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  • This publication is provided for historical reference only and the information may be out of date.

This publication is provided for historical reference only and the information may be out of date.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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1Introduction

Goal of the Report

This report identifies health care services that could be provided using telemedicine, and describes existing programs in three categories of telemedicine: store-and-forward, self-monitoring/testing, and clinician-interactive services. It also summarizes scientific evidence onthe efficacy, safety, and cost-effectiveness of these services; identifies gapsin the evidence; and makes recommendations for evaluating telemedicine services.

The report is intended to help policy-makers weighthe evidence relevant to insurance coverage of telemedicine services under Medicare. Consequently, the scopeof this report is limited to telemedicine programs and clinical settings thathave been used in, or are likely to be applied to, Medicare beneficiaries.

The report's primary focus is on whether there arewell-designed studies that examine the effectiveness, safety, and cost-effectiveness of specific telemedicine services. In addition, for each of the three categories of services, the report describes the characteristics of existing telemedicine programs, the types of procedures or services they provide, critical gaps in current information about these services, and futureresearch that could address these information gaps.

Definitions

Telemedicine is the use of telecommunications technology for medical diagnostic, monitoring, and therapeutic purposes when distance separates the participants. 1 Some descriptions use the broader term telehealth to indicate care beyond thatprovided by medical doctors -- for example, its use for patient-to-patient of care giver-to-caregiver communication. Other descriptions use narrower terms focused on medical specialties, such as teledermatology or teleradiology.

A telemedicine program is defined as a purposeful, organized set of recurrent actions taken to provide care using advanced telecommunication (i.e., more complex than use of the telephone) in response to apopulation-based medical or care-delivery problem. A program may include a linked network of intra-organizational activities across two or more geographic sites. Telemedicine activities, on the other hand, are specific, identifiable, and discreet interventions included in a program. Services are types of professional specialties, such as radiology, and procedures are reimbursable diagnostic or treatment tasks performed according to professionally prescribed methods.

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. It should be noted that the general use of these terms has been influenced by the decision of the Health Care Financing Administration (HCFA) to adopt anarrow spectrum of covered telemedicine services. The only telemedicine that HCFA currently covers which is a substitute for face-to-face encounters (i.e., not radiology or pathology) is the traditional medical consultation where the clinician is present during the consultation. Thus, HCFA does not cover general office visits nor store-and-forward consultations. As a result, HCFA's definition of a teleconsultation may be different from that used by the general telemedicine community. In this report, the term is mainly used in the context of store-and-forward telemedicine, which is usually used for specialty consultations.

Telemedicine Study Areas

This report examines telemedicine services in three areas: store-and-forward, self-monitoring/testing, and clinician-interactive services.

Store-and-forward telemedicine services collect medical data, store them, and then forward them to beinterpreted later. Store-and-forward systems provide the ability to capture and store electronic 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 a sa clinical consultation (as opposed to an office or hospital visit). The key coverage question associated with store-and-forward is, Can store-and-forward teleconsultations be an acceptable alternative to real-time consultations?

Self-monitoring/testing 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 while reducing the need for face-to-face visits with clinicians that may be inconvenient and costly for the patient. For example, several technologies allow patients to directly upload monitoring data 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 higher-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 carethrough early detection of problems or more precise dosing of medications and biologicagents, potentially reducing costs.

The most common forms of self-monitoring/testing are 1) blood pressure measurement and 2) blood glucose measurement performed by adiabetic patient and used by a physician to evaluate the patient's glycemic control and to recommend changes in management.2,3 Other conditions that are conducive to self-monitoring/testing include asthma (in which spirometry ismeasured), congestive heart failure (weights, symptoms, blood pressure), cardiac arrhythmias (electrocardiography), anticoagulation therapy (prothrombin time), and post-acute hospital care. Monitoring allows preventive measures to be taken before problems get so severe that hospitalization becomes necessary. This could be particularly helpful to people whose mobility is limited or who may not be well enough to travel. Telemetry devices could alsoprovide a more cost-effective method of care, by reducing medical visits for conditions that are not severe.

