Every organisation that can be categorised under the health care industry will not be able to survive unless they have some communicating link between them that is beyond the ordinary telephone, fax, courier service or face-to-face in the long term. The sheer pressures caused by the ever-relentless march of technology and the demands of the customers of the service would force even the most reluctant ones to embrace what t he modern technology offers.

The technology that telemedicine offers not only allows for easier and better patient management while concomitantly offering better supervision of the prescribed care. Offering this technology would allow a particular service provider to create innovativeness of their product mix as well as in developing a core competency in an area that would allow it to carve a distinct market niche. By the time the other providers manage to copy this idea and offer the same service, the provider that enters this market early would be able to establish a better competitive advantage and would not have to suffer from learning and experience curve defects that inevitably accompanies when any new technology is introduced for the very first time into any new environment, both macro and micro-microenvironment.

The initial investment cost is on the higher end of the scale. Thus, every provider has to make a very careful study not only of its free cash flows for a period of at least five years. But the provider must not allow itself to be swayed solely by the computation of the results of its free cash flows, NPV and/or IRR. He must also study the follow-on investment option as well as the abandonment option. This is because the investment into a new and emergent technology like telemedicine today would allow the provider to exercise a call option in five years time. This investment would also be possible since this technology, which is definitely here to stay, would allow itself to be upgraded with a better product to provide better services. That investment would not only cause a fresh set of in ward free cash flows to occur allowing the provider to continue to ensure it growth in profits but also to accrue the benefits (financial and otherwise) from going in for this technology today.

The abandonment option is an evaluation of the effects of going in for an investment which, even if found to be not viable enough, normally has a residual value of considerable proportions to justify the initial investments to acquire the asset. The abandonment option evaluation allows one to calculate the overall profitability of the in vestment if the investment is abandoned at some point of time and the various assets hived off for cash.

Considerations for the calculations of Discounted Free Cash Flows would depend upon the DFCF of high and low demands as determined by the possibility of potential gain or loss of market share due to the failure on the part of the provider in offering this technology and a competitor doing so instead. A decision tree analysis may be performed to help in assessing the various payoffs and the opportunity costs involved to help in choosing the ideal-fit solution. The abandonment option is essentially a put option. The high demands are reflected by the increased market share while the low by the decrease of or unrealisation of increase in customer volume.

The question that naturally springs to mind is that while this technology is indeed a most impressive, almost a fantastic one, where would its application be most beneficial?

The answer to this question lies in two parts:

1. Whether a particular provider can afford (or not) to have such a technology on hand for improved patient management, and
2. Whether or not this technology would prove to be of any benefit as far as improvement patient management is concerned.

The first fact has already been dealt with when the opportunity of follow-on investment or a call option and an opportunity of abandonment or put option for this technology was discussed ut supra. It is the second part which is discussed in some more detail below.

There is enough evidence to suggest that productivity can actually decrease when information systems simply mirror existing manual systems. If telemedicine technology is built and used merely an extension of an MIS with hardly any interactivity, no "intelligent" data retrieval and analysis system in the form of data query analysis possibly by the use of SQL, or no electronic mailing system nor scheduling, then investing in such a system is a colossal mistake.

Furthermore, even though the introduction of information systems was supposed to revolutionise office systems and create a paper-less office, in reality the amount of use of paper has gone up. However, the interactivity and fast access and multi-point data handling has offered the opportunity of having up-to-date, as well as old, documents readily available, no matter where they exist or from where the request is made, a s long as they are electronically linked up from the point of delivery to the processing of the request.

Also, the volume of information generated and required to be available as quickly as possible also determines the requirements for telemedicine or an equivalent information system. The questions that must be appropriately handled here should be:

1. Whether one can safely say that this technology is useless or unnecessary, even when it exists and is available, and
2. A customer can indeed be treated better (or with equal competence) and is in fact better off without the use of information systems.

Telemedicine embraces within its ambit the whole concept of information systems in health care industry, plus some more. Not only data can be accessed and exchanged without any hindrance across all geographical boundaries at a very fast rate without inconveniencing the customer and the provider much, but this technology would make it possible that better management and care may be delivered which would otherwise have been quite impractical, time consuming, expensive, and highly improbable as well at the very least.

Moreover, getting a second or expert opinion is very important in many situations that arise in health care. With this technology, the expert may be available at the point of delivery of the service at all times even if the is physically located half-way around the globe. By the use of telerobotics, it is even possible to perform procedures at long distance.

