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Page 233
29
Proposal for an Evaluation of Health Care Applications on the
NII
Joseph Gitlin
Johns Hopkins University
Statement of the Problem and
Issues
Telemedicine is being advocated as a process of delivering
health care to all segments of the population with the potential of
reducing the cost of care while maintaining its quality. However,
little is known about the efficacy and cost-effectiveness of the
technology in routine diagnostic and therapeutic practice. A
well-designed evaluation based on stringent criteria is needed to
determine the merits of telemedicine in utilizing the national
information infrastructure (NII) in the environment of health care
reform. Within this context, some of the more important concerns
related to the realization of telemedicine are the following:
•
The lack of "bandwidth on demand" to provide data
rates when they are needed at affordable costs to the health care
community;
•
The lack of availability of high-density,
low-cost, digital storage and related software for efficient access
by authorized users; and
•
The lack of standards and interfaces for both
health care data acquisition and for the effective use of such
information. This is particularly applicable to integration with
heterogeneous legacy systems used by a wide variety of health care
providers.
Projections Regarding the Problem and
Related Issues
Assuming the telecommunication "tariff" issue under the
jurisdiction of federal, state, and local authorities can be
resolved, it is anticipated that the technical barriers to
bandwidth on demand will be overcome in the next 5 to 7 years. The
efforts under way to develop a reliable storage and retrieval
system that is suitable for medical images and other health care
data should be realized before the year 2000. Though improved
interfaces and system integration techniques are expected to be
available shortly, the accommodation of heterogeneous legacy
systems may be delayed by economic and cultural factors for several
years.
Status of Key Developments
Recent developments in information technology and the
recognition of the need for reform provide a unique opportunity for
health care decisionmakers to capitalize on the availability of the
NII. If, for example, medical imaging advances are to be available
to all patients regardless of situation or geography, the storage,
transmission, and retrieval of large volumes of data must be
accommodated in all areas of the country. Also, access by secondary
users to clinical information for teaching, research, and
management (within appropriate security and privacy restrictions)
requires that the information be readily available to medical
students, research investigators, and health care policymakers.
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Representative terms from entire chapter:
care administration
Page 234
Key developments in telecommunications essential to meeting the
demand generated by health care activities include the availability
of high-speed communication networks in sparsely populated areas.
The economic and cultural aspects of the telemedicine applications
can then be identified, demonstrated, and evaluated. Technology
related to high-density storage and retrieval of medical images and
related patient data is immature. Much work remains to be done to
achieve reliable and cost-effective systems that will support
patient care, medical research and education, and health care
administration. The proliferation of personal computers and the
increase in computer literacy are major factors in user acceptance
of telemedicine and related technology.
Interaction Between Technical and
Nontechnical Factors
The regulatory authority of federal, state, and local agencies
to set tariffs has resulted in barriers to the economic reality of
telemedicine. If the quality of health care is to be maintained in
a cost-effective manner using the NII, clinical data must be
transmitted promptly within cost constraints.
Other legal and regulatory issues that must be addressed include
the privacy of patients and health care providers, and the security
of data against unauthorized access. Many questions need to be
answered regarding the "ownership" of medical information and the
responsibility for retention of medical records. The differing
state medical licensure requirements must be rationalized to permit
access, when needed, to specialists across state boundaries, and
malpractice regulations need to be modified to eliminate
unnecessary medical procedures that are performed solely to reduce
the threat of litigation. In the area of administration, the
adoption of a uniform claims data set would substantially reduce
current processing activities related to reimbursement.
Though health care costs in the United States amount to
approximately 15 percent of the gross domestic product, health care
information requirements alone cannot support the development and
deployment of the NII. However, health care is an important
contributor to the information community and is one of many large
economic segments that must be included in the utilization of the
NII. If the cost of the NII is shared among a large number of major
segments of the economy, the application of telecommunications will
be facilitated. Further advances in storage and retrieval
technology are largely dependent on government agencies and sectors
of the economy other than health care. The special requirements of
health care can then be met by modifying the basic developments
designed to meet other needs.
The current trend of health care reform emphasizes the
restructuring of the delivery system toward managed care
corporations. The driving force behind this restructuring is the
recognized need for cost containment. Today, the decisions to adopt
new technology for use in health care are predominantly made by
corporate managers rather than by individual practitioners. Since
health care is a labor intensive activity, in this new climate
technology that increases efficiency is more favorably
received.
