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Recent advances: Telemedicine
Average reader rating: 9  
by Richard Wootton 06 the future of Medicine

As telecommunication technology has advanced and costs have declined over the past decade, there has been a steady growth in telemedicine. Much of this growth, however, has been in the form of feasibility studies and pilot trials. As a result there is little convincing evidence of the cost effectiveness of many applications, apart from teleradiology (box). This paper reviews recent evidence and describes clinical applications where there is early evidence that telemedicine is not only of clinical benefit but cost effective too.

What is telemedicine?
Telemedicine is an umbrella term that encompasses any medical activity involving an element of distance. In its commonly understood sense, in which a doctor-patient interaction involves telecommunication, it goes back at least to the use of ship to shore radio for giving medical advice to sea captains. A few years ago the term telemedicine began to be supplanted by the term telehealth, which was thought to be more "politically correct," but in the past year or so this too has been overtaken by even more fashionable terms such as online health and e-health.

The implementation of telemedicine in routine health services is being impeded by the lack of scientific evidence for its clinical and cost effectiveness. The British government has stated that, without such evidence, telemedicine will not be widely introduced. Policymakers have been warned against recommending investment in unevaluated technologies. Recent advances in telemedicine can therefore be considered to be shown by studies that have obtained evidence of cost effectiveness.

I searched Medline and the specialist telemedicine information exchange database for recent (in the past two years) peer reviewed publications on telemedicine that included evidence of cost effectiveness. The keywords included "telemedicine" and its approximate synonyms "telehealth," "online health," and "e-health." This search produced a total of 969 articles. I then reviewed all articles containing the terms economics or cost effectiveness (184 articles). I also consulted the editorial board of the Journal of Telemedicine and Telecare, one of the specialist peer reviewed publications in the field.

Home telenursing
In the past decade there has been considerable interest in the possibility of using telemedicine as an aid in home nursing. Various feasibility studies into a range of different kinds of technology have been driven by the hope that care of chronically ill patients can either be provided more cheaply or be of a higher quality than traditional home visits. Although these studies indicate that patient satisfaction is not a problem, little hard evidence on cost effectiveness has been obtained.

The Kaiser Permanente organisation recently reported the first formal randomised controlled trial of home videophones. In this trial patients newly diagnosed with various chronic conditions (for example, congestive heart failure, chronic obstructive pulmonary disease, cerebral vascular accident, cancer, diabetes, anxiety, and need for wound care) were nursed at home. Patients in the intervention group were equipped with home videophones, an electronic stethoscope, and a digital blood pressure monitor. Over 18 months, patients in the telemedicine group received 17% fewer home visits by nurses than the control patients, but they had more telephone contact with the nursing staff (in addition to the video "visits"). The measures of quality of care in the two groups were similar. The patients receiving telemedicine were pleased with the equipment and were nursed as effectively as the control patients. The average cost of care in the telemedicine group was 27% less than that of the care in the control group. This is an important result, but because the practice of home nursing in the United Kingdom is rather different from that in the United States the potential of telenursing is likely to be different, and thus this work will need to be followed up in a British setting. (.......)

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