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Introduction to E-health

What is e-Health?

 

Gunther Eysenbach Editor, Journal of Medical Internet Research

 

Everybody talks about e-health these days, but few people have come up with a clear definition of this comparatively new term. Barely in use before 1999, this term now seems to serve as a general "buzzword," used to characterize not only "Internet medicine", but also virtually everything related to computers and medicine. The term was apparently first used by industry leaders and marketing people rather than academics. They created and used this term in line with other "e-words" such as e-commerce, e-business, e-solutions, and so on, in an attempt to convey the promises, principles, excitement (and hype) around e-commerce (electronic commerce) to the health arena, and to give an account of the new possibilities the Internet is opening up to the area of health care. Intel, for example, referred to e-health as "a concerted effort undertaken by leaders in health care and hi-tech industries to fully harness the benefits available through the convergence of the Internet and health care." Because the Internet created new opportunities and challenges to the traditional health care information technology industry, the use of a new term to address these issues seemed appropriate. These "new" challenges for the health care information technology industry were mainly (1) the capability of consumers to interact with their systems online (B2C = "business to consumer"); (2) improved possibilities for institution-to-institution transmissions of data (B2B = "business to business"); (3) new possibilities for peer-to-peer communication of consumers (C2C = "consumer to consumer").

So, how can we define e-health in the academic environment? One JMIR Editorial Board member feels that the term should remain in the realm of the business and marketing sector and should be avoided in scientific medical literature and discourse. However, the term has already entered the scientific literature (today, 76 Medline-indexed articles contain the term "e-health" in the title or abstract). What remains to be done is in good scholarly tradition to define as well as possible what we are talking about. However, as another member of the Editorial Board noted, "stamping a definition on something like e-health is somewhat like stamping a definition on 'the Internet': It is defined how it is used - the definition cannot be pinned down, as it is a dynamic environment, constantly moving."

It seems quite clear that e-health encompasses more than a mere technological development. I would define the term and concept as follows:

e-health is an emerging field in the intersection of medical informatics, public health and business, referring to health services and information delivered or enhanced through the Internet and related technologies. In a broader sense, the term characterizes not only a technical development, but also a state-of-mind, a way of thinking, an attitude, and a commitment for networked, global thinking, to improve health care locally, regionally, and worldwide by using information and communication technology.

This definition hopefully is broad enough to apply to a dynamic environment such as the Internet and at the same time acknowledges that e-health encompasses more than just "Internet and Medicine".

As such, the "e" in e-health does not only stand for "electronic," but implies a number of other "es," which together perhaps best characterize what e-health is all about (or what it should be). Last, but not least, all of these have been (or will be) issues addressed in articles published in the Journal of Medical Internet Research

 

Telecommunications Infrastructure

2001 Report to Congress on Telemedicine, Office for Advancement of TeleHealth, (Last visited: March 17, 2003)

 

 Overview

High transmission cost continues to deter telemedicine, particularly in rural areas of the United States. While it may be only a few years away, competition in telecommunications service has not yet reached much of rural America and transmission cost is still a significant part of a rural telemedicine project's overall budget.

Five years ago Congress passed the landmark Telecommunications Act of 1996 (the Act), providing a blueprint for major changes in the telecommunications industry, such as opening up competition between long distance carriers and the Regional Bell Operating Companies. The Act also stated that rural health care providers (HCPs) should have access to advanced telecommunications services at reduced rates.

In the Act, Congress charged the Federal Communications Commission (FCC) with administering the Universal Service program that would provide rural health care providers with a discount on their telecommunication transmission charges equaling the difference between urban and rural transmission rates. In 1997, the FCC established the Universal Service Administrative Company, (USAC) a separate, not for profit entity, which oversees both the E-Rate discount for Schools and Libraries and the Rural Health Care Program (RHCD).

After a number of false starts, the Rural Health Care Program issued its first funding commitments on June 25, 1999, five days before the end of the first 18-month program year. In total, 483 rural health care providers received $3.4 million out of a possible $400 million, which equaled the total requested support for completed applications received by USAC that year (January 1, 1998 through June 30, 1999).

Since then, the FCC has adopted a number of reforms to the program, as outlined below, which streamline the discount application process, and address practical concerns voiced by practitioners and others. Specifically, the FCC:

***Expanded the list of telecommunication carriers eligible to participate in the program to include non-ETC (long distance) carriers;

***Streamlined the application process;

***Changed the discount calculation to distance based charges paid by rural healthcare providers rather than a comparison of urban and rural published tariffs; and Eliminated bandwidth and quantity limits so that any bandwidth and any number of services could be supported.

