemedicine is to improve data collection and/or communication rather than to supplant conventional care (such as clinic or home visits). Thus, the lack of studies examining conventional measures of access to care is not surprising. Expanded definitions of access to care, such as “patient-centered access”¹¹ are applicable to home-based systems and may provide suitable models for future research on the deployment of home-based systems.

Office/Hospital-Based Telemedicine

Table 12

Summary of studies of office/hospital-based telemedicine (more...)

Table 12

Summary of studies of office/hospital-based telemedicine for diagnosis and/or management decisions

UPDATE	Total	I-A	I-B	I-C	II-B	II-C	II-D	III-B	III-C
Cardiology	2				2
Dermatology	1				1
Gastroenterology	1				1
Neurology	4				4
Ophthalmology	5		1	1	1	2
Otolaryngology	2		1		1
Psychiatry	3	1			2
Rheumatology	1		1
Vascular Surgery	1				1
Total	20	1	3	1	13	2	0	0	0
ORIGINAL	Total	I-A	I-B	I-C	II-B	II-C	II-D	III-B	III-C
Cardiology	5		1		3				1
Dentistry	1								1
Dermatology	7					2			5
Emergency Medicine	3				3
Neurology	2		1		1
Ophthalmology	2					1		1
Otolaryngology	2				1			1
Psychiatry	7		2		5
Pulmonary	1				1
Rheumatology	1						1
Trauma	1				1
Urology	1								1
Total	33	0	4	0	15	3	1	2	8

Table 13

Summary of studies of office/hospital-based telemedicine (more...)

Table 13

Summary of studies of office/hospital-based telemedicine for clinical outcomes

UPDATE	Total	I-A	I-B	I-C	II-B	II-C	II-D	III-B
Critical Care	1				1
Neurology	1					1
Orthopedics	2				2
Otolaryngology	1	1
Psychiatry	3	1			2
Wound Care	1				1
Total	9	2	0	0	6	1	0
ORIGINAL	Total	I-A	I-B	I-C	II-B	II-C	II-D	III-B
Dermatology	1				1
Emergency Medicine	1	1
Intensive Care	1				1
Neonatology	1				1
Neurosurgery	2							2
Total	6	1	0	0	3	0	0	2

Table 14

Summary of studies of the effect of office/hospital-based (more...)

Table 14

Summary of studies of the effect of office/hospital-based telemedicine on access to care

UPDATE	Total	I-B	I-C	II-B	II-C	III-B
Neurology	2				1	1
Orthopedics/Rheumatology	3	1		1		1
Ophthalmology	1					1
Multiple specialties	1		1
Psychiatry	1			1
Hematology	1			1
Total	9	1	1	3	1	3
ORIGINAL	Total	I-B	I-C	II-B	II-C	III-B
Neurosurgery	3			2		1
Cardiology	2					2
Multiple specialties	2					2
Total	7	0	0	2	0	5

For diagnosis and management decisions, the most commonly studied specialty was ophthalmology. As with store-and-forward studies, some aspects of ophthalmologic evaluation were amenable to interactive telemedicine, while others were not. One Class I study showed rates of disagreement in eye injuries under 10 percent,⁵³ while another found disagreement was consistently higher with telemedicine than when comparing two in-person evaluations.⁵⁴

Other frequently studied specialties included neurology and psychiatry. Although the studies were rated Class II, two studies showed neurological diagnosis was highly concordant^{55, 56} and two studies showed that the NIH Stroke Scale could be reliably administered via telemedicine.^{57, 58} A few Class II studies demonstrated concordance on a variety of psychiatric scales.⁵⁹–⁶¹ Studies in other specialties, such as dermatology,⁶² rheumatology,⁶³ and vascular surgery⁶⁴ demonstrated that some diagnostic assessments can be successfully administered interactively via telemedicine.

Studies of clinical outcomes also showed that for most of the clinical specialties assessed, outcomes between conventional and telemedicine interventions were comparable. However, most of these studies were limited by small sample sizes (with the caveats concerning statistical significance described earlier), lack of randomization, and assessment of less than the full range of clinical outcomes. None of these studies attempted to measure statistical power to avoid beta error. Class I RCTs showing comparable outcomes were done in otolaryngology⁶⁵ and psychiatry.⁶⁶

The studies of access have examined the use of office-based telemedicine in both suburban and rural settings and have examined both specialist evaluations and follow-up continuity care. In limited studies of patients with sickle cell anemia⁶⁷ and patients with chronic psychiatric disorders,⁶⁸ office-based telemedicine appeared to be adequate for the ongoing routine care of patients in rural areas, with few problems reported. For new evaluations by specialists of patients referred by general practitioners, the use of office-based telemedicine led to a significantly greater rate of diagnostic test utilization than face-to-face consultations for neurology patients⁶⁹ but not for patients needing other types of specialty care.^{70, 71} Two studies compared office-based telemedicine to telephone consultations between a referring physician and a specialist.^{63, 72} Both these studies had weak designs but had results suggesting that the telemedicine system provided faster access to definitive care.

Studies of Telemedicine in Non-Medicare Populations

A total of 28 studies identified in the literature search were excluded from consideration for evidence tables because they were conducted in populations not eligible for Medicare services based on their demographic characteristics. All of these 28 studies were considered to have evidence potentially applicable to the key questions on the basis of the initial title and abstract review. The populations examined in these studies included children, pregnant women, incarcerated prisoners, and active duty military personnel. These studies were subjected to further review, and twelve were deemed to have evidence suitable for inclusion in evidence tables if we had not applied the population exclusion. Seven of the studies examined home-based telemedicine, three examined store-and-forward techniques, and two examined office-based telemedicine applications. The studies' findings were consistent with the findings of the studies included in the evidence tables. We concluded that excluding studies conducted on non-Medicare populations had not biased our overall conclusions.

Evidence about Efficacy

This update on evidence about the efficacy of telemedicine for the Medicare population covered published peer-reviewed literature for the five years between 2000 and 2004. Similar to the findings of our original report a half-decade ago, there are still serious gaps in the evidence base for telemedicine. While this situation is hardly unique to telemedicine, having a solid evidence base is essential given that there is increased advocacy for health care payers, especially Medicare, to provide coverage for its use. In the discussion that follows, we will review telemedicine by specialty in the case of store-and-forward and office/hospital-based telemedicine and by disease domain in the case of home-based telemedicine.

The best evidence for the effectiveness of telemedicine is in medical specialties for which verbal interactions are a key component of the patient assessment, such as psychiatry and neurology. Various psychiatric and neurological assessments can be administered effectively via interactive videoconferencing. Likewise, treatments administered in these specialties via telemedicine appear to achieve comparability with face-to-face care. It can probably be concluded that medical care administered via interactive videoconferencing can achieve results that are comparable to their in-person counterparts.

Our systematic review also identified several studies, a few of them of high methodologic quality, showing benefits of home-based telemedicine interventions in chronic diseases. These systems appear to enhance communication with health care providers and provide closer monitoring of general health, but the studies of these techniques were conducted in settings that required additional resources and dedicated staff. Deployment of home monitoring technology in the absence of these integrated systems is unlikely to be beneficial. Systems designed to facilitate specific aspects of care, such as blood sugar and blood pressure measurements, provide less clear benefit. With ongoing improvements in telecommunications technology, particularly broadband connections to the home, further research, including larger clinical trials, will likely be informative.

The specialty with the largest number of studies is dermatology, and most studies of teledermatology have evaluated store-and-forward techniques. The body of evidence summarized in this report is consistent with the findings of the earlier report. There continues to be highly variable rates of interobserver and intraobserver agreement in diagnoses. This issue can only be resolved by high-quality studies that compare not only the concordance of telemedicine versus face-to-face diagnosis, but also the concordance of face-to-face versus face-to-face diagnosis in the same situation. It should be noted that the teleophthalmology field has done this in most of their diagnostic concordance studies.

The published studies of teledermatology have other flaws as well. For example, most of them included only a small number of teledermatologists. Over half of the studies we identified used three or fewer teledermatologists. In addition, most of the studies deployed teledermatology only in a laboratory type of setting. The few studies of real-world use of teledermatology found that most patients required subsequent face-to-face clinical encounters. Thus, it appears that the expense and time commitment of teledermatology systems have not yet demonstrated the potential for improving access to care.

Of course, rates of concordance in a vacuum, i.e., without a clinical context of how the patient fared, are also limited from an evidence standpoint. What we ultimately need to know is the patient outcome. In other words, did the teledermatology encounter at least provide comparable care for the patient? A corollary question that must be answered is whether teledermatology resulted in harm from any missed diagnoses or other aspects of the telemedicine situation. These questions can only be answered in studies of clinical outcomes, none of which were identified in this report. One study has been completed (personal communication, J Whited), but at the time of this writing has not yet been submitted for publication. In general, advocacy for an expanded role for teledermatology will require further studies that examine rates of missed diagnoses, incorrect treatments, and when the technology is insufficient to avoid in-person encounters.

Most published studies of teledermatology have examined store-and-forward techniques, with relatively few studies of real-time office-based techniques. Despite its current widespread use, additional evidence is required to conclude that store-and-forward teledermatology can be routinely substituted for face-to-face encounters in the evaluation of new referrals to dermatologists. Dermatologic practice also involves follow-up visits of patients who have previously received a comprehensive dermatologic evaluation. Store-and-forward teledermatology may be better suited to such follow-up visits, but there have been no published reports of experience with this type of visit. Store-and-forward techniques also may be a useful adjunct in dermatologic consultations for settings in which patients are located a great distance from the consultant (such as isolated rural settings). The published studies suggest that a fraction of such patients may successfully avoid face-to-face visits to complete the dermatologic evaluation.

Teleophthalmology has been widely studied, and this field has produced commercial systems for retinal photographs that are becoming widely used as a clinical tool to augment face-to-face evaluations of patients at risk for diabetic retinopathy.⁷³ The quality of studies in this domain is slightly higher than in dermatology, although the results are equivocal. Essentially, teleophthalmology results in high rates of diagnostic concordance and accuracy for only some eye conditions. It appears to be most efficacious for the assessment of diabetic retinopathy. However, there are a number of diagnoses for which it fares less well, and it is often unusable altogether when certain patient characteristics are present, such as cataracts and other lens abnormalities. The value of a technology that is only useful for some conditions must be assessed in the larger picture of clinical outcomes and ultimately the economics of investing in equipment that is not always useful.

Also widely studied is the use of telemedicine for wound care. The key observation from studies assessing telemedicine for this purpose is that all of the studies have small sample sizes, use only one assessor, and do not compare in-person examiners when assessing concordance. These studies present a trend of comparability, but serious questions remain about their statistical power and reproducibility.

The situation of gynecology, in particular telecolposcopy, is also instructive. Studies show that the accuracy of diagnosis by telemedicine is comparable to face-to-face assessment. However, the accuracy of neither of these approaches is terribly efficacious, in the range of 50–60 percent.

An often-touted benefit of telemedicine is the provision of care to rural areas, where specialists are less prevalent and individuals in need of them must travel great distances to see them. Studies of rural populations have tended to be of poorer methodological quality than studies of urban and suburban populations. The limited evidence available supports the use of office/hospital-based telemedicine for providing continuity care of stable patients by specialists. The technological platform for such systems is relatively uncomplicated and can be based on widely available teleconferencing equipment.

In general, the role of telemedicine most likely to demonstrate value could be as an adjunct to care that is centered around the in-person visit. As noted above, it could, for example, serve as a means to triage skin lesions, injuries, and other problems that arise where appropriate specialty care is not available. In most instances, clinical care will likely still require in-person diagnosis and management. Likewise, telemedicine may also play a role in managing the growing number of elderly and other infirmed individuals with chronic diseases. Its value may not be as a substitute for in-person care as much as an adjunct to it.

Experience with telemedicine has similarities to other attempts to apply computer technology to clinical environments. Computer-based expert systems went through a long period of experimental evaluation and limited deployment, and systems designed to enhance (or even replace) clinician judgment were found to be best suited to narrow clinical domains.⁷⁴–⁷⁶ Nevertheless, the use of computer-based decision support has steadily increased, as it has been more appropriately integrated into the clinical care process, serving more as an assistant than a replacement of clinical judgment and expertise.⁷⁷ Well-designed and definitive clinical trials of this type of decision support have enhanced the adoption of the technology.^{78, 79}

As noted in Chapter 1, this review is limited in scope to the peer-reviewed literature of telemedicine. While this spectrum of data does not cover all or even most of the experience with telemedicine, it does provide the most objective, evidence-based assessment of this technology. The presence of a small number of well-designed studies with positive outcomes that our analysis identified shows that it is possible to demonstrate efficacy of telemedicine.

Of course, there may be situations when the use of telemedicine is warranted even if the evidence is lacking. For example, there may be situations when care would be otherwise impossible to deliver except via telemedicine. This could include remote rural areas or other locations where medical care is not available locally and the patient is for whatever reason unable to travel to a setting where it can be obtained. However, even in these instances it is important to understand the efficacy of telemedicine so any clinical shortcomings can be anticipated. We are reassured that no studies show telemedicine to cause any significant harm.

We also acknowledge that the efficacy of telemedicine is not immune to other forces in health care, such as the structure of the delivery system. There are instances when reimbursement or other incentives are not amenable to innovations, technical or otherwise. In particular, fee-for-service health care will likely provide incentive for modalities of care that are reimbursed, not necessarily those that provide the best quality care. Therefore it will be important for ongoing research to take into account the health care setting when evaluating the efficacy of telemedicine.