Put very simply in my honest opinion, 'telemedicine' is the vehicle for delivery of the very best of quality health care of the day to patients physically located anywhere in the world by combining communications technology with medical expertise at any time. Telemedicine is an emerging field that could have a revolutionary impact on the delivery of medical care. Advocates envision the development of a global grid of medical service providers and consumers linked by telecommunications networks for the exchange of medical information. The goal is to improve access to and the delivery of high-quality medical care at an affordable cost. However, policy makers, health care organisations, and providers are successfully challenged to distinguish excitement and hyperbole from the practical implications of this new suit of technologies and applications.

Therefore, it is abundantly clear that telemedicine would definitely help in providing complete and accurate diagnostic opinion by the best available specialist residing physically anywhere who could then suggest an effective management plan for the patient.

It will not only dramatically reduce the costs as a result of less time and money being spent on travelling but also through obviating the necessity of maintaining specialists whose expertise is infrequently called upon. Overall expenditure control is exercised through maximisation of all round efficiency helping in optimising costs, and therefore prices, while increasing the overall productivity, profitability and competitiveness, is also made possible by the judicious use of this technology.

Imagine, if you will for a moment, an environment where a doctor is able to consult with another halfway across the globe at the touch of a button. Telemedicine is a technology that would make this a reality and allow the delivery of the very best of health care and management with the help of a PC (or a network of them) from anywhere to anywhere as long as they are linked to each other by a valid telecommunication connection. That is the power that this technology promises to the health care industry.

However, telemedicine does promise much further -

• Quick and efficient diagnosis through Clinical Decision Support Systems, etc.
• Ability to maintain constant contact with the medical experts in any discipline from anywhere;
• Helping in the reduction of the referrals which could be done 'online' ; increase in confidence, in and in the viability of, remote and rural health care centres; and in the personnel manning them.

Geography would not be an encumbrance to providing quality health care and management anymore.

Invariably a few cobwebs are present that still needs serious attention, cleaning and polishing. Current technological limitations lead to slow transmission rates while faster and more acceptable speeds are available at a price which is not yet cost justifiable. This situation is however bound to change very soon, possibly by the year 2000, if not earlier.

The omnipresent problem in the shape of data security, especially of the sensitive data concerning the patients whose confidentiality is of paramount importance to the doctors concerned.

Added to all this is the unavailability of congruent software and relative lack of computer awareness amongst the various constituents of the health care industry has led to the creation of serious barriers for the carers to offer this technology to the payers. Hopefully, with the increase interest in this technology and all that it can do for the health care industry, the ground conditions would alter favourably.

The real challenge to the various software manufacturers (and, I hasten to add, the hardware ones too) is for them to look at their strategic objectives and lunge headlong into this field in all seriousness that it demands. As with every innovation, there has to be pioneers and there has to be followers. Some make a pile and some lose a pile. High technology areas are treacherous when they are simple, and telemedicine is most certainly not.

Let me annotate the parable of the three cowboys. This is particularly pertinent to those organisations (including the manufacturers and suppliers of equipment, hardware and software, as well as the service providers) and is meant to enlighten them of the downsides they could expect.

There is this story of the three cowboys. [I heard this anecdote from my professor in finance, Prof. Ronald P. M. Poppe, Belgium.] They all went for the mountain of gold, one following the other. The first one found the gold and while bringing is home got scalped by the savages. The next one found it lying around the body of the first. He was also scalped while he was near to his home yet so far. The third one then picked it all up and brought home the booty, his scalp and all very much intact. All three positively contributed towards finding and eventual gain from the gold but it is the third one who actually accrued any benefit from all this hullabaloo.

There are several other additional challenges to seriously ponder about. Cultural barriers require to be overcome in certain areas of the globe where this technology could well be viewed as "foreign". Successful implementation and wider acceptance by the users elsewhere would no doubt help in bringing down these barriers sooner rather than later.

High costs, at least initially. The equipments required are costly and therefore high capital inlays are required initially along with continued maintenance costs.

Coupled with these is the additional cost due to the requirement of constant presence at the patient's side of at least one qualified health care personnel to actually administer care.

Furthermore, when computers and network connectivity do not work as they should, they can try even the patience of a saint. If you have used the Web, on several occasions you must have found that while most of the times they work pretty fast, sometimes they simply refuse to do so. This results in the modem connections being "timed out" , lost messages due to errors in transmission, garbled data being received, etc. At such times one can certainly get most frustrated.

So equanimity is required in all such matters. Especially at the initial stages when the system is in the process of getting stabilised. Once the system becomes 'critical' and things begin to work as they ought to, these problems would mostly be few and far between. Improved equipments are constantly coming in to the market and such obstacles shall largely be a thing of the past world over.

