SD28 - Report on Telemedicine Initiatives

Executive Summary:
Introduction. Senate Bill 1214 (1999) and Item 333 J of the 1999 Appropriations Act direct the State Health Commissioner to study Telemedicine initiatives in the Commonwealth of Virginia. Specifically, the budget amendment provides for a study of the cost effectiveness and medical efficacy of the telemedicine projects in the Virginia Department of Health (VDH) which are located in Lancaster County, Scott County, and the City of Danville. The bill language is broader and requires an annual report to the Governor and the General Assembly on the status of telemedicine initiatives by agencies of the Commonwealth. The report requirements include a summary of telemedicine initiatives; an analysis of the cost-effectiveness and medical efficacy of telemedicine services; recommendations for improvements, and identification of additional opportunities for the use of telemedicine to improve access to care and health professions education.

This type of study requires comparable data, data that has been collected from different telemedicine sites using a uniform study instrument. There has been no previous statewide effort to collect data on telemedicine programs. The second annual report contained herein presents the results of the completion and field testing of the study instrument. For this study, twenty-one representatives of selected Virginia telemedicine programs were interviewed at their telemedicine sites during the spring of 2000. Based on the response of physicians, nurses, systems consultants, and administrators at these site visits, preliminary evaluation assessment instruments have been developed. These instruments can be used to begin a uniform data collection and will allow a cost-effectiveness evaluation of Virginia's telemedicine programs to begin.

The first report of this telemedicine study was presented to the Joint Commission on Health Care in October of 1999 (Senate Document 18, 2000). With the consent of the money committees and the Joint Commission on Health Care, the decision was made to combine the language and intentions of both Senate Bill 1214 and the budget amendment and to focus primarily on clinical applications of telemedicine rather than video conferencing and distance learning. This first report included a summary of the telemedicine sites associated with state agencies and presented the study design. VDH had contracted with the Division of Quality Health Care, Department of Internal Medicine of Virginia Commonwealth University to design the prospective study instrument with which all the telemedicine initiatives could be compared.

The Commonwealth supports, through specific appropriations and general funding, the operations of the institutions of higher education that serve as hub sites and the state agencies and affiliates that serve as remote sites in telemedicine programs. The use of telemedicine in the Commonwealth is expected to expand in the number of sites involved, in the areas of medical education that can be addressed, and the clinical situations for which consultation is appropriate.

Telemedicine initiatives in Virginia. The hub sites of University of Virginia (UVA) and Virginia Commonwealth University (VCU) are the core of Virginia's telemedicine initiatives. UVA has arrangements with 30 separate remote sites for telemedicine activities and VCU has arrangements with 5 separate sites. Since 1996, UVA has performed 2,189 consults; since 1995, VCU has completed 2,139 patient consultations. Three other state agencies play important direct roles in the provision of clinical consultation in telemedicine. The Virginia Department of Corrections (DOC) is the primary source of financial support for telemedicine activities in the Commonwealth. The Virginia Department of Health (VDH) operates sites in three local health districts. The Virginia Department of Medical Assistance Services (DMAS) provides limited reimbursement for telemedicine consultations.

Challenges of cost-effectiveness evaluation. The analysis of cost-effectiveness and medical efficacy of these programs involves multiple challenges. A key requirement is that a minimum volume by medical procedure is needed to evaluate telemedicine cost-effectiveness. To date, especially in the VDH sites, sufficient volume for cost-effectiveness evaluation has not been achieved. Other challenges for evaluation include changing technologies and infrastructure, multiple perspectives of stakeholders, need for long-term analysis, and data collection burdens. Based on the site visits and interviews, obstacles to continued progress in Telemedicine were identified.

Four primary barriers confront telemedicine programs in Virginia as they seek to expand their capacity to improve access to health care and to reduce the costs of health care. The barriers are lack of adequate reimbursement and financing, technology integration needs, operational design, and physician acceptance of telemedicine. Reimbursement and financing are perceived to be the most important issues to be resolved before telemedicine programs can expand. Also, of special importance for future telemedicine programs is the need for a more rigorous community needs assessment, with close consultation with the local physicians, to determine their attitudes and perceived need for specific telemedicine initiatives.

Recommendations. To address these barriers and to continue the evaluation process, the investigative team made the following recommendations for the State Health Commissioner:

1. Use the recommended evaluation instruments to establish a baseline assessment of the telemedicine programs and initiate a continuous quality improvement and evaluation process.

2. Continue the Telemedicine Program Working Group at the Virginia Department of Health to direct the continuing telemedicine evaluation. This group can facilitate collaboration and development of Virginia's telemedicine initiatives and evaluate future needs, especially financing, and further opportunities for telemedicine initiatives by agencies of the Commonwealth.

3. For the Virginia Department of Health Telemedicine sites, ensure integration of technology through the use of an integrator.

4. Involve communities, especially local physicians, in the development and support of telemedicine programs.

Telemedicine is expected to grow 40 percent annually over the next 10 years. Telemedicine can increase access and distribute clinical, educational, and administrative health care resources by removing or reducing barriers imposed by time, distance, or geography in the provision of quality care. Financial and human resources investments required for telemedicine applications can be substantial. Evaluation for cost-effectiveness and quality will be essential to ensure efficient use of health care resources.