Clinician-interactive telemedicine services are real-time clinician-patient interactions that conventionally require face-to-face encounters between a patient and a physician. Examples of clinician-interactive 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. A list of these services is provided later in this report.

According to the Association of Telemedicine Service Providers (ATSP), about 2,000 out of 750,000 U.S. physicians use telemedicine. 4 (From 1998 report on telemedicine activity. 1999 report was unavailable at time of report.) Teleradiology is the most common application. In 1997 about 250,000 diagnostic teleradiology studies were done in the United States. 5 During the same period, 46,231 interactive video and store-and-forward telemedicine encounters were performed. The most active specialties were psychiatry (17.9 percent), cardiology (16.7 percent), ophthalmology (9.6 percent), and orthopedics (5.7 percent). 6 In some specialties, such as ophthalmology, one or two large programs account for almost all consultations nationwide.

Burden of Illness

Improving access toclinical services is a key goal of telemedicine. Access to care is defined as "the timely use of personal health services to achieve the best possible health outcomes." 7 The potentially mostimportant benefit of telemedicine is improved access for patients who live inmedically underserved areas and for patients who have difficulty traveling to medical facilities.

Many telemedicine programs focus on improving access to specialty physician care in rural areas. Rural residents in the United States, who make uproughly one-fourth of the nation's population, 8 face serious barriers that impede their access to health care, including poverty and lack of health insurance. 9 Rural Americans have higher rates of chronic diseases 10 and greater difficulty than non-rural residents in obtaining preventive and mental health services, as well as care for emergencies and chronic illness. Sparseness of health care facilities and providers has been the most intractable access barrier for mostrural Americans. The distance that rural residents must travel to obtain health care is nearly double that of their urban counterparts. 11 Recent hospital closures and the limited presence of health maintenance organizationsin rural areas have compounded this problem.2,12

Research on rural health care access has linked shortages in preventive services, mental health services, chronic disease management, and emergency care to greater disability, increased preventable hospitalizations, and poorer health status in rural areas.9,13-15

Comparable data for non-emergency specialty care such as dermatology are not widely available. Table 1, based on our analysis using the Medicare Statistical System, shows discrepancies in dermatological services between HPSA countiesand non-HPSA counties across the nation. The gap is most apparent in Arizona, where beneficiaries residing in non-HPSA counties visited dermatologists or hada dermatologic consult at a rate of 277 visits or consults per person-year per 1,000 persons. In contrast, beneficiaries residing in HPSA counties visited dermatologists or had a dermatologic consult at a rate of 109 visits or consults per person-year per 1,000 persons.

Table 1. Gap in dermatology utilization between HPSA and non-HPSA areas. (Source: Original analysis by OHSU EPC).

Table

Table 1. Gap in dermatology utilization between HPSA and non-HPSA areas. (Source: Original analysis by OHSU EPC).

In contrast to mental health, chronic disease management, and emergency care, the differential access to non-emergency specialty care has not been linked in research studies togreater disability and mortality. While telemedicine specialty care applications may make it easier and more convenient to obtain such services, their potential impact on the health of rural Americans is not known.

Residence in a health professional shortage area (HPSA) is often used as a criterion to determine theneed for telemedicine services. Nearly 30 percent of rural residents, asopposed to 10 percent of non-rural residents, live in HPSAs, where the ratio of population to primary care physicians exceeds 3500:1. 16 Medicare subscribers living in HPSAs have a higher rate of mobility and self-care restrictions than other subscribers. 17 In the 1991 Medicare Current Beneficiary Survey, Medicare beneficiaries in fair or poor health were 1.70 (95% confidence interval, 1.097ndash;2.65) times more likely to experience a preventable hospitalization if they resided in a HPSA after controlling for educational level, income, and supplemental insurance. 18

It is not clear, however, that residence in a HPSA is a meaningful indicator of which patients need telemedicine services. First, in a large analysis of Medicare data, physician supply did not explain differences in mortality or in rates of admissions for several common conditions. 19 Second, the remoteness and shortage of specialty services may be no different in HPSAs than in other rural non-HPSA areas. Third, within HPSAs, physician supply is not the only barrier to access. Even after statistical adjustment for physician supply there is substantial variation in utilization of health care services and in measures of health outcomes.