Future Research

The present evidence base provides guidance on the clinical areas in which future research is most likely to be useful. It now is clear that continued small or methodologically weak studies are unlikely to add to the evidence base for telemedicine. In teledermatology, larger and more comprehensive analyses that assess key patient outcomes are needed. Likewise, there is a need for similar studies of clinical outcomes using office/hospital-based telemedicine in fields such as psychiatry and neurology. Well-designed RCTs will likely provide valuable information on the potential of these clinical applications. Longitudinal observational studies and demonstration projects also will be useful. Studies of home-based telemedicine should carefully address the independent contributions of technology and human resources in the complex delivery models for patients with chronic diseases.

We recognize the limitations of advice that telemedicine be studied with more and larger RCTs. Not only are such trials expensive, but they are difficult to carry out. They also have a long lead-time from their planning and inception to completion and analysis of results. Another challenge with RCTs in this area is that telemedicine is not a single technology or intervention. It is a tool that is used to deliver different aspects of clinical care for diverse diseases. Due to the time and expense of RCTs, other means to assess telemedicine interventions objectively should also be explored. Given the growing use of electronic health records, selective data could be extracted on patients with telemedicine interventions to assess them longitudinally. Such studies will be most feasible in large integrated delivery networks with advanced electronic health record systems.

This report has found that the evidence base for telemedicine is incomplete yet improving. Further well-designed and targeted research that provides high-quality data will provide a strong contribution to understanding how best to deploy technological resources in health care.

Conclusion

The promise of telemedicine is not matched by the strength of its evidence base. The technology to administer telemedicine is prevalent and, in some locations, ubiquitous. Telemedicine is widely used, with increasing numbers of health care payers reimbursing for its use. However, outside of a small number of clinical specialties, the evidence base for the efficacy of telemedicine is weak. Areas where telemedicine is most promising include home health and specialties where care can be delivered via interactive videoconferencing, such as psychiatry and neurology. There is mixed evidence for the efficacy of telemedicine in dermatology and ophthalmology. Further research must address the limited evidence base so that the optimal use of telemedicine can be ascertained.

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Berg BW, Vincent DS, Hudson DA. Remote critical care consultation: telehealth projection of clinical specialty expertise. J Telemed Telecare. 2003; 9(Suppl 2): S9–11. Excluded - no comparison group. [PubMed]

Bielli E, Carminati F, La Capra S. et al. A Wireless Health Outcomes Monitoring System (WHOMS): development and field testing with cancer patients using mobile phones. BMC Med Inf Decis Mak. 2004 Jun 15;4(1): 7. Excluded - does not meet our definition of telemedicine.

Billingsley KG, Schwartz DL, Lentz S. et al. The development of a telemedical cancer center within the Veterans Affairs Health Care System: a report of preliminary clinical results. Telemed J E Health. 2002 Spring;8(1): 123–30. Excluded - contains no or inadequate data. [PubMed]

Bishai DM, Ferris DG, Litaker MS. What is the least costly strategy to evaluate cervical abnormalities in rural women? Comparing telemedicine, local practitioners, and expert physicians. Med Decis Making. 2003 Nov–Dec;23(6): 463–70. Excluded - does not address a key question. [PubMed]

Bishop JE, O'Reilly RL, Maddox K. et al. Client satisfaction in a feasibility study comparing face-to-face interviews with telepsychiatry. J Telemed Telecare. 2002; 8(4): 217–21. Excluded - does not address a key question. [PubMed]

Blomdahl S, Calissendorff B, Jacobsson U. Patient-focused urban tele-ophthalmology services. J Telemed Telecare. 2002; 8(Suppl 2): 43–4. Excluded - contains no or inadequate data. [PubMed]

Blomdahl S, Maren N, Lof R. Tele-ophthalmology for the treatment in primary care of disorders in the anterior part of the eye. J Telemed Telecare. 2001; 7(Suppl 1): 25–6. Excluded - contains no or inadequate data. [PubMed]

Bose U, McLaren P, Riley A. et al. The use of telepsychiatry in the brief counselling of non-psychotic patients from an inner-London general practice. J Telemed Telecare. 2001; 7(Suppl 1): 8–10. Excluded - contains no or inadequate data. [PubMed]

Boukhors Y, Rabasa-Lhoret R, Langelier H. et al. The use of information technology for the management of intensive insulin therapy in type 1 diabetes mellitus. Diabetes Metab. 2003 Dec;29(6): 619–27. Excluded - does not meet our definition of telemedicine. [PubMed]

Boulanger B, Kearney P, Ochoa J. et al. Telemedicine: a solution to the followup of rural trauma patients? J Am Coll Surg. 2001 Apr;192(4): 447–52. Excluded - does not address a key question. [PubMed]

Bove P, Stoianovici D, Micali S. et al. Is telesurgery a new reality? Our experience with laparoscopic and percutaneous procedures. J Endourol. 2003 Apr;17(3): 137–42. Excluded - does not address a key question. [PubMed]

Bowater M. The experience of a rural general practitioner using videoconferencing for telemedicine. J Telemed Telecare. 2001; 7(Suppl 2): 24–5. Excluded - contains no or inadequate data. [PubMed]

Bracale M, Cesarelli M, Bifulco P. Telemedicine services for two islands in the Bay of Naples. J Telemed Telecare. 2002; 8(1): 5–10. Excluded - does not address a key question. [PubMed]

Braun RP, Meier M, Pelloni F. et al. Teledermatoscopy in Switzerland: a preliminary evaluation. Journal of the American Academy of Dermatology. 2000; 42(5 Pt 1): 770–5. Excluded - included in previous report. [PubMed]

Brebner EM, Brebner JA. Implementation and evaluation of telemedicine for remote health-care the European Northern Periphery Programme Project. J Telemed Telecare. 2001; 7(Suppl 1): 68–9. Excluded - does not address a key question. [PubMed]

Brebner EM, Brebner JA, Ruddick-Bracken H. et al. Evaluation of a pilot telemedicine network for accident and emergency work. J Telemed Telecare. 2002; 8(Suppl 2): 5–6. Excluded - contains no or inadequate data. [PubMed]

Brebner EM, Brebner JA, Ruddick-Bracken H. et al. Evaluation of an accident and emergency teleconsultation service for north-east Scotland. J Telemed Telecare. 2004; 10(1): 16–20. Excluded - contains no or inadequate data. [PubMed]

Brebner JA, Brebner EM, Ruddick-Bracken H. et al. The development of a pilot telemedicine network in Scotland: lessons learned. J Telemed Telecare. 2001; 7(Suppl 2): 83–4. Excluded - contains no or inadequate data. [PubMed]

Bremner F, Kennedy C, Rees A. et al. Usefulness of teleconsultations in neuro-ophthalmology. J Telemed Telecare. 2002; 8(5): 305–6. Excluded - contains no or inadequate data. [PubMed]

Brennan DM, Georgeadis AC, Baron CR. et al. The effect of videoconference-based telerehabilitation on story retelling performance by brain-injured subjects and its implications for remote speech-language therapy. Telemed J E Health. 2004 Summer;10(2): 147–54. Excluded - contains no or inadequate data. [PubMed]

Brennan PF, Moore SM, Bjornsdottir G. et al. HeartCare: an Internet-based information and support system for patient home recovery after coronary artery bypass graft (CABG) surgery.[see comment]. J Adv Nurs. 2001 Sep;35(5): 699–708. Excluded - contains no or inadequate data. [PubMed]

Brenner B. Is the provision of laboratory results via the Internet acceptable to patients? A survey of private patients in a large, specialist gynaecology practice. N Z Med J. 2003 Dec 12;116(1187): U711. Excluded - does not address a key question. [PubMed]

Brian J, Jamieson S. Post-surgical cardiac patients receive new level of care. Caring. 2002 Mar;21(3): 28–9. Excluded - does not address a key question. [PubMed]

Broderick TJ, Harnett BM, Doarn CR. et al. Real-time Internet connections: implications for surgical decision making in laparoscopy. Ann Surg. 2001 Aug;234(2): 165–71. Excluded - does not address a key question. [PubMed] [Free Full text in PMC]

Brodey BB, Claypoole KH, Motto J. et al. Satisfaction of forensic psychiatric patients with remote telepsychiatric evaluation. Psychiatr Serv. 1305; 51(10): 1305–7. Excluded - wrong population. [PubMed]

Brown-Connolly NE. Patient satisfaction with telemedical access to specialty services in rural California. J Telemed Telecare. 2002; 8(Suppl 2): 7–10. Excluded - does not address a key question. [PubMed]

Brownrigg P, Lowry JC, Edmondson MJ. et al. Telemedicine in oral surgery and maxillofacial trauma: a descriptive account. Telemed J E Health. 2004 Spring;10(1): 27–31. Excluded - contains no or inadequate data. [PubMed]

Burgess LP, Syms MJ, Holtel MR. et al. Telemedicine: teleproctored endoscopic sinus surgery. Laryngoscope. 2002 Feb;112(2): 216–9. Excluded - contains no or inadequate data. [PubMed]

Bursell SE, Cavallerano JD, Cavallerano AA. et al. Stereo nonmydriatic digital-video color retinal imaging compared with Early Treatment Diabetic Retinopathy Study seven standard field 35-mm stereo color photos for determining level of diabetic retinopathy. Ophthalmology. 2001 Mar;108(3): 572–85. Excluded - does not meet our definition of telemedicine. [PubMed]

Buurke JH, Kleissen RF, Nene A. et al. A feasibility study of remote consultation to determine suitability for surgery in stroke rehabilitation. J Telemed Telecare. 2004; 10(2): 108–12. Excluded - contains no or inadequate data. [PubMed]

Bynum A, Hopkins D, Thomas A. et al. The effect of telepharmacy counseling on metered-dose inhaler technique among adolescents with asthma in rural Arkansas. Telemed J E Health. 2001 Fall;7(3): 207–17. Excluded - wrong population. [PubMed]

Bynum AB, Cranford CO, Irwin CA. et al. Participant satisfaction with a school telehealth education program using interactive compressed video delivery methods in rural Arkansas. J Sch Health. 2002 Aug;72(6): 235–42. Excluded - wrong population. [PubMed]

Bynum AB, Irwin CA, Cranford CO. et al. The impact of telemedicine on patients' cost savings: some preliminary findings. Telemed J E Health. 2003 Winter;9(4): 361–7. Excluded - does not address a key question. [PubMed]

Byrne JP, Mughal MM. Telementoring as an adjunct to training and competence-based assessment in laparoscopic cholecystectomy. Surgical Endoscopy. 1159; 14(12): 1159–61. Excluded - does not address a key question. [PubMed]

Cabrera MF, Arredondo MT, Quiroga J. Integration of telemedicine into emergency medical services. J Telemed Telecare. 2002; 8(Suppl 2): 12–4. Excluded - contains no or inadequate data. [PubMed]

Cadiere GB, Himpens J, Vertruyen M. et al. Evaluation of telesurgical (robotic) NISSEN fundoplication. Surgical Endoscopy. 2001 Sep;15(9): 918–23. Excluded - does not address a key question. [PubMed]

Car J, Sheikh A. Email consultations in health care: 1--scope and effectiveness. Bmj. 2004 Aug 21;329(7463): 435–8. Excluded - does not address a key question. [PubMed] [Free Full text in PMC]

Car J, Sheikh A. Email consultations in health care: 2--acceptability and safe application. Bmj. 2004 Aug 21;329(7463): 439–42. Excluded - does not address a key question. [PubMed] [Free Full text in PMC]

Cargill A, Watson AR. Telecare support for patients undergoing chronic peritoneal dialysis. Perit Dial Int. 2003 Jan–Feb;23(1): 91–4. Excluded - does not address a key question. [PubMed]

Cathala N, Brillat F, Mombet A. et al. Patient followup after radical prostatectomy by Internet medical file. J Urol. 2003 Dec;170(6 Pt 1): 2284–7. Excluded - does not address a key question. [PubMed]

Cavallerano AA, Cavallerano JD, Katalinic P. et al. Use of Joslin Vision Network digital-video nonmydriatic retinal imaging to assess diabetic retinopathy in a clinical program. Retina. 2003 Apr;23(2): 215–23. Excluded - no comparison group. [PubMed]

Cavan DA, Everett J, Plougmann S. et al. Use of the Internet to optimize self-management of type 1 diabetes: preliminary experience with DiasNet. J Telemed Telecare. 2003; 9(Suppl 1): S50–2. Excluded - contains no or inadequate data. [PubMed]

Cavina E, Goletti O, Lippolis PV. et al. Telesonography: technical problems, solutions and results in the routine utilization from remote areas. Studies in Health Technology & Informatics. 2001; 81: 88–9. Excluded - does not address a key question. [PubMed]

Cawthorpe D. An evaluation of a computer-based psychiatric assessment: evidence for expanded use. Cyberpsychol Behav. 2001 Aug;4(4): 503–10. Excluded - contains no or inadequate data. [PubMed]

Cervi PL, Everitt AS. Automatic voice mail for delivering computer-generated anticoagulant dose advice to patients. J Telemed Telecare. 2002; 8(5): 259–63. Excluded - does not address a key question. [PubMed]

Chae YM, Heon Lee J, Hee Ho S. et al. Patient satisfaction with telemedicine in home health services for the elderly. Int J Med Inf. 2001 May;61(23): 167–73. Excluded - does not address a key question.

