Skip to content
Permalink
main
Switch branches/tags

web-hack-mirror/mirror/1999/08/03/akamai.tamc.amedd.army.mil/eval_init.html

Go to file
 
 
Cannot retrieve contributors at this time
266 lines (263 sloc) 18.9 KB
Raw Blame
Open in GitHub Desktop
<html>
<head>
<title>Untitled Document</title>
<meta http-equiv="Content-Type" content="text/html; charset=iso-8859-1"></head>
<body bgcolor="#FFFFFF">
<table border="0" width="600" align="CENTER">
<tr>
<td valign="TOP">
<div align="RIGHT">
<font size="-1">Theoretical Foundations - <br>
Management of Medical Technology, <br>
Geisler, E. and Heller, O. (eds.), <br>
Kluwer Academic Press (in press). </font>
</div>
<p align="CENTER"><br>
<b>The AKAMAI Evaluation Initiative: Evaluating the Impact of<br>
Telemedicine on Health Care Delivery (Phase I)</b>
<p align="CENTER">V. Garshnek, Ph.D.* and L.H. Hassell, COL, MC, USA**
<p align="CENTER">*Pacific Region Program Office, Tripler Regional Medical
Center, HI<br>
**AMEDD Studies Branch, AMEDD Center and School, Fort Sam Houston, TX
<p><br>
<b>Abstract:</b> Telemedicine is the use of modern telecommunications
and information technologies for clinical care of individuals at a distance.
It has the potential to profoundly alter the medical landscape world-wide.
One effort in particular, Project AKAMAI, is contributing to this vision
by pioneering the implementation of telemedicine in the Pacific. AKAMAI
is a Federally funded program designed to augment health care delivery
to DoD and beneficiaries in the Pacific using advanced telecommunications
technology. The objective is to provide health care policy-makers with
scientific and technical information. AKAMAI, led by Tripler Regional
Medical Center (TRMC), Hawaii, consists of 27 individual projects and
studies. Among these is a research study evaluating telemedicine in a
limited setting (consultation between Hickam Primary Care Clinic, Hawaii,
and TRMC in the areas of Dermatology and Orthopedics). The study consists
of four sub projects in the areas of Clinical Outcomes, Patient/Provider
Satisfaction, Organizational Impact, and Cost/Benefit, with the intent
of providing information on the influence of telemedicine insertion into
a military health care system. The evaluation study will be conducted
in three phases: Phase I (Infrastructure design/instrument and procedure
development); Phase II (Experiment Verification Test (EVT) or system/procedure
simulation) and Phase III (Experiment/Data Analysis). Phase I is currently
in progress.
<p align="CENTER"><br>
<b>Introduction: What is Project AKAMAI?</b>
<p>Medicine is an infinite frontier - as infinite as the mysteries of the
human body. We are living in an extraordinary time for technology is rapidly
changing the face of health care practice, access, and education ushering
our planet into a new health care age for the new Millennium. Through
telecommunications and information technologies, medicine can extend its
reach regardless of physical distance through two-way transmission of
information between places of lesser and greater medical capability and
expertise. This capacity, known as telemedicine, has the potential to
profoundly alter the medical landscape world-wide. One effort in particular,
known as Project AKAMAI, is contributing to the fulfillment this vision
by pioneering the implementation of telemedicine in the Pacific.
<p>&quot;AKAMAI&quot; is a Hawaiian word for clever or smart. It embraces
the spirit of using new or improved tools and ideas to do things better.
We are becoming &quot;akamai&quot; in the way we practice medicine with
new technologies and methods that are expanding medicine's reach and effectiveness
with seemingly endless possibilities. Thus, the name &quot;Project AKAMAI&quot;
is appropriate for a Federally funded program, led by Tripler Regional
Medical Center (TRMC), HI, designed to augment health care delivery to
DoD and other beneficiaries in the Pacific using advanced telecommunications
technology. The new capability may allow more patients to receive definitive
treatment at their local health care facility and thus, avoid the requirement
for aeromedical evacuation.
<p>The vision of Project AKAMAI is (a) to enhance the health care delivery
system by linking Federal agencies with advanced telecommunications capabilities
that enable patient information to be transmitted digitally between health
care providers in local and remote geographic locations and (b) to improve
military medical readiness in the Pacific Basin Region by projecting the
medical specialty expertise of TRMC, Hawaii, to remote sites through the
use of telemedicine. A major objective of Project AKAMAI is to provide
healthcare policy-makers with scientific and technical information to
assist them in the decision to employ this telecommunications technology
within the scope of capabilities of all DoD medical treatment facilities.