A smaller number of telemedicine programs focus on patients living in urban and suburban areas who have other barriers to access, such as lack of health insurance, underinsurance (inadequate coverage), personal and cultural attitudes or preferences, physical disabilities, and other mobility restrictions. For patients with mobility restrictions, tele-home health services may be useful, since office-based teleservices may be relatively inaccessible.

Analytic Framework for Evaluating Telemedicine Services

The Evidence-based Approach

An evidence-based report focuses attention on the strength and limits of evidence from published studies about the effectiveness of a clinical intervention. The development of an evidence report begins with a careful formulation of the problem In this phase, a preliminary review of the literature and input from experts, stakeholders, and patients can be used toidentify the patient populations, interventions, health outcomes, and harms. These parameters are summarized in an analytic framework, or causal pathway, which is used in turn to generate a list of key questions to examinein a systematic review of the published literature.

An evidence-based report emphasizes the quality of the evidence, giving the most weight to studies that meet high methodologic standards in order to reduce the likelihood of biased results. It emphasizes studies that measure health outcomes instead of intermediate outcomes. For example, a study that measured the effect of a telediabetes program on patients' functional status and quality of life would be given more weight than one that reported only changes in health care utilization or laboratory markers of disease. An evidence-based report also emphasizes studies that reflect clinical efficacy in unselected patients and community practice settings. Finally, an evidence-based report considers the net benefit, after a thorough effort to assess both the benefits and the harms of aservice or technology.

In the context of developing clinical guidelines, evidence reports are useful because they define the limits of the evidence, clarifying when assertions about the value of the intervention are based on strong evidence from clinical studies. The quality of the evidence on effectiveness is a key component, but not the only component, of decision-making on coverage decisions. Medicare coverage determinations are also based on whether a service has been determined to be safe, medically appropriate, and provided in accordance with recognized standards of medical practice. 20 Other considerations are its expected cost and its potential for overutilization and abuse.

The Physician Payment Review Commission proposed evaluating telemedicine serviceson several dimensions: the value the services offer compared with traditional methods of performing the same service, access for underserved populations, increased efficiency in servicedelivery, improved quality of care through integrated approaches, strengthening capabilities for emergency services, and the potential for escalating Medicarecosts by stimulating overutilization. 21 Additional criteria include acceptability to physicians, patients, or others 22 and cost-effectiveness. 23

Key Questions About the Efficacy of Telemedicine Services

To determine the key questions and guide the review of the literature in the evaluation of telemedicine, we developed an analytic framework, shown in Figure 1. We then made explicit thequestions for each of the three study areas.

Figure 1. Analytic framework for each study area.

Figure

Figure 1. Analytic framework for each study area.

Store-and-forward

The key questions in Figure 2 correspond to the numbered arrows in the analytic framework for store-and-forward applications and articulate the main questions that guided our literature review and that we address in the Results section of this report.

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Figure 2. Key questions for store-and-forward telemedicine. (Numbered questions below correspond to arrows in Figure 1) 1a. To what extent does store-and-forward telemedicine have the same components as a face-to-face consultation? (This (more...)

We examined the use of store-and-forward telemedicine applications in patient populations relevant to Medicare. First, we examined the general literature, including non-peer-reviewed literature, to describe the characteristics of existing store-and-forward programs and applications (Arrow 1a).

The key underlying question is, To what extent does store-and-forward telemedicine have the same components as atraditional clinical encounter? These components are a clinical history, which may be problem-focused orcomprehensive; a physical examination; and medical decision-making, which usually includes an analysis of clinical data, a diagnosis, and a management plan. The time spent on the telemedicine encounter is also a component.

Then, to assess the diagnostic accuracy and the effect of these services on management decisions, we sought peer-reviewed, clinical studies of store-and-forwardtelemedicine (Arrow 1b). Specifically, we asked, Relative to usual care, does store-and-forward telemedicine result in comparable diagnosis and appropriate recommendations for management?

