October 2002

FCC urged to expand eligibilityfor telecommunications discount program
Five years since the passage of a federal law designed to increase access to telecommunications services for rural healthcare providers, the high cost of bandwidth continues to be one of the biggest stumbling blocks to telehealth program sustainability.

In an informal assessment of 26 telehealth programs conduced by the University of Missouri in 2002, 12 programs considered the cost of telecommunications services to be the single biggest barrier to sustaining their telehealth programs. An additional four programs placed telco costs near the top of the list of barriers.

The Telecommunications Act of 1996 established a universal service mechanism to provide discounts to rural healthcare providers to defray the cost of high-speed telecommunications lines used for telemedicine. The Act established a $400 million fund for this purpose.

Earlier this year, the Federal Communications Commission published a notice of proposed rulemaking alerting providers to changes in the program, with an aim to revise the program to encourage broader use. Specific changes include expanding eligibility to nursing homes and long-term care facilities. The agency also seeks to revise how Internet charges are reimbursed under the program.

Comments forwarded to the agency by the American Telemedicine Association urge the FCC to expand eligibility to certain not-for-profit hospitals as well as nursing homes and long-term care facilities. In addition, it asks the FCC to develop a less imposing application and administrative process, and to eliminate the way the agency calculates discounts based on distance from urban centers.

"The ATA has commented in the past about the onerous requirements placed on applicants wishing to take advantage of this program," noted Jonathan Linkous, executive director of the ATA. "This represents a large and artificial barrier to healthcare providers, and is one of the reason why the program has not met the expectations of Congress, the FCC, or advocates."

The ATA's 16-page comment document outlines specific ways the program could be improved. The agency closed its comment period July 1 and is expected to publish a response in the Federal Register this fall. (To view the full text of the ATA's comments, see www.americantelemed.org)
BY DEBORAH R. DAKINS

BMJ study slams quality of cost-effectiveness studies
Few telemedicine studies include cost data needed to evaluate its effectiveness, and those that do rely on faulty methodology, according to a study published in the British Medical Journal in June. Based on a review of 557 published peer-reviewed papers, the authors concluded that no good evidence exists that telemedicine is a cost-effective means of delivering healthcare.

Of that total, only 55 papers included cost data, and of these, 24 met quality criteria justifying inclusion in a quality review. The team of authors, headed by Pamela Whitten, associate professor in the department of communications at Michigan State University in East Lansing, found that most of these studies relied on simple cost comparisons.

Among those, only a handful explored the level of utilization needed for telemedicine to compare favorably with traditional healthcare, and none of the studies answered the question adequately. A primary problem with all of the cost-related studies was this use of inappropriate economic analytical techniques,Whitten noted. Despite the lack of hard data, the 55 studies nonetheless reported positive cost-effectiveness results.

Moreover, the lack of a standardized outcome measure such as cost utility analysis-an accepted way to compare interventions and assess which provides the best value for money-makes it difficult to determine whether telemedicine is a good healthcare investment.

Whitten, formerly of Kansas University Medical Center's telemedicine program and a long-time telehealth researcher, noted that the study is unlikely to be welcomed.

"In the case of telemedicine, although claims about the utility and efficacy of new telecommunications systems in practice have been made, these are not founded on strong evidence," Whitten wrote. "Given the paucity of methodologically sound studies - there is presently no persuasive evidence about whether telemedicine represents a cost effective means of delivering healthcare."

The study is a call-to-arms to the research community for better-designed and conducted telemedicine trials. But it also points out deficiencies in the peer review process by which the original 557 studies were published. Peer review has failed to address the range of basic errors in design and analysis in the studies reviewed, the study team noted.

"Peer reviewed publication is not necessarily an adequate guarantee of quality for economic evaluations of telemedicine," the authors noted.

To review the full study, as well as online responses to it, see www.bmj.com. (BMJ 2002;324:1434-143715 June).
BY DEBORAH R. DAKINS

DOC roundtable focuses on innovation and demand
The Department of Commerce (DOC) hosted a roundtable discussion in June with telemedicine industry leaders to discuss innovation, demand, and investment in telehealth. The DOC is preparing a report on telemedicine policy initiatives that is expected to be completed this fall.

The 30 participants, including representatives from the American Telemedicine Association, vendors, military, and telehealth providers, debated ways the industry can move forward. A key discussion involved the role of telemedicine in homeland security, the military, medically underserved areas, and in the home.

UTMB establishes research center to abet data analysis, reimbursement policy
The SBC Foundation is partnering with the University of Texas Medical Branch in Galveston (UTMB) to create a telehealth research center. A $1 million grant provided by the philanthropic arm of SBC Communications is intended to allow center researchers to evaluate the effectiveness of telemedicine in healthcare using rigorous scientific methods.

The SBC Telehealth Research Center at UTMB will collect data not only to demonstrate effectiveness of the technology and its applications, but also to help guide public and private insurers in developing reimbursement policies.

UTMB has one of the largest telehealth programs in the world, with a track record that began in 1994. The university has telemedicine contracts with five Texas school districts and a pilot project linking geriatric specialists with four rural community clinics and a county hospital.

The academic health center has expanded its program to the Regional Maternal and Child Health Program (RMCHP), which serves approximately 86,000 children and pregnant women each year throughout East and Southeast Texas.

First teleanesthesiology consult links Ecuador and Virginia
This spring physicians in Virginia conducted what they believe is the world's first case of teleanesthesiology. The gall bladder surgery performed on a patient in Ecuador could mark the beginning of a new trend in the operating room, according to Dr. Ronald Merrill director of the Medical Informatics and Technology Applications Group at Virginia Commonwealth University.

The NASA-sponsored research group facilitated the event, made possible by a satellite link from a clinic in Ecuador to anesthesiologist Dr. Lynne Gehr of Richmond. Gehr watched the patient's vital signs on her computer screen while communicating with the anesthesiologist who was in the operating room.

The operation's success "proves that telesurgery is more than a high-priced technological toy," Merrill said.