Telemedicine page on Wikipedia https://en.wikipedia.org/wiki/Telemedicine provides not only the definition of telemedicine but comprehensive information on its use and applications.

It could eventually reduce healthcare costs, however I would see it more as a way to access experienced, specialized, and high quality healthcare services from places where they are lacking, overcoming distance barriers.

@Ramon

I fully agree that telemedicine reduce healthcare costs sbstancially coupled with application of big data analytics.

ajit

very helpful in ideas sharing with health experts.

https://www.cio.com/article/2390576/healthcare/10-ways-telemedicine-is-changing-healthcare-it.html

https://evisit.com/10-pros-and-cons-of-telemedicine/

Dear Mr. Roy,

your question is very opportune. I'll try to answer it in an informal way. This will be my opinion, not a scientific text. I'll employ some colloquial language to underline a few viewpoints. In order to contextualize my response: I've been working for 14 years with the Santa Catarina State Integrated Telemedicine and Telehalth System - STT/SC (http://telessaude.sc.gov.br/), a project that started in 2004 and now covers the whole State of Santa Catarina in Southern Brazil, encompassing all 295 municipalities of the State and more than 700 healthcare institutions, from single-doctor primary healthcare facilities up to high complexity hospitals and oncology clinics.  Our institutional site, with information and material (mostly in Portuguese) is http://site.telemedicina.ufsc.br/.  Scientific publication you'll find here on RG and also on http://site.telemedicina.ufsc.br/publicacoes/.

Reducing healthcare costs goes hand-in-hand with sustainable telemedicine. So, first a concept that is key in implementing telemedicine in underdeveloped/under-served regions in a sustainable way:

• Resolubility in Primary Healthcare: the capacity of a primary healthcare facility/family doctor/general practitioner to solve the problem/healthcare condition brought by a given patient without referring the patient to secondary/tertiary healthcare or a specialist.

In order to telemedicine be sustainable and systematically help to reduce costs, it has to enhance resolubility at a primary healthcare level and not simply act as a faster way of performing patient brokering.  This means that telemedicine has to be implemented in a way, employing processes and protocols, that improves the problem-solution capacity of the endpoints of its network. 

Otherwise, by offering before unavailable examinations, you'll only be uncovering restrained demand and be generating more costs through more demand instead of less (even if you think ahead and say "I'm performing early detection of diseases and I'll help avoiding complications for these patients that will be much more expensive to treat"):  if you simply put an equipment to perform an exam in an upstate primary healthcare facility, e.g. tele-EKG, tele-dermatoscopy, tele-retinography, etc, provide findings reports and then refer all patients where some condition has been uncovered, without any infrastructure or protocol to process these patients in place, you'll be:

These problems above we have experienced ourselves when we started our telemedicine network 14 years ago (there wasn't anything like what we were trying to do then, that we could use as a reference) and they are also problems that still I see appearing in new research papers that I review (it should be common knowledge by now, but it's not).

We established a general strategy with a few rules that are all directed to:

These rules come from different sources and we have been adapting them to our environment and accordingly to the experience we amassed. The resolubility enhancement principle, for example, is a general directive from the Department of Primary Care of the Brazilian Health Ministry and not our idea.  The same applies to the doctor-to-doctor consultation concept explained below: it is also part of the Brazilian National Telehealth Program (http://dab.saude.gov.br/portaldab/ape_telessaude.php), we adapted it to the characteristics of our State and infrastructure.

Let's look at them:

• (1) Provide Access:
  • Patient and Family Doctor/Primary Healthcare Staff: When talking about patients the main directive is: take the patients away from the road and treat them, when possible, at their hometown. This means (a) moving to the countryside as many examination infrastructure as possible and performing exams via a store-and-forward process (asynchronous telemedicine) and then (b) put clinical protocols in place that help retain the patient there for as long as it makes sense, using telehealth to supporting the local primary care staff in treating the patient locally (more about telehealth X telemedicine later). A  patient should receive all the first steps e.g. in a cardiology or dermatology care in her/his home  neighborhood and the primary healthcare staff should receive clinical conduct support to treat this patient locally, being the patient only referred if specialized treatment is really necessary.
  • Specialist: For the reviewing physician this means easy and fast access to examinations, even emergency trauma CTs or MRIs, from anywhere through a special web & mobile  framework. E.g., the neuroradiologist providing an emergency findings report for a trauma CT in the middle of the night should be able to do this comfortably from home.

• (2) Optimize Specialist's Time: If you need telemedicine, then specialists are a scarce resource in your environment. Do not implement processes that won't optimize their expertise: videconsultations and other forms of real-time telemedicine, besides being a strain on network bandwidth availability in underdeveloped regions, do not optimize specialists as a resource: if a face-to-face consultation with a specialist to decide if a patient has a condition that should be treated by this specialist or a colleague takes 20 minutes to 1 hour of this specialist, a videconsultation performed on the same schema will take at least the same time. A specialist performing videoconsultations won´t process more patients than a specialist doing face-to-face consultations, you´re only avoiding physical travel, you´re not enhancing resolubility nor reducing specialist cost-per-patient. Unless you are talking about Prisonal Telemedicine, there is no resolubility gain here. The solution here is:

