Telemedicine Science: Oxymoron or Reality

Pamela Whitten, Ph.D.

Michigan State University

Agenda

• Traditional Approaches for Studying Telemedicine

• Nontraditional approaches

• Multidisciplinary Challenges

• Discussion Issues

Traditional Approaches for Studying Telemedicine

• The traditional 4-step dance

• Holle & Zahlmann, 1999, advocate this as an evolutionary approach for telemedicine research

• This advice not normally followed…dance steps often not done in sequence

1. Technical Pilot Study

• Measure the quality and performance of the hardware, software, telecommunications solution

1. Technical Pilot (Examples)

• Fetal Telemedicine (Fisk et al., 1996)– For women with high risk pregnancies,

conducted study to determine efficacy of image quality of ultrasound video images transmitted over “ISDN 30 telephone lines.” Study done from a district general hospital on the Isle of Wright to tertiary hospital in London

1. Technical Pilot (Examples)

• Wireless PDA as teleradiology terminal (Reponen et al., 2000)– Tested suitability of computerized tomograpgy

scans via wireless PDA based on GSM digital cellular phone

1. Technical Pilot (Examples)

• Remote Trauma Management (Tachakra, 2001)

– Linked two rooms in an emergency room and compared technical performance of telemedicine system versus face-to-face for remote trauma management. Parameters examined included overhead fluorescent lighting, video lighting, sound quality, echo cancellation, lip synchronization.

2. Feasibility Study

• Demonstrate the feasibility of telemedicine in a real world/clinical setting

2. Feasibility (examples)

• Telekidcare (Whitten et al., 2001)

– Demonstrated that children in inner city schools could come into a school nurses’ office and visit a pediatrician via telemedicine

2. Feasibility (examples)

• Telegenetics (Paulsen et al., 2003)

– Examined feasibility of conducting comprehensive genetics examination using telemedicine for children at the Children’s National Medical Center in Washington, D.C.

3. Controlled Effectiveness Study

• Controlled trial comparing the clinical outcomes effectiveness of telemedicine with standard healthcare

3. Controlled Effectiveness (Examples)

• Satisfaction (perhaps the most studied construct)

Satisfaction

• Teledermatology in Northern Ireland (Loane et al., 1998)

– Reported overall patient satisfaction with teledermatology consultation

Satisfaction

• Satisfaction with clinical telemedicine services from ECU (Gustke et al., 2000)

– N=495– 98% satisfied

Satisfaction

• Staff and patient satisfaction with telemedicine screening for diabetic retinothopy (Bratton, 2001)

– Study looked at family residents and patients and found patients more satisfied than providers

Problems with satisfaction studies

(Mair & Whitten, 2000) • Reviewed patient satisfaction studies and found

that methodological limitations of studies limited generalizability of results

(Whitten & Mair, 2000)

• The construct of satisfaction is too loose• Context matters (e.g., Comparison across two

satisfaction studies (telehome health and teleoncology found very different things)

• What is the real question?

Controlled EffectivenessClinical Outcomes

• Telepsychiatry (D’Souza, 2002)

– Examined use of telemedicine for discharge planning for inpatients in tertiary psych hospital

– Found more patients in control group were readmitted over a 12-month period and more from control group reported adverse medication effects

Controlled EffectivenessClinical Outcomes

• Home telehealth (Rogers et al., 2001)

– Study of home-based interventions reported improved mean arterial pressure in patients with hypertension

3. Controlled EffectivenessClinical Outcomes

• Whitten, in progress

– Looking at clinical outcomes for telehome health COPD/CHF patients in Michigan’s Upper Peninsula

• N=75 in experimental• N=69 in control

4. Cost Effectiveness Studies

• Examines the impact of telemedicine from a cost perspective

4. Cost Effectiveness Examples

• Telehospice (Doolittle, 2000)

– For telehome-based hospice services in Kansas, documented per visit cost of traditional visit at $126 USD and for telemedicine visits at $29 USD

4. Cost Effectiveness Examples

• Cost analysis of teledermatology vs real time consultations in New Zealand (Loane et al., 2001)

– Found average cost of traditional dermatology visit to be NZ$283.79 versus average cost of teledermatology to be NZ$279.23

