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Show much" type of calculation (Preston, 1993). Evaluating the cost effectiveness of telemedicine systems is complex and varies with the technology employed. Telemedicine system developers must consider how savings that result from the utilization of a telemedicine system will be "captured" and applied to the new system. For example, if a rural hospital installs a computerized medical records system and, as a result, purchases less paper, the savings in paper costs should be redirected into the new computer system. In an attempt to begin a discussion on this topic, a limited number of germane issues are divided below into those that "cost" and those that "save", realizing that sometimes a good investment in a "cost" actually results in a "saving". Upfront costs: Purchasing, installing, maintaining, operating, and upgrading the telemedicine systems can demand considerable financial resources. One alternative to purchasing equipment is to lease it. Leasing equipment can be advantageous in a market where equipment can swiftly become outdated due to the ongoing rapid evolution in the technology. Training of local personnel to maintain and operate the system: Telecommunication systems are generally quite dependable. While all equipment is subject to failures at times, a critical issue with telecommunication systems is that these are dynamic systems: new hardware and software must be incorporated into the systems over time. Upgrading and fixing problems requires a good grasp of the hardware and software configurations, and that means training. Users of these systems, particularly new users, are more likely to become discouraged and stop using the system if they have to wait to have problems fixed, or even to have routine questions answered. Locally trained people must be available to teach and trouble-shoot most of the day-to-day problems. People are less likely to use such systems if they have to wait for a person to come from another town to fix every problem or make every upgrade. Thus, it is critical to the adoption process that help be available locally when problems arise. Training local health care providers and/or their staff: If providers are not comfortable with these systems they simply won't use them. In conversations with telemedicine directors in other states, the author has repeatedly heard, "We should have put more into training". There appears to be a tendency to focus on the technical aspects of 98 TELEMEDICINE developing telemedicine systems (should we use microwave?, fiber?, screen size? various hardware and software decisions, etc.) and ignore the "people" side of implementation. With the best of intentions, hospital administrators often purchase and install these systems without ever consulting their providers or train them on how to use the systems. Rural providers may have to operate these systems by themselves (or another cross-training need has been added), so they must feel competent and comfortable using the equipment. Even under the best conditions it appears to take about a year for health care providers to fully incorporate telemedicine systems into their practice. Hence, training of providers and their staff is absolutely essential to the adoption process. User fees: Like the telephone system, user fees must be charged to keep such systems operational. Telemedicine systems must be part of the larger, emerging telecommunications systems to be cost effective. Telemedicine systems may initially emerge as stand-alone telecommunication systems, but such independence is exorbitantly expensive. It is more cost efficient to build upon an already existing infrastructure (such as telephone lines). In any case, increasing the number of users on a system means lowering building, operating and maintenance costs. While there are grants available to establish these systems in rural areas, ultimately, telemedicine systems must operate on a cost recovery basis. Cost to rural providers: First, the utilization of telemedicine system requires a change in how providers practice medicine. For example, sending x-rays via a telephone line raises some important issues, such as, "is it really as good as the original film?" Questions of "how good or reliable is this new technology" or "is this going to entail any new liability issues?" are important to address. While the answers are being established, there is always the danger that these new systems won't perform as touted and that they will be more of a liability than a blessing. Investing energy and time into an unproved system is always a risk. A second cost to rural providers is in dollars and cents. As is being detailed here, it costs to install and use these systems in a physicians office. It costs for equipment, training, and all the items listed here. Prudent providers will take a close look at the costs before jumping on the bandwagon. A third cost may be in a perceived erosion of independence from the urban health care centers. Rural providers may perceive telemedicine systems as yet another attempt on the part of urban health care facilities to "get" their patients or to dictate how, when, where, and why to practice medicine. Rural |