MANAGEMENT BRIEF

Number 12 Overviews of Health Care Topics for VA Senior Managers November 1999

Telemedicine – Health Care Technology Improving

Access, Efficiency, and Continuity of Care

“Telemedicine has vast potential to improve both patient- and system-level outcomes;

however, these benefits are not automatic. Policy decisions about the extension of telemedicine

must be informed by careful evaluations of exactly how telemedicine affects outcomes and

whether these outcomes justify the associated costs.”

John G. Demakis, MD

Director, Health Services Research and Development

What is telemedicine?

Telemedicine is the use of electronic information and communications technologies to provide and support health care

when distance separates the participants. The earliest documented use of telemedicine was a demonstration project in

Nebraska in the late 1950s, in which closed circuit television

was used to provide mental health services from the University medical center to a state hospital over 100 miles away.1

Today, telemedicine includes a wide and rapidly expanding

array of technologies and approaches for communicating patient data, voice or images in order to assist, augment or replace in-person clinical encounters. These technologies range

from the simple and inexpensive to the complex and costly.

How does telemedicine impact veterans’ health care?

Telemedicine serves a variety of purposes. In addition to

telemedicine between hospitals, and between ambulances and

hospital trauma units, VA pursues telemedicine applications

that link patients and family members to information that can

help them make more informed health care decisions. The potential to create or improve access to health services, especially in rural areas, remains a top VA priority. Following are

some examples of various telemedicine applications that are

used within the VA to improve the care of our veterans.

• Telecardiology: VA’s Pacemaker Surveillance Center

Program, located at the Washington, DC and San Francisco

VAMCs, provides follow-up pacemaker monitoring for

thousands of patients each year.

• Teledermatology: Dermatologists at the Baltimore VAMC

use video-conferencing and store-and-forward imaging to

assess skin conditions.

• Telemental Health: A demonstration project at the Milwaukee/Iron Mountain VAMCs provides improved access

to rural mental health care using compressed digital videoconferencing linkages.

• Telenuclear Medicine: For more than 20 years, nuclear

medicine images have been shared regularly among

VAMC’s using cost effective, ”low-tech” transmission to

facilitate consultative services.

• Telepathology: The Milwaukee/Iron Mountain VAMCs in

VISN 12 are linked by a unique, award-winning

telepathology system that uses a hybrid, dynamic, storeand-forward technology.

• Teleradiology: VA has led the way in the development and

implementation of filmless digital radiology systems in

clinical settings. In 1993 the Baltimore VAMC implemented the first filmless radiology department in the U.S.

• Telephone Liaison Care Program: Telephone liaison care

programs are in place at all VAMCs to provide information, guidance and direction for patients.2

Why is telemedicine important to VA managers?

The potential for telemedicine to improve both access to

care and continuity of care for veterans when distance and

VA HSR&D Management Brief November 1999 Page 1 of 3
VA HSR&D Management Brief Number 12, November 1999 Page 2 of 3

time present major obstacles is as limitless as the technologies that support this type of patient care. Further, telemedicine may be more of a necessity than a cost-saving

convenience for those veterans living in rural areas where

there is limited access to medical facilities, or for those who

are disabled and/or have limited mobility. Telemedicine has

vast potential to improve both patient- and system-level outcomes, yet this is a new area and there are many questions

that need to be answered. For example, many issues surrounding the efficacy, impact and cost of telemedicine need

to be addressed.

HSR&D supports numerous studies that focus on the

use of telemedicine. Below are recent findings from some

of these HSR&D studies.

Teledermatology results in reliable

and accurate diagnoses

Teledermatology, using digital imaging technology to

assess dermatologic conditions, holds great promise as an

alternative means of dermatologic health care delivery. Digital imaging generates digitized versions of visual information

that can be transmitted within telemedicine networks. This

HSR&D study evaluated the reliability and accuracy of dermatologists’ diagnoses and treatment plans generated from

telemedicine consultations when compared to clinic-based

consultations.

Investigators studied a sample of patients with skin lesions

that were referred to a dermatology consult service. Two different clinic-based dermatologists and three different digital

image consultants independently evaluated each lesion. The

skin conditions included in the study reflected a wide range

of dermatologic disease found in the ambulatory care population of the Durham VAMC. With the data analysis nearly

complete, the study indicates that there was a comparable

level of diagnostic agreement found between digital image

examiners and clinic-based examiners. This means that dermatologists agreed on their diagnoses of skin lesions equally

well whether evaluating the patient in person or reviewing the

digital image. Data thus far also shows that diagnostic accuracy is comparable among clinic-based examiners and digital

image examiners.

This suggests that comparable diagnostic outcomes can

be expected using teledermatology consults as a substitute

for traditional clinic-based evaluations. The knowledge that

digital imaging produces reliable and accurate diagnostic

outcomes, invites further investigation of other health services research questions about teledermatology in regard to

patient satisfaction, access to care, and cost-effectiveness.

Teledermatology may be especially important to those veterans who live in rural areas and do not have access to adequate

clinical consultation services.

Whited JD. Teledermatology: Diagnosing dermatologic

lesions by digital imaging. HSR&D study #IIR 95-045.

