### Evidence Report/Technology Assessment: Number 24, Supplement

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

## Summary

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Under its Evidence-based Practice Program, the Agency for Healthcare Research and Quality (AHRQ) isdeveloping scientific information for other agencies and organizations on which to base clinical guidelines,performance measures, and other quality improvement tools. Contractor institutions review all relevantscientific literature on assigned clinical care topics and produce evidence reports and technologyassessments, conduct research on methodologies and the effectiveness of their implementation, andparticipate in technical assistance activities.

Overview / Reporting the Evidence / Methodology / Findings / Future Research / Availability of Full Report

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## Overview

This report is a supplement to an earlier evidence report, *Telemedicine for the Medicare Population*, which was intended to help policymakers weigh the evidence relevant to coverage of telemedicine services under Medicare. The original report focused on telemedicine programs and clinical settings that had been used with or were likely to be applied to Medicare beneficiaries.

While preparing this report, it became apparent that there are also telemedicine studies among non-Medicare beneficiaries—e.g., children and pregnant women—that could inform policymakers and provide more comprehensive evidence of the state of the science regarding telemedicine applications. In addition, the evidence report only partially included a class of telemedicine applications (called self-monitoring/testing telemedicine) in which the beneficiary used a home computer or modem-driven telephone system to either report information or access information and support from Internet resources and indirectly interact with a clinician. Self-monitoring/testing applications in that report required direct interaction with a clinician. 

This supplemental report was prepared for the Agency for Healthcare Quality and Research (AHRQ) by a research and evidence review team from the Oregon Health Sciences University Evidence-based Practice Center (EPC). The goal of the report is to systematically review the evidence in the clinical areas of pediatric and obstetric telemedicine as well as home-based telemedicine where there is indirect involvement of the health care professional. (In this report, the latter is referred to as clinician-indirect home telemedicine.) Specifically, this report summarizes scientific evidence on the diagnostic accuracy, access, clinical outcomes, satisfaction, and cost-effectiveness of services provided by telemedicine technologies for these patient groups. It also identifies gaps in the evidence and makes recommendations for evaluating future telemedicine services for these populations. 

The evidence is clustered according to three categories of telemedicine services defined in the original evidence report:

- Store-and-forward.
- Self-monitoring/testing.
- Clinician-interactive services.

The three clinical practice areas reviewed in this report are defined as follows:

- The term "pediatric" applies to any telemedicine study in which the sample consisted wholly or partially of persons 18 years old or younger, including studies with neonatal samples.
-  The term "obstetric" applies to any telemedicine study in which the sample consisted entirely of women seeking pregnancy-related care.
-  The term "clinician-indirect home telemedicine" applies to home-based telemedicine (called self-monitoring/testing in the original report) where a telemedicine application used in the home has only indirect involvement by the health care professional.

Interactive home telemedicine was applied in this report to all patient populations.

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## Reporting the Evidence

The key questions that served as a guide for reviewing the literature in the evaluation of pediatric, obstetric, and clinician-indirect home telemedicine applications were derived by consensus among the evidence review team based on the analytic framework established for the original evidence report.

For this supplemental report, the questions were applied to studies in all three practice areas as a whole group within each of the three categories of telemedicine services:

- Store-and-forward.
- Self-monitoring/testing.
- Clinician-interactive services.

The specific key questions were:

- 	Does telemedicine result in comparable diagnosis and appropriateness of recommendations for management?
- 	Does the availability of telemedicine provide comparable access to care?
- Does telemedicine result in comparable health outcomes?
- 	Does telemedicine result in comparable patient or clinician satisfaction with care?
- 	Does telemedicine result in comparable costs of care and/or cost-effectiveness?

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## Methodology

Peer-reviewed literature was searched using several bibliographic databases. In addition, hand searches were conducted of leading telemedicine journals and identified key papers from the reference lists of journal articles. For the original evidence report, a search was developed and designed to find any publications about telemedicine. It was used to search the MEDLINE, CINAHL, and HealthSTAR databases for all years the databases were available. Through this process, studies of pediatric, obstetric, and clinician-indirect home telemedicine were captured; however, they were excluded from the original report since they were outside its scope. 

For this supplemental report, the original search results were reviewed in order to identify studies relevant to the report. Also, additional studies were identified from the reference lists of included papers and from hand searching two peer-reviewed telemedicine publications: the *Journal of Telemedicine and Telecare* and the *Telemedicine Journal*.

The EPC research team critically appraised the included studies for each study area and key question and discussed the strengths and limitations of the most important studies. They also developed recommendations for research to address telemedicine knowledge gaps. To match these gaps with the capabilities of specific research methods, the team classified the telemedicine services according to the type of evidence that would be needed to determine whether the specific goals of covering such services had been met. The team emphasized the relationship between the type and level of evidence found in the systematic review of effectiveness and the types of studies that might be funded to address the gaps in knowledge in this growing field of research.

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## Findings

A total of 28 eligible studies were identified. In the new clinical areas, few studies in store-and-forward telemedicine were found. There is some evidence of comparable diagnosis and management decisions made using store-and-forward telemedicine from the areas of pediatric dental screening, pediatric ophthalmology, and neonatalogy.

In self-monitoring/testing telemedicine for the areas of pediatrics, obstetrics, and clinician-indirect home telemedicine, 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. Access is particularly enhanced when the telehealth system enables timely communication between patients or families and care providers that allows self-management and necessary adjustments that may prevent hospitalization. There is some evidence that this form of telemedicine improves health outcomes, but the study sample sizes are usually small, and even when they are not, the treatment effects are small.

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 include emergency medicine, psychiatry, and cardiology. Most of the studies measuring access to care provide evidence that it has improved. Although none of these studies were randomized controlled trials, they provide some evidence of access improvement over prior conditions. Clinician-interactive telemedicine was the only area for which any cost studies were found. The three cost studies identified did not adequately demonstrate that telemedicine reduces costs of care (except when comparing only selected costs), and no study addressed cost-effectiveness.

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## Future Research

This supplemental report covering the areas of pediatrics, obstetrics, and indirect-clinician home telemedicine echoes the findings of the first evidence report for the Medicare domain, which is that while the use of telemedicine is small but growing, the evidence for its efficacy is incomplete. Many of the studies are small and/or methodologically limited, so it cannot be determined whether telemedicine is efficacious.

Future studies should focus on the use of telemedicine in conditions where burden of illness and/or barriers to access for care are significant. The 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 should set high standards for methodologic quality so that evidence reports need not rely on studies with marginal methodologies.

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## Availability of Full Report

The full evidence report from which this summary was derived was prepared for the Agency for Healthcare Research and Quality by the Oregon Health Sciences University Evidence-based Practice Center under contract  No. 290-97-0018. Printed copies may be obtained free of charge from the AHRQ Publications Clearinghouse by calling 800-358-9295. Requestors should ask for Evidence Report/Technology Assessment Supplement  No. 24, *Telemedicine for the Medicare Population: Pediatric, Obstetric, and Clinician-Indirect Home Interventions* (AHRQ Publication  No. 01-E060). 

The Evidence Report is also online on the National Library of Medicine Bookshelf, or can be downloaded as a zipped file.

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*AHRQ Publication Number 01-E059Current as of August 2001*

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**Internet Citation:**

*Telemedicine for the MedicarePopulation: Pediatric, Obstetric, and Clinician-Indirect Home Interventions*. Summary, Evidence Report/Technology Assessment: Number 24, Supplement. AHRQ Publication Number 01-E059, August 2001. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/clinic/epcsums/telmedsup.htm

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