The patient base of the Shriners Hospitals for ChildrenâHon- olulu extends .... WHY? AND HOW? Jolene A. Davidson, PT, MPT, Mark Hakel, PhD, CCC-SLP ...... Group, Yokota Air Base, Japan; 4121 General Hospital, Seoul, Korea;. 5United States Naval Hospital, Okinawa; 6Department of Pediatrics,. Tripler Army Medical ...
POSTER PRESENTATIONS ABSTRACTS P1 STEPS TO HIPPA COMPLIANCE—THE CTA APPROACH, A PRESCRIPTION FOR SUCCESS Elliott Abraham, MCSE, Nik Beaty, CPT Wes Burnett, BS TAMSCO, Fort Gordon, GA Health Insurance Portability and Accountability Act (HIPAA) compliance will impact the entire healthcare industry. The new security regulations of HIPAA are designed to protect the availability, confidentiality, and integrity of patient data. In light of these new regulations, teleconsultation is just one of many business processes that must migrate to HIPAA compliance by 2002. Analysts estimate that the costs of HIPAA compliance will be 3 to 4 times that of Y2K. Some even estimate the total to reach as high as $25 billion dollars. The Center for Total Access, or CTA, has regional oversight of a Web-based, store-and-forward Teledermatology service. In its original configuration, this service would not meet the HIPAA standards for security. To develop a Teledermatology service that meets HIPAA compliance, the CTA has adopted a layered approach to security. These layers consist of complex access control lists on our routers, load-balanced firewalls, intrusion detection systems, and strong authentication systems, all built around the advanced Windows 2000 Active Directory platform. All servers will be further “hardened” against hack attacks by proactive probing and scanning to reveal and correct areas of weakness.
P2 CLINICAL EVALUATIONS OF TELERADIOLOGY: A PRIMER FOR CONDUCTING AND EVALUATING CLINICAL EFFICACY STUDIES Zia Agha, MD, MS,1 Azhar Turab Ali, MD,3Craig A. Beam, PhD2 1Division of General Internal Medicine; 2Department of Radiology, Medical College of Wisconsin, Milwaukee, WI; 3Department of Radiology, Mayo Clinic Jacksonville, FL Studies on the clinical evaluation of teleradiology vary in quality because of a lack of established standards for conducting such studies. Our objective is to describe standards for clinical evaluations of teleradiology. We propose that research aimed at evaluating the clinical efficacy of teleradiology should fulfill the following criteria: study purpose, design, and implementation: The study should provide evidence of research planning, use of a standard of reference, randomization in the order of interpretation of images, observer blinding, and the measurement of inter and intra-observer variability. Details of how the study was implemented, including the type and number of subjects enrolled, how they were enrolled, and the number excluded from analyses should be evaluated. Descriptors of type of teleradiology, system/equipment, bandwidth used for transmitting images, and type of radiologic procedures need to be detailed. Statistical Information: The evaluation should assess whether numeric parameters of any kind (kappa statistics) are utilized, and if so estimates of variability (standard errors) should be reported. In addition, the statistical inferential procedure employed (confidence intervals or hypothesis tests) should be assessed, and power analysis needs to be reported. These standards will contribute to improve the quality of teleradiology research and provide clinicians with a framework to critically evaluate teleradiology studies.