Increased access to quality care by patients regardless of
situation or geography is the primary justification for
telemedicine and for health care reform. To some extent, this
implies "patient acceptance" of the NII and related technology;
however, health care provider acceptance is pivotal to adoption of
telemedicine in practice. The acceptance of new technology requires
many cultural and procedural changes by physicians, nurses, and
allied health care workers. These changes have already occurred in
health care financial activities such as billing and reimbursement
and in medical research but are lagging in patient care delivery
functions.
Contingencies and Uncertainties
The investment in and deployment of new technologies applicable
to health care are partly dependent on the success of health care
reform. "Many of the political imperatives driving telemedicine
derive from the anticipated use of managed care incentives to
provide accessible low-cost health care to all Americans."1 It is expected that the information
infrastructure will be deployed because of impetus by government
agencies and industries other than health care. The implementation
of the NII for the delivery of health care is dependent on the
cost-effectiveness of the technology as perceived by the decision
makers within health care reform.
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Other contingencies and uncertainties related to investment and
deployment of the NII and its use in health care include the
following:
•
Availability of appropriate network connections
throughout the country;
•
Willingness by health care providers to share new
technologies;
•
Resolution of security and privacy issues;
•
Cost-effective solutions to integration of legacy
systems;
•
Resolution of telecommunications tariff issues,
particularly bandwidth on demand;
•
Adoption of a uniform claims data set;
•
Acceptance by physicians of "compressed" data,
especially in medical imaging; and
•
Completion of the comprehensive computer-based
patient record.
Key Applications, Enabling
Technologies, and Capabilities
Several recent technological developments make it possible for
health care to take advantage of many of the capabilities offered
by the NII. The following are among the more important developments
available to health care providers:
•
A range of workstations accommodates the spectrum
of needs of health care providers, particularly the high-resolution
and luminance requirements of radiologists, as well as the needs of
other specialists and primary care physicians.
•
Several standards have been developed for health
care data interchange. These include the Digital Imaging
Communication in Medicine (DICOM), HL7, and MEDIX P1157. However,
it is necessary to identify and develop other standards that will
facilitate further use of the NII by health care providers.
•
Preliminary results of the large-scale effort to
develop a comprehensive computer-based patient record are
available, and there is momentum to complete the task.
•
Various technical approaches have made "electronic
signature" available. However, some legal questions remain to be
answered before broad acceptance can be achieved.
•
Recent advances in "speech recognition" technology
are most important to health care provider input to medical
records. This is especially applicable to medical imaging, where
interpretation of examinations is basic to the specialty.
•
The use of compression algorithms to decrease data
volume has proved cost-effective and reduces transmission time.
However, there is concern about the loss of pertinent information
when "destructive" compression is applied. This is especially true
of medical images, where radiologists require all of the original
data for detecting subtle abnormalities.
Classes of Users
In health care, there are several types of users to be
considered when access to the NII is planned. Among those users who
are relatively easy to accommodate and who may adapt quickly to the
new technology are the following:
•
Computer-literate health care providers,
researchers, educators, and students in academic settings;
•
Computer-literate health care providers and other
personnel in managed care settings; and
•
Government and insurance agencies concerned with
reimbursement.
There are also a large number of potential health care users of
the NII that will require substantial training and education, as
well as appropriate hardware and software to be capable of using
the infrastructure:
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•
Older health care providers in small groups and
solo practices, and
•
Health care providers in remote locations.
If the technology proves to be cost effective, the increase in
managed care organizations should expedite the use of the NII for
patient care, medical research and education, and health care
administration. Though the primary factors relative to ramp-up
expectations and determinants are outside the health care
environment, government actions regarding Medicare and Medicaid
will affect investments in technologies intended for health care
markets.
Public and Private Sector
Responses
Since health care is uniquely the purview of both the public and
private sectors, such an application of NII technology is affected
by government and industry. Acceptance by health care providers and
related organizations in terms of cost-effectiveness and utility is
affected by both political and economic considerations.
Recommendations
A comprehensive evaluation based on a realistic demonstration
should be conducted to identify the factors related to the
utilization of the NII by health care providers and related
organizations. The evaluation should be based on stringent criteria
that focus primarily on patient care issues such as quality and
access, and that measure selected key parameters related to
technology, economics, and legal/regulatory and social/cultural
factors. The project will require the participation of industry,
academia, and government in cooperation with health care providers
to develop the evaluation criteria, design the study, and conduct
the demonstration of cost-effective systems that will support
telemedicine, medical research and education, and health care
administration. It is intended that this white paper will provoke
serious consideration of health care applications on the NII.
Reference
1. Perednia, D.A., and A. Allen. 1995.
"Telemedicine Technology and Clinical Applications," Journal of
the American Medical Association 273:483–488.