Chae YM, Park HJ, Cho JG. et al. The reliability and acceptability of telemedicine for patients with schizophrenia in Korea. J Telemed Telecare. 2000; 6(2): 83–90. Excluded - does not address a key question. [PubMed]

Chambers M, Connor S. Technology as an aid to coping with caring: a usability evaluation of a telematics intervention. Medinfo. 2001; 10(Pt 2): 1130–4. Excluded - does not meet our definition of telemedicine. [PubMed]

Chambers M, Connor SL. User-friendly technology to help family carers cope. J Adv Nurs. 2002 Dec;40(5): 568–77. Excluded - does not meet our definition of telemedicine. [PubMed]

Chambers MG, Connor SL, McGonigle M. et al. Multimedia software to help caregivers cope. J Am Med Inform Assoc. 2003 Sep–Oct;10(5): 504–11. Excluded - does not meet our definition of telemedicine. [PubMed] [Free Full text in PMC]

Chan DS, Callahan CW, Sheets SJ. et al. An Internet-based store-and-forward video home telehealth system for improving asthma outcomes in children. Am J Health Syst Pharm. 2003 Oct 1;60(19): 1976–81. Excluded - wrong population. [PubMed]

Chan WM, Woo J, Hui E. et al. The role of telenursing in the provision of geriatric outreach services to residential homes in Hong Kong. J Telemed Telecare. 2001; 7(1): 38–46. Excluded - contains no or inadequate data. [PubMed]

Chao LW, Cestari TF, Bakos L. et al. Evaluation of an Internet-based teledermatology system. J Telemed Telecare. 2003; 9(Suppl 1): S9–12. Excluded - contains no or inadequate data. [PubMed]

Chao LW, Enokihara MY, Silveira PS. et al. Telemedicine model for training non-medical persons in the early recognition of melanoma. J Telemed Telecare. 2003; 9(Suppl 1): S4–7. Excluded - contains no or inadequate data. [PubMed]

Chase HP, Pearson JA, Wightman C. et al. Modem transmission of glucose values reduces the costs and need for clinic visits.[see comment]. Diabetes Care. 2003 May;26(5): 1475–9. Excluded - wrong population. [PubMed]

Chen K, Lim A, Shumack S. Teledermatology: influence of zoning and education on a clinician's ability to observe peripheral lesions. Australas J Dermatol. 2002 Aug;43(3): 171–4. Excluded - contains no or inadequate data. [PubMed]

Chen RS, Chen SK. Teledentistry using videoconferencing and a DICOM image management system. J Telemed Telecare. 2002; 8(4): 244–6. Excluded - contains no or inadequate data. [PubMed]

Cherry JC, Dryden K, Kobb R. et al. Opening a window of opportunity through technology and coordination: a multisite case study. Telemed J E Health. 2003 Fall;9(3): 265–71. Excluded - contains no or inadequate data. [PubMed]

Cherry JC, Moffatt TP, Rodriguez C. et al. Diabetes disease management program for an indigent population empowered by telemedicine technology. Diabetes Technol Ther. 2002; 4(6): 783–91. Excluded - does not address a key question. [PubMed]

Chetney R. The Cardiac Connection program: home care that doesn't miss a beat. Home Healthc Nurse. 2003 Oct;21(10): 680–6. Excluded - does not address a key question. [PubMed]

Cheung JC, Dick PT, Kraft SP. et al. Strabismus examination by telemedicine. Ophthalmology. 1999; 107(11): 1999–2005. Excluded - wrong population. [PubMed]

Choremis J, Chow DR. Use of telemedicine in screening for diabetic retinopathy.[see comment]. Can J Ophthalmol. 2003 Dec;38(7): 575–9. Excluded - no comparison group. [PubMed]

Chua R, Craig J, Wootton R. et al. Cost implications of outpatient teleneurology. J Telemed Telecare. 2001; 7(Suppl 1): 62–4. Excluded - does not address a key question. [PubMed]

Cipolat C, Bader U, Rufli T. et al. Teledermatology in Switzerland. Aktuelle Probl Dermatol. 2003; 32: 257–60. Excluded - contains no or inadequate data.

Clement PF, Brooks FR, Dean B. et al. A neuropsychology telemedicine clinic. Mil Med. 2001 May;166(5): 382–4. Excluded - contains no or inadequate data. [PubMed]

Clifton GD, Byer H, Heaton K. et al. Provision of pharmacy services to underserved populations via remote dispensing and two-way videoconferencing. Am J Health Syst Pharm. 2003 Dec 15;60(24): 2577–82. Excluded - does not address a key question. [PubMed]

Collins K, Bowns I, Walters S. General practitioners' perceptions of asynchronous telemedicine in a randomized controlled trial of teledermatology. J Telemed Telecare. 2004; 10(2): 94–8. Excluded - contains no or inadequate data. [PubMed]

Collins K, Walters S, Bowns I. Patient satisfaction with teledermatology: quantitative and qualitative results from a randomized controlled trial. J Telemed Telecare. 2004; 10(1): 29–33. Excluded - does not address a key question. [PubMed]

Collins PW, Bolton-Maggs P, Stephenson D. et al. Pilot study of an Internet-based electronic patient treatment record and communication system for haemophilia, Advoy.com. Haemophilia. 2003 May;9(3): 285–91. Excluded - does not address a key question. [PubMed]

Cone SW, Gehr L, Hummel R, et al. Case report of remote anesthetic monitoring using telemedicine. Anesth Analg 2004 Feb; 98(2):386–8, table of contents. Excluded - contains no or inadequate data.

Constable IJ, Yogesan K, Eikelboom R. et al. Fred Hollows lecture: digital screening for eye disease. Clinical & Experimental Ophthalmology. 2000; 28(3): 129–32. Excluded - does not address a key question. [PubMed]

Cook DJ, Doolittle GC, Whitten PS. Administrator and provider perceptions of the factors relating to programme effectiveness in implementing telemedicine to provide end-of-life care. J Telemed Telecare. 2001; 7(Suppl 2): 17–9. Excluded - does not address a key question. [PubMed]

Cook HL, Heacock GL, Stanford MR. et al. Detection of retinal lesions after telemedicine transmission of digital images. Eye. 2000; 14(Pt 4): 563–71. Excluded - does not meet our definition of telemedicine. [PubMed]

Cook J, Edwards J, Mullings C. et al. Dentists' opinions of an online orthodontic advice service. J Telemed Telecare. 2001; 7(6): 334–7. Excluded - does not address a key question. [PubMed]

Cook J, Mullings C, Vowles R. et al. Online orthodontic advice: a protocol for a pilot teledentistry system. J Telemed Telecare. 2001; 7(6): 324–33. Excluded - contains no or inadequate data. [PubMed]

Corcoran H, Hui E, Woo J. The acceptability of telemedicine for podiatric intervention in a residential home for the elderly. J Telemed Telecare. 2003; 9(3): 146–9. Excluded - contains no or inadequate data. [PubMed]

Cornish PA, Church E, Callanan T. et al. Rural interdisciplinary mental health team building via satellite: a demonstration project. Telemed J E Health. 2003 Spring;9(1): 63–71. Excluded - does not address a key question. [PubMed]

Corr P, Couper I, Beningfield SJ. et al. A simple telemedicine system using a digital camera. J Telemed Telecare. 2000; 6(4): 233–6. Excluded - does not meet our definition of telemedicine. [PubMed]

Cowain T. Cognitive-behavioural therapy via videoconferencing to a rural area. Aust N Z J Psychiatry. 2001 Feb;35(1): 62–4. Excluded - no comparison group. [PubMed]

Coyle N, Khojainova N, Francavilla JM. et al. Audio-visual communication and its use in palliative care. J Pain Symptom Manage. 2002 Feb;23(2): 171–5. Excluded - contains no or inadequate data. [PubMed]

Craig J, Chua R, Russell C. et al. A cohort study of early neurological consultation by telemedicine on the care of neurological inpatients. J Neurol Neurosurg Psychiatry. 2004 Jul;75(7): 1031–5. Excluded - contains no or inadequate data. [PubMed] [Free Full text in PMC]

Cummings DM, Morrissey S, Barondes MJ. et al. Screening for diabetic retinopathy in rural areas: the potential of telemedicine. J Rural Health. 2001 Winter;17(1): 25–31. Excluded - no comparison group. [PubMed]

Dadd M, Doyle B, Wilson L, et al. Lessons learned from the Hospital Without Walls project. J Telemed Telecare 2002 8(Suppl 3):S3:11–4. Excluded - does not address a key question.

Dale J, Connor S, Tolley K. An evaluation of the west Surrey telemedicine monitoring project. J Telemed Telecare. 2003; 9(Suppl 1): S39–41. Excluded - contains no or inadequate data. [PubMed]

d'Annunzio G, Bellazzi R, Larizza C. et al. Telemedicine in the management of young patients with type 1 diabetes mellitus: a follow-up study. Acta Biomed Ateneo Parmense. 2003; 74(Suppl 1): 49–55. Excluded - contains no or inadequate data.

Dansky KH, Bowles KH. Lessons learned from a telehomecare project. Caring. 2002 Apr;21(4): 18–22. Excluded - contains no or inadequate data. [PubMed]

Dansky KH, Palmer L, Shea D. et al. Cost analysis of telehomecare. Telemed J E Health. 2001 Fall;7(3): 225–32. Excluded - does not address a key question. [PubMed]

Dansky KH, Yant B, Jenkins D. et al. Qualitative analysis of telehomecare nursing activities. Journal of Nursing Administration. 2003 Jul–Aug;33(78): 372–5. Excluded - contains no or inadequate data. [PubMed]

Davis P. The application of telehealth to rheumatology. Clin Rheumatol. 2003 Sep;22(3): 168–72. Excluded - contains no or inadequate data. [PubMed]

Davis P, Howard R, Brockway P. Telehealth consultations in rheumatology: cost-effectiveness and user satisfaction. J Telemed Telecare. 2001; 7(Suppl 1): 10–1. Excluded - does not address a key question. [PubMed]

Davis P, Howard R, Brockway P. An evaluation of telehealth in the provision of rheumatologic consults to a remote area.[see comment]. J Rheumatol. 2001 Aug;28(8): 1910–3. Excluded - does not address a key question. [PubMed]

Davis RM, Fowler S, Bellis K. et al. Telemedicine improves eye examination rates in individuals with diabetes: a model for eye-care delivery in underserved communities. Diabetes Care. 2003 Aug;26(8): 2476. Excluded - does not address a key question. [PubMed]

De Las Cuevas C, Artiles J, De La Fuente J. et al. Telepsychiatry in the Canary Islands: user acceptance and satisfaction. J Telemed Telecare. 2003; 9(4): 221–4. Excluded - does not address a key question. [PubMed]

de Lusignan S, Althans A, Wells S, et al. A pilot study of radiotelemetry for continuous cardiopulmonary monitoring of patients at home. J Telemed Telecare 2000 6(1) Excluded - contains no or inadequate data.

Deb N, Thuret G, Estour B. et al. Screening for diabetic retinopathy in France. Diabetes Metab. 2004 Apr;30(2): 140–5. Excluded - contains no or inadequate data. [PubMed]

Debray M, Couturier P, Greuillet F. et al. A preliminary study of the feasibility of wound telecare for the elderly. J Telemed Telecare. 2001; 7(6): 353–8. Excluded - contains no or inadequate data. [PubMed]

Deitsch SE, Frueh BC, Santos AB. Telepsychiatry for post-traumatic stress disorder. J Telemed Telecare. 2000; 6(3): 184–6. Excluded - contains no or inadequate data. [PubMed]

DeLeo G, Krishna S, Balas EA, et al. WEB-WAP based telecare. Proc AMIA Symp 2002:200–4. Excluded - contains no or inadequate data.

Delgado DH, Costigan J, Wu R. et al. An interactive Internet site for the management of patients with congestive heart failure. Can J Cardiol. 2003 Nov;19(12): 1381–5. Excluded - contains no or inadequate data. [PubMed]

DeMaio J, Schwartz L, Cooley P. et al. The application of telemedicine technology to a directly observed therapy program for tuberculosis: a pilot project. Clin Infect Dis. 2001 Dec 15;33(12): 2082–4. Excluded - contains no or inadequate data. [PubMed]

Demartines N. Telemedicine applications in surgery. Aktuelle Probl Dermatol. 2003; 32: 94–101. Excluded - does not address a key question.

