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Hersh WR, Wallace JA, Patterson PK, et al. Telemedicine for the Medicare Population. Rockville (MD): Agency for Healthcare Research and Quality (US); 2001 Jul. (Evidence Reports/Technology Assessments, No. 24.)

  • This publication is provided for historical reference only and the information may be out of date.

This publication is provided for historical reference only and the information may be out of date.

Cover of Telemedicine for the Medicare Population

Telemedicine for the Medicare Population.

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4Conclusions

Evidence about Effectiveness

This report finds that while the use of telemedicine is small but growing, the evidence for its efficacy is incomplete. We found that store-and-forward telemedicine appears to be comparable to usual care for diagnosis and management decisions in the area in which it has been most assessed -- dermatology. Store-and-forward telemedicine has not been well-assessed in other clinical domains, which does not rule out its being effective within them, but means that well-designed studies are necessary to determine whether this is so.

For self-monitoring/testing telemedicine, relatively strong evidence supports the use of a computer-controlled telephone system that enabled patients to regularly report self-measured blood pressures and medication use to a physician. Augmenting home health care with interactive video appears to result in comparable care and possibly decreased costs. But for other applications, the studies assessing self-monitoring/testing telemedicine are of insufficient quality to definitively demonstrate effectiveness or lack thereof.

There is more evidence for the efficacy of clinician-interactive telemedicine, but the studies do not clearly define which technologies provide benefit or cost-efficiency. Some promising areas with evidence appear to be dermatology, cardiology, emergency medicine, and otolaryngology.

In interpreting these results, it is important to recognize the possibility of publication bias, whereby studies with negative results may be less likely to be published. Because of the heterogeneous studies in the data we have uncovered, we cannot assess whether such a bias is present. We do know that many programs have not published efficacy data, but cannot determine whether this is due to failure to collect data, rather than a failure to publish it.

Gaps in Research

A gap remains between the claims made for telemedicine and scientific validation of these claims. The problem is not that studies have strong evidence against efficacy, but rather that their methodologies preclude definitive statements. Many of them have small sample sizes that limit statistical power. Others are done in settings that may not generalize to real clinical settings. Most include convenience samples of patients rather than target populations that might benefit most from improved access to health services, such as those who are indigent and/or have complex chronic diseases.

The number of empty cells in the summary tables (see Tables 7, 11, and 12 in Chapter 3) show there is also alarge gap between practice (actual programs providing telemedicine services) and evidence (studies of efficacy to support their use). While this gap underscores the importance of scientific validation, it does not diminish the case for developing telemedicine. It is important that these gaps be closed by research funded by objective third parties, such as the National Institutes of Health (NIH) and the Agency for Healthcare Research and Quality (AHRQ).

In the peer-reviewed literature as well as other media reports, we found a preponderance of observational studies evaluating active telemedicine programs. Active programs demonstrate that the technology can be made operational and, in some cases, may be clinically and economically viable. The longevity of these programs, however, is not clear, and many may fail to survive beyond initial funding or enthusiasm. Lack of information about the viability of these programs limits the generalizability of these studies. Although we sought information to determine which programs were still active, we were not able to identify factors which are associated with viability. For example, while we heard anecdotally that several programs have failed because they could not attract or keep participating primary care physicians, data about strategies for and resource costs of recruiting and keeping participants are nearly non-existent. This is an important gap in research about telemedicine.

Another gap in research is that many studies are not focused on the patients who stand to gain the most from the availability of telemedicine services. It may well be that telemedicine studies in the somewhat artificial experimental conditions set up in outpatient clinics, emergency rooms, and nursing homes would have different results in actual underserved rural or inner city locations. This is because the research goals of most evaluations are often limited to proving the feasibility of implementing new technology. As McLaren and Ball wrote in 1995,

(Telemedicine's) driving force has been developments in communications technology, and as new communications systems are developed health applications are proposed such as supporting the delivery of primary health care to geographically remote areasor regions underserved through the maldistribution of professional expertise. Despite rapid technological advances, evaluations of such systems have been largely superficial, and more thorough evaluations have failed to show significant advantages for more advanced and expensive technology over older technology such as the telephone. Methods for evaluating the impact of particular technologies on the health care system need to be developed and clearer benefits shown in terms of improved standards of care. 128

This pattern is not unique to telemedicine. Frequently, when new technologies are introduced into practice, they are introduced "without a clear idea of which patients will benefit most, what the balance of benefits and harms is, and what value for money technologies offer." 129 To close these information gaps, specific hypotheses concerning a target population, methods of implementation, and effects on access to care, resource use, and health outcomes must be the driving force in research.

These gaps in information limit the ability of policy-makers to make informed judgments about telemedicine coverage. This is particularly a problem if the decision to provide reimbursement for a particular service depends on having high-quality evidence that the benefits outweigh the harms and that the service is cost-effectiveness. For many services, we found no reliable evidence about clinical effectiveness, harms, or cost-effectiveness. In these cases, decisions about coverage may have to be made on other grounds. From a research standpoint, these decisions could create opportunities to use HCFA's data systems to obtain data about effectiveness and costs as services become available.

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