Assessment of Approaches to Evaluating Telemedicine. 6. Appropriateness

12/01/2000

The appropriateness of a technology refers to a judgment about whether the technology should be used in particular circumstances. Appropriateness is a function of other evaluation attributes such as access, safety, effectiveness, and cost in a particular situation. For example, the appropriateness of a teleconsultation system may depend on its accessibility and effectiveness compared to alternative available interventions for a particular patient indication, geographic setting, and prevailing resource constraints.

Uncertainty about the appropriateness pertains to many new technologies, where multiple indications are feasible and clinicians are learning about the advantages and disadvantages of technologies when applied under various circumstances. Medical lasers have been applied for a variety of indications, including ones that persist (e.g., laser keratotomy), ones that are used rarely (e.g., laser coronary revascularization), and others under investigation (e.g., lasers used in intervertebral disc surgery). While minimally invasive surgery has flourished for some indications (e.g., laparoscopic cholecystectomy) it has been tried but largely abandoned for others (e.g., laparoscopic appendectomy).

As with many new technologies that have the potential for multiple applications, health care providers and administrators have been trying to determine the most appropriate applications of telemedicine. This is of particular importance for teleconsultations given the costs associated with implementing new telemedicine systems, the potential for teleconsultations to replace face-to-face consultations in instances where doing so might compromise the quality of care, and concerns among health care payers that providing coverage to telemedicine services could lead to costly, unnecessary use of these services.

Providers and administrators need guidance regarding the circumstances in which the use of telemedicine is appropriate. Various forms of "triage" may be necessary to minimize the potential for inappropriate use of telemedicine technology (Bashshur 1998). This should include establishment of specific telemedicine-related protocols to reduce arbitrary or unnecessary use of the technology. In an evolving field such as telemedicine, an important role of evaluation is to determine when new applications yield clinically significant gains in accessibility and effectiveness for a given indication, and are cost-effective relative to alternative interventions. For example, full-motion video, as opposed to still images, may be appropriate for some types of teleconsultation, but superfluous for others. While a powerful televideo system may provide clinically important information for certain indications, a simple telephone conversation may suffice for others. Findings of these evaluations can be incorporated into the guidance or protocols for appropriate use of telemedicine, as noted above. By the same token, a determination that a technology is inappropriate (e.g., is not safe, effective, or cost-effective) for a given indication or circumstance is not necessarily generalizable to other indications or circumstances.

As is the case for other attributes of telemedicine, evaluation of appropriateness must account for the changing nature of the technology and costs. Greater bandwidth and lower costs can convert what was an inappropriate application to an appropriate one. As clinicians and administrators gain familiarity with telemedicine, they will continue to experiment with it and otherwise push the envelope of applications. As such, determinations of appropriateness is a continual process.

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