Demartines N, Mutter D, Marescaux J. et al. Preliminary assessment of the value and effect of expert consultation in telemedicine. J Am Coll Surg. 2000; 190(4): 466–70. Excluded - does not address a key question. [PubMed]

Demartines N, Mutter D, Vix M. et al. Assessment of telemedicine in surgical education and patient care. Ann Surg. 2000; 231(2): 282–91. Excluded - contains no or inadequate data. [PubMed] [Free Full text in PMC]

Demartines N, Otto U, Mutter D. et al. An evaluation of telemedicine in surgery: telediagnosis compared with direct diagnosis. Archives of Surgery. 2000; 135(7): 849–53. Excluded - does not address a key question. [PubMed]

Demichelis F, Barbareschi M, Boi S. et al. Robotic telepathology for intraoperative remote diagnosis using a still-imaging-based system. American Journal of Clinical Pathology. 2001 Nov;116(5): 744–52. Excluded - does not address a key question. [PubMed]

Demiris G, Speedie S, Finkelstein S. et al. Communication patterns and technical quality of virtual visits in home care. J Telemed Telecare. 2003; 9(4): 210–5. Excluded - does not address a key question. [PubMed]

DeMolles DA, Sparrow D, Gottlieb DJ. et al. A pilot trial of a telecommunications system in sleep apnea management. Med Care. 2004 Aug;42(8): 764–9. Excluded - does not meet our definition of telemedicine. [PubMed]

Denton IC. Will patients use electronic personal health records? Responses from a real-life experience. J Healthc Inf Manag. 2001 Fall;15(3): 251–9. Excluded - does not address a key question. [PubMed]

Deodhar J. Telemedicine by email--experience in neonatal care at a primary care facility in rural India. J Telemed Telecare. 2002; 8(Suppl 2): 20–1. Excluded - does not address a key question. [PubMed]

Diamond BJ, Shreve GM, Bonilla JM. et al. Telerehabilitation, cognition and user-accessibility. NeuroRehabilitation. 2003; 18(2): 171–7. Excluded - does not address a key question. [PubMed]

DiCianni N, Kobza L. A chance to heal. Home health agencies can improve patient care and increase profits with telehealth wound consulting. Health Manag Technol. 2002 Apr;23(4): 22–4. Excluded - does not address a key question. [PubMed]

Dimmick SL, Burgiss SG, Robbins S. et al. Outcomes of an integrated telehealth network demonstration project. Telemed J E Health. 2003 Spring;9(1): 13–23. Excluded - contains no or inadequate data. [PubMed]

Dimmick SL, Mustaleski C, Burgiss SG. et al. A case study of benefits & potential savings in rural home telemedicine. Home Healthc Nurse. 2000; 18(2): 124–35. Excluded - does not address a key question. [PubMed]

Doarn CR, Fitzgerald S, Rodas E. et al. Telemedicine to integrate intermittent surgical services into primary care. Telemed J E Health. 2002 Spring;8(1): 131–7. Excluded - contains no or inadequate data. [PubMed]

Docherty EM, Ferguson J. Telemedical management of an odontoid peg fracture in the Shetland Isles. J Telemed Telecare. 2000; 6(6): 350–1. Excluded - contains no or inadequate data. [PubMed]

Dreyer NC, Dreyer KA, Shaw DK. et al. Efficacy of telemedicine in occupational therapy: a pilot study. J Allied Health. 2001 Spring;30(1): 39–42. Excluded - contains no or inadequate data. [PubMed]

D'Souza R. Telemedicine for intensive support of psychiatric inpatients admitted to local hospitals. J Telemed Telecare 2000 6(1) Excluded - contains no or inadequate data.

Dulou R, Poichotte A, Goasguen O. et al. Telemedicine in the management of a cervical dislocation by a mobile neurosurgeon. J Telemed Telecare. 2002; 8(4): 241–3. Excluded - contains no or inadequate data. [PubMed]

Dunn BE, Choi H, Almagro UA. et al. Combined robotic and nonrobotic telepathology as an integral service component of a geographically dispersed laboratory network. Hum Pathol. 2001 Dec;32(12): 1300–3. Excluded - does not address a key question. [PubMed]

Dunne MG, Dunne SB. Improved teleradiology reporting using fax software. AJR Am J Roentgenol. 2004 Apr;182(4): 871–4. Excluded - does not address a key question. [PubMed]

Durtschi A. Three patients' tele-home care experiences. Home Healthc Nurse. 2001 Jan;19(1): 9–11. Excluded - contains no or inadequate data. [PubMed]

Egol KA, Helfet DL, Koval KJ. Efficacy of telemedicine in the initial management of orthopedic trauma. Am J Orthop. 2003 Jul;32(7): 356–60. Excluded - contains no or inadequate data. [PubMed]

Eich HT, Muller RP, Schneeweiss A. et al. Initiation of a teleradiotherapeutic network for patients in German lymphoma studies. Int J Radiat Oncol Biol Phys. 2004 Mar 1;58(3): 805–8. Excluded - does not address a key question. [PubMed]

Eisdorfer C, Czaja SJ, Loewenstein DA. et al. The effect of a family therapy and technology-based intervention on caregiver depression. Gerontologist. 2003 Aug;43(4): 521–31. Excluded - wrong population. [PubMed] [Free Full text in PMC]

Ellis DG, Mayrose J. The success of emergency telemedicine at the State University of New York at Buffalo. Telemed J E Health. 2003 Spring;9(1): 73–9. Excluded - does not address a key question. [PubMed]

Ellis DG, Mayrose J, Jehle DV. et al. A telemedicine model for emergency care in a short-term correctional facility. Telemed J E Health. 2001 Summer;7(2): 87–92. Excluded - wrong population. [PubMed]

Erlanger D, Kaushik T, Cantu R. et al. Symptom-based assessment of the severity of a concussion. J Neurosurg. 2003 Mar;98(3): 477–84. Excluded - does not address a key question. [PubMed]

Fabrizio MD, Lee BR, Chan DY. et al. Effect of time delay on surgical performance during telesurgical manipulation. J Endourol. 2000; 14(2): 133–8. Excluded - does not address a key question. [PubMed]

Farup PG, Skar V. Collaboration by use of the Internet yields data of high quality and detects non-uniform management of patients with Helicobacter pylori infection.[see comment]. Scand J Gastroenterol. 2002 Dec;37(12): 1466–70. Excluded - no comparison group. [PubMed]

Farzanfar R, Finkelstein J, Friedman RH. Testing the usability of two automated home-based patient-management systems. J Med Syst. 2004 Apr;28(2): 143–53. Excluded - does not address a key question. [PubMed]

Faulkner K. Successes and failures in videoconferencing: a community health education programme. J Telemed Telecare. 2001; 7(Suppl 2): 65–7. Excluded - does not address a key question. [PubMed]

Ferguson J, Rowlands A, Palombo A. et al. Minor injuries telemedicine. J Telemed Telecare. 2003; 9(Suppl 1): S14–6. Excluded - does not address a key question. [PubMed]

Ferris DG, Litaker MS, Gilman PA. et al. Patient acceptance and the psychological effects of women experiencing telecolposcopy and colposcopy. J Am Board Fam Pract. 2003 Sep–Oct;16(5): 405–11. Excluded - does not address a key question. [PubMed]

Finch T, May C, Mair F. et al. Integrating service development with evaluation in telehealthcare: an ethnographic study. Bmj. 2003 Nov 22;327(7425): 1205–9. Excluded - does not address a key question. [PubMed] [Free Full text in PMC]

Finkelstein J, Cabrera MR, Hripcsak G. Internet-based home asthma telemonitoring: can patients handle the technology? Chest. 2000; 117(1): 148–55. Excluded - included in previous report. [PubMed]

Finkelstein SM, Speedie SM, Demiris G. et al. Telehomecare: quality, perception, satisfaction. Telemed J E Health. 2004 Summer;10(2): 122–8. Excluded - contains no or inadequate data. [PubMed]

Fortin JP, Gagnon MP, Cloutier A. et al. Evaluation of a telemedicine demonstration project in the Magdalene Islands. J Telemed Telecare. 2003; 9(2): 89–94. Excluded - contains no or inadequate data. [PubMed]

Fries BE and James M. Identifying “appropriate” applicants for home and community based services: the MI Choice screening system. Cent Home Care Policy Res Policy Briefs 2003 Spring; (13):1–6. Excluded - does not address a key question.

Fries BE, Shugarman LR, Morris JN. et al. A screening system for Michigan's home- and community-based long-term care programs. Gerontologist. 2002 Aug;42(4): 462–74. Excluded - does not address a key question. [PubMed]

Frosch DL, Kaplan RM, Felitti VJ. A randomized controlled trial comparing internet and video to facilitate patient education for men considering the prostate specific antigen test.[see comment]. J Gen Intern Med. 2003 Oct;18(10): 781–7. Excluded - does not address a key question. [PubMed] [Free Full text in PMC]

Fujiwara T, Nishimura T, Ohkuko T. et al. Rationale and design of HOMED-BP Study: hypertension objective treatment based on measurement by electrical devices of blood pressure study. Blood Press Monit. 2002 Feb;7(1): 77–82. Excluded - contains no or inadequate data. [PubMed]

Galvan FH, Bing EG, Bluthenthal RN. Accessing HIV testing and care. Journal of Acquired Immune Deficiency Syndromes: JAIDS. 2000; 25(2): 15. Excluded - contains no or inadequate data.

Gilbertson L, Langhorne P, Walker A. et al. Domiciliary occupational therapy for patients with stroke discharged from hospital: randomised controlled trial. Bmj. 2000; 320(7235): 603–6. Excluded - does not address a key question. [PubMed] [Free Full text in PMC]

Givens GD, Blanarovich A, Murphy T. et al. Internet-based tele-audiometry system for the assessment of hearing: a pilot study. Telemed J E Health. 2003 Winter;9(4): 375–8. Excluded - does not address a key question. [PubMed]

Goldfield GS, Boachie A. Delivery of family therapy in the treatment of anorexia nervosa using telehealth. Telemed J E Health. 2003 Spring;9(1): 111–4. Excluded - contains no or inadequate data. [PubMed]

Gomez EJ, Caceres C, Lopez D. et al. A web-based self-monitoring system for people living with HIV/AIDS. Comput Methods Programs Biomed. 2002 Jul;69(1): 75–86. Excluded - contains no or inadequate data. [PubMed]

Gomez EJ, Hernando ME, Garcia A. et al. Telemedicine as a tool for intensive management of diabetes: the DIABTel experience. Comput Methods Programs Biomed. 2002 Aug;69(2): 163–77. Excluded - no comparison group. [PubMed]

Gonzalez F, Iglesias R, Suarez A. et al. Tele-ophthalmology link between a primary health care centre and a reference hospital. Med Inform Internet Med. 2001 Oct–Dec;26(4): 251–63. Excluded - no comparison group. [PubMed]

Graham LE, McGimpsey S, Wright S, et al. Could a low-cost audio-visual link be useful in rheumatology? J Telemed Telecare 2000 6(1) Excluded - included in previous report.

Granlund H. Aspects of quality: face-to-face versus teleconsulting. Aktuelle Probl Dermatol. 2003; 32: 158–66. Excluded - does not address a key question.

Granlund H, Thoden CJ, Carlson C. et al. Realtime teleconsultations versus face-to-face consultations in dermatology: immediate and six-month outcome. J Telemed Telecare. 2003; 9(4): 204–9. Excluded - does not address a key question. [PubMed]

Gray J, Brain K, Iredale R. et al. A pilot study of telegenetics. J Telemed Telecare. 2000; 6(4): 245–7. Excluded - does not address a key question. [PubMed]

Gray JE, Safran C, Davis RB. et al. Baby CareLink: using the internet and telemedicine to improve care for high-risk infants. Pediatrics. 1318; 106(6): 1318–24. Excluded - wrong population. [PubMed]

Greist JH, Marks IM, Baer L. et al. Behavior therapy for obsessive-compulsive disorder guided by a computer or by a clinician compared with relaxation as a control. J Clin Psychiatry. 2002 Feb;63(2): 138–45. Excluded - does not meet our definition of telemedicine. [PubMed]

Guilfoyle C, Wootton R, Hassall S, et al. Videoconferencing in facilities providing care for elderly people. J Telemed Telecare 2002 8(Suppl 3):S3:22–4. Excluded - does not address a key question.

Haegen TW, Cupp CC, Hunsaker DH. Teleotolaryngology: a retrospective review at a military tertiary treatment facility. Otolaryngol Head Neck Surg. 2004 May;130(5): 511–8. Excluded - wrong population. [PubMed]

Hagan L, Morin D, Lepine R. Evaluation of telenursing outcomes: satisfaction, self-care practices, and cost savings. Public Health Nurs. 2000; 17(4): 305–13. Excluded - does not address a key question. [PubMed]

Hall JA, Huber DL. Telephone management in substance abuse treatment. Telemedicine Journal & E Health. 2000; 6(4): 401–7. Excluded - contains no or inadequate data. [PubMed]

Hansson KS, Allebeck P, Malm U. Event recording in psychiatric care: development of an instrument and 1-year results. Nord J Psychiatry. 2001; 55(1): 25–31. Excluded - contains no or inadequate data. [PubMed]

Harley J, McLaren P, Blackwood G. et al. The use of videoconferencing to enhance tertiary mental health service provision to the island of Jersey. J Telemed Telecare. 2002; 8(Suppl 2): 36–8. Excluded - contains no or inadequate data. [PubMed]

Harno K, Arajarvi E, Paavola T. et al. Clinical effectiveness and cost analysis of patient referral by videoconferencing in orthopaedics. J Telemed Telecare. 2001; 7(4): 219–25. Excluded - contains no or inadequate data. [PubMed]

Harno K, Paavola T, Carlson C. et al. Patient referral by telemedicine: effectiveness and cost analysis of an Intranet system. J Telemed Telecare. 2000; 6(6): 320–9. Excluded - does not address a key question. [PubMed]

Harper DM, Moncur MM, Harper WH. et al. The technical performance and clinical feasibility of telecolposcopy. J Fam Pract. 2000; 49(7): 623–7. Excluded - no comparison group. [PubMed]

Hashimoto S, Shirato H, Kaneko K. et al. Clinical efficacy of telemedicine in emergency radiotherapy for malignant spinal cord compression. Journal of Digital Imaging. 2001 Sep;14(3): 124–30. Excluded - contains no or inadequate data. [PubMed]

