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