Telecare: Informatics in Health Care

Telemedicine refers to the use of information and communication technologies to transfer medical information for the delivery of clinical and educational services. It dates from the sixties, during the space race, when the vital bodily functions of astronauts in the space were remotely monitored from the Earth by doctors of the National Aeronautics and Space Administration (NASA) (Lima CMAO et al, 2007, 341).

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The medical information may include images, live video and audio, video and sound files, patient medical records, and output data from medical devices. The transfer may involve interactive multimedia communication between patients and medical professionals or between those professionals without patient participation. Like any technology, telemedicine has its own advantages and disadvantages.

Telemedicine has many potential benefits such as improved access to information, provision of care to remote areas, improved access to services and increasing care delivery, improved professional education and reduced health care costs and there are some drawbacks such as a breakdown in the relationship between health professional and patient and between health professionals, privacy issues, accuracy problems, financial issues and organizational and bureaucratic difficulties (Hjelm, 2005, 60). Thesis: The benefits of telemedicine are substantial, assuming that more research will reduce or eliminate the obvious drawbacks.

Consider the scene where a nurse in a dialysis unit moves a video monitor from bed to bed so that a nephrologist 50 miles away can consult with patients regarding their dialysis regimen. An emergency room in a rural clinic connects via videoconferencing equipment to an academic medical center emergency room to help save a car accident victim who needs to be anesthetized. A surgeon in Hawaii performs an orthoscopic surgery on a patient while being coached through the procedure via videoconference by an orthopedic specialist from Cleveland’s Mayo Clinic (Thompson et al, 2003, 515).

Each of these cases is an example of how healthcare professionals are using telemedicine technology to extend quality medical care over constraints of distance and time. Telemedicine serves the general public in the realm of healthcare in three main ways: addresses the uneven geographic distribution of health care resources, facilities, and personnel; improves access to health care among underprivileged, isolated, and confined populations; and slows the rising cost of care (Bashshur, 1997, 5).

Debakey (1995, 15)) argued that telemedicine, or the use of telecommunications technologies within the field of health care, has the potential for having a greater impact on the future of medicine than any other modality.

From the viewpoint of patients, telemedicine expands their choice of providers, makes culturally competent providers accessible, expands access to specialty care, reduces patient travel time and expense and reduces work/school absences (Speck, 2005: 20). From the viewpoint of physicians, telemedicine eliminates “windshield” time for physicians and other specialty staff, reduces travel expense, reduces staff downtime and creates flexibility thru dynamic scheduling (Speck, 2005, 21).

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Telemedicine has created a new ways of interaction between different groups of people. Interaction can now take place between specialists and general practitioners, nurses and physicians, or groups of specialists. Consultations among providers are not a new concept but consultations within the presence of the patient are a new kind of encounter. Research shows that such kind of interaction provided educational opportunities for all parties involved (Whitten, 1995, 203). During real-time telemedicine consultations, the specialist, general practitioner, and patient are in the room at the same time – each informing the other.

Telemedicine allows patients to receive medical care in their own community. This allows rural medical facilities to operate at minimal cost and strengthens the rural economy by keeping the flow of resources in local communities. Telemedicine, by providing specialty care services to rural areas saves travel time for patients and the specialist. Even if at a later stage in treatment, the patient is referred or transferred to an urban facility, he would already have had the services of a physician.

Physicians and on-site care providers benefit as they receive quick and efficient consultations and the sense of isolation experienced by rural physicians is also reduced. Telemedicine forges a bridge between rural and urban hospitals providing benefits to both (UND, 1998, 3)

Warisse (1996) found that telemedicine decreased the number of referrals within some specialties as the general practitioner became educated on certain diagnoses. The nurse may develop an expanded role within telemedicine interactions as well. Turner (2000) found that nurses within the dialysis unit enjoyed telemedicine encounters because they were given more control of the session. During traditional sessions, the nurse was delegated to following the doctor from bed to bed, taking notes.

However, during telemedicine sessions, where the nurse remained at the bedside with the patient and the physician consulted from a remote office, nurses reported that they were given the increased responsibility of becoming the hands of the doctor. The nurses provided the in-person medical observation to the physician. When a physical exam was necessary, the nurse had to complete it.

Closed health care systems like HMOs, the Veteran’s Administration, prisons, and the military offer the greatest opportunity for a return on investment through telemedicine by providing efficient use of a fully capitated environment (Grigsby, 1997, 30). The primary successful applications of telemedicine have come from prison and military settings. These contexts are not hampered by licensure and reimbursement concerns and therefore provide a more fertile ground for telemedicine use to develop.

In addition, the incentives to overcome the costs of transporting patients are high. Within prison settings, transportation of inmate patients for health care requires expensive security measures along with additional costs incurred in case of an inmate escaping. Telemedicine also finds significant application in the military where there is need to provide prompt and quality care to individuals quite often isolated from medical care and in need of rapid access to specialty care (Edwards & Motta, 1997, 327).