Hatzakis M Jr., Haselkorn J, Williams R. et al. Telemedicine and the delivery of health services to veterans with multiple sclerosis. J Rehabil Res Dev. 2003 May–Jun;40(3): 265–82. Excluded - wrong population. [PubMed]

Hauber RP, Jones ML. Telerehabilitation support for families at home caring for individuals in prolonged states of reduced consciousness. J Head Trauma Rehabil. 2002 Dec;17(6): 535–41. Excluded - contains no or inadequate data. [PubMed]

Helveston EM, Orge FH, Naranjo R. et al. Telemedicine: Strabismus e-consultation. J Aapos. 2001 Oct;5(5): 291–6. Excluded - contains no or inadequate data. [PubMed]

High WA, Houston MS, Calobrisi SD. et al. Assessment of the accuracy of low-cost store-and-forward teledermatology consultation. Journal of the American Academy of Dermatology. 2000; 42(5 Pt 1): 776–83. Excluded - included in previous report. [PubMed]

Hildebrand R, Chow H, Williams C. et al. Feasibility of neuropsychological testing of older adults via videoconference: implications for assessing the capacity for independent living. J Telemed Telecare. 2004; 10(3): 130–4. Excluded - does not meet our definition of telemedicine. [PubMed]

Hill JV, Allman LR, Ditzler TF. Utility of real-time video teleconferencing in conducting family mental health sessions: two case reports. Telemed J E Health. 2001 Spring;7(1): 55–9. Excluded - contains no or inadequate data. [PubMed]

Hilty DM, Luo JS, Morache C. et al. Telepsychiatry: an overview for psychiatrists. CNS Drugs. 2002; 16(8): 527–48. Excluded - does not address a key question. [PubMed]

Hilty DM, Marks SL, Urness D. et al. Clinical and educational telepsychiatry applications: a review.[see comment]. Can J Psychiatry. 2004 Jan;49(1): 12–23. Excluded - does not address a key question. [PubMed]

Hilty DM, Nesbitt TS, Canning RD. et al. Telepsychiatry for the management of a liver transplantation candoesate in the primary care setting. Gen Hosp Psychiatry. 2000; 22(2): 122–3. Excluded - contains no or inadequate data. [PubMed]

Hilty DM, Sison JI, Nesbitt TS. et al. Telepsychiatric consultation for ADHD in the primary care setting. J Am Acad Child Adolesc Psychiatry. 2000; 39(1): 15–6. Excluded - wrong population. [PubMed]

Hui E and Woo J. Telehealth for older patients: the Hong Kong experience. J Telemed Telecare 2002 8(Suppl 3):S3:39–41. Excluded - does not address a key question.

Hui E, Woo J, Hjelm M. et al. Telemedicine: a pilot study in nursing home residents. Gerontology. 2001 Mar–Apr;47(2): 82–7. Excluded - contains no or inadequate data. [PubMed]

Hunkeler EM, Meresman JF, Hargreaves WA. et al. Efficacy of nurse telehealth care and peer support in augmenting treatment of depression in primary care.[see comment][comment]. Archives of Family Medicine. 2000; 9(8): 700–8. Excluded - does not meet our definition of telemedicine. [PubMed]

Jacklin PB, Roberts JA, Wallace P. et al. Virtual outreach: economic evaluation of joint teleconsultations for patients referred by their general practitioner for a specialist opinion. Bmj. 2003 Jul 12;327(7406): 84. Excluded - does not address a key question. [PubMed] [Free Full text in PMC]

Jacobsen SE, Sprenger T, Andersson S. et al. Neuropsychological assessment and telemedicine: a preliminary study examining the reliability of neuropsychology services performed via telecommunication. J Int Neuropsychol Soc. 2003 Mar;9(3): 472–8. Excluded - does not address a key question. [PubMed]

Jamara RJ, Denial A, Valentini D. et al. Clinical quality assessment using computer monitor photoimages of optic nerve head cupping. Optometry & Vision Science. 2000; 77(8): 433–6. Excluded - does not address a key question. [PubMed]

Jian G, Mao J, Jiang J. Telediagnosis of 168 cases of renal disease. J Telemed Telecare. 2002; 8(6): 360–1. Excluded - no comparison group. [PubMed]

Jithoo R, Govender PV, Corr P. et al. Telemedicine and neurosurgery: experience of a regional unit based in South Africa. J Telemed Telecare. 2003; 9(2): 63–6. Excluded - contains no or inadequate data. [PubMed]

Johanson M, Gustafsson M, Johansson LA. A remote auscultation tool for advanced home health-care. J Telemed Telecare. 2002; 8(Suppl 2): 45–7. Excluded - contains no or inadequate data. [PubMed]

Johnston D, Jones BN 3rd. Telepsychiatry consultations to a rural nursing facility: a 2-year experience. J Geriatr Psychiatry Neurol. 2001 Summer;14(2): 72–5. Excluded - no comparison group. [PubMed]

Jones BN,, 3rd.; Johnston, D.; Reboussin, B.et al. Reliability of telepsychiatry assessments: subjective versus observational ratings.[see comment]. J Geriatr Psychiatry Neurol. 2001 Summer;14(2): 66–71. Excluded - contains no or inadequate data. [PubMed]

Jones D, Gill P, Harrison R. et al. An exploratory study of language interpretation services provided by videoconferencing. J Telemed Telecare. 2003; 9(1): 51–6. Excluded - does not address a key question. [PubMed]

Kaufman DR, Patel VL, Hilliman C. et al. Usability in the real world: assessing medical information technologies in patients' homes. J Biomed Inform. 2003 Feb–Apr;36(12): 45–60. Excluded - does not address a key question. [PubMed]

Kawasaki S, Ito S, Satoh S. et al. Use of telemedicine in periodic screening of diabetic retinopathy. Telemed J E Health. 2003 Fall;9(3): 235–9. Excluded - does not address a key question. [PubMed]

Kennedy C, Blignault I, Hornsby D. et al. Videoconferencing in the Queensland health service. J Telemed Telecare. 2001; 7(5): 266–71. Excluded - does not address a key question. [PubMed]

Kennedy C, Kirwan J, Cook C. et al. Telemedicine techniques can be used to facilitate the conduct of multicentre trials. J Telemed Telecare. 2000; 6(6): 343–7. Excluded - does not address a key question. [PubMed]

Kennedy C, Van Heerden A, Cook C. et al. Utilization and practical aspects of tele-ophthalmology between South Africa and the UK. J Telemed Telecare. 2001; 7(Suppl 1): 20–2. Excluded - contains no or inadequate data. [PubMed]

Kennedy C and Yellowlees P. A community-based approach to evaluation of health outcomes and costs for telepsychiatry in a rural population: preliminary results. J Telemed Telecare 2000 6(1) Excluded - contains no or inadequate data.

Kenwright M, Marks IM. Computer-aided self-help for phobia/panic via internet at home: a pilot study. Br J Psychiatry. 2004 May;184: 448–9. Excluded - no comparison group. [PubMed]

Kerner R, Yogev Y, Belkin A. et al. Maternal self-administered fetal heart rate monitoring and transmission from home in high-risk pregnancies. Int J Gynaecol Obstet. 2004 Jan;84(1): 33–9. Excluded - wrong population. [PubMed]

Kirkwood KT, Peck DF, Bennie L. The consistency of neuropsychological assessments performed via telecommunication and face to face. J Telemed Telecare. 2000; 6(3): 147–51. Excluded - included in previous report. [PubMed]

Kiuru MJ, Paakkala TA, Kallio TT. et al. Effect of teleradiology on the diagnosis, treatment and prognosis of patients in a primary care centre. J Telemed Telecare. 2002; 8(1): 25–31. Excluded - no comparison group. [PubMed]

Kobza L, Scheurich A. The impact of telemedicine on outcomes of chronic wounds in the home care setting. Ostomy Wound Management. 2000; 46(10): 48–53. Excluded - no comparison group.

Korhonen I, Iivainen T, Lappalainen R. et al. TERVA: system for long-term monitoring of wellness at home. Telemed J E Health. 2001 Spring;7(1): 61–72. Excluded - contains no or inadequate data. [PubMed]

Kornowski R, Zlochiver S, Botzer L. et al. Validation of vital signs recorded via a new telecare system. J Telemed Telecare. 2003; 9(6): 328–33. Excluded - contains no or inadequate data. [PubMed]

Kruger DF, White K, Galpern A. et al. Effect of modem transmission of blood glucose data on telephone consultation time, clinic work flow, and patient satisfaction for patients with gestational diabetes mellitus. J Am Acad Nurse Pract. 2003 Aug;15(8): 371–5. Excluded - wrong population. [PubMed]

Krupinski E, Barker G, Rodriguez G. et al. Telemedicine versus in-person dermatology referrals: an analysis of case complexity. Telemed J E Health. 2002 Summer;8(2): 143–7. Excluded - does not address a key question. [PubMed]

Krupinski EA, Barker G, Lopez AM. et al. An analysis of unsuccessful teleconsultations. J Telemed Telecare. 2004; 10(1): 6–10. Excluded - does not address a key question. [PubMed]

Krupinski EA, Engstrom M, Barker G. et al. The challenges of following patients and assessing outcomes in teledermatology. J Telemed Telecare. 2004; 10(1): 21–4. Excluded - contains no or inadequate data. [PubMed]

Labiris G, Coertzen I, Katsikas A. et al. An eight-year study of internet-based remote medical counselling. J Telemed Telecare. 2002; 8(4): 222–5. Excluded - does not address a key question. [PubMed]

Labiris G, Fanariotis M, Christoulakis C. et al. Tele-ophthalmology and conventional ophthalmology using a mobile medical unit in remote Greece. J Telemed Telecare. 2003; 9(5): 296–9. Excluded - does not address a key question. [PubMed]

Labiris G, Papadopoulis G, Lentaris G. et al. Internet based counseling to remote orthopedic patients. Acta Orthop Scand. 2004 Jun;75(3): 366–7. Excluded - does not address a key question. [PubMed]

Ladyzynski P, Wojcicki JM, Krzymien J. et al. Teletransmission system supporting intensive insulin treatment of out-clinic type 1 diabetic pregnant women. Technical assessment during 3 years' application. Int J Artif Organs. 2001 Mar;24(3): 157–63. Excluded - wrong population. [PubMed]

Lahtela JT, Lamminen H. Telemedical devices in diabetes management. Ann Med. 2002; 34(4): 241–7. Excluded - does not address a key question. [PubMed]

Lamminen H, Lamminen J, Ruohonen K. et al. A cost study of teleconsultation for primary-care ophthalmology and dermatology. J Telemed Telecare. 2001; 7(3): 167–73. Excluded - does not address a key question. [PubMed]

Lamminen H, Tuomi ML, Lamminen J. et al. A feasibility study of realtime teledermatology in Finland. J Telemed Telecare. 2000; 6(2): 102–7. Excluded - contains no or inadequate data. [PubMed]

Lange A, van de Ven JP, Schrieken BA. et al. Internet-mediated, protocol-driven treatment of psychological dysfunction. J Telemed Telecare. 2000; 6(1): 15–21. Excluded - contains no or inadequate data. [PubMed]

Lankford DA. Wireless CPAP patient monitoring: accuracy study. Telemed J E Health. 2004 Summer;10(2): 162–9. Excluded - does not address a key question. [PubMed]

Lateef F, Anantharaman V. Maritime radio-medical services: the Singapore General Hospital experience. Am J Emerg Med. 2002 Jul;20(4): 349–51. Excluded - does not address a key question. [PubMed]

Lau C, Churchill RS, Kim J. et al. Asynchronous web-based patient-centered home telemedicine system. IEEE Trans Biomed Eng. 2002 Dec;49(12): 1452–62. Excluded - contains no or inadequate data. [PubMed]

Lee BR, Png DJ, Liew L. et al. Laparoscopic telesurgery between the United States and Singapore. Annals of the Academy of Medicine, Singapore. 2000; 29(5): 665–8. Excluded - does not address a key question.

Lee JH, Kim JH, Jhoo JH. et al. A telemedicine system as a care modality for dementia patients in Korea. Alzheimer Disease & Associated Disorders. 2000; 14(2): 94–101. Excluded - contains no or inadequate data. [PubMed]

Leifer D. Net gains for health. Nurs Stand. 2003 May 28–Jun 3;17(37): 16–8. Excluded - does not address a key question.

Leonard S. The development and evaluation of a telepsychiatry service for prisoners. J Psychiatr Ment Health Nurs. 2004 Aug;11(4): 461–8. Excluded - wrong population. [PubMed]

Leong FJ, Nicholson AG, McGee JO. Robotic telepathology: efficacy and usability in pulmonary pathology. J Pathol. 2002 Jun;197(2): 211–7. Excluded - does not address a key question. [PubMed]

Lessing K, Blignault I. Mental health telemedicine programmes in Australia. J Telemed Telecare. 2001; 7(6): 317–23. Excluded - does not address a key question. [PubMed]

Lester J, Prady S, Finegan Y. et al. Learning from e-patients at Massachusetts General Hospital. Bmj. 2004 May 15;328(7449): 1188–90. Excluded - does not address a key question. [PubMed] [Free Full text in PMC]

Lieder TR. Telemedicine company brings ICU patients to the physician. American Journal of Health System Pharmacy. 2000; 57(24): 2246–7. Excluded - contains no or inadequate data. [PubMed]

Lim AC, See AC, Shumack SP. Progress in Australian teledermatology. J Telemed Telecare. 2001; 7(Suppl 2): 55–9. Excluded - contains no or inadequate data. [PubMed]

Lin CC, Bai Y, Chen JY. Reliability of information provided by patients of a virtual psychiatric clinic. Psychiatr Serv. 2003 Aug;54(8): 1167–8. Excluded - does not address a key question. [PubMed]

Lin CC, Chen HS, Chen CY. et al. Implementation and evaluation of a multifunctional telemedicine system in NTUH. Int J Med Inf. 2001 May;61(23): 175–87. Excluded - does not address a key question.

