|
|||||
|
|||||
|
|
|
|
Member and |
Seminar Series II MODELS OF TELEHEALTHORGANIZATIONS AND STRATEGIES IN DELIVERY OF SERVICESby Arturo M. Pesigan, M.D. and Roderico H. Ofrin, M.D. What I'm going to do this afternoon are to define telemedicine and telehealth, discuss telemedicine's historical developments, and present some country models of telemedicine. As well, l will highlight some relevant issues we may have to face in the implementation of telemedicine programs. We will also take a look at the future of telehealth , if there is any, in the country. Definition The key words in telemedicine are tele and medicine. Basically, telemedicine is the application of telecommunication in the practice of medicine. Originally, the old literature would refer to telemedicine. It's good that there is the realization that we have to do a shift in definition and use health instead of medicine. Using medicine will confine applications of telemedicine to the medical aspect. On the other hand, with telehealth we will be talking of a broader scope. I think it's fairer to use telehealth. In terms of current definition, telemedicine is the use of audiovisual and digital telecommunications technology. It is a means of facilitating access to medical information and expertise. And what should be given emphasis here is the goal of improving delivery of health care and reducing cost. Other literature would emphasize the use of modern information technology, specially two-way interactive audio-video telecommunications, computers, and telemetry, emphasizing again delivery of health services to remote patients. Other models, however, would show that even within the hospital we may use telemedicine for communication. Telemedicine is also used to facilitate information exchange between primary care physicians and specialists at some distances from each other (Bashshur, Sanders, Shannon, 1997). Telehealth, meanwhile, is the provision of health services to remote sites using interactive video, television, and computer technology. The other important concepts we need to know are telemedicine system and telemedicine services. When we talk of system, we refer to the whole team consisting of hardware, software, infrastructure, and network connections (Levens, 1997). Services, on the other hand, refer to the whole spectrum of the patient -- clinical practice, clinical staff, support staff, administration, and payments. The last item, payments, is important because when you talk of telemedicine, specially in the Western world, you cannot separate the issue of cost. Limitations in the definition Literature would also show that there are limitations in the definition of telemedicine. They say that it is lifeless if little attention is given to systemic qualities. They also point out that we must view telemedicine as a new, integrated system of care, an innovative bundle. In fact, they're saying that if telemedicine will succeed, it will change the pace of health and medical practice in the world. They're also saying that with telemedicine, health and educational services are unhindered by space and time. It is also a means of triaging patients to appropriate sources of care and clinical decision making. Rationale Why was telemedicine developed or how did it evolve? We go back to the issue of problems faced by the health care system, issues which are actually universal. One issue is the uneven geographic distribution of health care resources, health care facilities, and health human resources. The other is the issue of inadequate access to health care. Even in Metro Manila where there are the best hospitals and medical centers in the country, people still lack access to health care. Either they cannot afford health care or they have problems relating with the health care professionals. And, of course, there is the issue of unabating rise in cost of health care. Major issues
History The history of telemedicine globally is something like wax and wane. We had the rudiments of telemedicine way back to the time when the telephone was made available. This made possible consultations through the telephone. In the late 1960s, the Nebraska General Hospital and a state mental health hospital did psychiatric consultation using a two-way, closed circuit microwave television. In 1968, there was a project link between Logan International Airport in Boston and the Massachusetts General Hospital using real time interactive audio-video system. The National Aeronautics and Space Administration (NASA) used telemedicine in monitoring the vital signs of astronauts in space. They also experimented with delivering health care in a reservation in Arizona using the STARPAHC (Space Technology Applied to Rural Papago Health Care) program. The first edited volume on telemedicine was published in 1975 but few people took notice of it. Some dismissed it as a mismatch of a high technology solution to simple problems in primary health care. The first generation of