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Consultations on the battlefield, training, preventive care, and specialty consultations are areas served by telemedicine. Of all medical branches, psychiatric treatments rank first in using telemedicine because they are less technology-intensive, do not require peripheral devices, and can be accomplished effectively using low bandwidths (128 Kbps) (Grigsby & Allen, 1997).

In fact, telepsychiatry ranks among the first uses of two-way audiovisual telecommunications in health care. A two-way closed-circuit microwave television system established in 1959 between the Nebraska Psychiatric Institute and Norfolk State Hospital in Nebraska proved effective at providing consultations, education, training, and research (Wittson & Benschoter, 1972, 624). According to Dr. Ronald S. Weinstein, Director of the Arizona Telemedicine Program and President of the American Telemedicine Association “telepsychiatry in Arizona is a major success story in mental health”.

Arizona has two nationally recognized telemedicine programs that partner in providing a variety of telehealth and distance learning services. The Arizona Telemedicine Program (ATP) provides a broad spectrum of telehealth services, including telepsychiatry, whereas the Northern Arizona Regional Behavioral Health Authority (NARBHA) provides telebehavioral health services through mental health centers. Both programs have received national awards. The Arizona Telemedicine Program that was started as a 8-site pilot project has evolved into one of the largest and most successful comprehensive telemedicine programs in the world.

Today, the Arizona Telemedicine Program operates a remarkably cost-effective broadband telecommunications network that links over 150 sites and saves the State of Arizona hundreds of thousands of dollars. Over 150,000 Arizonans have received health care services by telemedicine. Quality of services is high and routinely accepted by both service providers and patients. Services are available in 60 subspecialties of medicine, surgery, pediatrics, psychiatry, radiology, pathology, and many others.

Over 100 telephysicians and telenurses have provided services over the network. Over one million dollars were saved by the Arizona Department of Corrections by avoiding costly transports of prisoners to regional medical centers. Over a hundred thousand dollars have been saved reducing the need for psychiatrists to travel to dozens of rural communities.

Reduced air transports of patients injured in automobile accidents have saved additional hundreds of thousands of dollars. The delivery of specialty services into underserved areas has saved lives. The Arizona Telemedicine Program Network provides thousands of hours of interactive video continuing education programming. In addition, the educational programs of the University of Arizona Colleges of Nursing and Public Health offer for-credit courses over the network to busy health care professionals and students at selected locations throughout Arizona. Thus the Arizona Telemedicine Program contributes to the statewide effort to increase the number of health care providers available to Arizonans (ATP, 2004, 2).

Reviews of telemedicine via videoconferencing technology across a variety of specialties reveal positive clinical outcomes. Gutske et al. (2000) also found high satisfaction levels (98.35), noting that telemedicine satisfaction studies tend to report higher levels of satisfaction than even traditional doctor and patient satisfaction studies. They attribute this to the characteristics surrounding telemedicine interactions, including less waiting time, less travel time, and ease in arranging appointments. One patient satisfaction study within a prison setting explored patient perceptions of telemedicine across informational and relational dimensions (Mekhjian, Turner, Gailiun, & McCain, 1999, 55).

This study found that patients were satisfied with both dimensions of the exchange, although most satisfied with the informational dimension. Allen and Hayes (1994) found that ease of access and the physician’s communication style were important contributors to patient satisfaction with telemedicine encounters (Thompson, 2000, 525). Callahan, Hilty, and Nesbitt (1998) found that patients perceived that the simultaneous involvement of a primary care provider and a specialist provided additional comfort and confidence in the telemedicine encounter. The additional personnel helped to confirm the diagnoses and provided additional consistency to the encounter.

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When pediatricians at Sacred Heart Medical Center in Eugene are confronted with a tricky case, consulting with specialists at Doernbecher Children’s Hospital in Portland is now facilitated through video conferencing. Hospital officials say that the video consultation will provide immediate expert advice to local pediatricians and parents, and should reduce the number of children who must be taken to Doernbecher by helicopter or ambulance (Christie, 2007, b1).

Telemedicine has revolutionized healthcare by restructuring every professional relationship and technical activity. Medical care in this new environment is evolving from the physician-centered model to a new model of shared responsibilities where consumers, isolated or in groups make health-related decisions assisted by a variety of practitioners, sources of information, and decision-support tools. This empowerment of consumers is perhaps the most dramatic advantage of telemedicine (Rodrigues, 2000, 3)

Telemedicine helps the aging baby-boomer generation, living in assisted living situations, much safer. At 9:30 a.m. on a recent Monday, nurse Linda McRae asks her patient: “How’s your appetite? What about your bowels? Are you coughing up anything?” The questions sound routine but the nurse is far away from the patient. Elwin Geyer, a 69-year-old chronic lung disease patient, is at home, some 25 miles away from McRae. From the video room in Kaiser Permanente’s Sacramento, Calif., home health-care facility, the two are virtually connected by the flip of a switch, and McRae can examine Geyer long-distance, thanks to telemedicine (Lewis, 2001, 10).

