Access refers to the ability of a patient to avail himself or herself of appropriate health care in a timely manner. As suggested by the IOM (1996), access can be enhanced by increased availability of health information, allowing patients or other consumers to learn more about health problems, care options, and prevention strategies. This study focused on the former definition of access to care. Among our respondents, access to health care was generally regarded as the greatest advantage that telemedicine affords, and it was given highest priority (together with quality of care and health outcomes) with respect to areas of telemedicine evaluation on which to focus.
Among the main purposes of implementing a telemedicine program is to improve access to care by lowering geographical and temporal barriers. A telemedicine application may provide care that would otherwise not have been provided, i.e., yielding a net increase in care.
Telemedicine remains underutilized in the views of many observers. According to the 1999 Report on U.S. Telemedicine Activity of the Association of Telehealth Service Providers (ATSP), there were an estimated 41,740 telemedicine consults in 1997 and 52,223 in 1998, with 75,000 projected for 1999 (based on first quarter data). (These estimates did not include radiology and home health consults.) The most active specialties in telemedicine are mental health, dermatology, cardiology, orthopedics, and radiology. According to ATSP, given underreporting of visits, the actual numbers of telemedicine consultations may have been 40-100% higher. In comparison, there were some 750 million in-person patient-provider visits in 1998 (ATSP 2000).
The types of factors that may affect access to health care services include:
- geographic proximity of a service provider;
- financial status and insurance coverage;
- motivation and care-seeking behavior;
- convenience (timing, availability of transportation, etc.); and
- socioeconomic status.
Most of our respondents cited geographic barriers as a primary factor that limits access to care in rural settings and that may be overcome with telemedicine. Systemic (i.e., related to health care delivery or organization) barriers such as lack of inner-city health care services or inadequate health care services were more often cited as limiting access in urban settings. It was also pointed out that urban programs may be focused more on efficiency (i.e., removing internal systemic or bureaucratic barriers to treating existing patients) rather than overcoming geographic barriers to access.
In evaluation, utilization is often used as a proxy for access to care. For example, in one network's telepsychiatry program, 46% of those patients taking part in the program were seeing a psychiatrist for the first time, suggesting that psychiatric assistance was not available to these individuals before it was offered through telemedicine. It is important to note, however, that an initial surge in telemedicine utilization may reflect pent-up demand and may subside once this consultation backlog is handled. That is, an evaluation of access may reveal a spike in patient volume at the onset of a telemedicine program as patients who have yet to seek care may have their initial appointment via telemedicine. Following these initial visits, the immediate needs of the population have been met and thus the number of visits may drop until a steady, maintainable level is reached. Further, any estimate of the rate of patients seeing a provider for the first time in a telemedicine program should be compared to the rate for patients in conventional settings.
In evaluating telemedicine, it is not sufficient to compare its effectiveness against conventional care. It also is important to identify ways in which telemedicine provides care that would not be available through conventional means. For example, telemedicine may improve access by coordinating care in a way that would otherwise not have occurred, as in an instance recounted by one of our study sites. A boy was involved in a motor vehicle accident early in 1999, during which he sustained a traumatic brain injury. He returned to school in late summer after sufficient recovery. However, the boy's injuries had behavioral effects, and it became apparent that both he and his teachers would need assistance in dealing with sometimes very disruptive behavioral problems. Through the use of the telemedicine facility, a real-time conference with two of the boy's clinical providers, his mother, his classroom teacher, the school counselor, and the school speech therapist was held. The teachers and counselors were able to express their observations and concerns, and the clinical staff was able to explain the changes in the boy's behavior and provide the educational team with some guidance on what future behaviors to expect. During the course of a two-hour teleconference, they drafted a plan for how to proceed and best allow the boy to continue to function in a regular classroom. Real-time conferences of this sort rarely occur at a single location given the difficulty of having a team of local providers (e.g., teachers, parents, and therapists) travel to a larger health care center, or having specialists from the health care center travel to a remote location.