telemedicine was unsuccessful and could not be sustained. The innovation failed to diffuse and become an accepted mode of health care delivery. Why was this so? At that time, the information highway was still at its infancy. Furthermore, information capability was primitive. Dedicated phone lines could only transmit slow-scan analog images. The quality of audio transmission was poor with the use of coaxial cables. As well, medical providers were at that time inexperienced in the efficient use of the technology. And funding agencies thought only of funding short-term projects. The 1980s spawned the second generation of telemedicine. At this time, telemedicine was still at its early stage of development. The 1990s saw the strong revival of telemedicine. It was at this time that telemedicine was seen as an effective and versatile solution to many problems in health care delivery. Models Let's take a look at some models of telemedicine. USA. In the USA, telemedicine was primarily used by the military and NASA. It also found utility in teleconsultation and continuing education. As early as 1968, the Massachusetts General Hospital and the Logan Airport Project employed microwave transmission of two-way audio-video. The Navy Remote Medical Diagnoses System used in 1972 slow scan television in ship-to-ship and ship-to-land transmission of x-rays and electronic stethoscope. Other projects in which telemedicine was used include the ATS-6 Satellite Advanced Health Care and Education in 1974-1975. In this project, the Alaska health experiment used telemedicine in the transmission of x-rays and EKG tracings. In 1975, the Playas Telehealth system in New Mexico utilized microwave, two-way audio-video, telephone, and facsimile. The Rhode Island Rural Health Demonstration Project used from 1976-1979 slow-scan television for primary care applications. Some of the applications of telemedicine in the US include teleradiology, telepathology, teledermatology, teleoncology, telepsychiatry, and clinical telemedicine particularly in cardiology and ENT. Telemedicine is also used in prisons/correctional systems and in home health care. The telemedicine infrastructure in the US consists of the transmission media -- terrestrial lines, microwave, radio, and satellites; a band width (bit rate) of T1=1.544 mbps and T3=44.736 mbps; asynchronous transmission mode (ATM); and integrated services digital network (ISDN). Funding for telemedicine usually comes from federal funds, state funds, research funds, and fee for service. Japan. The use of telemedicine in Japan can be traced back to 1971 when 192 experiments in telemedicine were carried out to provide medical care in remote areas. Thus far, 88 projects have been carried out in teleradiology, 48 in teleconsultation, 33 in tele-homecare, and 23 in pathology. The infrastructure consists of satellites, ISDN lines, appropriate diagnostic equipment, and facsimile. Funding for telemedicine comes mostly from research as well as government grants. Canada. Meanwhile, the development of telemedicine in Canada could be attributed to geographic need. The leading institutions that used telemedicine are the Memorial University of Newfoundland, University of Alberta, and Dalhousie University. Telemedicine in Canada found its use in educational case conferences, child telepsychiatry, and teleradiology. At the Memorial University of Newfoundland, telemedicine is an important tool in educational technology, literacy programs, fisheries, and conflict resolution. The infrastructure consists of satellites, one-way video and two-way audio, PC-based and non-PC-based videoconferencing, telephone lines, as well as T1 and T3 lines. Funding for telemedicine comes from the government. Asia. In China, Malaysia, and Thailand, telemedicine is an important means of delivering services to remote areas. It is also used in teleconsultations. In China, the Medical University of Shanghai uses telemedicine. In Malaysia and Thailand, their respective Ministry of Health takes the lead in the application of telemedicine. The telemedicine infrastructure in these three countries consists of ISDN lines and desktop videoconferencing. Europe. In Norway and Finland, telemedicine has contributed extensively in providing rural areas access to medical care, and in networking to address disasters. It finds application in consultation and diagnosis, teledermatology, telecardiology, teleradiology, telepathology, telepsychiatry, and ENT. It is also used in remote teaching particularly in geriatrics and nursing physiotherapy. The infrastructure uses ISDN lines. Funding for telemedicine comes from the government. Philippines. In the Philippines, telemedicine is used mainly for continuing education, professional education particularly in post-graduate studies, and in teleconsultation. In 1993, the UP College of Public Health started using telemedicine/audioconferencing. The UP Open University uses telemedicine in teletutorials in its Master