How to evaluate telemedicine ? The use of multiple criteria decision analysis in health economics

Rationale : Telemedicine is "a system of health care delivery in which physicians examine distant patients through the use of telecommunication technology" (Mitchell, 2000). Telemedicine appears in a context of limited resources, which is why economic evaluation of the telemedicine becomes a need to justify allocation choices between the various existing projects. Furthermore, its diffusion is primarily based on the persuasiveness of some doctors and on public subsidies without any established policy. Thus, it is necessary to propose a framework for the assessment of telemedicine.Objectives : The first objective of this paper is to make an assessment of the economic evaluation methods used and the results obtained. The second objective is to use the multi-criteria decision making approach to analyse telemedicine, a complex medical practice. Methodology : Initially, relevant literature published on economic evaluation of telemedicine was identified through a computer search in Medline from 1996 to 2003. After, we examined how the multicriteria analysis methodology is used in health and for which applications. This method is described and further thought is given to its application to telemedicine, particularly the development of significant criteria and their values. We propose a position matrix applied to a project of teleconsultation. Results : Currently, economic assessment of telemedicine is based only on cost-effectiveness methods. The principal efficiency criterion is the saved transport costs which are compared with the costs of investment and maintenance. Moreover, even if the majority of the projects are not profitable, we observe that telemedicine practice is diffused to the detriment of the economic conclusions. Thus, it is undeniable that other benefits appear and are not taken into account by the evaluation methods. They are mainly human factors, such as measurement of patient satisfaction, quality of life, accessibility and organisational impact. These various criteria can be included in a multiple criteria decision making (MCDM) approach. It is noted that whatever the indicator we consider their measurement is studied in health. Care accessibility can be measured by a composite index of price including costs of displacement and time. The quality of life is assessed by preset scale. Satisfaction is estimated using a questionnaire addressed to physicians and patients. The organisational impact is more difficult to approach because telemedicine induces new agency relations between the actors of the system. Conclusions : Telemedicine is a complex object to analyse. We think that multiple criteria analysis can improve cost-benefit or cost-effectiveness analysis. Indeed, it is difficult to get within only one result all the economic stakes of the health system. Moreover, homogeneity in its analysis would make it possible to compare the various existing technological solutions and help the decision makers. To conclude, it is necessary to suggest all possible ways of telemedicine evaluation, it's a need both of doctors who practise telemedicine and of the regulatory authority which attaches great value to controlling health expenditure.