Funding in the second year of program, after reforms were implemented, increased to approximately $6.1 million. Moreover the FCC and USAC expect that third-year funding figures will increase to nearly $10 million, once all reforms have been in place for a full year. (For a detailed history of the Rural Health Care Division, see Appendix 6 and OAT's FCC filing on Universal Service at http://telehealth.hrsa.gov/pubs.htm.)

 Next Steps

***The Office for the Advancement of Telehealth (OAT) recently filed comments with the FCC on the question of "possible impediments to deployment and subscribership in unserved and underserved areas of the nation." (See OAT's FCC filing on Pacific Basin at http://telehealth.hrsa.gov/pubs.htm) Follow-up with the FCC on this issue continues.

***OAT also filed comments on the FCC's proposal to set aside spectrum for the use of Wireless Medical Telemetry. (See http://telehealth.hrsa.gov/pubs.htm) OAT's comments also reflected concern about adequate spectrum for future telemedicine applications, which may require more bandwidth than currently allocated for telemetry.

 

  

Evaluation and Research 

2001 Report to Congress on Telemedicine, Office for Advancement of TeleHealth, (Last visited: March 17, 2003)

***Overview

***Patient and Physician Satisfaction with Telemedicine bulletTable 4: Patient/Provider Satisfaction with Telemedicine bulletBox 8: ECU Study Results

***Telemedicine Cost Savings bulletBox 9: Kaiser Tele-homecare Study Results

***Next Steps  

Overview

Despite telemedicine's relatively long history, few statistically significant studies of efficacy, patient/physician satisfaction, or effectiveness have been conducted. This dearth of research and data may be due in part to the relatively small number of telemedicine consultations within a given specialty or across specialties within individual telemedicine projects, and to the lack of a standard methodology to study efficacy, patient/physician satisfaction, or effectiveness across projects.

Despite the lack of statistical significance in most of the studies examined by this Report, all showed high patient satisfaction with telemedicine as shown in Table 4. Provider satisfaction was more variable, but generally moderate to high. Moreover, although one cannot generalize to all telemedicine applications, studies of specific services, such as tele-homecare and tele-dermatology, suggest that at least for these services, there may be real cost savings to be realized from telemedicine.

Recent research on evaluation methodologies, such as the Lewin Group Inc.'s draft study on the Assessment of Approaches to Evaluating Telemedicine, funded by the Office of the Assistant Secretary for Planning and Evaluation, the Department of Health and Human Services (DHHS), may offer hope for more statistically robust studies in the near future.

 Patient and Physician Satisfaction with Telemedicine

To develop a better sense of patient and physician satisfaction, this Report to Congress examined four recent reviews of studies on patient and/or provider satisfaction with telemedicine. These reports offer sufficient breadth or depth in their data to warrant a closer look. Table 4 below highlights the general findings and the strengths and weaknesses of the reports. They include:

 

*** Telemedicine for the Medicare Population by the Oregon Health Sciences University funded by the Agency for Healthcare Research and Quality for DHHS;

***Patient Satisfaction with Telemedicine by the East Carolina University Medical School Telemedicine Center;

***A DRAFT Assessment of Approaches to Evaluating Telemedicine by the Lewin Group, Inc, funded by the Office of the Assistant Secretary for Planning and Evaluation; and

***The 1999 Annual Report of the Association of Telehealth Service Providers.  Table 4: Studies of Patient/Physician Satisfaction with Telemedicine Name of Report No. of Studies Reviewed Patient Satisfaction Provider Satisfaction Strengths/ Weaknesses DHHS/Oregon Health Sciences University (2000) 30 studies Highly Satisfied HighlySatisfied Large survey of studies/ small data samples in each study. Studies only look at one application such as teledermatology East Carolina University (2000) 12 studies plus ECU study of 492 teleconsults HighlySatisfied 98.3% Rating NA Large data sample in ECU study with different applications and different settings/ small survey of 12 other studies with small data samples. Association of Telehealth Service Providers (1999) Study based on 132 network responses NA Moderate to Highly Satisfied Large survey of users/ only looks at technology and users Oregon Health Sciences University/DHHS Report

In 1999, the DHHS' Agency for Healthcare Research and Quality funded the Oregon Health Sciences University to study Telemedicine for the Medicare Population. The Report assesses telemedicine technologies that substitute for face-to-face medical diagnosis and treatment, focusing on three technologies -- store and forward, self-monitoring/testing and non-surgical services.

