Unlike most new technologies that diffuse smoothly into health care delivery, implementing telemedicine systems, and teleconsultations in particular, often presents departures from standard means of health care delivery, administration, and financing. Most new medications, medical devices, and medical procedures are delivered within already existing systems. Some technologies have necessitated special arrangements, such as magnetic resonance imaging (MRI) and positron emission tomography (PET) scanners that require special rooms and related facilities, but they are otherwise similarly captured in medical records systems, billing systems, and other standard processes.
Although teleconsultations can improve health care access, efficiency, and other attributes, in certain important respects it has been necessary to conduct teleconsultations outside of the health care mainstream. Given the need to accommodate the necessary video and related telecommunications technology, special rooms have been designated for teleconsultations that may be apart from the regular clinic traffic flow. Processes for making teleconsultation appointments have been separate from routine appointment systems. Because teleconsultations have not been reimbursed in the manner as other physician visits, billing and related coding and payment of teleconsultations has been conducted in separate, parallel systems. Furthermore, they may hinder data collection and evaluation. As one respondent stated, "In the eyes of the reimbursement bureaucracy, no services are being provided if no CPT code is assigned to those services." These differences represent departures from the health care mainstream that clinicians, patients, and other participants are seeking to diminish.
In order to be successful, telemedicine must be integrated as smoothly as possible into existing, routine clinical and administrative functions. This does not preclude some adaptation on the part of these existing functions if the net result is more efficient health care delivery overall. Therefore, it is critical for telemedicine evaluations to distinguish between any inefficiencies or lack of acceptance that are inherent in telemedicine applications themselves, as opposed to those that derive from an awkward fit between the telemedicine application and the clinical mainstream.
Integration of telemedicine into the clinical and administrative mainstream was well demonstrated during our site visits. At to the University of Missouri, dermatology consultations are held in one of the standard examination rooms, which is equipped with the necessary telecommunications equipment that links the dermatologist in the exam room to a patient and accompanying nurse in an exam room at a remote site. The visits are conducted as routine visits of approximately 15 minutes. Scheduling and appointments, patient records, coding, and billing for teleconsultations are handled within the same systems as other types of encounters.
Aside from physical proximity, evaluation of telemedical consultations should inquire how or to what extent these consultations cause clinicians and health care management to depart from routine care. The further this departure, experts argue, the less likely it is that the program will succeed. As described above regarding clinician acceptance, implementing a telemedicine program may disrupt physician practice patterns and income streams. Interviewees at our site visits indicated that they have tried to ensure that referring physicians remain integral to teleconsultations and that patients (and income) are not taken away from them. The implication for evaluation is that gauging the integration of teleconsultations into the health care mainstream should consider their impact on practice patterns, patient flow, and income streams, along with any resulting physician or institutional resistance to the program. These findings can contribute to modifications toward achieving better integration of programs into delivery environments.
The views of our expert interviewees and demonstrations in our site visits indicate that ongoing integration of telemedicine into the health care mainstream may be a defining criterion for success. As stated by Grigsby, "Success [of a telemedicine program should be] measured by the extent to which it is no longer a stand-alone application" (Grigsby, Schlenker et al. 1995). Concurring is Michael Ackerman, of the Lister Hill National Center for Biomedical Communications of the NLM (Interview, May 3, 2000), who asserts that the most effective programs are those that are most seamlessly integrated into current clinical and business practice and that can operate on their own in the absence of outside funding.
Independent financial viability of a telemedicine program will increase its prospects for integration into the health care mainstream and long-term success. Indeed, the single most important evaluation criterion for any telemedicine program may be its ability to achieve independent financial viability. The ability of most programs to achieve financial viability will depend on their ability to secure appropriate coverage and adequate third-party payment for their services. Proposed telemedicine programs should include multi-year business plans that describe how the program will progress toward financial viability as outside funding from grants or other temporary sources diminishes. Such plans should be considered in any grants review process, and financial status with respect to these plans should be regularly monitored.