Information Technology in Biomedicine, IEEE Transactions - IEEE Xplore

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IEEE TRANSACTIONS ON INFORMATION TECHNOLOGY IN BIOMEDICINE, VOL. .... Luis G. Kun (M'83–SM'84) received a degree from the Merchant Marine ...



Editorial Telecommunications and the Reform Process in Public Health I. LEGISLATIVE ACTIONS


MPORTANT strides in Federal policy toward healthcare and the information infrastructure were made in the past year. The link between healthcare and the universal service policy was made explicit in the Telecommunications Act of 1996. This act requires that the Federal Communications Commission (FCC) and the states revise the universal service system based on seven principles, including the principle that schools, libraries, and healthcare providers should have access to advanced telecommunications services. In addition to these broad principles, additional provisions should be made that require the FCC to assure that healthcare providers serving rural areas have access to telecommunications services “necessary for the delivery of healthcare” at rates that are comparable to those for similar services in urban areas. The FCC has authorized $400 million per year in discounts for rural telehealth access. Beginning January 1, 1998, institutions providing rural healthcare will be eligible for discounted telecommunications rates. This is the result of the FCC authorizing the establishment of a universal service fund to which telecommunications carriers will contribute for the purpose of making equal-cost access available in nonurban areas. The discounts will be available for obtaining toll-free Internet access, discounted rates for T-1 Internet connectivity, and other distance-related telecommunications charges [1]. Also in the balanced budget act of 1997, $200 million were allocated for reimbursement of telemedicine services of Medicare patients and $30 million for a demonstration and evaluation project of telehealth home care services for the elderly with diabetes mellitus living in underserved rural and urban areas [2]. II. IMPLEMENTATION ACTIONS Infrastructure Computing, Information, and Communications: “Technologies for the 21st century.” The Federal Computing, Information and Communications (CIC) programs, formerly known as the High Performance Computing and Communications program, invest in long-term research and development (R&D) to advance computing, information, and communications in the United States. The results of these efforts help government departments, such as Health and Publisher Item Identifier S 1089-7771(97)09425-9.

Human Services and its agencies, fulfill their research missions by improving healthcare, teaching our children, providing lifelong training to our workforce, and providing the tools for fighting and preventing disease, drug development, modeling and simulation, and in general for providing an environment that allows for real-time telesurgery as well as health services research in extremely large populations. One of the nine committees of the National Science and Technology Council, the Committee on CIC oversees R&D programs conducted by 12 Federal departments and agencies and coordinates research in cooperation with United States academia and industry. These R&D programs are organized into five program component areas. One of them, the LargeScale Networking working group has been chartered to create the Next Generation Internet Initiative (NGII), an initiative of the Federal Government to foster a scientific and researchoriented, high-speed telecommunications network with more advanced capabilities than are currently available on the public Internet [3], [4]. III. APPLICATIONS Telehealth: Collectively, the public and private sectors have funded hundreds of telemedicine projects that could improve and, perhaps, significantly change how healthcare is provided in the future. However, the amount of the total investment is unknown. The General Accounting Office (GAO) (5) identified nine Federal departments and independent agencies that invested at least $646 million in telemedicine projects from fiscal years 1994 to 1996. The Department of Defense (DOD) is the largest Federal investor with $262 million and is considered a leader in developing this technology. Statesupported telemedicine initiatives are growing. Estimates of private sector involvement are impossible to quantify because most cost data are proprietary and difficult to separate from healthcare delivery costs. In March 1995, the Vice President directed the Secretary of Health and Human Services to lead efforts to develop Federal policies that foster cost-effective health applications using communications technologies, including telemedicine. Health and Human Services was required to prepare a report on current telemedicine projects, the range of potential telemedicine applications and public and private actions to promote telemedicine, and remove existing barriers to its use. The Vice President also directed that this effort include representatives from several specific departments and agencies. As a result, Health and Human Services organized the