Further developments in the technology is however expected to see to it that both the costs of acquiring the technology and the maintenance thereof would be well within affordable ranges, with the investment costs being recovered within a financially viable period, while the use of personnel required to run it being progressively lessened till such time when they are mostly required during emergencies, if at all.

Telemedicine would definitely help in research and development of better management protocols, Clinical Decision Support Systems (CDSS), efficient and detailed epidemiological studies, statistical analysis, and through well designed data warehousing techniques the eventual building of a health data mart from where data could be mined for various purposes.

General efficiency of the health care system can be created by the use of this technology with successful computerisation yielding many tangible benefits to the health care management. Relevant information diffusion is accelerated so that the provision of overall care is improved and the demands for information of various natures are met. The decision-making process streamlined and made more efficient through the active participation of the payers themselves. Telemedicine would also help in transforming the health care industry into an integrated system as a whole supporting the continuum of health care.

The technology would definitely help to reduce professional isolation and provide the ideal medium for the deliverance of Continued Medical Education (CME) on a continuous basis with the latest information being available literally at the touch of a button. With CME being available at any time at anywhere, even from the comfort of one's home, the need to travel and spend time away from work simply to re-train and hone one's professional knowledge and skills would be eliminated. The care provider can hone his skills in laparoscopic or endoscopic or other non-invasive procedures by watching "live" events online. Such "live" events may be recorded and replayed endlessly, even in slow motion if necessary, so that one gets the hang of it to his heart's content.

It positively contributes towards the safety of out-of-hours care by less skilled personnel even in areas demanding high skills. This is as a direct consequence of online supervision by skilled personnel. The technology would allow the supervisor equal opportunity, whether he is in the next room or half-way across the globe and in the sky. The only drawback being his inability to directly intervene on-hand should, God-forbid, the need for it ever arise.

Increased job satisfaction amongst health care workers in the rural and remote areas as a consequence of their involvement in the ongoing care of patients in their own community is bound to happen. As a direct consequence, their experience and knowledge levels would concomitantly increase. Remote access to archived electronic scans and patient-related health data as well as other relevant records, and the provision of health care information (pre-operative, antenatal care, various support groups, etc.) direct to patient's home would also be made possible through this technology.

Emergent technology (ET) in the field of Information Systems (IS) will further enhance the quality, quantity and efficiency of telemedicine. It is rather the acceptance of the technology by the health care professionals and the administrators that happens to be the main stumbling block that needs very careful handling. The reasons for this is because these professionals still view telemedicine as a threat to their livelihood, disruptive in their otherwise normal day-to-day functioning, and a n overall challenge to their own understanding and expertise in a subject area in which they are expected to be a master.

Telemedicine allows the active participation of the family in the management and care process of the patient concerned. This invariably increases the overall effectiveness of the healing process.

It would also be an additional revenue generator by way of additional patient consultations as they may now "virtually" visit the health care providing organisations from within the comfort of their homes.

It would also cause increased patronage by the remote and rural centres allowing the organisations possessing telemedicine technology to export their various skills to them. Since telepsychiatry has been found to be a much less threatening consultative medium than the real one, increased customer volumes would doubtlessly result. Effective and ability to treat incarcerated felons in a secure environment is also possible with this technology as the need for transporting them to health care facilities would be reduced thereby reducing the risk of these offenders of the law of the land, some of whom are of the most dangerous nature capable of committing the most heinous of crimes, to escape.

Thus we see that telemedicine appears to yield such benefits that the possession of it would prove to be a boon rather than a burden on the organisation even with the still lingering, and essentially niggling, downsides. This one technology truly can create an effective global health village, albeit in "virtual reality", and make health for all a real possibility.

Telemedicine is not only mutually congruent with health care industry, but if successfully and carefully implemented, telemedicine would inevitably prove to be a real asset to the organisation in possession of it and would definitely help in transforming it into such an industry the likes of which has never been seen before. All the inhabitants of this world of ours would have an equal opportunity to receive the very best of medical attention and care that is available every time he is in the need of it.

Once telemedicine is accepted and used as a viable technology, with the utilisation of existing technology and facilities, it would soon be able to demonstrate its usefulness to the health care industry and its customers and provide an ample glimpse about its immense potentiality. Initially, the components of the industry and the final customer in his home may be linked up using the existing telephone lines with narrow bandwidths. This hinders the quick exchange of transmission, especially the video part, thereby extinguishing the magical charm of telemedicine and frustrating the various end-users.

