Transcript A Bird’s Eye View of Telemedicine

Telemedicine in the USA
and the World:
Progress and Prospects
2o Congresso Internacional de Telemedicina,
Educação e Treinamento à Distância
Rashid Bashshur, Ph.D.
Director of Telemedicine
University of Michigan
Health System
Topics to be covered

Review of Telemedicine

Current Status

Challenges

Future Prospects
Genesis


NASA space exploration (1958-70)
• Effect of zero gravity on astronauts
• Need for remote monitoring, telemetry
Terrestrial applications (1970-1980)
• Remote/isolated areas (rural and remote)
• Confined populations (nursing homes, prisons)
• Underserved urban populations (nhs, urban
hospitals)
Demise
Why did the first wave fail?
 Powerless constituency
 Rudimentary technology
 High cost
 Reliance on external funding/ Short term perspective
 Limited organizational support
 Limited provider acceptance
 Change in political environment: anti-technology
Rebirth
Why Returned?

Intractable problems
in health care
• Uneven quality
• Limited access
• Cost inflation
Why uneven quality?

Technical Quality
• Specialization
• Spatial
distribution
• Ability to pay
• Imperfect
knowledge

Interpersonal
Quality
• Ability to pay
• Physical attributes
• Case complexity
• Limited patient
participation
Why unequal access?




Geography/proximity
Economic status
Culture
Opportunity cost
Why cost inflation?




Technology
Demand
Moral hazard
Professional
control
The Telemedicine
Solution

Information age
• Data compression
• The NGI
• Miniaturization

Declining price
The impossible promise
Improve Quality and Access and Contain Costs
How Can the Promise be
Achieved
Quality
Improvement
Large scale
conversions
Access
Enhancement
Ubiquitous
Systems
Cost
Containment
Substitutions
Broad provider
adoption
Affordable
Production
function
Decision support
Continuing
education
Current Status
Current growth areas
 Realized
• Confined, regimented, and institutionalized
 Expected
• Home-bound
• Disabled
• Chronically ill
Current growth areas

Why?
•
•
•
•
Identified service population
Custodial or public responsibility
Accountability
Global budgeting
The Technology of
Telemedicine

3 Basic stages
• Telecommunications of the 70s
• Digital age of the 90s
• Broadband Internet of the new millenium
The prevailing wisdom
is wrong



Technology is a major problem
Still imperfect, unreliable, costly
• Efficient design
• reliability
• Speed of obsolescence
Design engineering
• Not just equipment
• Configuration
• Total System design
• Human factors
Research Findings

Biomedical Research
• Feasibility
• Clinical efficacy/effectiveness

Health Services Research
Access

Predominant mode is hub and spoke
structures >100 federally supported
networks

Increased access to about 18 million
people, located within 40 mile radius
Cost


Cost savings when:
• Services populations are locationally confined, such
as prisons, ships and homes
• When time to treatment is critical, such as
emergencies
Cost savings depend upon:
• Opportunity cost (transportation)
• Volume
• Time sensitivity
• Cost of alternative
Quality



Interpersonal dimension
• General satisfaction among providers and clients
• No indications of discomfort, impersonality; no breach of
confidentiality among patients
Technical dimension
• No serious research on structural effects
• Primary emphasis on diagnostic accuracy, precision, specificity
and reliability
Two conclusions
• Telemedicine delivers adequate information for a majority of
clinical and diagnostic procedures
• Specific instances of failure were fully attributable to the
specific technology that was used
Challenges


The scope
• Integrated Systems versus Categorical
Applications: Regional, National, and
International Collaboration
The Human Dimension
• User Acceptance
• Human Factor Engineering
Socio-Economic
Differentials

Availability and Accessibility

Affordability
Legal & Regulatory
Constraints





Individual Autonomy
• Privacy, Confidentiality
• Informed Consent
• Authentication
Legal Liability
• Jurisdiction
• Venue
Intellectual Property Rights
Licensure & Credentialing
Reimbursement
Agenda for Action






The Process of Harmonization
Universal not National Standards
Compatibility
(Interoperability) of System
Scalable Systems
User Involvement
Cultural Relativity
• Language
• Cultural Sensitivity
The Future

The Scope
• Telemedicine-Telehealth-E-Health (Applications)
• (Blurring of Boundaries)

• Health Informatics; Bioinformatics (Science)
Issues Concerning the Technology
• The Drivers
• (Health care is Beneficiary, not Driver)
• The Pace of Change
• (Speed of Obsolescence)
• Innovation
• (Incompatibility with Current Systems)
The Broadband Internet
Bandwidth/Speed
Time to Transfer
680M bytes
54 hours
Type
Modem
Speed
28.8 Kbps
ISDN (1 channel)
64 Kbps
24 hours
ISDN (2 channels)
128 Kbps
12 hours
T1
1.544 Mbps
1 hour
T3
45 Mbps
2 minutes
OC-3c
155 Mbps
40 seconds
OC-12c
622 Mbps
9 seconds
OC-48c
2.5 Gbps
2.2 seconds
OC-192c
9.5 Gbps
0.5 seconds
Internet2 Participants
and GigaPoPs
Legend
• Internet2 participants
GigaPoPs
GigaPoP Regional aggregation points that connect
Internet2 participants to each other and the
Internet2 networks
Internet Growth


Last 24 hours, Internet added
• 2 million pages of information
• 147,000 new web pages
• 196,000 new Internet-access devices
• In 2002- more web pages than humans
U.S. Physicians’ use of the Internet
• 89% use through home or office
• Primary use: clinical reference, knowledge enhancement,
e-mail
• 15% used for clinical work
• 7% used for patient care
Internet Security

Password inadequate, can be:
• Lost
• Forgotten
• Breached





Unique Biometric Signatures
Finger Print Scanners
Iris Scanners
Voice recognition
Public Key with Certificates
• PKI-Public Key Infrastructure
• Digital Signature
• Certificate Authority
Other Systems




Smart Cards
Bar Codes
Quantum Computers
• Molecular Size Switches
• Unbreakable Keys
Compression
Health Care Delivery


Locus of Care
Informed Consumers
• Sophisticated Patients
• Altered Doctor/Patient Relationship

Personalized Health care
• Lifetime Health Plan (Malaysia)
Expanded Business
Opportunities in Health Care



Multiple Source of Revenue
• Sponsorship Fees
• Advertising
• Electronic Prescription
• Pharmaceuticals
• Stand Alone Diagnostic Facilities
• Health Claims
• Consumer Advice
Effect on Professional Role of Medicine
Emergent Organizations
• Virtual Organizations
• Networks
• Winners and Losers
International Cooperation

Various Levels
• Regional
• Hemisphere
• World