An economic analysis of email-based telemedicine: A cost minimisation study of two service models

<p>Abstract</p> <p>Background</p> <p>Email-based telemedicine has been reported to be an efficient method of delivering online health services to patients at a distance and is often described as a low-cost form of telemedicine. The service may be low-cost if the healthcare organisation utilise their existing email infrastructure to provide their telemedicine service. Many healthcare organisations use commercial-off-the-shelf (COTS) email applications. COTS email applications are designed for peer-to-peer communication; hence, in situations where multiple clinicians need to be involved, COTS applications may be deficient in delivering telemedicine. Larger services often rely on different staff disciplines to run their service and telemedicine tools for supervisors, clinicians and administrative staff are not available in COTS applications. Hence, some organisations may choose to develop a purpose-written email application to support telemedicine. We have conducted a cost-minimisation analysis of two different service models for establishing and operating an email service. The first service model used a COTS email application and the second used a purpose-written telemedicine application.</p> <p>Methods</p> <p>The actual costs used in the analysis were from two organisations that originally ran their counselling service with a COTS email application and later implemented a purpose-written application. The purpose-written application automated a number of the tasks associated with running an email-based service. We calculated a threshold at which the higher initial costs for software development were offset by efficiency gains from automation. We also performed a sensitivity analysis to determine the effect of individual costs on the threshold.</p> <p>Results</p> <p>The cost of providing an email service at 1000 consultations per annum was $19,930 using a COTS email application and$31,925 using a purpose-written application. At 10,000 consultations per annum the cost of providing the service using COTS email software was $293,341 compared to$272,749 for the purpose-written application. The threshold was calculated at a workload of 5216 consultations per annum. When more than 5216 email consultations per annum are undertaken, the purpose-written application was cheaper than the COTS service model. The sensitivity analysis showed the threshold was most sensitive to changes in administrative staff salaries.</p> <p>Conclusion</p> <p>In the context of telemedicine, we have compared two different service models for email-based communication – purpose-written and COTS applications. Under the circumstances described in the paper, when workload exceeded 5216 email consultations per annum, there were savings made when a purpose-written email application was used. This analysis provides a useful economic model for organisations contemplating the use of an email-based telemedicine system.</p

A review of the first year's experience with an automatic message-routing system for low-cost telemedicine

The Swinfen Charitable Trust has used email for some years as a low-cost telemedicine medium to provide consultant support for doctors in developing countries. A scalable, automatic message-routing system was constructed which automates many of the tasks involved in message handling. During the first 12 months of its use, 1510 messages were processed automatically. There were 128 referrals from 18 hospitals in nine countries. Of these 128 queries, 89 (70%) were replied to within 72 h; the median delay was 1.1 day. The 39 unanswered queries were sent to backup specialists for reply and 36 of them (92%) were replied to within 72 h. In the remaining three cases, a second-line (backup) specialist was required. The referrals were handled by 54 volunteer specialists from a panel of over 70. Two system operators, located 10 time zones apart, managed the system. The median time from receipt of a new referral to its allocation to a specialist was 0.2 days (interquartile range, IQR, 0.1-0.8). The median interval between receipt of a new referral and first reply was 2.6 days (IQR 0.8-5.9). Automatic message handling solves many of the problems of manual email telemedicine systems and represents a potentially scalable way of doing low-cost telemedicine in the developing world

Prospective case review of a global e-health system for doctors in developing countries

The Swinfen Charitable Trust has managed email consultations for doctors in developing countries since 1999. The process was handled manually for the first three years and then subsequently using an automatic message-handling system. We conducted a prospective review of email consultations between referring doctors and consulting specialists during six months of automatic operation (December 2003 to May 2004). During the study period 125 consultations took place. These concerned a wide range of specialties (e.g. orthopaedics 17%, dermatology 16%, obstetrics and gynaecology 11%, radiology 10%). Of these referrals, 33% (41) were for paediatric cases. Consulting specialists, who were based in five countries, were volunteers. Referring doctors were from 24 hospitals in 12 developing countries. The median time from referral to definitive reply was 1.5 days (interquartile range 0.6-4.9). There was an 85% response rate (n = 106) to a survey concerning the value of the consultation to the referring doctor. All the referring doctors who responded made positive comments about the service and half said that it improved their management of the case. The second-opinion consultation system operated by the Swinfen Charitable Trust represents an example of a global e-health system operated for altruistic, rather than commercial, reasons

