Gaumer, Gary

Grisby, Jim

Hassol, Andrea

Irvin, Carol

Puskin, Dena

English

UND Scholarly Commons (University of North Dakota)

North Dakota Law Review Volume 73 Number 1 Article 8 1997 Rural Applications of Telemedicine Final Report Andrea Hassol Gary Gaumer Carol Irvin Jim Grisby Dena Puskin Follow this and additional works at: https://commons.und.edu/ndlr  Part of the Law Commons Recommended Citation Hassol, Andrea; Gaumer, Gary; Irvin, Carol; Grisby, Jim; and Puskin, Dena (1997) "Rural Applications of Telemedicine Final Report," North Dakota Law Review: Vol. 73 : No. 1 , Article 8. Available at: https://commons.und.edu/ndlr/vol73/iss1/8 This Report is brought to you for free and open access by the School of Law at UND Scholarly Commons. It has been accepted for inclusion in North Dakota Law Review by an authorized editor of UND Scholarly Commons. For more information, please contact und.commons@library.und.edu. RURAL APPLICATIONS OF TELEMEDICINEFINAL REPORT*EXECUTIVE SUMMARY**The Office of Rural Health Policy (ORHP), Health Resources andServices Administration (HRSA), Department of Health and HumanServices (HHS), and other state and federal governmental agencies havedevoted considerable financial support to rural telemedicine demonstra-tion projects. The projects are using modem telecommunication tech-nology to improve access to health care for rural populations. ORHPhas been involved in telemedicine since 1988 and currently funds eleventelemedicine projects through its Rural Telemedicine Grant program, alarge demonstration project in West Virginia, and six telehealth projectsthrough its Rural Health Outreach grant program. One of the missingpieces in assessing the value of telemedicine was a comprehensive studyof the use of this technology throughout rural America. This project,which was the first nationwide survey of rural telemedicine (not limitedto interactive video), examined the status of rural telemedicine. It alsodeveloped evaluation tools and methods for agencies and individualprograms to use in assessing the contribution of telemedicine to ruralhealth care delivery. As such, this study represents an early snapshot ofa technology that is expanding rapidly both in technical capability andpotential applications for health care.Rural Telemedicine is in the earliest stages of development, but isexpanding quickly. More than 40% of the telemedicine programssurveyed had been providing teleconsults for one year or less.Networks had an average of 9.3 facilities participating and manyplanned to expand. By the end of 1996, networks expected to havean average of 13 participating sites.• By the end of 1996, nearly 30% of rural hospitals will be usingsome sort of telemedicine technology to deliver patient care. Ofthese, 68% will offer only teleradiology.* The authors of the Final Report are: Andrea Hassol, Gary Gaumer, Ph.D., and Carol Irvin,Ph.D., all of Abt Associates Inc., and Jim Grisby, Ph.D., and Dena Puskin, Sc.D., of the Office ofRural Health Policy.** The full Final Report appears on the Internet and can be accessed at: <http://www.hrsa.dhhs.gov/news.htm>.NORTH DAKOTA LAW REVIEW* Age of the telemedicine system and receipt of federal funding wereall positively and significantly associated with total utilization of thetelemedicine system (clinical and nonclinical sessions combined).The strongest association was between utilization and age of thesystem; as facilities gain experience with telemedicine, utilizationincreases.* Some clinical applications appear to gain earlier acceptance intelemedicine than others. Radiology and cardiology were the mostcommon clinical applications reported, followed by orthopedics,dermatology, and psychiatry. The most common nonclinicalapplications were education, administrative meetings, anddemonstrations of the system to health care personnel.The Exploratory Evaluation of Rural Applications of Telemedicinewas conceptualized by ORHP and conducted by Abt Associates, Inc.,assisted by the University of Colorado. The objectives of the studyincluded:1) Determining the current status of telemedicine in ruralhealth care with respect to the number and types of systems inoperation, levels of technology employed, types of specialtyservices provided, utilization of services, costs, and patient andprovider acceptance.2) Exploring the effects of telemedicine on access to care,practitioner isolation, and the development of health carenetworks.3) Exploring the organizational factors (at facility, network,community, and State levels) that aid or impede the successfuldevelopment and implementation of telemedicine systems.4) Developing, testing, and refining data collection instrumentsthat may be used in subsequent evaluation efforts.The study design specified by ORHP included the followingactivities:0 Nationwide surveys of all rural hospitals to identify thoseactively using telemedicine (summer 1995).