Although the main thrust of the Oregon Health Sciences University's report is telemedicine technologies and not patient/physician satisfaction with telemedicine, the authors devoted a chapter to their findings on satisfaction.

This chapter drew upon an extensive literature search of both ongoing telemedicine programs around the world and peer reviewed studies assessing the efficacy and cost of telemedicine. The survey of telemedicine literature and projects was extensive and about 30 studies fit the authors' criteria for inclusion in the patient/physician satisfaction chapter. The authors selected 18 studies that examined patient satisfaction with telemedicine and 10 studies that looked at physician satisfaction. Most of these focused on one clinical specialty such as oncology, psychiatry or dermatology, or on a particular setting such as a prison or emergency room.

The majority of the Report's selected studies show patients satisfied with their telemedicine treatment. Out of 18 studies examined, only one study showed that most patients preferred face to face assessment in lieu of teleconsults. The rest of the studies reveal high levels of satisfaction.

Similarly, the Report found that, overall, physicians' satisfaction ranges from "satisfied" with telemedicine technical quality to high levels of satisfaction. However, one study out of the ten showed that while the participating psychiatrists were satisfied, given a choice, they preferred face to face assessments.

Despite these positive outcomes, the Oregon Health Sciences University does not draw any conclusions about patient or physician satisfaction because the authors felt that the studies were not statistically significant. However, the authors do acknowledge that further study or more statistically significant study may not provide any different conclusions than those already offered by these.

As shown in Table 4, most of the studies were based on relatively small data sample sizes ranging from one to about 100 patients. Two of the 18 patient studies were based on larger sample sizes. One was based on a prison inmate population of 576 inmates; the other was based on a sample of 294 dermatological patients. Most of the studies concentrated on only one specialty such as mental health or dermatology. A few studies did assess satisfaction across a few specialties but these were the exception.

Telemedicine Center of the East Carolina University School of Medicine

The University of East Carolina (ECU) School of Medicine recently published a report entitled "Patient Satisfaction with Telemedicine," in the Telemedicine Journal (Vol. 5, Num.1). In this report, the authors review other non-telemedicine studies that look at patient satisfaction as well as 12 studies of patient satisfaction in telemedicine applications. They also report their own findings about patient satisfaction based on data collected and evaluated from 495 real-time interactive telemedicine clinical consultations associated with their Telemedicine Center at the School of Medicine. ECU's Telemedicine Center is the hub to eight spoke sites, including six hospitals, one rural health clinic and one maximum-security prison.

ECU's review of 12 telemedicine studies showed patient satisfaction ranging between 71% to 100%. And similar to the Oregon Health Sciences University's review of 18 telemedicine studies, above, ECU found that the 12 telemedicine studies they reviewed tended to have small sample sizes, ranging from 21 to 292 patients. Also similar to the DHHS studies was the focus on one clinical specialty or particular setting, such as a prison.

 Box 8: ECU Study Results

Overall patient satisfaction with telemedicine applications was found to be a high 98.3%. Patients were highly satisfied with consultations through telemedicine, and reported that care was easier to obtain.

In contrast to the reviewed studies, the ECU study has a much larger data sample size (495 responses) and looks at patient satisfaction across telemedicine specialties. ECU studied a wide variety of clinical specialists including dermatology (33.5%), allergy (21%), cardiology (17%), psychiatry (5.1%), endocrinology (4.2%) and rehabilitation medicine (4.0%).

Patient satisfaction was examined in relation to patient age, gender, race, income and insurance. Overall patient satisfaction with telemedicine applications was found to be a high 98.3%. Patients were highly satisfied with consultations through telemedicine and reported that care was easier to obtain.

