Focus on telemedicine
Can J Rural Med vol 3 (1):39-40
© 1998 Society of Rural Physicians of Canada
A MEDLINE search using the keywords "telemedicine" and "rural," unearths 75 references between 1993 and 1997. One early reference is of interest as it represents a consensus view from 1994.
Delivery of health care to the underserved: potential contributions of telecommunications technology. Consensus conference entitled "Telemedicine and Access to Care". McGee R, Tangalos EG. Mayo Clin Proc 1994;69(12):1131-6.
Two important recommendations emerged: "(1) to focus on the needs of the underserved people more than on the capabilities of the available technologies and the regional centers and (2) to use the least expensive but appropriate telecommunications technology for any specific application." It is pertinent to reflect on whether these principles have been adhered to in the intervening years.
Teleradiology
Teleradiology as a subset of the telemedicine continuum is the subject of a significant number of articles. Issues of quality and needs assessment are prominent. The latter is addressed in an article from Iowa, which documents the use made of a teleradiology system by physicians in a small rural hospital.
Teleradiology consultation for a rural hospital: patterns of use. Franken EA Jr, Harkens KL, Berbaum KS. Acad Radiol 1997;4(7):492-6.
These authors found that radiologic consultations were requested most frequently for "trauma, spine, abdomen, and the infant age group." This includes examinations that may be difficult to interpret (i.e., children) or where the consequences of missing a lesion may be major (i.e., spine).
Implementation
Telemedicine and the New Children's Hospital (Royal Alexandra Hospital for Children). Manson N. J Telemed Telecare 1997;3 Suppl 1:46-8.
The New Children's Hospital (Royal Alexandra Hospital for Children) in New South Wales, Australia, also promotes its role in providing telemedicine services but is hampered in implementing this technology by factors that are common to many countries. In their view, ". . . in Australia, as in other countries, the adoption of telemedicine may outstrip the ability of the legislative and administrative frameworks to keep pace. Thus, the enablers appear to be cultural and technological while the obstacles are rooted in the way in which health systems are financed and administered."
Quality
The issue of quality was addressed in an article from another pediatric centre, where the interpretations of 153 cases by general radiologists using teleradiology were compared to the interpretations by pediatric radiologists of the original radiographs.
Pediatric radiology at a rural hospital: value of teleradiology and subspecialty consultation. Franken EA Jr, Berbaum KS, Brandser EA, D'Alessandro MP, Schweiger GD, Smith WL. AJR Am J Roentgenol 1997;168(5):1349-52.
The authors found that their sample consisted mainly of x-rays of common conditions, mostly "pneumonia and fractures." They found no significant differences in the interpretations by the 2 groups, and concluded that: "Simple pediatric radiographs obtained at a rural primary care institution and transmitted by teleradiology can be adequately interpreted by general radiologists."
Caution
Telemedicine: a cautious welcome. Wootton R. BMJ 1996;313(7069):1375-7.
In an editorial in the British Medical Journal, R. Wootton (no relation to CJRM editor) notes: "Rushing into equipment purchase, however is almost certain to prove counterproductive. Face to face contact is fundamental to health care and enthusiasts of telemedicine should recognise that it is not as good as the real thing (and unlikely ever to be)."
Telemedicine and competitive change in health care. LaMay CL. Spine 1997;22(1):88-97.
From Northwestern University comes the following caveat: "Telemedicine in the United States has yet to prove itself economically viable, and it faces a number of political and regulatory barriers. Even more significantly, telemedicine's potential to increase overall health care spending by increasing access to health care has deterred private industry from investing heavily in it."
Cost-effectiveness
And from Norway comes a large study that specifically compares the cost of providing teleradiology to 2 alternatives, including maintaining the status quo.
Radiology services for remote communities: cost minimisationstudy of telemedicine. Halvorsen PA, Kristiansen IS. BMJ 1996;312(7042):1333-6.
The authors compared 3 scenarios: (1) A small x-ray unit in the rural site and all other examinations at the host site (the existing system). (2) A teleradiology system with most examinations done at the rural site and only more advanced examinations at the host site and (3) all examinations at the host site. They factored in direct medical costs, nonmedical (travel) costs and indirect costs such as lost production and the value of lost leisure. Surprisingly (at least to telemedicine fans) they found that, "the existing system is the least costly option except when lost leisure is valued as highly as lost production." The authors did admit, however, that such a system might be justifiable on grounds other than cost, such as "equity of access and quality of care."