4. Cost Effectiveness Studies

• Tremendous problems with cost effectiveness publications (Whitten et al., 2002)

– Reviewed 612 articles– No evidence that telemedicine is or is not cost

effective means of delivering care

Nontraditional Approaches

1. Theory Testing

• Academic applications to test or develop theory

1. Theory Testing Examples

• Structuration Theory (Kouroubali, 2002)

– Demonstrated applicability of structuration theory to implementation of health information systems in primary care clinics in Greece

1. Theory Testing Examples

• Diffusion of Innovations (Whitten & Collins, 1997)

• Communication perspective for studying diffusion of telemedicine offers more insight than traditional linear diffusion theories

1. Theory Testing Examples

• Objectivist approaches to study health information systems riddled with problems…researchers should look toward subjectivist alternatives (Moehr,2002)

2. Formative/Summative Evaluation

• Formative evaluation- focuses on the process

• Summative evaluation – focus is on the outcomes

2. Formative/Summative Evaluation

• Telemedicine system for home dialysis (Skiadas et al., 2002)

– Telemedicine system for home haemodialysis was designed to produce hardware and software specs. Evaluation from trials at 4 European locations included evaluability assessment and formative evaluation

2. Formative/Summative Examples

• Beaver Island (Whitten & Adams, 2003)

– Evaluated the process of developing and implementing telemedicine on a remote island in Lake Michigan with 600 inhabitants in

– Evaluated the outcomes once the project was launched (utilization, perceptions, etc.)

2. Formative/Summative Examples

• Study of formative processes through which telemedicine system designed and launched in the UK (May et al., 2003)

• Effective design and evaluation of decision support systems dependent upon a systems modeling approach that includes formative and summative evaluation (Carson et al., 1998)

3. Systems Issues

• Focus on telemedicine as a health delivery system

3. Systems Issues Examples

• Teleradiology as health care delivery system (Dionisio et al., 2000)

– Integrated system that support integrated modules for patient, primary care provider and specialist

3. Systems Issues Examples

• Longitudinal study of organizational issues in a telemedicine program (Cook & Whitten, 2002)

– Examined structural issues, goals, leadership, organizational characteristics

4. Qualitative

• Non-quantitative analyses often used to explain successes and failures related to telemedicine programs

4. Qualitative Examples

• Organizational consequences of telemedicine (Aas,2001)

– What happens in organizations when telemedicine is implemented?

4. Qualitative Examples

• Factors that influence the evaluation of telemedicine (May et al., 2002)

– Issues that affect/impact ability to evaluate telemedicine

5. Ethical/Policy

• Wide range of issues– Ethical issues for provision of care– Ethical issues related to policy/regulation

5. Ethical/Policy

• Suggested principles of professional ethics for online provision of mental health services (Hsiung, 2001)

5. Ethical/Policy

• Resource and allocation of health care in Canada (Joshi et al., 1990)

5. Ethical/Policy

• Projects to overcome digital divide (Kreps, in press)

– NCI digital divide funded projects

Food for Thought

Issue 1

• Can we understand telemedicine if we study issues in isolation?

OutcomesClinical

Cost

Organizational/Delivery IssuesInadequate LeadershipTechnological Access Certification Processes

Inconvenience of Using SystemDelay of Institution Adaption

Interpersonal/Individual PerceptionsAcceptance/Satisfaction

-By Patient -By Provider

Legal RegulationLiability

LicensurePrivacy/SecurityReimbursement

Social Embeddedness(Granovetter, 1985; Uzzi, 1996)

– Embeddedness is a multidimensional construct indicating that people (actors) within complex social networks (healthcare!!) face unique resources and constraints than those not embedded in such relations.

• Structural Cohesion (Moody & White, 2001)– Minimum # of actors (disciplines) that if removed from

the group would disconnect the group thus impacting the success or failure of telemedicine

• To explain success/failure, must know the contribution/interrelationship of each discipline

Issue 2

• What do we do about limited generalizability due to poor quality to date of many studies?

Issue 3

• In regard to traditional versus nontraditional approaches: would it help if there was a defined agenda for research?

Issue 4

• Are we holding telemedicine to the same or a different standard than traditional medicine?

Your Turn

• What are other key issues?