ECU suggests several reasons for the high patient satisfaction rate. For example, travel time can be a factor in patient satisfaction. Travel distances for patients seen over the telemedicine link were on average 81 percent shorter, when compared to the distance to the School of Medicine clinics. The overwhelming majority of patients indicated that telemedicine had made it easier for them to obtain medical care. For example, scheduling a time to see a telemedicine specialist was easier than trying to schedule an appointment with a traditional specialist at ECU's clinics. The amount of time the telemedicine specialist spent on a patient's interview, physical examination and discussion of treatment options was greater and more satisfying to the patient. Part of the reason was that the telemedicine physician received patient information several days prior to the consultation and spent less time gathering information about medical history and more time on the problem at hand. According to the ECU study, although the telemedicine consult usually takes longer than a traditional exam, "it is plausible that these factors make the patient feel more involved in the consultation and increase(s) satisfaction in the process."

Association of Telehealth Service Providers

The Association of Telehealth Service Providers' (ATSP) annual report provides findings from a nation wide survey of active telehealth networks. The purpose of the 1999 Report on US Telemedicine Activity, was to assess the state of telemedicine from the clinical provider's organizational perspective; describe and characterize telemedicine/telehealth activity for 1998 and the first quarter of 1999; and provide reference material. The report does not include patient or physician satisfaction with telemedicine per se but does survey clinical providers' satisfaction with specific types of telemedicine technology. ATSP's 1999 report is based on responses from 132 telehealth networks.

In this report, ATSP's findings on provider satisfaction of telemedicine technology could be viewed as a proxy for health provider satisfaction with telemedicine. The report shows clinical providers' satisfaction with several types of telemedicine technology with data from about 4 to 69 users. Overall the majority (94%) of those interviewed indicated moderate to high levels of satisfaction with the different types of equipment used for telemedicine such as teleradiology, telepathology, videoconferencing, laptops, set tops, home health systems.

Overall, each of these reports and the studies they review or the programs they survey show that patient satisfaction with telemedicine is high and that physician satisfaction is moderate to high. Despite the lack of statistically significant data underpinning most of the studies, it is notable that they all show positive satisfaction.

The Office of the Assistant Secretary for Planning and Evaluation/ Lewin Group, Inc. Report

The Office of the Assistant Secretary for Planning and Evaluation(OASPE) of the DHHS funded Lewin Group Inc. has drafted a report titled Assessment of Approaches to Evaluating Telemedicine. This draft highlights some of the difficulties of evaluating an industry driven by rapidly changing technology and, given these difficulties, reviews the frameworks needed to appropriately evalutate telemedicine projects. For the report, Lewin conducted a literature search on a number of telemedicine studies and visited five telemedicine sites, first hand. Additionally, 15 telemedicine experts were extensively interviewed. Although the main purpose of the report was assessing telemedicine evaluation and not patient satisfaction with telemedicine, it does address what subjects should be appraised in the future and what subjects, such as patient satisfaction, may be sufficiently evaluated.

As the Lewin Group Inc.'s Draft Report points out "patient satisfaction with telemedicine has consistently been demonstrated to be high. As such, resources for future evaluations may be better allocated to areas of higher priority."

 

 Telemedicine Cost Savings  Box 9: Kaiser Tele-homecare Study Results

The Study found no difference in quality indicators, patient satisfaction or use between a control group and a tele-homecare group. Although the average direct cost for home health services was $1,830 in the tele-home group and $1,167 in the control group, the total mean costs of care, excluding home health care costs, were $1,948 in the tele-home group and $2,674 in the control group.

Just as there has been an absence of statically significant studies about patient/ provider satisfaction, at present, few telemedicine or other health care projects track the number of patients, who would have been denied access to health care, died or suffered grave consequences in the absence of telemedicine services. As for other tangible benefits related to telemedicine services, they too have not been systematically studied across telemedicine applications on a large scale.

This report briefly looks at several studies that examine telemedicine cost savings for a specific telemedicine application. Kaiser Permanente Medical Center of Sacramento, California conducted an in-depth study on tele-homecare 11 between 1996 to 1997. (See http://www.archfammed.com). In the cost control study home-care patients were assigned to two different groups: a telemedicine intervention group and a control group. The telemedicine intervention group included 102 patients, who had access to a remote video system that allowed nurses and patients to interact in real time; the control group included 110 home health patients, who were visited by nurses. The study showed that remote video technology in the home care setting was effective and well received by patients. Moreover, the quality of care provided by this technology yielded similar outcomes to those of the control group. Finally, the study found that tele-homecare had the potential for cost savings, which was mostly attributable to hospitalization cost reduction as shown in Box 9.

