Systematic review of cost effectiveness studies of telemedicine interventions

EDITOR, In his comment on our systematic review of cost-effectiveness
studies of telehealthcare systems Professor Kirshen observes that we have
not searched the wider government - and especially defence related -
literature. My colleague Pamela Whitten offers a robust defence of our
search strategy in this exercise in her response. We were concerned
primarily with the peer-reviewed literature published in scientific
journals. The reason for our interest will, I hope, be apparent to readers
of the concluding paragraph of the article.

Professor Kirshen’s point about the value of telemedicine in defence
applications is an important one, since very little is actually known
about some of these systems in practice. But it's is a bit of a red
herring in relation to our review’s stated objectives. There is no doubt
that the armed forces of the United Kingdom, United States, France,
Russia, and the People’s Republic of China amongst others, regard
telemedicine systems as a cost effective solution to specific problems in
the provision of health care. The British Antarctic Survey and a number of
oil companies also employ telehealthcare systems for much the same reason:
they may be the only possible means of providing diagnostic support and
advice about treatment and management to small groups of people in remote
and hostile settings.

These technologies have, in recent months, been employed to support
and guide self-treatment for a life threatening disease in Antarctica, and
to provide expert neurosurgical advice to a regimental medical officer in
the Sierra Leonian hinterland. Doubtless British and American soldiers
presently have such support on remote mountainsides in Afghanistan. (The
concept isn't a new one: in various wars over the last 150 years in
Afghanistan, British soldiers have used horse-mounted messengers,
heliographs and short wave morse radio to do this.) Such systems allow
military healthcare expertise to be globally distributed from safe central
locations - but it should also be remembered that these activities are not
restricted by restraints on licensure and liability experienced across
national and state boundaries by civilian doctors.

The important point that needs to be made here is that battlefield
and near-combat applications of telemedicine might be seen to be cost
effective by armed forces not just because they distribute expertise
globally and rapidly in unpredictable circumstances, but also because they
do not place expert clinicians at risk of loss to enemy action. (In
action, army medical officers and their assistants have a
disproportionately high casualty rate.) These circumstances are
structurally quite different to those in which these technologies are
usually employed in civilian medicine. Civilian telehealthcare systems
have been shown to be clinically effective in the rural mid-west of the
USA, Australia, Canada and Norway where geography and climate intervene in
the provision of care. However, the jury is still out on whether
telemedicine is cost-effective because - as we show in our review - the
current scientific literature is run through with methodologically
inadequate studies.