Objectives:

The goal of this report is to extend our original evidence report on the efficacy of telemedicine by extending the assessment to the pediatrics and obstetrics populations along with those receiving home telemedicine where the health care provider was involved in an indirect manner.As with the initial report, which covered telemedicine for the Medicare population, we assessed telemedicine services that substitute for face-to-face medical diagnosis and treatment and focused on three distinct telemedicine study areas -- store-and-forward, self-monitoring/testing, and clinician-interactive services.

Search Strategy:

We conducted a search in the peer-reviewed literature for studies assessing the efficacy and cost of telemedicine in the study areas and designated populations. The search focused on peer-reviewed articles in the MEDLINE, CINAHL, and HealthSTAR databases. We also identified relevant articles through hand searching and reference lists in key papers.

Selection Criteria:

The inclusion criteria were that the study addressed one of the designated patient populations, was relevant to at least one of the three study areas, addressed at least one key question in the analytic framework for that study area, and contained reported results. We excluded articles that assessed clinical services that did not historically require face-to-face encounters (e.g., radiology or pathology diagnosis).

Data Collection and Analysis:

Included articles were categorized by the key question(s) they addressed. For each study area, we constructed a summary table of the results and strength of the evidence for each key question.

Main Results:

We identified a total of 28 studies that met inclusion criteria. In the new clinical areas, we found few studies in store-and-forward telemedicine. There is some evidence that diagnosis and clinical management decisions are improved by store-and-forward telemedicine in the areas of pediatric dental screening, pediatric ophthalmology, and neonatalogy. In self-monitoring/testing telemedicine for the areas of pediatrics and obstetrics 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. In the study area of clinician-indirect home telemedicine, there is evidence that clinical outcomes are improved for patients with Human Immunodeficiency Virus (HIV) infection and Alzheimer Disease.

There is some evidence that this form of telemedicine provides comparable health outcomes relative to face-to-face care, but the study sample sizes were usually small, as were the treatment effects. 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 included emergency medicine, psychiatry, and cardiology. Most of the studies measuring access to care provide evidence that it is improved. Clinician-interactive telemedicine was the only area for which any cost studies were found. The three cost studies did not adequately demonstrate that telemedicine reduces costs of care (except when comparing only selected costs). No study addressed cost-effectiveness.

Conclusions:

Our conclusions echo the original report: Existing telemedicine programs demonstrate that the technology can be made operational, but most of the studies assessing the efficacy or cost are insufficient to permit definitive statements about the evidence supporting (or not supporting) the benefits of telemedicine. Future studies should focus on the use of telemedicine in conditions where burden of illness and/or barriers to access for care are significant. 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 must set high standards for methodologic quality so that evidence reports need not rely on studies with marginal methodologies.