The University of Tennessee Medical School (UT) also published a study on tele-homecare, conducted between April 1998 and June 1999. UT's A Case Study of Benefits and Potential Savings in Rural Home Telemedicine12 evaluated 444 tele-home health visits to 14 patients using the Home Touch* system. The Home Touch system included a 13-inch monitor, a speaker phone, a camera and ViaTV converter equipment to provide a real-time home health consultation with UT Home Health nurses in both Knoxville and Jefferson City. The cost of the system was about $1,500. UT conducted in-depth interviews and monthly surveys with nine of the 14 patients, as well as their caregivers. The results from the Case Study show that:

 

*** 98% of the patients were satisfied with telemedicine;

***100% said the equipment was easy to use;

***Use of the Home Touch program saved more than 27,000 nurse travel miles between April '98 and June '99, representing potential savings of $7,091.76 @ $0.26/mile;

***For the 14 patients seen by telemedicine, the mileage reimbursement and drive time potential savings were $49.33 per visit.

The Walter Reed Army Medical Center's (WRAMC) Army Telemedicine Directorate recently evaluated the use of teledermatology for several military sites. Although actual travel and dermatology contract costs for the different military locations were not available, the study found that teledermatology's current benefits are "reduced travel and contract dermatologist costs, increased Primary Care Manager (PCM) education, increased access to dermatologists and increased patient/provider satisfaction"13. This study was based upon findings from WRAMC's Web-Based Telemedicine Consult Management System (TCMS) for teledermatology which conducted 108 clinical consults between April 22, 1998 and July 15, 1998.

Finally, the OASPE/ Lewin Group Inc.'s report findings suggest that "some of the commonly recognized types of economic impact of telemedicine applications are costs associated with: patient time and productivity; transportation; capital (equipment, space, etc.); maintenance; and communications; utilization of health care services; and staffing levels and productivity of health professionals."

 Next Steps

*** Future evaluations might use the results of the OASPE/Lewin Group Inc. Report to conduct research that yields data with greater statistical significance, by using cross-project evaluation methodologies suggested in the Report.

***Future evaluations should examine provider satisfaction, quality and cost implications of telemedicine for specific applications such as tele-homecare, teledermatology and mental health. Footnotes

11 "Outcomes of the Kaiser Permanente Tele-home Health Research Project," Archives of Family Medicine, Volume 9, January 2000.

12 "A Case Study of Benefits andPotential Savings in Rural Home Telemedicine", Home Healthcare Nurse, Vol. 18, No. 2, Feb. 2000, p.125.

* Home Touch is a registered trademark of the University of Tennessee Medical Center at Knoxville.

13 Advanced Concept Technology Demonstrations Letter of Finding, Telemedicine Directorate, Walter Reed Army Medical Center, 2000.

 

 Emerging Trends and Policy

2001 Report to Congress on Telemedicine, Office for Advancement of TeleHealth, (Last visited: March 17, 2003)

***Overview

***Technology Changes

***Related Technology Policy Issues

***Aging Demographics, Home Care and Urban Telemedicine  

Overview

Two important trends that may greatly affect the telehealth industry and raise key policy issues are rapid technology changes and the aging population of America. However, predicting the future of the telehealth industry and the technical standards that will underpin "next generation" technology is like predicting the lottery. At most, we can describe some important emerging trends in the telehealth industry over the short term and suggest some related policy issues for the future.

 

 Technology Changes

Over the past five years, significant changes in the telehealth industry have been tied to rapid

 

technology advances and the convergence of the communications, media and computer industries. What has been even more dramatic is the exponentially expanding global reach of the Internet, which grew out of a community of U.S. academic and military developers to reach a world wide global audience in just a few years. Technology trends that will likely influence the near future of the telehealth industry and dictate the need for technical standards and guidelines are:

*** Next generation Internet;

*** The digitization of information; and

*** The migration toward wireless communications. Next Generation Internet

As consumers and businesses find more ways to use the Internet in their homes and businesses, the next generation Internet will enable these tasks to be accomplished faster, more securely and reliably than on our present system. Part of the anticipated next generation Internet, Internet2 is a joint venture by academia, the federal government and industry. This group is using a new high-speed backbone network with a core sub-network consisting of a 2.4 Gbps, 13,000-mile research network to test Internet applications such as Internet Protocol (IP) multicasting, differentiated service levels and advanced security. It will also allow researchers to test and resolve problems such as bandwidth constraints, quality and security issues.