<p align="CENTER"><b>Telemedicine Evaluation Study</b>
<p>AKAMAI consists of 27 individual projects and studies divided into the
broad areas of operations (teleradiology, multimedia systems, needs assessments),
evaluation, and emerging technology exploration. Of these, one is a scientifically
peer-reviewed and approved research study entitled, &quot;A Pilot Project
to Evaluate the Impact of Telemedicine on Health Care Delivery.&quot;
Its primary focus is to evaluate telemedicine in a limited military setting
between Tripler Regional Medical Center and Hickam Primary Care Clinic,
HI. The evaluation study was launched due to the fact that despite the
simplicity and apparent logic of the telemedicine concept and three decades
of experience, we are still unable to show that telemedicine improves
access, reduces cost, or affects the quality of healthcare.
<p>The evaluation study consists of four sub-projects, each with a principal
investigator and co-investigators representing full research studies in
their own right, yet highly interdependent to yield an integrated &quot;big
picture&quot; of the influence of telemedicine insertion into the military
health care system. The four sub projects address the following research
aims: to investigate if telemedicine consultation between medical treatment
facilities (a) impacts the clinical outcome of patients compared to usual
care; (b) affects patient and provider satisfaction compared to usual
care and (c) reduces cost in relation to benefits compared to usual care;
and (d) to investigate the organizational changes that occur when telemedicine
is implemented in a medical treatment facility.
<p>The general protocol employs a randomized design to compare patient and
process outcomes of two methods of consultation (telemedicine and usual
care) from a primary care outpatient clinic (at Hickam AFB, HI) to a tertiary
care medical center (TRMC). The sample population for this study is active
duty and retired military and their dependents requiring consultation
from a primary care to a tertiary care facility and their health care
providers. For the study, we made the a priori assumption that technology
is currently available to transmit diagnostic quality media elements necessary
for clinical decision making. We also established &quot;boundaries&quot;
which include the following:
<p>- Only routine consultations will be evaluated<br>
- Store and forward technology will be used<br>
- Focus on population health care delivery<br>
- Physician to physician consultation<br>
- Only Dermatology and Orthopedics specialties will be utilized for data
collection
<p>The Evaluation Study will be conducted in three phases over a two-year
period: <br>
<br>
Phase I: Infrastructure design, formally known as the Tripler Telemedicine
Prototype Project (T2P2) -- In this part of the study, we are designing
and building the infrastructure to capture clinical information from a
patient at a remote site and electronically transfer this information
to TRMC for consultation. Also during this phase, survey instruments and
data-gathering procedures will be developed.<br>
Phase II: Experiment Verification Test (EVT) -- During this phase, a system/procedure
simulation at TRMC will take place and instruments/methods refined based
on the simulation outcomes.<br>
Phase III: Experiment/Analysis -- During this phase, data will be gathered
over a 90-day period. TRMC Dermatology and Orthopedics Services will be
asked to see routine consults from the Hickam Primary Care Clinic. <br>
<br>
As of this writing, Phase I is currently in progress. The following describes
the background, current status, and plans of the four sub project areas.
<p><b><i>Project #1: The Effect of Telemedicine Implementation on Clinical
Outcomes in a Limited Military Setting</i> -- Principal Investigator:
L.H. Hassell, COL, MC, USA (AMEDD Center and School, TX); Co-Investigators:
V. Garshnek, Ph.D. (TRMC, HI); M. Nadeau, LTC, MC, USAF (Hickam AFB, HI);
G. Underwood, M.D. (TRMC, HI)</b>
<p>Few well-designed studies exist evaluating the influence of telemedicine
on health care delivery. In addition, of the few studies existing, it
is very difficult to generalize the findings to the military health care
system and patient population. Consequently, there is clearly a need for
well designed research on (a) outcomes in telemedicine in general and
(b) outcomes in telemedicine in the military health care system. The objective
of this particular study is to provide a scientific evaluation of clinical
outcomes resulting from insertion of telemedicine into a primary care
clinic that routinely refers patients to a tertiary medical center for
specialty care (specifically, comparing the impact of telemedicine with
usual care on key processes and outcome measures). The central hypothesis
states that the clinical outcomes of patients are not adversely affected
when telemedicine is used as a substitute for usual care in the military
health care delivery system.
<p>The study uses store and forward telemedicine technology (internet-based),
a method that appends textual information about a clinical problem with
graphic data files of physical exam findings and diagnostic results. Clinical
protocols (consult &quot;worksheets&quot;) have been developed for 12
specialty areas. These clinical protocols were developed jointly by Tri-Service
primary and specialty physicians on Oahu. Each protocol defines the essential
history and physical examination information, lab, and radiograph results,
and clinical images required for a consultant to make a remote diagnosis
and recommend treatment for a distinct clinical problem.
<p>The process envisioned consists of the following: The health care provider
accesses the server using an off-the-shelf web browser and selects a clinical
consultation protocol to initiate a consult. The server will assemble
information from a number of sources on the hospital local area network.
This consult will then be &quot;mailed electronically&quot; over the internet
to medical specialists for analysis and recommendation. The system will
allow the health care provider to choose the time the electronic consult
is reviewed. This method overcomes the distinct limitations caused by
interactive video systems in the past. Importantly, the remote physician
will initiate, and the consultant answer, the consult from their desktop
personal computer. We will pilot the server as part of the AKAMAI Evaluation
Initiative in 1998.