of Public Health (MPH) and Master of Hospital Administration (MHA) programs. It has also participated in international videoconferencing with Australia on women's health. Together with UNDP, it sponsored an international videoconference on HIV/AIDS linking Manila with Kuala Lumpur and New Delhi. We've also had active audioconferencing before with Canada. There is also the telepathology program of the Department of Pathology and the Advanced Science and Technology Institute of the Department of Science and Technology (ASTI-DOST). Aside from all these, there is the Makati Medical experience on telemedicine which will be discussed by our speaker later on. I've read that a local government in Mindanao is also developing and supporting telemedicine programs but I'm not sure if it's in Cotabato. The local telemedicine infrastructure is still crude. It consists of telephone lines, e-mail, and audioconferencing kits/speakerphones. Funding for telemedicine comes from foreign sources and from the Department of Science and Technology. Issues of concern Now, what are the major issues of concern with regard to telemedicine? We go back again to the four As of health care, namely accessibility, affordability, adequacy, and availability. How are we going to address them with telemedicine? Telemedicine is a very expensive endeavor. There is, therefore, the need for collaborative efforts and networking between institutions. Estimates in 1997 placed the cost of teleradiology hardware for a community hospital at US$87,050. The estimated cost of teleradiology for an academic department is US$143,600. These are the costs of actual hardware. Telecommunication costs at least US$1,612 per month. But things are getting a little cheaper right now. And that's perhaps when telemedicine will really bloom and fully develop. It's interesting to note that proponents of telemedicine will always say that telemedicine is always surprising. We'd like to emphasize, too, that telemedicine is about solutions and not just plain technologies. Different business models exist for each application area and subsidies are not a business model. We'd like to promote telemedicine as a low-cost tool and not as a decision. Telemedicine must be part of a broader information management fabric and not just a point-to-point solution. In the US, there are issues on risk arrangements and capitation which we hope will not concern us immediately. Other issues are security and confidentiality specially with access to computer technology. There is also the issue of standards in transmission specially with pathology and teleradiology and the other clinical sciences vis-a-vis the quality of images that are transmitted. This is relevant because quality of images will have a bearing on the decisions that you may have to make. Later on there will be the issue of liability and malpractice. Perhaps this could not to be tackled right now because we are not on the full implementation of telemedicine in the country. With the presence of insurance and health maintenance organizations, the issue of compensation and reimbursement will also have to be dealt with. Future of telemedicine in the Philippines I'd like to pose some questions as to how we will nurture the development of telemedicine in our country. A very important question is Will it really answer the needs in remote areas? Will it help make specialty services become more affordable? Will quality of care be safeguarded? Will the development of telecommunication and the computer industry in the country move with the needs of telemedicine? We've been a little slow in terms of the development of information technology (IT) in the country and telemedicine will have to depend on IT. Another thing is that we should not be blinded and say or promote that telemedicine definitely is the panacea du jour for improving health services. Because it is an innovative idea, we still have to be cautious about it. The future is in harnessing existing technologies, matching appropriate technologies to the country's needs, and in pursuing collaborative activities because the technology is expensive. We also have a great future in terms of the use of telemedicine in distance education for health human resource development. And this is what we want to promote and hope the government will support in the UP Open University -- the establishment of the TeleSenter. TeleSenter is the telecommunications for learning and services which we hope to integrate in learning centers nationally. In closing, I'd like to quote Dr. Everette Koop (1995), the former US surgeon-general. He said "Through telemedicine, we are going to be able to enjoy some things that we were never able to do before. If this system eventually works in the way we envision, every encounter you have with the medical system will not only inform the next; it will also inform all the encounters other people have with the medical system." e-Health Seminar Series Seminar II |
|
|
|