• (3) Give More Powers to Primary Healthcare Staff:
  • Enhance the examination/diagnostic powers of primary care facilities/family medicine practitioners through moving telemedicine-backed examination equipment to the countryside (from simple EKGs to Computed Radiography) and developing and putting adequate protocols in place that help you systematize patient triage (http://site.telemedicina.ufsc.br/atendimento/);
  • Support the Decision Making/Clinical Conduct of the Primary Healthcare Staff through teleconsultations  between family doctors and specialists in order to solve doubts and define the best clinical conducts, indicate when the patient is to be referred and when she/he should remain there and be treated locally, give feedback about expected treatment outcomes, etc and also provide a continuing education program to provide focused assessment of the weaknesses and needs of the local primary healthcare team.
• (4) Use the Telediagnostic Infrastructure to Provide Extra Services and Data that otherwise would be difficult to offer/gather:  Let's imagine that your telemedicine network operates the way most initiatives start: as a telediagnostic network, with store-and-forward examination reporting. This will be the most obvious solution if you're trying to meet the needs of under-served communities. Telediagnostic networks are also the easiest to implant: there are always local and regional governments, politicians, philanthropies and other players willing to obtain and distribute equipment. It is highly visible and the need to be met is obvious. We have observed that such networks are also sustainable if you meet the requirements above. But you can go further, there are other opportunities in such an infrastructure:
  • Focused Primary Healthcare Staff Support: as I said above, primary healthcare staff (family doctors, nurses, technicians, dentists, psychologists), especially in remote locations, will, in many occasions, need experienced support to make decisions.  If they are forgotten and do not receive this support, they'll become insecure and will tend to refer to a specialist everything that is a little more difficult or out of the everyday routine. If you redirect part of the time of your specialists to answer specific questions from primary healthcare staff (doctor-to-doctor or nurse-to-doctor teleconsultations and second opinions)  about particular cases,  you'll enhance resolubility for that specific case and the staff will learn from the answers: the next time a similar case appears, there's a chance they won't ask, they'll know how to apply the protocols and clinical conducts the teleconsultant suggested (again: http://site.telemedicina.ufsc.br/atendimento/ and http://telessaude.ufsc.br/teleconsultoria/).
  • Primary Healthcare Staff Continuing Education: I said before that videoconferences are inefficient.  This is true for patient-to-doctor teleconsultations, but there are other ways to use them efficiently: continuing education. To obtain resources for a widespread program of continuing education for primary healthcare staff in order to enhance resolubility is difficult. Many governments do not see education as a primary need and continuing education for trained medical staff has a "postgraduation" flavor that makes it look like a really, really optional and luxurious thing.  Everyone who already worked with primary healthcare staff in remote areas knows that it is not so: staff need updating and weaknesses have to be identified (see epidemiological data below). With an operating telemedicine network already in place and the countryside staff used to look at his network as a reference, with specialists that already collaborate with this network, it will become much more cost effective and easy to provide supplementary training a "knowledge refreshing" seminars via simple infrastructures like webconferences (http://telessaude.ufsc.br/teleeducacao/).
  • Epidemiological Data Gathering and Healthcare Policy Making: you tagged your question BigData and this is true for telemedicine. As supporting tools for data acquisition and consolidation, telemedicine technologies have become relevant as a basis for epidemiological studies: very few countries have widepread public EHRs that could be used to gather epidemiological data efficiently, telemedicine networks can supply this role. Due to its distributed, unconstrained geographical reach, such technologies allow the data acquisition from telediagnosis and teleconsultation, assisting the epidemiological surveillance through online identification and monitoring of public health issues. The acquired data could contribute to improve epidemiological investigations, disease control, and clinical case management, helping healthcare policy makers to direct resources and relocate professionals based on concrete scenarios.  We have been experimentally operating such an infrastructure a few years now:  http://site.telemedicina.ufsc.br/gistelemed/

@Aldo

I agree with your points that for ' Reducing healthcare costs goes hand-in-hand with sustainable telemedicine 'and telemedicine be sustainable and systematically help to reduce costs, it has to enhance resolubility at a primary healthcare level .

Dear Aldo

To add further Telemedicine mixes teleconferencing, document-sharing and mobile technology in order to improve healthcare quality, largely for those who lack access to care.

Telemedicine uses a variety of electronic communications media, ranging from teleconferencing to image-sharing to remote patient monitoring, to provide clinical services to a patient. As the American Telemedicine Association points out, telemedicine is associated with, but not the same as, telehealth, which also refers to nonclinical services such as research, training and administration.

The use of telemedicine technology dates back to the late 1960s, when physicians ran a microwave line under Boston Harbor to connect Massachusetts General Hospital with Logan International Airport in order to examine patients at the airport clinic while avoiding Boston traffic.

Today, telemedicine is used in medical fields such as dermatology, behavioral health and cardiology as a way to provide better care to communities under served by physicians, hospitals or both; it is also considered a way to significantly reduce the cost of treating health conditions, including hypertension, diabetes and sleep apnea, which benefit from continued monitoring of a patient's condition.

https://www.cio.com/article/2390576/healthcare/10-ways-telemedicine-is-changing-healthcare-it.html

Telemedicine helps to prevent delay in diagnosis, treatment and development of medical staff in primary hospitals as a result of contact with specialist doctors.

Telemedicine is the best solution for countries with health service problems of access to medical consultations in the latest of modern medicine.

@Ahmed

I agree with your statement that Telemedicine is the best solution for countries with health service problems.

ajit

You might find this research example relevant

Article Editorial. Telemedicine for elective neurosurgical routine f...

And another example about Cost-Effectiveness of a Savings-Led Economic Empowerment Intervention for AIDS-Affected Adolescents in Uganda: Implications for Scale-up in Low-Resource Communities

https://www.jahonline.org/article/S1054-139X(17)30493-7/fulltext

impressive due to the fact that ' Cost-Effectiveness of a Savings-Led Economic Empowerment Intervention for AIDS-Affected Adolescents in Uganda'.thanks dr Christine.

thanks for recommending my question@

• Craig Refugio