DigitizationSimilar to the next generation Internet, the digital revolution is already upon us. Digitized data, voice, still images and motion-video can be mixed, matched, melded and sent over myriad types of conduits. Advances in digital and compression technology enable vast amounts of information to be stored onto smaller and smaller chips. Applications of this technology include the creation of digital medical libraries and medical databases, as well as the potential to widely adopt Electronic Medical Record Systems and Smart Cards that can hold medical information on a card the size of a credit card. Smart cards are already in use to a limited degree here in the U.S. and more widely overseas. Currently, however, there are no technical standards that can help to easily integrate telemedicine clinical data onto these systems and cards.

Wireless Technology

The use of wireless telemetry in hospital settings is already standard practice as discussed in the Chapter on Safety and Standards. (Examples of medical telemetry equipment include heart, blood pressure and respiration monitors.) In addition, Emergency Medical Services companies are or will be important users of telemetry and other wireless technology. Companies already use wireless telemetry or more advanced wireless technology such as wireless interactive video on emergency vehicles and to communicate with emergency physicians. It enables a paramedic to confer with an emergency physician for an early assessment, well before the patient's arrival at the hospital. Telemedicine equipment can be as simple as a laptop computer with desktop video conferencing capabilities that provide simultaneous two-way video, two-way voice, vital signs, cardiac and other data to a trauma center. Wireless technology is also useful in an emergency care hospital because emergency physicians, consulting a hand-held wireless device, do not have to leave the patient's side while researching unfamiliar symptoms.

Other wireless technology applications in telemedicine and telehealth will emerge as people adopt wireless applications in their every day lives. For example, the average consumer will be able to carry a mobile library of health information and diagnostics contained in a pocket-sized, handheld wireless computer. With such a wireless palm computer, the practitioner can send patient medical information from the hand held device to another wireless device next door or around the world or to a main data center in the hospital for storage.

 Related Technology Policy Issues Policy Lags Technology

Policy makers have not been able to anticipate the changes brought about by the rapid technological advances, revolutionizing the health care industry. In just the past five years, discoveries related to DNA sequencing, the Human Genome Project, cloning and other scientific breakthroughs have raised questions about ethics, privacy and security. These types of discoveries combined with the exponential growth and use of the Internet have created a "policy lag" whereby policy is developed and implemented many months or even years after technology has changed lives, businesses and health care delivery. In the past, the development of regulatory policy, technical standards and protocols could be created over a number of years but not now. Internet time relates not only to businesses that must adjust to rapid industry changes but also to industry regulators.

Privacy Issues

Federal health privacy laws such as the Health Portability and Administrative Act (HIPAA) were conceived a few years before anyone could anticipate the dramatic growth and global reach of the Internet or the convergence of cable, digital, telephony and video technologies. HIPAA rules did not anticipate health practitioners, who could send multiple or a billion copies of a patient record in both text and video clips over the Internet in the form of email. Consequently, HIPAA policy and rules may have to be retrofitted to the current technology landscape and its future possibilities. For example, HIPAA proposed rules do not cover many health-related Web sites. The Next Generation Internet will raise other important privacy and security issues as health care administration and services migrate toward Internet and wireless technologies.

Technical Standards and Guidelines

With an increase in the use of advanced wireless technologies, such as hand-held devices with video Internet capabilities, there will be a critical need for technical standards. Standards will help to ensure interoperability, interconnection reliability, quality and security of medical data, images and video transmitted over the airwaves.

Telemedicine providers are already finding it difficult to get their equipment to "talk" to one another even if both perform the same function. Older machines will not talk to newer versions of themselves; different brands will not interconnect. This is frustrating to the health practitioner, trying to provide services, and it is very expensive.

Spectrum Frequency Allocation

As the health care industry adopts more sophisticated technology, requiring more bandwidth, the bandwidth size, location and status of spectrum frequency that the Federal Communications Commission allocates for medical purposes will likely become a key policy issue for the telehealth industry.

For example, streaming video requires a much larger bandwidth to convey natural movement than bandwidth required for wireless monitoring of vital statistics. An on-going dialogue about the "primary or secondary use" of designated or shared spectrum may be required between the Federal Communications Commission and health related organizations, particularly as the use of telemetry and more advanced wireless telehealth applications is more widely used and moves from institutions to the home or to other health related venues.