Thankfully the situation is changing quite rapidly. Larger bandwidths are already being offered by the telecommunications departments/providers in an ever increasing number of countries through the laying of fibre-optic cables and ISDN (Integrated Services Digital Network - now being offered by many phone companies, this can offer 56 KBPS or 128 KBPS, depending on the hardware) lines. Already T1 (common for links between Internet servers; roughly 1500 KBPS, or 12 times faster than ISDN) lines are being used to provide CME. Soon the more innovative ADSL technology is expected to revolutionise it further by bringing down the transmission times and thereby the variable costs in the long term.

The existent technology already allows PCs, laptops and workstations to communicate face-to-face using the not-so-costly-anymore video e-mail and the easily-available Internet phone. Increasingly "virtual" offices are being encouraged in a number of organisations and telemedicine is an extension of the very same concept to the realms of health care industry with the providers and the providees communicating amongst themselves at various levels.

Digitised pictures of the various radio-diagnostic scans (e.g., X-rays, UltraSound, Computerised Tomography or CT Scans, Magnetic Resonance Imaging or MRI) as well as the pictures and/or picto-micrographs of pathological specimens are already being sent over in ever increasing volumes. One can even scan them prior to sending/storing instead o f using the expensive digitisers for the very same purpose, though this is dependent on the type of photographs being "captured" electronically and there is a distinct diminishing of the overall image quality. Video e-mail would allow videoconferencing where not only sound but live video pictures are transmitted/exchanged over phone lines/satellite link-ups in real-time between the patient and/or his doctor/carer communicating face to face with the expert as in a real consultation setting.

In fact, the technology promises further. Since it would allow anyone to see, hear and talk to anyone at the other end, all one needs is to have proper equipment(s) to "hook up" the body to the piece of instrument so that the various vital signs may be telemetered through to the other end. This would allow medical personnel to assess/monitor the "hooked up" patient from a distance and manage him without any difficulty at all.

As with any technology, telemedicine too should be gradually be 'phased-in' as the older and essentially conservative system is 'phased-out'. This point should be noted and followed with the utmost of convictions and care, else the organisation introducing telemedicine would be in a state of constant turmoil at least in the initial stages beset with the various teething problems. This in itself would ensure the certain premature demise of telemedicine, at least within that organisation.

As the infrastructure is built up and eventually put in place, the usefulness of telemedicine increasingly appreciated, the demand for newer and better techniques would automatically grow. As the growth of ancillary technology continues to become better and more cost-effective, the telemedicine product-mix on offer can change accordingly and newer, and hopefully better, facilities may then be provided.

Several very important strides in the field of telemedicine have already been initiated. The introduction of the so-called 'virtual patient record' coupled with the development and use of Read Codes, International Classification of Diseases (ICD), Diagnostic Related Groups (DRGs) with its 23 chapters of Major Diagnostic Categories (MDC), and Health Related Groups (HRGs) have in themselves gone a long way in making comprehensive telemedicine a real possibility.

Currently there are about 100,000 preferred terms and a further 150,000 synonyms or index terms. They cover the whole length and breadth of clinical medicine from subjective and objective findings, diagnoses, procedures and treatment, to administrative arrangements, all using the form and language which clinicians normally use in their day-to-day activities.

The use of smartcards, which the patients could carry on their person like any plastic credit card, enabled with flash memory chips would be of immense advantage. These cards would allow access to the information stored within through a password known only to its owner. Relevant information like a summary of the last visit to a health care providing center, vital statistics, summary of significant past history, details of investigations and findings thereof, etc. could be downloaded on to these cards and handed over to the patient. Since such cards are now coming with memory chips that can hold files in binary format, it is possible to have even images and sounds to be downloaded to, and subsequently uploaded from, them at will whenever the need for doing so arises.

For the general public without access to a PC and a modem-linked POTS (Plain Old Telephone System) at hand, information kiosks or cash-point like machines could be used for contacting medical personnel by the patients for advise and treatment whenever they require. PC Keyboards with suitable interfaces for reading smart cards/fingerprints are already available commercially, and the medical professionals may be consulted "on-line" from the comfort of the one's residence.

Additionally, telemedicine would allow an organisation to position itself favourably in the market. The competitors would certainly strike back, but as the entry cost are high, both due to the capital expenditures and the learning curve involved, the strength of their attaining a sustainable competitive leverage leading to the establishment of serious advantage is bound to be low.

The buyers would be attracted by the quality of services which would undoubtedly go up. If the organisation can truly practice 'value pricing', it would be able to create a strong customer loyalty which the competitors would find very hard to counter at least in the short-to-medium term. [Top]