<p><b><i>Project #2: Designing a Satisfaction Tool for Telemedicine Services</i>--
Principal Investigator: S. DeRuvo, LTC, NC, USA (Landstuhl RMC, Germany);
Co-Investigator: E. Hill, LTC, NC, USA (TRMC,HI)</b>
<p>The purpose of this study is to develop, pilot, and revise as needed,
an instrument for evaluating patient and provider satisfaction with the
delivery of health care through telemedicine. While there is a great deal
of literature related to telemedicine, there are few studies adequately
assessing satisfaction of either patient or provider. As this particular
study will be conducted as an ongoing project during the initial implementation
of telemedicine in the region, feedback from both patients and providers
can be used to make changes in the system as it is being developed. In
addition, investigators will develop a concept analysis of telemedicine,
to be used in future applications related to this study.
<p>Initial surveys will be piloted, revised as needed, and then final surveys
developed and tested. Once the systems for telemedicine consultation are
up and running for at least 2 to 3 months, focus groups evaluating patient
and provider satisfaction will be conducted. Prior to this, other focus
groups will be conducted off-site to give some initial groundwork and
an idea of what should be done in setting up telemedicine at TRMC, as
well as some interesting comparisons of how the civilian, mainland systems
compare to the system that will be established and used by the military
here on Oahu, and later in the Pacific Region. Arrangements are currently
underway to conduct the preliminary focus groups.
<p><b><i>Project #3: Assessing Organizational Impact of the Implementation
of a Telemedicine System </i>-- Principal Investigator: R. Doktor, Ph.D.;
Co-Investigator: D. Bangert, Ph.D. (University of Hawaii College of Business
Administration) </b>
<p>The Organizational Impact study seeks to assess the impact on the organization
which occurs as a consequence of the introduction of telemedicine technology,
and concomitantly seeks to identify and assess the organizational factors
which, if effectively prepositioned, will minimize resistance and maximize
acceptance and utilization of telemedicine technology. The study team
has chosen to focus upon variables at the individual group and organizational
level. Sensitivity analysis will be performed in order to identify variables
which have the greatest potential impact in insuring successful implementation
of future telemedicine program introductions. Thus far, on the individual
level, the research team has identified an inventory which measures cognitive
perceptions of the caregivers job characteristics. On the group level,
the team has identified the medical decision making process as the variable
to be measured and has adopted qualitative research methodology of ethnography
as the operative tool. Thus, through observation and interview, the research
team will study medical decision making which may occur. On the macro
or organizational level, the team has chosen an inventory assessing organizational
learning as the measuring instrument and plan to administer it with the
same regimen as the job characteristics inventory. The variables measured
by the organizational learning inventory, give an indication of changes
in the organization's culture as a consequence of the introduction of
telemedicine. Currently, the team is finalizing the evaluation instruments
and preparing procedures to test these instruments during the EVT phase
of this study.
<p><b><i>Project #4: Assessing Cost-Effectiveness in a Telemedicine System</i>
-- Principal Investigator: E. Mais, Ph.D. (University of Hawaii College
of Business Administration)</b>
<p>An analysis of the cost-benefit/effectiveness that occurs within a medical
care system when new technology is introduced has not been adequately
addressed. Virtually no evidence exists concerning the economic viability
of telemedicine. Therefore, a strong need exists for concrete, scientific
evidence on (a) the cost-effectiveness of telemedicine in general and
(b) the cost-effectiveness of telemedicine in the military health care
system. The aim of this study is to investigate if telemedicine consultation
between medical treatment facilities reduces cost in relation to benefits
compared to usual care. The economic analysis of this project will proceed
in five parts. Part 1 will identify the important and relevant costs and
consequences for the two alternatives specified (telemedicine vs. usual
care). Part 2 will accurately measure the identified costs and consequences
in appropriate physical units. Part 3 will value the measured costs and
consequences in a credible and valid manner. Part 4 will comprise a sensitivity
analysis of the costs and consequences. Part 5 will present the results
using decision indices that will summarize the findings of the study.
The point of view will be that of the patient and the health care provider
and will include both direct and indirect costs and consequences. The
analysis will follow closely the research design of Project 1 (Clinical
Outcomes) so as to appropriately capture the economic differences between
consultation to a tertiary care medical center by telemedicine technology
versus usual care. Currently, refinement of an initial cost/benefit model
is underway based on a high-level process flow diagram for the telemedicine
consults and will continue refinement through the EVT phase.
<p align="CENTER"><b>Summary/Conclusion</b>
<p>This paper addresses the background, development, and status of the AKAMAI
Telemedicine Evaluation pilot study. Currently the study is in the first
phase of activity, concentrating on development of infrastructure, procedures,
and instruments. It is our sincere hope that our methodology and final
results will be of value and applicable to other telemedicine research
activities in the future.
</td>
</tr>
</table>
</body>
</html>