Technical and clinical progress in telemedicine.

Abstract

TELEMEDICINE IS DEFINED AS THE DElivery of health care and sharing of medicalknowledgeover adistance using telecommunications systems. Although the telephone is certainly the oldest such system, the term telemedicine is usuallyappliedtotelecommunicationssystems of more recent origin: interactive televideo, “store-and-forward” imageand medical record transmission via personal computers, and remote monitoring. Two technological developments in the early 1990shave ledtoasurge in interest in telemedicine. One is the increasing deploymentofhigh-speed,high-bandwidth telecommunications systems around the world. The second development is the invention of devices capable of capturing and transmitting images and other data in digital form. While the costs for the hardware, software, and signal transmission are high, they are declining significantly each year. Interactive video equipment that cost more than $100 000 in 1992can todaybepurchased for less than $20 000—and today’s equipment has more capabilities. Most telemedicine programs in the United States support either interactive video–mediated clinical consultations or store-and-forward teleradiology. Storeand-forward teleconsultations involve exchange of static images (as opposed to video images in motion) that are stored in the telecommunications equipment and forwarded as image files. This takes less bandwidth than motion video. Relatively few programs support both interactive and store-and-forward technologies. Teleradiology is the most common application: in 1997 about 250 000 diagnostic teleradiology studies were done in the United States. During the same period 46 231 interactive video and store-and-forward teleconsultations were done (FIGURE). The most active specialties were psychiatry (17.9%), cardiology (16.7%), ophthalmology (9.6%), and orthopedics (5.7%). Research throughout the world, published in 2 peer-reviewed journals (Journal of Telemedicine and Telecare and Telemedicine Journal), is addressing important concerns: Do telemedicine consultations provide effective, satisfactory health care? Should these services be reimbursed? Are the services worth the stillsignificant cost for equipment and telephone line charges? Starting in January 1999, the Health Care Financing Administration (HCFA) is reimbursing physicians for some telemedicine services to Medicare patients. Many telemedicine advocates are disappointed about HCFA’s restrictions on what will qualify as a reimbursable consultation. Such teleconsultations must be to a patient in an underserved rural area, require the presence of the referring practitioner, exclude storeand-forward technology except for teleradiology, and obligate the consultant to remit 25% of the payment to the presenting practitioner. The first 3 conditions limit the scope of consultations. The last condition raises concerns about antikickback rules. However, Medicare’s reimbursement seems to acknowledge the growing use of telemedicine. Some private health insurance companies, managed care organizations, and state Medicaid programs are reimbursing for telemedicine services and some states (eg, Louisiana and California) have passed laws requiring reimbursement.