Lin DY, Blumenkranz MS, Brothers RJ. et al. The sensitivity and specificity of single-field nonmydriatic monochromatic digital fundus photography with remote image interpretation for diabetic retinopathy screening: a comparison with ophthalmoscopy and standardized mydriatic color photography.[see comment]. Am J Ophthalmol. 2002 Aug;134(2): 204–13. Excluded - does not address a key question. [PubMed]

Liu L and Miyazaki M. Telerehabilitation at the University of Alberta. J Telemed Telecare 2000 6(2) Excluded - contains no or inadequate data.

Loane MA, Bloomer SE, Corbett R. et al. A randomized controlled trial assessing the health economics of realtime teledermatology compared with conventional care: an urban versus rural perspective. J Telemed Telecare. 2001; 7(2): 108–18. Excluded - does not address a key question. [PubMed]

Loane MA, Bloomer SE, Corbett R. et al. A comparison of real-time and store-and-forward teledermatology: a cost-benefit study. Br J Dermatol. 143(6): 1241–7. Excluded - no comparison group. [PubMed]

Loane MA, Bloomer SE, Corbett R, et al. A randomized controlled trial to assess the clinical effectiveness of both realtime and store-and-forward teledermatology compared with conventional care. J Telemed Telecare 2000 6(1) Excluded - included in previous report.

Loh PK, Ramesh P, Maher S. et al. Can patients with dementia be assessed at a distance? The use of Telehealth and standardised assessments. Intern Med J. 2004 May;34(5): 239–42. Excluded - does not address a key question. [PubMed]

Louis AA, Turner T, Gretton M. et al. A systematic review of telemonitoring for the management of heart failure. Eur J Heart Fail. 2003 Oct;5(5): 583–90. Excluded - contains no or inadequate data. [PubMed]

Lowry J. The development of a telemedicine system for a centralized maxillofacial unit serving four towns. J Telemed Telecare. 2001; 7(Suppl 1): 58–9. Excluded - does not address a key question. [PubMed]

Luethi U, Risch L, Korte W. et al. Telehematology: critical determinants for successful implementation. Blood. 2004 Jan 15;103(2): 486–8. Excluded - contains no or inadequate data. [PubMed]

Lyketsos CG, Roques C, Hovanec L. et al. Telemedicine use and the reduction of psychiatric admissions from a long-term care facility. J Geriatr Psychiatry Neurol. 2001 Summer;14(2): 76–9. Excluded - contains no or inadequate data. [PubMed]

Lynch J, Weaver L, Hall P. et al. Using telehealth technology to support CME in end-of-life care for community physicians in Ontario. Telemed J E Health. 2004 Spring;10(1): 103–7. Excluded - contains no or inadequate data. [PubMed]

Macduff C, West B, Harvey S. Telemedicine in rural care. Part 1: Developing and evaluating a nurse-led initiative. Nurs Stand. 2001 Apr 25–May 1;15(32): 33–8. Excluded - does not address a key question.

Macduff C, West B, Harvey S. Telemedicine in rural care. Part 2: Assessing the wider issues. Nurs Stand. 2001 May 2–8;15(33): 33–7. Excluded - does not address a key question.

MacFarlane A, Harrison R, Wallace P. The benefits of a qualitative approach to telemedicine research. J Telemed Telecare. 2002; 8(Suppl 2): 56–7. Excluded - does not address a key question. [PubMed]

Mair F, Boland A, Angus R. et al. A randomized controlled trial of home telecare. J Telemed Telecare. 2002; 8(Suppl 2): 58–60. Excluded - contains no or inadequate data. [PubMed]

Malone F, Callahan CW, Chan DS. et al. Caring for children with asthma through teleconsultation: “ECHO-Pac, The Electronic Children's Hospital of the Pacific” Telemed J E Health. 2004 Summer;10(2): 138–46. Excluded - wrong population. [PubMed]

Mann T, Colven R. A picture is worth more than a thousand words: enhancement of a pre-exam telephone consultation in dermatology with digital images. Acad Med. 2002 Jul;77(7): 742–3. Excluded - contains no or inadequate data. [PubMed]

Mantzouranis EC. User friendliness aspects of home care telematics. Methods Inf Med. 2002; 41(5): 370–5. Excluded - does not address a key question. [PubMed]

Marchevsky AM, Lau SK, Khanafshar E. et al. Internet teleconferencing method for telepathology consultations from lung and heart transplant patients. Hum Pathol. 2002 Apr;33(4): 410–4. Excluded - does not address a key question. [PubMed]

Marcin JP, Nesbitt TS, Kallas HJ. et al. Use of telemedicine to provide pediatric critical care inpatient consultations to underserved rural Northern California. J Pediatr. 2004 Mar;144(3): 375–80. Excluded - wrong population. [PubMed]

Maree DM, Videler EA, Hallauer M. et al. Comparison of a new desktop spirometer (Diagnosa) with a laboratory spirometer. Respiration. 2001; 68(4): 400–4. Excluded - does not address a key question. [PubMed]

Marietti C. Healthcare innovations in technology systems Telehealth in the city. The Charles R. Drew University-Nortel partnership delivers quality healthcare to an urban neighborhood. Healthcare Informatics. 2001 Jun;18(6): 97–8. Excluded - does not address a key question. [PubMed]

Marks IM, Kenwright M, McDonough M. et al. Saving clinicians' time by delegating routine aspects of therapy to a computer: a randomized controlled trial in phobia/panic disorder. Psychol Med. 2004 Jan;34(1): 9–17. Excluded - does not address a key question. [PubMed]

Martin EM, Coyle MK, Warden DL. et al. Telephonic nursing in traumatic brain injury. Am J Nurs. 2003 Oct;103(10): 75–81. Excluded - does not address a key question. [PubMed]

Martin S, Rankin G. Using commercially available technology to assist in the delivery of person-centred health and social care. J Telemed Telecare. 2002; 8(Suppl 2): 60–2. Excluded - contains no or inadequate data. [PubMed]

Mathewson C, Adkins VK, Jones ML. Initial experiences with telerehabilitation and contingency management programs for the prevention and management of pressure ulceration in patients with spinal cord injuries. J Wound Ostomy Continence Nurs. 2000; 27(5): 269–71. Excluded - contains no or inadequate data. [PubMed]

Mattson S, Shearer N, Long C. Exploring telehealth opportunities in domestic violence shelters. J Am Acad Nurse Pract. 2002 Oct;14(10): 465–70. Excluded - contains no or inadequate data. [PubMed]

Mavrogeni SI, Tsirintani M, Kleanthous C. et al. Supervision of thrombolysis of acute myocardial infarction using telemedicine. J Telemed Telecare. 2000; 6(1): 54–8. Excluded - contains no or inadequate data. [PubMed]

May C, Gask L, Ellis N, et al. Telepsychiatry evaluation in the north-west of England: preliminary results of a qualitative study. J Telemed Telecare 20006(1) Excluded - contains no or inadequate data.

Mbao MN, Eikelboom RH, Atlas MD. et al. Evaluation of video-otoscopes suitable for teleotology. Telemed J E Health. 2003 Winter;9(4): 325–30. Excluded - contains no or inadequate data. [PubMed]

McCafferty M, Sorbellini D, Cianci P. Telemetry to home: successful discharge of patients with ventricular assist devices. Crit Care Nurse. 2002 Jun;22(3): 43–51. Excluded - contains no or inadequate data. [PubMed]

McGauran A. Telemedicine Straight to video. Health Service Journal. 2003 Jul 31;113(5866): 26–7. Excluded - contains no or inadequate data. [PubMed]

McIntosh A, Thie J. The development of a new model for community telemedicine services. J Telemed Telecare. 2001; 7(Suppl 1): 69–72. Excluded - does not address a key question. [PubMed]

McKinstry B, Walker J, Campbell C. et al. Telephone consultations to manage requests for same-day appointments: a randomised controlled trial in two practices. Br J Gen Pract. 2002 Apr;52(477): 306–10. Excluded - does not meet our definition of telemedicine. [PubMed] [Free Full text in PMC]

McLaren P, Ahlbom J, Riley A. et al. The North Lewisham telepsychiatry project: beyond the pilot phase. J Telemed Telecare. 2002; 8(Suppl 2): 98–100. Excluded - contains no or inadequate data. [PubMed]

Meade B, Barnett P. Emergency care in a remote area using interactive video technology: a study in prehospital telemedicine. J Telemed Telecare. 2002; 8(2): 115–7. Excluded - does not address a key question. [PubMed]

Melcer T, Crann B, Hunsaker D. et al. A retrospective evaluation of the development of a telemedicine network in a military setting. Mil Med. 2002 Jun;167(6): 510–5. Excluded - wrong population. [PubMed]

Melcer T, Hunsaker D, Crann B. et al. A prospective evaluation of ENT telemedicine in remote military populations seeking specialty care. Telemed J E Health. 2002 Fall;8(3): 301–11. Excluded - contains no or inadequate data. [PubMed]

Mengden T, Vetter H, Tisler A. et al. Tele-monitoring of home blood pressure. Blood Press Monit. 2001 Aug;6(4): 185–9. Excluded - does not address a key question. [PubMed]

Michelson G, Striebel W, Prihoda W, et al. Telemedicine in the control of intra-ocular pressure. J Telemed Telecare 2000 6(1) Excluded - contains no or inadequate data.

Mielonen ML, Vaisanen L, Moring J. et al. Implementation of a telepsychiatric network in northern Finland. Aktuelle Probl Dermatol. 2003; 32: 132–40. Excluded - does not address a key question.

Miller EA. Telemedicine and doctor-patient communication: an analytical survey of the literature. J Telemed Telecare. 2001; 7(1): 1–17. Excluded - does not address a key question. [PubMed]

Miller GG, Levesque K. Telehealth provides effective pediatric surgery care to remote locations. J Pediatr Surg. 2002 May;37(5): 752–4. Excluded - wrong population. [PubMed]

Miloud GL. Response to: Heartcare: an Internet-based information and support system for patient home recovery after coronary artery bypass graft (CABG) surgery by P. Flatley Brennan, S.M. Moore, G. Bjornsdottir, J. Jones, C. Visovsky and M. Rogers (2001) Journal Of Advanced Nursing 35, 699–708.[comment]. J Adv Nurs 2002 May; 38(4):425; author reply 425–6. Excluded - does not address a key question.

Mitchell JG, Disney AP, Roberts M. Renal telemedicine to the home. J Telemed Telecare. 2000; 6(1): 59–62. Excluded - contains no or inadequate data. [PubMed]

Miyashita T, Takizawa M, Nakai K. et al. Realtime ultrasound screening by satellite telecommunication. J Telemed Telecare. 2003; 9(Suppl 1): S60–1. Excluded - does not address a key question. [PubMed]

Miyashita T, Takizawa M, Nakai K. et al. Telemedicine of the heart: real-time telescreening of echocardiography using satellite telecommunication. Circ J. 2003 Jun;67(6): 562–4. Excluded - does not address a key question. [PubMed]

Miyazaki M, Stuart M, Liu L. et al. Use of ISDN video-phones for clients receiving palliative and antenatal home care. J Telemed Telecare. 2003; 9(2): 72–7. Excluded - does not address a key question. [PubMed]

Mizushima H, Uchiyama E, Nagata H. et al. Japanese experience of telemedicine in oncology. Int J Med Inf. 2001 May;61(23): 207–15. Excluded - does not address a key question.

Molinari G, Reboa G, Frascio M. et al. The role of telecardiology in supporting the decision-making process of general practitioners during the management of patients with suspected cardiac events. J Telemed Telecare. 2002; 8(2): 97–101. Excluded - does not address a key question. [PubMed]

Moller DS, Doeseriksen A, Sorensen S. et al. Accuracy of telemedical home blood pressure measurement in the diagnosis of hypertension. J Hum Hypertens. 2003 Aug;17(8): 549–54. Excluded - does not address a key question. [PubMed]

Moller DS, Doeseriksen A, Sorensen S. et al. Tele-monitoring of home blood pressure in treated hypertensive patients. Blood Press. 2003; 12(1): 56–62. Excluded - does not address a key question. [PubMed]

Montani S, Bellazzi R, Quaglini S. et al. Meta-analysis of the effect of the use of computer-based systems on the metabolic control of patients with diabetes mellitus. Diabetes Technol Ther. 2001 Fall;3(3): 347–56. Excluded - does not address a key question. [PubMed]

Montironi R, Thompson D, Scarpelli M. et al. Transcontinental communication and quantitative digital histopathology via the Internet; with special reference to prostate neoplasia. J Clin Pathol. 2002 Jun;55(6): 452–60. Excluded - does not address a key question. [PubMed] [Free Full text in PMC]

Morrison J, Bergauer NK, Jacques D, et al. Telemedicine: cost-effective management of high-risk pregnancy. Manag Care 2001 Nov; 10(11):42–6, 48–9. Excluded - wrong population.