The most powerful evidence for the safety and efficacy of store-and-forward telemedicine applications would directly link their use to improved health outcomes such as functional status, quality of life, or mortality (Arrow 3). In the absence of such direct evidence, the effectiveness of store-and-forward telemedicine might be inferred from evidence about improved diagnosis, coordination, or management decisions. To make this inference, we should have evidence that these particular intermediate outcomes are reasonable indicators, or proxies, for actual health outcomes (Arrow 4). For example, for a teledermatology application, we should seek evidence that more timely oraccurate diagnosis of specific skin conditions reduces morbidity or mortality.

We also sought evidence that these programs improved access to care for the targeted populations (Arrow 1c) and evidence about the potential adverse effects of the encounter (Arrow2). The remaining links in the analytic framework address whether store-and-forward telemedicine improves patient and provider satisfaction (Arrow 5), reduces costs (Arrow 6), or can provide added health benefits at a reasonable marginal cost (Arrow 7).

Self-monitoring/testing

The key questions for evaluating self-monitoring/testing applications are shown in Figure 3. We examined the effect of self-monitoring/testing telemedicine applications in several groups of patients at high risk of preventable morbidity and mortality from chronic illnesses or other causes. Again, direct evidence from controlled trials of the impact of these applications on health outcomes would provide the strongest support for the effectiveness of these interventions (Arrow 3). In the absence of such studies, effectiveness might be inferred from evidence that self-monitoring/testing telemedicine applications improve laboratory or utilization measures (Arrow 1b) and access (Arrow1c), plus evidence that these measures are reliable indicators of changesin health outcomes (Arrow 4). The remaining key questions (Arrows 1a, 2, 5, 6, 7) are similar to those for store-and-forward.

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Figure 3. Key questions for self-monitoring/testingtelemedicine. (Numbered questions below correspond to arrows in Figure 1) 1a. What are the characteristics of self-monitoring/testing telemedicine in terms of patients included, services (more...)

Clinician-interactiveservices

The key questions for evaluating clinician-interactive telemedicine are shown in Figure 4. As with the other study areas, a key underlying question is, To what extent does the remote, telemedicine version of the procedure have the same components as a face-to-face encounter? While the question is the same, the components of a face-to-face encounter vary greatly among these services. For example, in addition to a history, physical examination, and medical decision-making, outpatient visits for evaluation and management (CPT codes 99201-99205, 99212-99215) may also include counseling, coordination of care, and care of the patient's family. For many psychiatric evaluation and management services (in particular, CPT codes 90801-90862), a physical examination is not a usual component of the face-to-face encounter. For several other procedures, such as special ophthalmologic examinations and electrocardiogram interpretation, the history may not be a component of the currently covered service.

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Figure 4. Key questions for clinician-interactive telemedicine. (Numbered questions below correspond to arrows in Figure 1) 1a. What clinical services are or might be provided by clinician-interactive telemedicine? (This question was addressed (more...)

To assess the diagnostic accuracy and the effect of these services on management decisions, we sought peer-reviewed, clinical studies of clinician-interactive telemedicine (Arrow 1b). Specifically, we asked, Relative to usual care, does clinician-interactive telemedicine resultin comparable diagnosis and appropriate recommendations for management?

As with the other study areas, the most powerful evidence for the safety and effectiveness of clinician-interactive telemedicine applications would directly link their use to improved health outcomes such as functional status, quality of life, or mortality (Arrow 3). In the absence of such direct evidence, the effectiveness of this form of telemedicine might be inferred from evidence about improved diagnosis, coordination, or management decisions. To make this inference, we should have evidence that these particular intermediate outcomes are reasonable indicators, or proxies, for actual health outcomes (Arrow 4).

We also sought evidence that these programs improved access to care for the targeted populations (Arrow 1c) and evidence about the potential adverse effects of the encounter (Arrow2). The remaining links in the analytic framework address whether clinician-interactive telemedicine improves patient and provider satisfaction (Arrow5), reduces costs (Arrow 6), or can provide added health benefits at a reasonable marginal cost (Arrow 7).

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