telemedicine in the usa and the world: progress and prospects 2o congresso internacional de...
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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
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Topics to be covered
Review of Telemedicine
Current Status
Challenges
Future Prospects
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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)
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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
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Rebirth
Why Returned?
Intractable problems in health care
• Uneven quality• Limited access• Cost inflation
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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
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Why unequal access?
Geography/proximity Economic status Culture Opportunity cost
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Why cost inflation?
Technology Demand Moral hazard Professional
control
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The Telemedicine Solution
Information age
• Data compression
• The NGI
• Miniaturization
Declining price
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The impossible promise
Improve Quality and Access and Contain Costs
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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
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Current Status
Current growth areas Realized
• Confined, regimented, and institutionalized Expected
• Home-bound• Disabled• Chronically ill
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Current growth areas
Why?
• Identified service population• Custodial or public responsibility• Accountability• Global budgeting
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The Technology of Telemedicine
3 Basic stages
• Telecommunications of the 70s• Digital age of the 90s• Broadband Internet of the new millenium
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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
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Research Findings
Biomedical Research
• Feasibility
• Clinical efficacy/effectiveness
Health Services Research
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Access
Predominant mode is hub and spoke structures >100 federally supported networks
Increased access to about 18 million people, located within 40 mile radius
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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
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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
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Challenges
The scope
• Integrated Systems versus Categorical Applications: Regional, National, and International Collaboration
The Human Dimension
• User Acceptance
• Human Factor Engineering
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Socio-Economic Differentials
Availability and Accessibility
Affordability
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Legal & Regulatory Constraints
Individual Autonomy• Privacy, Confidentiality• Informed Consent• Authentication
Legal Liability• Jurisdiction• Venue
Intellectual Property Rights Licensure & Credentialing Reimbursement
???
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Agenda for Action
The Process of Harmonization Universal not National Standards Compatibility
(Interoperability) of System Scalable Systems User Involvement Cultural Relativity
• Language• Cultural Sensitivity
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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)
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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
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Internet2 Participants and GigaPoPs
Legend • Internet2 participants GigaPoPs
GigaPoP Regional aggregation points that connect Internet2 participants to each other and theInternet2 networks
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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
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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
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Other Systems
Smart Cards Bar Codes Quantum Computers
• Molecular Size Switches
• Unbreakable Keys Compression
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Health Care Delivery
Locus of Care Informed Consumers
• Sophisticated Patients• Altered Doctor/Patient Relationship
Personalized Health care• Lifetime Health Plan (Malaysia)
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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
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International Cooperation
Various Levels
• Regional
• Hemisphere
• World