Spectrum frequency allocation has also become a growing safety issue. For example, in March 1999, incidences of digital TV interference with wireless medical telemetry equipment occurred at two hospitals in Dallas. (Examples of medical telemetry equipment include heart, blood pressure and respiration monitors.) When new digital TV services were piloted, medical telemetry equipment in these two hospitals did not work. Incidences like these highlight the dangers of electromagnetic interference with the operation of critical medical equipment and underline the need for appropriate spectrum allocation and designation.

In June 2000, the FCC allocated new spectrum and established rules for a Wireless Medical Telemetry Service (WMTS) that allows telemetry equipment to operate on an interference-protected basis. The FCC based its decision on formal comments from a number of organizations including the Food and Drug Administration and the American Hospital Association's Medical Telemetry Task Force, which provided specific recommendations for spectrum allocation. OAT also filed comments with the FCC, supporting the AHA recommendations and submitted additional comments concerning the possible future uses and spectrum needs of telemedicine and telehealth applications.

Border Issues

With the Internet, digitization and wireless technologies, the concept of either domestic or international borders will become blurred. As this trend accelerates, cross-state jurisdiction and enforcement issues will become harder to disentangle. Blurring borders may also expand the purview of general practitioners. For instance, if a Physician Assistant or Nurse Practitioner works with a primary care physician or specialist on an ongoing basis and slowly assumes more of the physician's basic duties, then a gradual change in practice will naturally occur over time. How will states decide to license these practitioners? Will they receive special credentials?

Aging Demographics, Home Care and Urban Telemedicine

A discussion of how demographic trends will affect the health industry is not within the scope of this Report but it is hard to ignore the effect the aging of the Baby Boomer generation will have on the health care and telehealth industry. An aging population with a longer life expectancy may mean a larger population of "fragile" elderly, the chronically ill and those requiring rehabilitation.

Given this demographic trend, recent studies and workshops14 show that home care medical devices were the fastest growing segment of the medical device industry throughout the 1990s. A report from the Workshop on Home Care Technologies for the 21st Century suggests: "Consumer demand for home health and home health care is not new. When patients have a choice, and if they have a reasonably stable and caring home environment, they choose to go home, almost without exception. If they have a severe, chronic, difficult condition it is difficult to permit them to go home, unless the home is fitted with the appropriate technology and care giver. We have the opportunity today to make this choice possible by developing technology that is easy to use, suitable for the patients' particular needs and allows access to trained, off-site professionals who can work with the patient on educational/problem areas of concern."15 Given the movement toward home health care, tele-homecare will most likely play an increasingly larger and more important role in the home health care industry.

Home care in the future may rely on new applications for wireless technology. Tele-homecare can be defined as providing monitoring (telemetry) and home health care services at a distance, using advanced telecommunications and information technology. Aside from videophones, wireless biosensors and feedback loops data can be used to monitor patients who can not get out of bed. OAT grantees have found that tele-home health care has been largely successful, and can allow greater access to care, particularly in rural settings where a nurse may have to travel 200 miles one-way to see a patient at home face-to-face. With tele-homecare, a rural nurse can "visit" six patients in one day, using interactive video instead of traveling 200-300 miles to visit one patient face-to-face for 20 minutes.

Providing tele-home care to the elderly or disabled populations, using telemedicine raises important policy questions about health care access and the reimbursement of telemedicine services for both rural and urban patients. It can be argued that urban patients who are very elderly, chronically ill, poor or disabled may be as isolated and have as much difficulty getting access to needed health services as those patients, living in rural areas. Most of these urban patients cannot drive to their local clinics and many require assistance getting from point A to point B. Traveling a mile for such an urban patient may be as difficult as the two hundred-mile or more drive, that a mobile rural patient must make to see a specialist.

Reimbursement for both urban and rural patients may be a cost effective policy decision for tele-homecare. Studies show tele-homecare can save money by decreasing unnecessary hospital and emergency room admittances. Around-the-clock monitoring and nurse availability over videoconferencing has helped patients better self-diagnose and maintain drug therapies.

This policy issue may be resolved at the third party payer level, if cost savings are sufficiently great enough to attract the attention of this group.

Footnotes

14"Future Trends in Medical Device Technology: Results of an Expert Survey," FDA, April 1998 and Workshop on Home Care Technologies for the 21st Century, Catholic University, April 1999

15"Personal Status Monitoring in the Home," Report Topic B, Workshop on Home Care Technologies for the 21st Century, Catholic University, April 1999.