Despite the continued expansion of telemedicine use in terms of applications and services there are still several barriers to the use of telemedicine. Sanders and Bashshur (1995) identified six challenges to the development of telemedicine applications: interstate licensing and institutional credentialing of physicians; legal liability and litigation; privacy concerns; reimbursement; knowledge about telemedicine, and system design and infrastructure. Most of these challenges reflect the problems in moving a system that has previously existed within a face-to-face, geographically centered environment to a virtual setting.

The medical licensing system acts as a barrier to telemedicine. Each state is free to determine how and under what conditions it will license practitioners and therefore during telemedicine consultations, it becomes difficult to determine “where” care is practiced within virtual environments (Cwiek et al, 2007: 141). When the patient is located in Wyoming and the physician is located in Ohio, where should the physician be licensed? – This is the problem. Only a national licensing system or adoption of a specific provision for telemedicine practice can overcome the regulatory concerns that prevent the implementation of telemedicine across state boundaries.

Legal liability within telemedicine contexts creates another area of concern for practitioners and patients (Granade, 1995, 87). A practitioner can be held accountable in a court of law only if the court has personal jurisdiction over the health professional (Blair, Bambas, & Stone, 1998, 49). Therefore, if the physician is not in the state where the patient is located, it could be difficult to press charges against that physician in case of malpractice. Hence, standards of care regarding telemedicine have also yet to be determined.

As geographical boundaries between the doctor and patient are being erased, there is a need for medical records to become digitized and transmitted, and the need for more individuals to be involved in the encounter. This could compromise the patient’s privacy (Gilbert, 1995, 91). Gilbert (1995) argued that most of the reported cases of unauthorized disclosure or use of patient confidential information happened when legally authorized persons misused their authority or when personnel who operate the equipment were exposed to private information that they had no obligation to protect.

As telemedicine is a new branch of healthcare, there are no systematic procedures in place for maintaining patient records. Some telemedicine programs have decided not to videotape telemedicine encounters because they do not have a system or space for storing the videotape record. This lack of systematic procedures and policies regarding electronic medical records and telemedicine interactions has slowed telemedicine deployment (Sanders & Bashshur, 1995, 115).

Many telemedicine applications are not reimbursed and this is a barrier in the practice of telecare. The U. S. Health Care Financing Administration (HCFA), the federal agency responsible for Medicare and Medicaid, requires a face-to-face consultation for reimbursement (Brecht & Barrett, 1998, 25).

In 1999, based on a mandate from Congress, HCFA began paying for telemedicine services within a limited context in Health Professional Shortage Areas. Some states (for example California, Oklahoma, and Texas) have legally allowed the elimination of face-to-face requirements when telemedicine is considered an appropriate alternative. However, those states that have developed reimbursement mechanisms for telemedicine only provide a fee for the consultant and do not make provisions for communication, infrastructure, or other inherent costs (Brecht & Barrett, 1998, 30).

In the financial context, telemedicine needs a large initial investment to cover the costs of implementing and supporting a telemedicine program which can help save money in the long run. In addition to start up costs, consideration must be given to the charge by the consultation team. Transmission charges can be costly (UND, 1998, 3).

But this is not a very significant barrier as equipment and transmission costs are steadily decreasing since the 1990s and federal grant money is being allocated to support the development of telecommunications infrastructure in rural and remote areas to make healthcare more accessible for all. According to Roberta J. Rodrigues (2000, 5), the economic impact of Telemedicine is enormous and is realized through better health care at lower cost at the microeconomic level, and increased competition at the macro level. In the educational context, telemedicine helps in continuing medical education, transcending geographic or geopolitical isolation (Rodrigues, 2000, 7).

One of the primary challenges to telemedicine expansion involves the need to transform the traditional environment of the doctor and patient encounter to include individuals and organizations at distant locations. This transformation requires the development of a new virtual organization (Turner, 1999) with new organizational goals, strategies, and individual work practices and this takes time and effort (Turner & Peterson, 1998, 41). In addition to the new organizational forms that are created through telemedicine, new relationships must develop between health care practitioners. There must be a facilitation of a trusting relationship between the health care practitioners involved at each site (Whitten, 1995, 203).

Turner (2000) in a study of dialysis patients’ perceptions of telemedicine encounters found that during times of low uncertainty (blood pressure and fluid check) or high uncertainty (emergency problem with their access site), telemedicine was a helpful substitute for a traditional consult. During the low uncertainty time, patients didn’t really need a physician and during the high uncertainty time they would accept whatever access to a physician was available.

However, during periods of moderate uncertainty (need for a medication change or change in dialysis prescription), patients preferred face-to-face, traditional consultations. These findings corresponded with media richness theory (Daft & Lengel, 1986, 554), suggesting that “the richer social presence of an in-person consultation helps to alleviate the ambiguity created by the conditions of the illness” (Turner et al., in press).

Thus telemedicine is a recent development in healthcare services. The advances in communication and information technology have contributed to its growth and it helps in bringing quality specialty healthcare to remote places where it is not easily available. There are many benefits of telemedicine and some drawbacks as well. With greater awareness of the social and economic benefits of telemedicine, efforts are being taken to reduce the drawbacks. Telemedicine is today a new and dynamic environment for health care communication scholars to explore.

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