Post on 02-Jan-2016
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 Access Cost
Improvement Enhancement Containment
Large scale Ubiquitous Substitutions
conversions Systems
Broad provider Affordable Production
adoption 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
Type SpeedTime to Transfer
680M bytesModem 28.8 Kbps 54 hours
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 theInternet2 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