[VOL. 73:1451997] RURAL APPLICATIONS OF TELEMEDICINE EXECUTIVE SUMMARY 147Detailed follow-up surveys of participants and their affili-ates to describe uses of telemedicine; equipment andtransmission media in use; funding sources and costs oftelemedicine installations; volume of care being providedand volume of nonclinical uses of the systems; and use oftelemedicine to fill gaps in specialty access in remote ruralareas (December of 1995 to January of 1996).Intensive site visits at four rural telemedicine programs toinvestigate issues not readily studied via a survey and toprovide the context for the survey data.The screening survey was mailed to all 2,472 non-federal U.S.hospitals that are outside metropolitan areas, as defined by the U.S.Census. Those that did not respond were interviewed via telephone. Thefinal response rate was 95%. All those who reported that they had someform of telemedicine capability, and all the telemedicine affiliates theynamed, became the sample for the follow-up survey. Affiliates includedmetropolitan medical centers, rural clinics, mental health centers, andnursing homes. Each target respondent received two instruments in themail: one for programs that do only teleradiology, and a longerquestionnaire for those who have other telemedicine applicationsavailable beyond radiology. Respondents were asked to select, complete,and return the appropriate questionnaire. Again, nonrespondents wereinterviewed by telephone. The telephone follow up portion of thesample were interviewed using an abbreviated instrument; they were notasked to obtain information from administrative or financial recordsbecause this is difficult to do in the course of a telephone interview.From the group of 558 active rural telemedicine sites and their affiliates,499 (89%) completed the follow-up survey.The very high overall response rates were accompanied by signifi-cant item nonresponse on some survey questions. The most problematicwere questions about the precise equipment in use (e.g., resolution ofmonitors), about billing practices, and about reimbursement for telemedi-cine sessions. Questions about the number of sessions and the percentthat was for clinical versus nonclinical purposes also appeared to bedifficult for many sites to answer, largely because they did littlesession-level data collection beyond simple counts. The final chapter ofthis report recommends "model" data collection tools, an encountersession form which could be aggregated annually (or more often), and afacility level survey which could be conducted annually.NORTH DAKOTA LAW REVIEWThe following are additional key findings from the survey effortsand the case study investigations:Telemedicine networks were complex, with an average of fourspoke sites, two hubs, and four facilities that both provided andreceived consults.Many rural hospitals were taking full advantage of the availabletechnology. The equipment base was large, sophisticated, andgrowing quickly. Most rural telemedicine sites (excludingthose doing only teleradiology) offered full-motion interactivevideo for live interviews, meetings, and educational sessions.Despite the growth and expansion of this technology, the costof telemedicine remained high. The average equipmentpurchase, excluding switches and new lines, ranged from$134,378 for spoke sites to $287,503 for hub sites. Reportedannual transmission costs were also high, ranging from- anaverage of $18,573 for spokes to $80,068 for hubs.Utilization was low in the first years of most rural telemedicineprograms. The average number of total sessions per month(clinical and nonclinical combined) was 24, with a median of11. The median or typical telemedicine facility was con-ducting approximately one clinical session per week and 1-2nonclinical sessions per week in early 1996.High costs, combined with low utilization in the early years ofoperation, yielded high unit costs. A teleconsult cost themedian or typical hub site $1,181, while the median spoke sitespent $476 per consult, exclusive of any reimbursement toclinicians.* Federal and State grants were common sources of directfunding for telemedicine programs, and the majority of sitesalso received hospital financial support. Third-party reimburse-ment for telemedicine was elusive: fewer than 25% of hubfacilities had successfully negotiated payment with insurancecarriers and many had not yet undertaken such negotiations.* Lack of reimbursement, lack of clinical standards, scheduling,and time commitment remain challenges to furtherdevelopment and use of rural telemedicine.[VOL. 73:1451997] RURAL APPLICATIONS OF TELEMEDICINE EXECUTIVE SUMMARY 149The findings of this study confirmed many issues previouslyidentified in grant projects relating to organizational challenges andbarriers to expansion. At the same time, the survey pointed out somenew developments in the field. First, most of the surveyed programswere quite new. This may in part explain the relatively low utilizationfigures reported on the survey, and the high resulting unit costs. It isimportant to note that those systems able to survive and expand experi-ence higher utilization after the second year of operations. It is alsoclear that more rural hospitals were turning to telemedicine as a tool forimproving health care delivery, despite the fact that there is limitedreimbursement for these services from third-party payers.

Rural Applications of Telemedicine Final Report

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