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# Telemedicine for the Medicare Population: Pediatric, Obstetric, and                Clinician-Indirect Home Interventions in Telemedicine (Supplement)

*Evidence Reports/Technology Assessments, No. 24S*

Investigators: William R Hersh, MD, Principal Investigator, James A Wallace, BA, Patricia K Patterson, PhD, RN, Dale F Kraemer, PhD, W Paul Nichol, MD, Merwyn R Greenlick, PhD, Kathryn Pyle Krages, AMLS, MA, and Mark Helfand, MD, MPH, EPC Director.

Agency for Healthcare Research and Quality (US)2001 Aug
Report No.: 01-E0601-58763-056-7

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## Structured Abstract

#### Objectives:

                The goal of this report is to extend our original evidence report on the efficacy                    of telemedicine by extending the assessment to the pediatrics and obstetrics                    populations along with those receiving home telemedicine where the health care                    provider was involved in an indirect manner.As with the initial report, which                    covered telemedicine for the Medicare population, we assessed telemedicine                    services that substitute for face-to-face medical diagnosis and treatment and                    focused on three distinct telemedicine study areas -- store-and-forward,                    self-monitoring/testing, and clinician-interactive services.

#### Search Strategy:

                We conducted a search in the peer-reviewed literature for studies assessing the                    efficacy and cost of telemedicine in the study areas and designated populations.                    The search focused on peer-reviewed articles in the MEDLINE, CINAHL, and                    HealthSTAR databases. We also identified relevant articles through hand                    searching and reference lists in key papers.

#### Selection Criteria:

               The inclusion criteria were that the study addressed one of the designated                    patient populations, was relevant to at least one of the three study areas,                    addressed at least one key question in the analytic framework for that study                    area, and contained reported results. We excluded articles that assessed                    clinical services that did not historically require face-to-face encounters                    (e.g., radiology or pathology diagnosis).

#### Data Collection and Analysis:

                Included articles were categorized by the key question(s) they addressed. For                    each study area, we constructed a summary table of the results and strength of                    the evidence for each key question.

#### Main Results:

                We identified a total of 28 studies that met inclusion criteria. In the new                    clinical areas, we found few studies in store-and-forward telemedicine. There is                    some evidence that diagnosis and clinical management decisions are improved by                    store-and-forward telemedicine in the areas of pediatric dental screening,                    pediatric ophthalmology, and neonatalogy. In self-monitoring/testing                    telemedicine for the areas of pediatrics and obstetrics there is evidence that                    access to care can be improved when patients and families have the opportunity                    to receive telehealth care at home rather than in-person care in a clinic or                    hospital. In the study area of clinician-indirect home telemedicine, there is                    evidence that clinical outcomes are improved for patients with Human                    Immunodeficiency Virus (HIV) infection and Alzheimer Disease.

There is some evidence that this form of telemedicine provides comparable health                    outcomes relative to face-to-face care, but the study sample sizes were usually                    small, as were the treatment effects. There is also some evidence for the                    efficacy of clinician-interactive telemedicine, but the studies do not clearly                    define which technologies provide benefit or cost-efficiency. Some promising                    areas for diagnosis included emergency medicine, psychiatry, and cardiology.                    Most of the studies measuring access to care provide evidence that it is                    improved. Clinician-interactive telemedicine was the only area for which any                    cost studies were found. The three cost studies did not adequately demonstrate                    that telemedicine reduces costs of care (except when comparing only selected                    costs). No study addressed cost-effectiveness.

#### Conclusions:

                Our conclusions echo the original report: Existing telemedicine programs                    demonstrate that the technology can be made operational, but most of the studies                    assessing the efficacy or cost are insufficient to permit definitive statements                    about the evidence supporting (or not supporting) the benefits of telemedicine.                    Future studies should focus on the use of telemedicine in conditions where                    burden of illness and/or barriers to access for care are significant. Use of                    recent innovations in the design of randomized controlled trials for emerging                    technologies would lead to higher quality studies. Journals publishing                    telemedicine evaluation studies must set high standards for methodologic quality                    so that evidence reports need not rely on studies with marginal                    methodologies.

## Contents

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                        - Preface
                        - Summary
                        - 1. Introduction                           - Goal of the Report
                          - Definitions
                          - Telemedicine Study Areas
                          - Key Questions about the Efficacy of Telemedicine Services
                        - 2. Methods                           - Literature Search
                          - Selection of Abstracts and Retrieval of Full-text Articles
                          - Data Abstraction
                          - Assessment of Study Quality
                          - Data Synthesis and Identification of Information Gaps
                        - 3. Results                           - Results of the Systematic Review
                          - Store-and-Forward Telemedicine
                          - Self-Monitoring/Testing Telemedicine
                          - Clinician-Interactive Telemedicine
                        - 4. Conclusions and Future Research                           - Gaps in Research
                          - Priorities for Future Research
                          - Need for Experimental Designs and Registry Methods
                          - Basic Research to Inform Telemedicine
                          - Other Recommendations for Research
                          - Conclusions on Future Research
                        - Evidence Tables
                        - Appendixes                           - Appendix A. Literature Search Strategies
                          - Appendix B. Task Order Personnel and Peer Reviewers
                          - Appendix C. General Comments
                        - References
                        - Bibliography

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Prepared for: Agency for Healthcare Research and Quality, U.S. Department                of Health and Human Services.1                 Contract No. 290-97-0018.                Prepared by: Oregon Health Sciences                    University, Evidence-based Practice Center.

#### Suggested citation:

Hersh WR, Wallace JA, Patterson PK, et al.                    Telemedicine for the Medicare Population: Pediatric, obstetric, and                    clinician-indirect home interventions. Evidence Report/Technology Assessment No.                    24, Supplement (Prepared by Oregon Health Sciences University, Portland, OR                    under Contract No. 290-97-0018). AHRQ Publication No. 01-E060. Rockville (MD):                    Agency for Healthcare Research and Quality. August 2001.

On December 6, 1999, under Public Law 106-129, the Agency for Health Care Policy and                Research (AHCPR) was reauthorized and renamed the Agency for Healthcare Research and                Quality (AHRQ). The law authorizes AHRQ to continue its research on the cost,                quality, and outcomes of health care and expands its role to improve patient safety                and address medical errors.

This report may be used, in whole or in part, as the basis for development of                clinical practice guidelines and other quality enhancement tools, or a basis for                reimbursement and coverage policies. AHRQ or U.S. Department of Health and Human                Services endorsement of such derivative products may not be stated or implied.

The authors of this report are responsible for its content. Statements in the report                should not be construed as endorsement by the Agency for Healthcare Research and                Quality or the U.S. Department of Health and Human Services of a particular drug,                device, test, treatment, or other clinical service.

                        - 1
                        - 
2101 East Jefferson Street, Rockville, MD 20852. www​.ahrq.gov

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Bookshelf ID: NBK36492

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