Mueller TM, Vuckovic KM, Knox DA. et al. Telemanagement of heart failure: a diuretic treatment algorithm for advanced practice nurses. Heart Lung. 2002 Sep–Oct;31(5): 340–7. Excluded - does not address a key question. [PubMed]

Mukundan S Jr., Vydareny K, Vassallo DJ. et al. Trial telemedicine system for supporting medical students on elective in the developing world. Acad Radiol. 2003 Jul;10(7): 794–7. Excluded - does not address a key question. [PubMed]

Murdoch I, Bainbridge J, Taylor P, et al. Postoperative evaluation of patients following ophthalmic surgery. J Telemed Telecare 2000 6(1) Excluded - contains no or inadequate data.

Murphy JC. Telemedicine offers new way to manage asthma. Am J Health Syst Pharm. 2001 Sep 15;58(18): 1693–1696. Excluded - contains no or inadequate data. [PubMed]

Nakagawa A, Marks IM, Park JM. et al. Self-treatment of obsessive-compulsive disorder guided by manual and computer-conducted telephone interview. J Telemed Telecare. 2000; 6(1): 22–6. Excluded - does not meet our definition of telemedicine. [PubMed]

Nakajima I, Juzoji H, Wijarnpreecha S. et al. The final report of the project ‘AMINE’ the Asia Pacific Medical Information Network using with ETS-V. Int J Med Inf. 2001 May;61(23): 87–96. Excluded - does not address a key question.

Nakamoto H, Hatta M, Tanaka A. et al. Telemedicine system for home automated peritoneal dialysis. Advances in Peritoneal Dialysis. 2000; 16: 191–4. Excluded - contains no or inadequate data. [PubMed]

Nakamoto H, Kawamoto A, Tanabe Y. et al. Telemedicine system using a cellular telephone for continuous ambulatory peritoneal dialysis patients. Advances in Peritoneal Dialysis. 2003; 19: 124–9. Excluded - contains no or inadequate data. [PubMed]

Nelson EL, Barnard M, Cain S. Treating childhood depression over videoconferencing. Telemed J E Health. 2003 Spring;9(1): 49–55. Excluded - wrong population. [PubMed]

Niiranen S, Lamminen H. Feasibility of personal prothrombin time measurement in anticoagulant treatment follow-up. J Telemed Telecare. 2002; 8(6): 359–60. Excluded - contains no or inadequate data. [PubMed]

Niiranen S, Lamminen H, Mattila H. et al. Personal health care services through digital television. Comput Methods Programs Biomed. 2002 Jun;68(3): 249–59. Excluded - does not address a key question. [PubMed]

Niiranen S, Lamminen H, Niemi K. et al. A cost study of new media supported near oral anticoagulant treatment follow-up. Int J Med Inf. 2003 Apr;70(1): 19–29. Excluded - does not address a key question.

Norris TE, Hart GL, Larson EH. et al. Low-bandwidth, low-cost telemedicine consultations in rural family practice.[see comment]. J Am Board Fam Pract. 2002 Mar–Apr;15(2): 123–7. Excluded - does not address a key question. [PubMed]

Nowakowski R, Hammack G. Ophthalmic telemedicine at the Alabama Institute for Deaf and Blind. Optometry (St Louis, Mo ). 2001 Jan;72(1): 8–12. Excluded - contains no or inadequate data.

Oakley AM. Teledermatology in New Zealand. J Cutan Med Surg. 2001 Mar–Apr;5(2): 111–6. Excluded - contains no or inadequate data. [PubMed]

Oakley AM, Kerr P, Duffill M. et al. Patient cost-benefits of realtime teledermatology--a comparison of data from Northern Ireland and New Zealand. J Telemed Telecare. 2000; 6(2): 97–101. Excluded - does not address a key question. [PubMed]

Ogasawara K, Ito K, Jiang G. et al. Preliminary clinical evaluation of a video transmission system for home visits. J Telemed Telecare. 2003; 9(5): 292–5. Excluded - does not address a key question. [PubMed]

Oh JA, Kim HS, Yoon KH. et al. A telephone-delivered intervention to improve glycemic control in type 2 diabetic patients. Yonsei Med J. 2003 Feb;44(1): 1–8. Excluded - does not address a key question. [PubMed]

Oliveira MR, Wen CL, Neto CF. et al. Web site for training nonmedical health-care workers to identify potentially malignant skin lesions and for teledermatology. Telemed J E Health. 2002 Fall;8(3): 323–32. Excluded - does not address a key question. [PubMed]

Olver IN, Selva-Nayagam S. Evaluation of a telemedicine link between Darwin and Adelaide to facilitate cancer management. Telemedicine Journal. 2000; 6(2): 213–8. Excluded - does not address a key question. [PubMed]

Orlov OI, Levanov VM, Merrell RC. et al. A pilot telemedicine project in the Privolzhsky District, Russia. Telemed J E Health. 2003 Fall;9(3): 291–5. Excluded - contains no or inadequate data. [PubMed]

Ostojic V, Stipic-Markovic A, Tudman Z. et al. A feasibility study of realtime telemedicine in Croatia using Internet videoconferencing. J Telemed Telecare. 2000; 6(3): 172–6. Excluded - does not address a key question. [PubMed]

Paiva T, Coelho H, Almeida A. et al. Neuroteleconsultation for general practitioners. Studies in Health Technology & Informatics. 2000; 78: 329–41. Excluded - does not address a key question. [PubMed]

Paiva T, Coelho H, Araujo MT. et al. Neurological teleconsultation for general practitioners. J Telemed Telecare. 2001; 7(3): 149–54. Excluded - does not address a key question. [PubMed]

Pak HS. Teledermoscopy: a specific application of teledermotology [comment]. Skinmed. 2002 Sep–Oct;1(1): 18–9. Excluded - does not address a key question. [PubMed]

Pallawala PM, Lun KC. EMR based telegeriatric system. Int J Med Inf. 2001 May;61(23): 229–34. Excluded - does not address a key question.

Pallawala PM, Lun KC. EMR-based TeleGeriatric system. Medinfo. 2001; 10(Pt 1): 849–53. Excluded - contains no or inadequate data. [PubMed]

Palombo A, Ferguson J, Rowlands A. et al. An evaluation of a telemedicine fracture review clinic. J Telemed Telecare. 2003; 9(Suppl 1): S31–3. Excluded - does not address a key question. [PubMed]

Pandit RB. Role of cardiophone in the pre-hospital treatment of acute myocardial infarction. Journal of the Association of Physicians of India. 2001 Sep;49: 946. Excluded - does not meet our definition of telemedicine. [PubMed]

Park DG, Kim HC. Comparative study of telecommunication methods for emergency telemedicine. J Telemed Telecare. 2003; 9(5): 300–3. Excluded - does not address a key question. [PubMed]

Patricoski C, Ferguson AS. ECG acquisition using telemedicine in Alaska. Alaska Med. 2003 Jul–Sep;45(3): 60–3. Excluded - contains no or inadequate data. [PubMed]

Patricoski C, Kokesh J, Ferguson AS. et al. A comparison of in-person examination and video otoscope imaging for tympanostomy tube follow-up. Telemed J E Health. 2003 Winter;9(4): 331–44. Excluded - does not address a key question. [PubMed]

Patten SB. Prevention of depressive symptoms through the use of distance technologies. Psychiatr Serv. 2003 Mar;54(3): 396–8. Excluded - does not meet our definition of telemedicine. [PubMed]

Patterson V. Teleneurology in Northern Ireland: a success. J Telemed Telecare 2002 8(Suppl 3):S3:46–7. Excluded - does not address a key question.

Patterson V, Hoque F, Vassallo D. et al. Store-and-forward teleneurology in developing countries. J Telemed Telecare. 2001; 7(Suppl 1): 52–3. Excluded - contains no or inadequate data. [PubMed]

Patterson V, Humphreys J, Chua R. Teleneurology by email. J Telemed Telecare. 2003; 9(Suppl 2): S42–3. Excluded - does not address a key question. [PubMed]

Patterson VH, Craig JJ, Wootton R. Effective diagnosis of spinal cord compression using telemedicine. Br J Neurosurg. 2000; 14(6): 552–4. Excluded - contains no or inadequate data. [PubMed]

Pearson B, Katz SE, Soucie V. et al. Evidence-based care for depression in Maine: dissemination of the Kaiser Permanente Nurse Telecare Program. Psychiatr Q. 2003 Spring;74(1): 91–102. Excluded - does not meet our definition of telemedicine. [PubMed]

Pedley D, Ferguson J, Palombo A. et al. Community coronary units: strategies to promote pre-hospital thrombolysis. J Telemed Telecare. 2002; 8(Suppl 2): 24–5. Excluded - does not address a key question. [PubMed]

Pelletier-Fleury N, Gagnadoux F, Philippe C. et al. A cost-minimization study of telemedicine. The case of telemonitored polysomnography to diagnose obstructive sleep apnea syndrome. Int J Technol Assess Health Care. 2001 Fall;17(4): 604–11. Excluded - does not address a key question. [PubMed]

Perlemuter L, Yomtov B. Feasibility and usefulness of dedicated software and e-mail for self-monitoring blood glucose in treating diabetes. Diabet Med. 2002 Aug;19(8): 701–2. Excluded - does not address a key question. [PubMed]

Person DA. Pacific Island Health Care Project: early experiences with a Web-based consultation and referral network. Pacific Health Dialog. 2000; 7(2): 29–35. Excluded - contains no or inadequate data. [PubMed]

Piccolo D, Peris K, Chimenti S. et al. Jumping into the future using teledermoscopy.[see comment]. Skinmed. 2002 Sep–Oct;1(1): 20–4. Excluded - contains no or inadequate data. [PubMed]

Pierce LL, Steiner V, Govoni AL. et al. Internet-based support for rural caregivers of persons with stroke shows promise. Rehabil Nurs 2004. 2004 May–Jun;29(3): 95–9. Excluded - does not address a key question.

Piwernetz K. DIABCARE Quality Network in Europe--a model for quality management in chronic diseases. Int Clin Psychopharmacol. 2001 Apr;16(Suppl 3): S5–13. Excluded - does not address a key question. [PubMed]

Pollard SE, LePage JP. Telepsychiatry in a rural inpatient setting. Psychiatr Serv. 2001 Dec;52(12): 1659. Excluded - does not address a key question. [PubMed]

Poon WS, Leung CH, Lam MK. et al. The comparative impact of video-consultation on neurosurgical health services. Int J Med Inf. 2001 Jul;62(23): 175–80. Excluded - no comparison group.

Port K, Palm K, Viigimaa M. Self-reported compliance of patients receiving antihypertensive treatment: use of a telemonitoring home care system. J Telemed Telecare. 2003; 9(Suppl 1): S65–6. Excluded - no comparison group. [PubMed]

Prado M, Roa L, Reina-Tosina J. et al. Renal telehealthcare system based on a patient physiological image: a novel hybrid approach in telemedicine. Telemed J E Health. 2003 Summer;9(2): 149–65. Excluded - does not address a key question. [PubMed]

Reeves PM. Coping in cyberspace: the impact of Internet use on the ability of HIV-positive individuals to deal with their illness. J Health Commun. 2000; 5: 47–59. Excluded - does not address a key question. [PubMed]

Regnard C. Using videoconferencing in palliative care. Palliative Medicine. 2000; 14(6): 519–28. Excluded - does not address a key question. [PubMed]

Ricker JH, Rosenthal M, Garay E. et al. Telerehabilitation needs: a survey of persons with acquired brain injury. J Head Trauma Rehabil. 2002 Jun;17(3): 242–50. Excluded - contains no or inadequate data. [PubMed]

Robinson JG, Conroy C, Wickemeyer WJ. A novel telephone-based system for management of secondary prevention to a low-density lipoprotein cholesterol < or = 100 mg/dl. American Journal of Cardiology. 2000; 85(3): 305–8. Excluded - does not meet our definition of telemedicine. [PubMed]

Rogers MA, Buchan DA, Small D. et al. Telemedicine improves diagnosis of essential hypertension compared with usual care. J Telemed Telecare. 2002; 8(6): 344–9. Excluded - does not meet our definition of telemedicine. [PubMed]

Romano MJ, Hernandez J, Gaylor A. et al. Improvement in asthma symptoms and quality of life in pediatric patients through specialty care delivered via telemedicine. Telemed J E Health. 2001 Winter;7(4): 281–6. Excluded - no comparison group. [PubMed]

Rosenfeld BA, Dorman T, Breslow MJ. et al. Intensive care unit telemedicine: alternate paradigm for providing continuous intensivist care.[see comment]. Crit Care Med. 2000; 28(12): 3925–31. Excluded - included in previous report. [PubMed]

Ross MD, Twombly IA, Bruyns C. et al. Telecommunications for health care over distance: the Virtual Collaborative Clinic. Studies in Health Technology & Informatics. 2000; 70: 286–91. Excluded - contains no or inadequate data. [PubMed]

Ross SE, Moore LA, Earnest MA. et al. Providing a web-based online medical record with electronic communication capabilities to patients with congestive heart failure: randomized trial.[see comment]. J Med Internet Res. 2004 May 14;6(2): e12. Excluded - does not address a key question. [PubMed]

Russell TG, Jull GA, Wootton R. The diagnostic reliability of Internet-based observational kinematic gait analysis. J Telemed Telecare. 2003; 9(Suppl 2): S48–51. Excluded - no comparison group. [PubMed]

Safran C. The collaborative edge: patient empowerment for vulnerable populations. Int J Med Inf. 2003 Mar;69(23): 185–90. Excluded - wrong population.