Telecare improves ambulatory care for veterans

Diabetes mellitus is one of the leading causes of morbidity, mortality and costs in the VA, and complications associated with diabetes are the leading cause of blindness,

end-stage renal disease, and amputation in the western

world. An HSR&D study evaluated the use of automated

voice messaging (AVM) with nurse telephone follow-up to

improve the health and self-care of veterans with diabetes.

This study looked at 300 patients with diabetes mellitus

from clinics within VA’s Palo Alto health care system.

Patients were randomly assigned to usual care, or usual

care and AVM intervention. Patients who received the

AVM intervention were called weekly to monitor their

health status and provide the first line of clinical intervention for self-care and health behavior problems. The study

nurse would then use the patient’s responses to the AVM

calls to determine an appropriate patient and/or health care

provider follow-up. Results of this study show that the

automated system identified a number of serious health

problems that otherwise might have gone undetected, thus

avoiding acute events and subsequent hospitalization.

This study shows that a telephone-based disease management system may be a viable “clinical extender” for

diabetic patients, bringing monitoring, diabetes education,

and behavior support services into the homes of VA patients with diabetes.

Piette JD. Automated calls with nurse follow-up to

improve diabetes ambulatory care.

HSR&D study #IIR 95-084.

Piette JD. Moving diabetes management from clinic

to community: development of a prototype based on

automated voice messages. The Diabetes Educator,

23: 672-80, 1997.

A similar HSR&D study is evaluating the Telephonelinked Computer (TLC) System, a computer-based telecommunications system that can monitor, educate and

counsel patients with chronic obstructive pulmonary

disease (COPD) through regular automated conversations

in patients’ homes. Subject enrollment is ongoing, but it is

anticipated that application of TLC in patients with symptomatic COPD will lead to earlier detection of clinical deterioration, permitting more timely intervention by health

care providers and improved self-care, such as adherence

to medication regimens. Telecare, such as the kinds used in

these HSR&D studies, has the potential for significant cost

savings.

Sparrow D. Effectiveness and cost impact of a telecommunications system in COPD. HSR&D study #IIR 97-022.

Telephone counseling improves physical

activity in older patients

Many older individuals are at high risk for health complications and functional impairment due to low levels of

physical activity. Patients with arthritis, heart disease,
For more information about this issue of

MANAGEMENT BRIEF, or to send comments contact:

Gerry McGlynn, MEd, MDRC, Manager, Information

Dissemination Program, 150 S. Huntington Avenue, Boston,

MA 02130. Phone: FTS 700-839-4433 or 617-278-4433.

Fax: 617-278-4438.

Visit the Research and Development web page at

http://www.va.gov/resdev/prt or the Intranet site at

http://vaww.va.gov/resdev, or utilize the MDRC Fax-onDemand system by calling 617-278-4492 to see additional

MDRC publications and reports.

This is our twelvth MANAGEMENT BRIEF. Please give us your

suggestions and comments:

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The MANAGEMENT BRIEF is produced by the Management Decision

and Research Center, a program within VA’s Office of Research &

Development, Health Services Research & Development Service. The

purpose of the MANAGEMENT BRIEF is to provide VA senior management

with a concise and timely overview of a specific health care topic that

includes topic definition, benefits, VA research activities, and resources

for further information.

hypertension, depression, and other problems common in

veterans could benefit by increased physical activity. This

HSR&D study’s primary objective is to determine whether

or not telephone counseling provided by a nurse would assist

60- to 80-year old veterans, who are VA primary care patients, in establishing and maintaining a walking regimen.

This randomized controlled trial compares three levels of

telephone counseling over 12 months: 1) 20 calls initiated by

the nurse; 2) 10 calls initiated by the nurse and 10 initiated

by an automated telephone message delivery system; or

3) no follow-up calls. Self-reported walking for the 210 patients enrolled in this study is assessed from weekly diaries

and confirmed by significant others. Smoking status, physical

symptoms, gait and balance, and psychosocial variables including mood, stress, exercise confidence, and social support

are all evaluated in relation to the walking regimen. Primary

care visits are also monitored throughout the exercise intervention.

Preliminary analyses show that the daily physical activity

of the study participants is unrelated to demographics or

health variables, but is associated with recall of provider advice to exercise. In other words, a patient who lives in a rural

area and/or is having a physical problem is more likely to

walk if he speaks to the nurse counselor. Increased physical

activity, such as walking, could improve quality of life as

well as decrease risk and disability in a large number of elderly veterans. Results of this study will help inform decisions

about cost-effective methods for exercise and other health

promotion counseling in primary care settings. It also will

improve physical activity among elderly patients, which can

result in significant health benefits.

Dubbert P. Nurse counseling for physical activity in

primary care patients. HSR&D study # NRI 95-022.

VA HSR&D Management Brief Number 12, November 1999 Page 3 of 3

References:

1. Telemedicine, http://vaww.va.gov/telemed/ 10/25/99.

2. VA Research & Development, Solicitation for

Research on Cross-Cutting Issues in Telemedicine,

http://vaww.va.gov/resdev/ps/pshsrd/ccissues.htm

10/25/99.