1089–7771/97$10.00  1997 IEEE


Joint Working Group on Telemedicine (JWGT). The National Telecommunications and Information Administration (NTIA) of the U.S. Department of Commerce, in consultation with the U.S. Department of Health and Human Services, published the “Telemedicine Report to the Congress” this year. This publication contains, among other issues, a working inventory of all Federal projects [6]. As telehealth technology evolves, it will become better and cheaper. Consequently, the questions facing telemedicine today involve not so much whether it can be done, but rather where investments should be made and who should make them. The solution lies in the public and private sectors’ ability to jointly devise a means to share information and overcome barriers. The goal is to ensure that an affordable telecommunications infrastructure, with interoperable software and hardware, is in place and that the true merits and cost benefits of telemedicine are attained in the most appropriate manner. Telecommunications costs are often a major component of a telemedicine project’s overall costs. These costs can be very high. Different telehealth applications require different technologies. As a result, assessing the costs for different combinations of technologies and infrastructures can be a difficult exercise. Another factor affecting the telecommunications cost and ultimately the cost of the total telemedicine system is the uneven distribution of modern telecommunications infrastructure across the country. In those areas where the information infrastructure is underdeveloped, unreliable, or nonexistent, the cost of upgrading the infrastructure can be prohibitive. Yet these same areas would most likely benefit the most from telemedicine services. Rural areas in particular have the least access to high-quality and high-capacity modern telecommunications infrastructure. The Koop Institute estimates that the U.S. telemedicine market totals $20 billion for telecommunications infrastructure, computer hardware and software, and biomedical equipment. A breakdown of this funding is unavailable. Also, the Koop Foundation, a sister organization to the institute, is expected to compile an inventory by the year 2000 of private-sector telemedicine projects. Very few comprehensive studies have been completed to prove that telemedicine delivers cost-effective, quality care and quantified to prove the benefits through a comprehensive cost-benefit analysis. Within the Department of Health and Human Services, four agencies—the Agency for Health Care Policy and Research (AHCPR), the Health Care Financing Administration (HCFA), the Health Resources and Services Administration (HRSA), and the National Library of Medicine (NLM)—are conducting research in the area of telehealth. The subjects evaluated relate to many topics, including cost/effectiveness, reimbursement, rural areas, and transmission of images. Through information technologies, research agencies such as AHCPR [7] can benefit the providers of healthcare services, the consumers, and the researchers across the world with


timely and important evidence-based studies. Telecommunications through the national and global information infrastructures are the highways of information; the vehicles of these highways are multiple. Telehealth applications can vary from diagnostics, such as teleradiology, to treatment through telesurgery or telementoring, where a specialist surgeon can guide a beginner. Decision support systems, on the other hand, may be accessed from Internet websites and inform and lead the provider with better decision-making tools. Computer-based patient records (CPR’s) have an enormous importance since they are the enablers of large population studies, which will lead to better outcomes research and, therefore, better cost and medical effectiveness of the healthcare delivery system. Yet, in order to attain these goals, international collaboration is fundamental. It is needed primarily to establish standards development, such as vocabulary or universal language. The growing use of information technology in the healthcare sector demands that issues of patient privacy and data security again be analyzed to ensure that policies, practices, and procedures for handling health information take into account the vulnerabilities these systems entail [8].

LUIS G. KUN Agency for Health Care Policy and Research Center for Information Technology Rockville, MD 20852 USA

REFERENCES [1] FCC document, “Frequently-asked-questions on universal service,” da971932.html. Also a selection on a broader “Health care and the FCC” home page at [2] Balanced Budget Act of 1997. Conf. Rep. to accompany HR 2015, Sec. 4206. Medicare reimbursement for telehealth service and Sec. 4207. Informatics, telemedicine, and education demonstration project, [3] The National Coordination Office for Computing, Information, and Communications has a Web site containing information about the Next Generation Internet, For other types of information, go to: [4] J. Smith and F. Weingarten, eds., “Research challenges for the next generation internet,” Computing Research Association (CRA), May 12–14, 1997, [5] United States General Accounting Office (GAO), Telemedicine: Federal Strategy Is Needed to Guide Investments, http://www., Feb. 1997. [6] National Telecommunications and Information Administration (NTIA)/Dept. Commerce (DOC), Telemedicine Rep. to the Congress, Jan. 31, 1997, [7] Agency for Health Care Policy and Research (AHCPR), http:// [8] “For the Record—Protecting Electronic Health Information,” Committee on Maintaining Privacy and Security in Health Care Applications of the National Information Infrastructure, Computer Science and Telecommunications Board, Nat. Res. Council, Washington, DC: National Academy Press, Mar. 1997. [9] American Medical Informatics Association (AMIA), http://www. [10] Highway to Health: Transforming the U.S. Health Care in the Information Age, Council on Competitiveness, March 1996.



Luis G. Kun (M’83–SM’84) received a degree from the Merchant Marine Academy, Uraguay, and the B.S.E.E., M.S.E.E., and Ph.D. degrees in biomedical engineering, all from the University of California, Los Angeles. He was with IBM for 14 years, Director of Medical Systems Technology and Strategic Planning at Cedars-Sinai Medical Center, Los Angeles, and President of Kun & Associates, a consulting company. He is currently the Senior Information Technology Advisor at the Agency for Health Care Policy and Research (AHCPR), Rockville, MD. Dr. Kun represents AHCPR at the Joint Working Group on Telehealth (JWGT), where he chairs the group on Security, Privacy, and Confidentiality. He also is a member of the National Science and Technology subcommittees: Computers, Information and Communications (CIC R&D) Subcommittee and Applications Council Subcommittee, the U.S.-Israel Steering Committee on telemedicine, tele-education, and digital libraries, and the Security Implementation Team for the Health Insurance Portability and Accountability Act of 1996. He is on the Editorial Board of the IEEE Spectrum and the IEEE TRANSACTIONS ON INFORMATION TECHNOLOGY IN BIOMEDICINE.

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