CHAPTER 2. PROGRAM OBJECTIVES

Successful telemedicine programs need to establish well-defined program objectives - the specific goals to be attained through the implementation of the telemedicine program. AMD has found that programs often seek to achieve one or more of the following objectives:

• Improve Access – Telemedicine, using new advances in telecommunications, semiconductors, and sensor electronics, improves health care service availability in remote or difficult to operate environments. Many telemedicine programs seek to improve access to health care services, either by making services readily available for the first time (e.g. rural or markets with new delivery system infrastructure), or by improving access to specialty services without the need for the patient to travel a considerable distance to a facility where those services have been traditionally provided. AMD refers to this telemedicine program model as the "Access Model".

  Quite often, the Access Model seeks to respond to a particular set of health care issues in a local market. Ultimately, development of a successful program requires identification of the particular medical problems to be addressed, the potential telemedicine applications which provide the solution, and an analysis of the costs and benefits of the telemedicine application relative to other alternatives.

  There are numerous examples of use of telemedicine in the Access Model. Many countries, which are experiencing greater participation in an expanding world economy, are now seeking to improve access to health care services for their citizens. In addition, countries must often develop a health care delivery system to attract foreign investment or to encourage the relocation of foreign managers to support economic development. Instead of reliance on expensive health care facilities with a high concentration of resources, many governments are taking advantage of advances in telecommunications and computing power to develop a more flexible and cost effective approach to building a health care delivery infrastructure. Telemedicine allows development of local primary care health centers supported by regional diagnostic centers and hospitals, all of which are electronically connected to permit efficient flow of mission critical medical information and to support professional consultation. In this model, the most expensive and medically challenging care may be limited to a select number of health care facilities where the care can be offered cost effectively. In some instances, governments have sought to establish relationships with world-renowned medical centers to transport the most challenging cases to those centers, instead of incurring the cost of developing all services within the country. This approach to health care delivery, which incorporates telemedicine where it provides clear advantages, is providing improved access to care in local communities with minimal travel for basic care, while limiting the development of facilities which are expensive to build and maintain.

  As an example of the Access Model, AMD has worked with the State of Alaska, under a program originally sponsored by the U.S. National Library of Medicine, to institute primary care telemedicine capabilities north of the Arctic Circle. In this environment, which is difficult to access during the extreme winter months, the telemedicine program is focused on management of ear infections in children and avoidance of excessive administration of antibiotics.

  AMD devices are also being used in various school-based programs for asthma management and to increase access to health care services to children in the school setting. These programs reduce absenteeism through better management of pediatric illness, often producing additional revenue for the local school system when reimbursed under an Average Daily Attendance model, which rewards school systems that maintain high attendance.

  In many countries Telemedicine is the best alternative to expand access to primary medical services.

  If your program is based on the Access Model, success can be measured by documenting i) the improved access (e.g. number of consults provided, populations covered), ii) effect on health status, and iii) cost savings achieved through improved access (e.g. elimination of transportation and lodging cost for patients, improved work productivity and reduction of facility-based medical costs). Measurement of success in the Access Model almost always requires long-term assessment of data to obtain a complete picture of the beneficial effects of the program.

• Enhance Competitive Position - A telemedicine program sponsor may desire to expand the sponsor's market zone to increase business opportunities. Traditionally, the market zone of a health care provider has been limited to the distance a patient is willing to travel to receive services. Telemedicine permits the export of medical expertise to any location in the world where the requisite telecommunications infrastructure exists. Academic medical centers use telemedicine to support local health care professionals by making consultative professional services available in the local market. The telemedicine sponsor receives income for the consultative services and establishes valuable professional relationships that lead to increased referrals for facility-based care. AMD refers to this as the "Competition Model".

  In the Competition Model, the telemedicine program sponsor supports community-based caregivers in the management of medical care, and serves as the consulting expert whenever the medical condition of patients requires consultative support. Success in the Competition Model is directly dependent upon the dedication and support of the consulting professionals. Consulting professionals must be mindful of the services available in the local market, and must be responsive to the patient and community caregiver.

  Many academic medical centers around the world are turning to telemedicine to improve their ability to obtain referrals of the most medically challenging cases. The Competition Model dovetails with the Access Model whenever a country seeks to establish a relationship with an academic medical center to refer the most medically challenging cases.

  Success in the Competition Model is usually assessed by comparing the changes in services rendered to residents of different geographic regions beyond the traditional primary market zone of the program sponsor, taking into account consultative services and facility-based services referred by community physicians with whom the program sponsor maintains a telemedicine program relationship. Successful implementation of a Competition Model increases referrals of the most medically challenging cases.

• Reduce Cost – In many markets, a health care delivery infrastructure exists, but telemedicine is being used to deliver health care services of comparable or higher quality at a lower cost. AMD terms this the "Cost Saving Model". Successful implementation of the Cost Saving Model requires a careful examination of all costs, direct and indirect, and the medical outcomes, over time.

  As one example, home care providers are turning to telemedicine to reduce home visit rates and to continuously monitor chronic medical conditions with the goal of reducing costly hospital utilization. As another example, prisons have used telemedicine to lower the cost of health care delivery, principally through elimination of security, transportation costs and unnecessary emergency department utilization. Tertiary care providers are using telemedicine to monitor changes in medical condition without the need of the patient to physically appear at the office of the consulting professional.

  Successful implementation of a Cost Saving Model requires a careful examination of the benefits received from introduction of a telemedicine program, an identification of the parties who benefit from the program, and how parties contribute to program funding. It is not uncommon for telemedicine to achieve cost savings in multiple departments of an organization, or for the benefit of multiple parties. In the prison example, savings may be achieved on both medical and transportation costs, often affecting two different departments or cost centers. Because the savings achieved through use of telemedicine often effect multiple departments within an organization, or even multiple parties (e.g. insurer, patient, employer, etc.), a program sponsor should seek to monitor all savings produced by the telemedicine program, not just medical benefits, to assess the cost effectiveness of the telemedicine solution.

  Success in the Cost Saving Model is quite often measured in terms of the cost reductions achieved through the implementation of telemedicine. In assessing success, it is necessary to identify all cost savings, and not to limit a cost saving analysis to medical cost savings only.

  No matter which objective you are seeking to achieve, the early identification and documentation of program objectives will serve as a firm foundation for development of your successful telemedicine program.