Telemedical support for Iraq

The Swinfen Charitable Trust (SCT) provided two kinds of telemedical support to Iraq during 2004. Starting in January 2004, the Al-Yarmouk Teaching Hospital in Baghdad was able to refer cases into the well established global e-health network that the SCT has operated for the last five years. (In the first quarter of 2004, the SCT dealt with a total of 57 referrals from 15 hospitals in eight countries.) Two cases were referred from Baghdad in March 2004, both gynaecological, which were dealt with by consultants from the UK and Australia. The SCT administrators visited Basrah during April 2004 and met Iraqi doctors at the Shaibah Hospital as part of the international initiatives to improve health care there. Following this visit, the SCT network expanded to include another four hospitals in Iraq (Table 1). In addition, the SCT provided an electronic health records (EHR) system to support the rebuilding of maternity services, which has been led by the British Royal Colleges. The maternity records system is a Web-based EHR system, running on a secure server, which allows integrated access from antenatal clinics, from hospitals and from postnatal clinics in Iraq. Patients can view their own notes, thus promoting ownership of medical information, and doctors can view the notes of their own patients, from any Internet-connected PC. No special software is required by the user

Experience with a low-cost telemedicine system in three developing countries

The Swinfen Charitable Trust was established in 1998 with the aim of helping the poor, sick and disabled in the developing world. It does this by setting up simple telemedicine links based on email to support doctors in isolated hospitals. The first telemedicine link was established to support the lone orthopaedic surgeon at the Centre for the Rehabilitation of the Paralysed (CRP) in Savar, near Dhaka in Bangladesh, in July 1999. An evaluation of the 27 referrals made during the first year of operation showed that the telemedical advice had been useful and cost-effective. Based on the success of the Bangladesh project, the Swinfen Charitable Trust supplied: digital cameras and tripods to more hospitals in other developing countries. These are Patan Hospital in Nepal (March 2000), Gizo Hospital in the Solomon Islands (March 2000), Helena Goldie Hospital: on New Georgia in the Solomon Islands (September 2000) and LAMB Hospital in Bangladesh (September 2000)

Experience with a low-cost telemedicine system in three developing countries

The Swinfen Charitable Trust was established in 1998 with the aim of helping the poor, sick and disabled in the developing world. It does this by setting up simple telemedicine links based on e-mail to support doctors in isolated hospitals. The first telemedicine link was established to support the lone orthopaedic surgeon at the Centre for the Rehabilitation of the Paralysed (CRP) in Savar, near Dhaka in Bangladesh in July 1999. An evaluation of the 27 referrals made during the first year of operation showed that the telemedical advice had been useful and cost effective. Based on the success of the Bangladesh project, the Swinfen Charitable Trust supplied digital cameras and tripods to more hospitals in other developing countries. These are Patan Hospital in Nepal (March 2000), Gizo Hospital in the Solomon Islands (March 2000), Helena Goldie Hospital on New Georgia in the Solomon Islands (September 2000), and LAMB Hospital in Bangladesh (September 2000)

Referral patterns in a global store-and-forward telemedicine system

We examined the nature of the referral patterns in the email telemedicine network operated by the Swinfen Charitable Trust with a view to informing long-term resource planning. Over the first six years of operation, 62 hospitals from 19 countries registered with the Trust in order to be able to refer cases for specialist advice; 55 of these hospitals (89%) actually referred cases during this period. During the first six years of operation, nearly 1000 referrals were submitted and answered, from a wide range of specialty areas. Between July 2002 and March 2005 the referral rate rose from 127 to 318 cases per year. The median length of time required to provide a specialist's response was 2.3 days during the first 12 months and 1.8 days during the last 12 months. Five hospitals submitted cases for more than four years (together sending a total of 493 cases). Their activity data showed a trend to declining referral rates over the four-year period, which may represent successful knowledge transfer. There is some evidence that over the last three years the growth in demand has been exponential, while the growth in resources available (i.e. specialists) has been linear, a situation which cannot continue for very long before demand outstrips supply