Do you see telemedicine as a method to promote more contact with physicians and health care professionals with their customers? What changes to current reimboursement system would be required to pay for this? Does medicaid or medicare cover telehealth vists/consultations?

I have been puzzling with this question too - and I'm beginning to think that the problem is that we (i.e. clinicians and health informaticians) have modelled our thinking on hospitals and sick people rather than homes and well people. EPR's are less important to people's lives than we think they are!

There is much to learn from UTube and MySpace which have used Web 2.0 technology to enable people to communicate in new and amazing ways. In my own organisation we have started to use the same technology to allow clinicians to set up ad-hoc communities of best practice (www.sybermedica.com/pacsmail) - and have found this is being adopted more widely and more quickly than any system we have made before.

So part of the answer may be in building systems that allow people the freedom to build their own clinical networks - around their own lives - MySpace for medicine?

I know telemedicine has been used to create support groups and family involvement to ease isolation with regards to chronic diseases. Chronic Diseases especially plague the elderly who in many cases are isolated. Phone calls and telemedicine technology remove the isolation and in many cases improves the quality of care.

Perhaps it is not only closer contact with health care providers also contact with others with similar health issues that is needed. Successful strategies that has been utilized by one with a certain health issue could be used by others to improve self-management.

Another approach is to design our telemedicine systems to create (simulated) intimacy with patients. I've been investigating ways that automated health counselors can do this, and have shown that if systems properly use human social cues that people respond in positive ways, measured both on working alliance/caring/trust scales and on stated desire to continue using the systems.

See for example: http://www.ccs.neu.edu/home/bickmore/publications/IWC05.pdf

This is not to say that such systems are a replacement for human intimacy. The idea is to see if existing approaches to automated chronic disease management and lifestyle health behavior change can be made even better through the addition of (simulated) human social, emotional and relational cues.

That said, however, I think using such systems to address social isolation directly is an interesting area of research. Such systems could not only provide some kinds of social support directly (it's the perception of social support that has important health benefits), but could promote human social network formation and maintenance (eg motivate isolated individuals to get out and meet others).

Personally, I think that the greatest potential value of Telehealth lies in providing a mean of communication to ease the gap between patients and their health care providers.

Physicians could have short teleconference calls with patients they need to follow-up with at the end of each clinic. The benefit is for both parties: chronically ill patients or patients in remote areas could still feel they are cared for without actually stepping out of their home. Physicians could follow-up in five minutes instead of 15-30 minutes of clinic time. This would ease the clinic schedule without sacrificing patient care. But most of all, patients are going to feel cared for, and when dealing with a chronic illness the personal interaction with the person they trust is very important.

Hello, I thought I would add this link to an online video of a presentation I chaired at Institute of Rural Health to contribute to this discussion.

http://video.google.com/videoplay?docid=-4697411112477529973&q=John+lester (btw it would have great if we could embed videos etc...in this discussion group)

A lot of web 2.0 platforms already provide this by default (eg. Ning.com) Title of presentation: Online communities and virtual worlds for patient and caregiver self-help groups.

And I would also like to plug Play2Train (www.play2train.org), which again illustrates the kind of 'intimacies' possible between trainees, patients, docs, healthcare providers, various stakeholders etc...

I have often wondered why it takes decades for such paradigms to emerge and get established in the healthcare sector. I think it is great that we are having such discussions going on. It is great that we can also use the connected-health RSS feed. I urge members to use that so that they can get the posts delivered to their machines and get the information in a more timely fashion. Information management unfortunately is a skill that we all will have to deal with in the future, and this is an important issue that I often have to deal with when dealing with my target audience whose time is often worth much more than the common crowd.

I think an interesting approach for telemedicine to create intimacy is by looking at existing online support groups.

These sites have been created for patients by patients and serve as both an educational source, and emotional outlet.

This past year, we at the Center for Connected Health have been working on a survey study that examined the users and perceived benefits of online psoriasis support groups.

By surveying the online user population and through patient self reporting, it has become more evident that participating in online support groups makes a difference in the general well being of psoriatic patients.

We could deduct two main benefits associated with online support: The first, being that patient's perceived improvement in their overall quality of life and psychological well being. The second being that patient's felt content with their general health status.

Something to consider by health care service providers would be to develop the infrastructure of online support groups.

By integrating psychological aspects of chronic diseases with established therapies into community-based applications, we would be offering patients a complete approach to both the mind and body aspects of chronic disease management…

Few people have the interpersonal skills needed to induce a strong human connection by phone or email. Many more can achieve it via high resolution televideo that enables eye contact. The latter is still fairly expensive, but it's rapidly getting cheaper.

At MedHelp.org we have been working since 1993 on ways of providing patients with online medical support and information. Our experience has been that even before the Web 2.0 technologies it was possible to create intimacy online and all the new technologies have added to the experience. It is easy to think of multiple situations where the online experience is superior to the offline one.

Some users crave intimacy when coupled with anonymity. Many of the posts in our AIDS forum show that people can develop a degree of intimacy that would be difficult when speaking with a doctor face to face. They feel free to ask things they would otherwise feel inhibited or embarrassed to ask. This new found intimacy can result in a much more fruitful relationship.

Some users develop intimacy through predictability. A patient can “sit in” on a doctor’s visits with other patients and select a doctor that s/he believes s/he can connect with. This pre-selection increases the odds of developing a more intimate relationship with the doctor. In real life this is nearly impossible and you hope that you connect with the doctor you meet.

Some users feel intimate in large groups especially when dealing with chronic diseases. Our Hepatitis C forum has shown us how users can create strong virtual bonds when provided with a means of connecting with others that share their condition. Oftentimes this is hard to do in the physical world.

The challenge in speeding up the adoption of telemedicine lies not as much with the medium but with its relationship with the various stakeholders. The easier it is for doctors and clinics to participate, the clearer it is for insurance companies to understand its benefits and the greater the number of employers that extend telemedicine options to their employees, the faster will be the adoption.

This is a very timely discussion as it is a perspective that I have been researching, developing and been in discussion with various groups over the past few months. My perspective is best summarized by some comments made by Don Jones (Qualcomm) on a related issue when he referred to a number of factors that would lead users to utilize whatever telemedicine technology. One of those factors was what he called "Confidentiality" meaning, that a patients ailment was confidential to them alone. People generally do not want others to know about their having an ailment (my mother aside). And so to improve widespread adoption, and it's even more important cousin, adherence, solutions have to cater to this premise. It should be less about the technology and more about behaviour management, with the technology addressing that issue directly. At our group, we feel we have done just that but until recently, we gave been hitting our heads against the wall of 'technology is the thing' as opposed to just a tool. So, this discussion is bang on and encouraging indeed.

Your comments are helpful. Since my last posting we have embarked on the design of a new affordable assisted living approach for Michigan, for low to moderate income elderly. The units will be a person's home first, with a services and support system. We would like to present telemedicine concepts to our steering committee, for incorporation in the program as we develop its features and standards.. As people age in place, telemedice could become part of the toolkit that helps them maintain control of their health and lives and closer better contact with their community health care professionals. Since these are new construction, we have the opportunity to incorporate technology at a cheaper cost then retrofitting.

What do you think are some of the most promising technologies we should consider for these?