Saligari J, Flicker L, Loh PK, et al. The clinical achievements of a geriatric telehealth project in its first year. J Telemed Telecare 2002 8(Suppl 3):S3:53-5. Excluded - no comparison group.

Salmon S, Brint G, Marshall D, et al. Telemedicine use in two nurse-led minor injuries units. J Telemed Telecare 2000 6(1) Excluded - contains no or inadequate data.

Sanford JA, Jones M, Daviou P. et al. Using telerehabilitation to identify home modification needs. Assist Technol. 2004 Summer;16(1): 43–53. Excluded - does not address a key question. [PubMed]

Savard L, Borstad A, Tkachuck J. et al. Telerehabilitation consultations for clients with neurologic diagnoses: cases from rural Minnesota and American Samoa. NeuroRehabilitation. 2003; 18(2): 93–102. Excluded - contains no or inadequate data. [PubMed]

Scalvini S, Zanelli E, Volterrani M. et al. A pilot study of nurse-led, home-based telecardiology for patients with chronic heart failure. J Telemed Telecare. 2004; 10(2): 113–7. Excluded - contains no or inadequate data. [PubMed]

Scherrer-Bannerman A, Fofonoff D, Minshall D, et al. Web-based education and support for patients on the cardiac surgery waiting list. J Telemed Telecare 2000 6(2) Excluded - contains no or inadequate data.

Schmid-Grendelmeier P, Doe P, Pakenham-Walsh N. Teledermatology in sub-Saharan Africa. Aktuelle Probl Dermatol. 2003; 32: 233–46. Excluded - does not address a key question.

Schopp LH, Johnstone BR and Merveille OC. Multidimensional telecare strategies for rural residents with brain injury. J Telemed Telecare 2000 6(1) Excluded - does not address a key question.

Setterberg SR, Busseri MA, Fleissner RM. et al. Remote assessment of the use of seclusion and restraint with paediatric psychiatric patients. J Telemed Telecare. 2003; 9(3): 176–9. Excluded - wrong population. [PubMed]

Sezeur A, Degramont A, Touboul E. et al. Teleconsultation before chemotherapy for recently operated on patients. American Journal of Surgery. 2001 Jul;182(1): 49–51. Excluded - contains no or inadequate data. [PubMed]

Shannon G, Nesbitt T, Bakalar R. et al. Telemedicine/telehealth: an international perspective. Organizational models of telemedicine and regional telemedicine networks. Telemed J E Health. 2002 Spring;8(1): 61–70. Excluded - does not address a key question. [PubMed]

Sicotte C, Lehoux P. Teleconsultation: rejected and emerging uses. Methods Inf Med. 2003; 42(4): 451–7. Excluded - does not address a key question. [PubMed]

Sicotte C, Lehoux P, Fortier-Blanc J. et al. Feasibility and outcome evaluation of a telemedicine application in speech-language pathology. J Telemed Telecare. 2003; 9(5): 253–8. Excluded - no comparison group. [PubMed]

Simpson J, Doze S, Urness D. et al. Telepsychiatry as a routine service--the perspective of the patient. J Telemed Telecare. 2001; 7(3): 155–60. Excluded - does not address a key question. [PubMed]

Sing A, Salzman J, Sing D. Problems and risks of unsolicited e-mails in patient-physician encounters in travel medicine settings. J Travel Med. 2001 May–Jun;8(3): 109–12. Excluded - does not address a key question. [PubMed]

Sixsmith AJ. An evaluation of an intelligent home monitoring system. J Telemed Telecare. 2000; 6(2): 63–72. Excluded - contains no or inadequate data. [PubMed]

Smith AC, Batch J, Lang E. et al. The use of online health techniques to assist with the delivery of specialist paediatric diabetes services in Queensland. J Telemed Telecare. 2003; 9(Suppl 2): S54–7. Excluded - wrong population. [PubMed]

Smith AC, Isles A, McCrossin R. et al. The point-of-referral barrier--a factor in the success of telehealth. J Telemed Telecare. 2001; 7(Suppl 2): 75–8. Excluded - wrong population. [PubMed]

Smith AC, Kairl JA, Kimble R. Post-acute care for a paediatric burns patient in regional Queensland. J Telemed Telecare. 2002; 8(5): 302–4. Excluded - wrong population. [PubMed]

Smith AC, Williams M, Van der Westhuyzen J, et al. A comparison of telepaediatric activity at two regional hospitals in Queensland. J Telemed Telecare 2002 8(Suppl 3):S3:58–62. Excluded - wrong population.

Stalfors J, Edstrom S, Bjork-Eriksson T. et al. Accuracy of tele-oncology compared with face-to-face consultation in head and neck cancer case conferences. J Telemed Telecare. 2001; 7(6): 338–43. Excluded - no comparison group. [PubMed]

Steel S, Lock S, Johnson N. et al. A feasibility study of remote monitoring of asthmatic patients. J Telemed Telecare. 2002; 8(5): 290–6. Excluded - contains no or inadequate data. [PubMed]

Stormo A, Sollid S, Stormer J. et al. Neurosurgical teleconsultations in northern Norway. J Telemed Telecare. 2004; 10(3): 135–9. Excluded - does not address a key question. [PubMed]

Stroetmann KA, Gruetzmacher P and Stroetmann VN. Improving quality of life for dialysis patients through telecare. J Telemed Telecare 2000 6(1) Excluded - does not address a key question.

Sumner CR. Telepsychiatry: challenges in rural aging. J Rural Health. 2001 Fall;17(4): 370–3. Excluded - contains no or inadequate data. [PubMed]

Tachakra S. Depth perception in telemedical consultations. Telemed J E Health. 2001 Summer;7(2): 77–85. Excluded - does not address a key question. [PubMed]

Tachakra S, Dutton D, Newson R, et al. How do teleconsultations for remote trauma management change over a period of time? J Telemed Telecare2000 6(1) Excluded - contains no or inadequate data.

Tachakra S, Jaye P, Bak J, et al. Supervising trauma life support by telemedicine. J Telemed Telecare 2000 6(1) Excluded - does not address a key question.

Tachakra S, Loane M, Uche CU. A follow-up study of remote trauma teleconsultations. J Telemed Telecare. 2000; 6(6): 330–4. Excluded - no comparison group. [PubMed]

Tachakra S, Lynch M, Newson R, et al. A comparison of telemedicine with face-to-face consultations for trauma management. J Telemed Telecare 2000 6(1) Excluded - included in previous report.

Taylor P. An assessment of the potential effect of a teledermatology system. J Telemed Telecare 2000 6(1) Excluded - contains no or inadequate data.

Tennant MT, Greve MD, Rudnisky CJ. et al. Identification of diabetic retinopathy by stereoscopic digital imaging via tele-ophthalmology: a comparison to slide film. Can J Ophthalmol. 2001 Jun;36(4): 187–96. Excluded - does not address a key question. [PubMed]

Theodoros D, Russell TG, Hill A. et al. Assessment of motor speech disorders online: a pilot study. J Telemed Telecare. 2003; 9(Suppl 2): S66–8. Excluded - no comparison group. [PubMed]

Thorley PJ, Beacock DJ, Trickett CA. et al. 18FDG SPECT to assess myocardial viability: initial experience at a hospital remote from a cyclotron. Nuclear Medicine Communications. 2000; 21(8): 715–8. Excluded - does not address a key question. [PubMed]

Ting HH, Garratt KN, Singh M. et al. Low-risk percutaneous coronary interventions without on-site cardiac surgery: two years' observational experience and follow-up.[see comment]. American Heart Journal. 2003 Feb;145(2): 278–84. Excluded - does not address a key question. [PubMed]

Tomuro K. Development of oral home telecare programme for the home-dwelling elderly: a pilot study. Gerodontology. 2004 Sep;21(3): 177–80. Excluded - contains no or inadequate data. [PubMed]

Tsang MW, Mok M, Kam G. et al. Improvement in diabetes control with a monitoring system based on a hand-held, touch-screen electronic diary. J Telemed Telecare. 2001; 7(1): 47–50. Excluded - does not address a key question. [PubMed]

Tsilimigaki A, Maraka S, Tsekoura T. et al. Eighteen months' experience with remote diagnosis, management and education in congenital heart disease. J Telemed Telecare. 2001; 7(4): 239–43. Excluded - wrong population. [PubMed]

Tually P, Janssen J, Cowell S. et al. A preliminary assessment of Internet-based nuclear telecardiology to support the clinical management of cardiac disease in a remote community. J Telemed Telecare. 2003; 9(Suppl 1): S69–71. Excluded - contains no or inadequate data. [PubMed]

Varri A, Koivuluoma M, Morvan C. A computer-assisted visual sleep scoring program. Studies in Health Technology & Informatics. 2000; 78: 285–97. Excluded - does not address a key question. [PubMed]

Wakefield BJ, Buresh KA, Flanagan JR. et al. Interactive video specialty consultations in long-term care. J Am Geriatr Soc. 2004 May;52(5): 789–93. Excluded - no comparison group. [PubMed]

Wakefield BJ, Holman JE, Ray A. et al. Nurse and patient communication via low- and high-bandwidth home telecare systems. J Telemed Telecare. 2004; 10(3): 156–9. Excluded - does not address a key question. [PubMed]

Warden DL, Salazar AM, Martin EM. et al. A home program of rehabilitation for moderately severe traumatic brain injury patients. The DVHIP Study Group.[see comment]. J Head Trauma Rehabil. 1092; 15(5): 1092–102. Excluded - does not address a key question. [PubMed]

Watson J, Gasser L, Blignault I. et al. Taking telehealth to the bush: lessons from north Queensland. J Telemed Telecare. 2001; 7(Suppl 2): 20–3. Excluded - does not address a key question. [PubMed]

Whited JD. Teledermatology Current status and future directions. Am J Clin Dermatol. 2001; 2(2): 59–64. Excluded - does not address a key question. [PubMed]

Whitlock WL, Brown A, Moore K. et al. Telemedicine improved diabetic management. Mil Med. 2000; 165(8): 579–84. Excluded - does not address a key question. [PubMed]

Whitten P and Rowe-Adjibogoun J. Success and failure in a Michigan telepsychiatry programme. J Telemed Telecare 2002 8(Suppl 3):S3:75–7. Excluded - does not address a key question.

Whitten PS. Teledermatology delivery modalities: real time versus store and forward. Aktuelle Probl Dermatol. 2003; 32: 24–31. Excluded - contains no or inadequate data.

Wiborg A, Widder B, Telemedicine in. Stroke in Swabia P. Teleneurology to improve stroke care in rural areas: The Telemedicine in Stroke in Swabia (TESS) Project.[see comment]. Stroke. 2003 Dec;34(12): 2951–6. Excluded - contains no or inadequate data. [PubMed]

Wilson L, Onslow M, Lincoln M. Telehealth adaptation of the Lidcombe Program of Early Stuttering Intervention: five case studies. Am J Speech Lang Pathol. 2004 Feb;13(1): 81–93. Excluded - wrong population. [PubMed]

Winters JM, Wang Y. Wearable sensors and telerehabilitation.[see comment]. IEEE Eng Med Biol Mag. 2003 May–Jun;22(3): 56–65. Excluded - does not address a key question. [PubMed]

Wojcicki JM, Ladyzynski P, Krzymien J. et al. What we can really expect from telemedicine in intensive diabetes treatment: results from 3-year study on type 1 pregnant diabetic women. Diabetes Technol Ther. 2001 Winter;3(4): 581–9. Excluded - wrong population. [PubMed]

Wootton R, Bloomer SE, Corbett R. et al. Multicentre randomised control trial comparing real time teledermatology with conventional outpatient dermatological care: societal cost-benefit analysis.[see comment]. Bmj. 1252; 320(7244): 1252–6. Excluded - does not address a key question. [PubMed]

Wootton R, McKelvey A, McNicholl B, et al. Transfer of telemedical support to Cornwall from a national telemedicine network during a solar eclipse. J Telemed Telecare 2000 6(1) Excluded - does not address a key question.

Yogesan K, Cuypers M, Barry CJ, et al. Tele-ophthalmology screening for retinal and anterior segment diseases. J Telemed Telecare 2000 6(1) Excluded - included in previous report.

Young NL, Barden W, Lefort S. et al. Telehomecare: a comparison of three Canadian models. Telemed J E Health. 2004 Spring;10(1): 45–52. Excluded - contains no or inadequate data. [PubMed]

Young TL, Ireson C. Effectiveness of school-based telehealth care in urban and rural elementary schools. Pediatrics. 2003 Nov;112(5): 1088–94. Excluded - wrong population. [PubMed]

Zabalgoitia M, Ismaeil M. Diagnostic and prognostic use of stress echo in acute coronary syndromes including emergency department imaging. Echocardiography. 2000; 17(5): 479–93. Excluded - does not address a key question. [PubMed]

Zaylor C, Nelson EL, Cook DJ. Clinical outcomes in a prison telepsychiatry clinic. J Telemed Telecare. 2001; 7(Suppl 1): 47–9. Excluded - wrong population. [PubMed]

Zenk BM, Bratton RL, Flipse TR. et al. Accuracy of detecting irregular cardiac rhythms via telemedicine. J Telemed Telecare. 2004; 10(1): 55–8. Excluded - no comparison group. [PubMed]

Zhang R, Yamauchi K, Nonogawa M. et al. A telemedicine system for collaborative work on radiographic coronary video-images. J Telemed Telecare. 2004; 10(3): 152–5. Excluded - contains no or inadequate data. [PubMed]