P3 DIAGNOSIS OF NONDIABETIC OCULAR DISEASE WITH THE JOSLIN VISION NETWORK IN PATIENTS WITH DIABETES MELLITUS Lloyd M. Aiello, MD, Sven-Erik Bursell, PhD, Anthony Cavallerano, OD, Jerry Cavallerano, OD, PhD, Paula Katalinic, B.Optom, Kristen Hock Joslin Vision Network Research Team, Beetham Eye Institute, Joslin Diabetes Center, Boston, MA The Joslin Vision Network is the telemedicine platform for the Joslin Diabetes Eye Health Care program. Over 2000 patients have had retinal imaging performed to determine level of diabetic retinopathy and appropriate clinical management using the Joslin Vision Network. While the JVN has been validated for determining clinical level of diabetic retinopathy, the JVN is also useful in identifying ocular disease that is not diabetic in origin. These conditions include retinal emboli, choroidal nevi, age-related macular degeneration, hypertensive retinopathy, periorbital dermatological disease, cataract, and glaucoma. This poster reports the findings of nondiabetic ocular disease using the JVN, suggesting the value of the JVN for managing eye disease in addition to diabetic retinopathy. P4 TELEHEALTH OUTREACH FOR UNIFIED COMMUNITY HEALTH (TOUCH) Dale C. Alverson, MD,1 Stan Saiki, MD2 1University of New Mexico School of Medicine, Albuquerque, NM; 2University of Hawaii John A. Burns School of Medicine, Honolulu, HI The Telehealth Outreach for Unified Community Health project, or TOUCH, is a proposed multi-year strategy to improve the quality of health care service and education in remote, multicultural areas in Hawaii and New Mexico. The Schools of Medicine of these states, in collaboration with their rural hospital and training sites, including pilot sites at the Northern Navajo Medical Center and the Maui Community College, will employ telehealth technologies to serve the unique health care needs of their isolated, culturally diverse populations. TOUCH teams healthcare professionals, educators, librarians, and students work with computing scientists and engineers from the University of New Mexico’s high performance computing centers in Albuquerque and Maui, to integrate advanced computing methods, including virtual reality. The collaboration will deploy a prototype system for enhanced applications in virtual collaborative distance learning, education, training, patient care management, and problem solving. This system utilizes the Access Grid, a technology that provides an environment where multiple users can all see, talk and hear, and share information, including 3-D models and images, simultaneously over the Internet. The TOUCH approach of collaborative development between healthcare professionals and high performance computing scientists and engineers will serve as a model for training in other rural environments. P5 VIDEOPHONE USE BETWEEN A UNIVERSITY NICU AND RURAL COMMUNITY HOSPITALS: PARENTAL SURVEY REGARDING THE IMPACT Cindy Gyure, RN, CNNP, Virginia Laadt, PhD, Dale Alverson, MD University of New Mexico Department of Pediatrics, Albuquerque, NM Videophone (VP) technology which uses existing lower band analog communication infrastructure, standard touch-pad
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phones and televisions provides a low cost solution for families in rural communities to see their newborn infant during hospitalization in an often-distant tertiary care Newborn Intensive Care Unit (NICU). A pilot program, “Mira Los Ninos,” was initiated in the NICU at the University of New Mexico along with three distant community hospitals. A study was conducted to determine level of utilization, family satisfaction, and impact of the VP experience on the parent using retrospective phone interviews and a standardized survey tool. The number of families who used the VP compared to those who could have used the technology was lower than expected, 9/34 (27%). Overall satisfaction was very high. 86% felt it was equal to or better than expectations. 57% felt it decreased anxiety, and 57% stated it increased desire to be with their baby. All respondents would enthusiastically encourage other families to use the VP. VP interaction is a potentially cost effective means of enhancing communication with families who have infants in NICU. Strategies to provide adequate family promotion of VP availability and staff training need to be implemented to increase effective utilization. P6 HIPAA AND THE MILITARY HEALTH SYSTEM Archie D. Andrews, MS,1 Lynn S. Crane, MS,1 Steve L. Packard, MS,2 Steve V. Pellissier, MS1 1Advanced Technology Institute, N. Charleston, SC; 2BWXT Y-12 LLC, Oakridge, TN An integral part of the Defense Healthcare Information Assurance Program is the examination of the advantages and disadvantages of introducing information assurance technologies in the medical treatment facilities. This examination is referred to as the Technical Business Case Analysis. To support this work the analysis team developed a repeatable process that includes examination of the suitability, benefits, risks, cost, and operational impact of implementing information assurance technology. These factors are applied to the target technology in the context surrounding the operations of military medical treatment facilities. Technologies examined using the process include remote access dial-in user authentication, user authentication, access control, and auditing of access. This presentation will discuss the methodology developed and refined by the analysis team to support the analyses and a presentation of key findings and recommendations from the business case analyses completed to the date of the presentation. P7 THE OPERATIONAL USE AND CONSIDERATIONS OF REMOTE HEART RATE VARIABILITY DATA ACQUISITION AND ANALYSIS Suresh A. Atapattu, MSBE,1 Raul D. Mitrani, MD2 1University of Miami, Department of Biomedical Engineering, Coral Gables, FL; 2University of Miami, Department of Cardiology, Miami, FL We present the characteristics and results of the operational use of our computer program for the remote acquisition, analysis, and demographic database of patient data in clinical heart rate variability research. Given the growing evidence that autonomic reflex alterations play an important role in many pathophysiological situations, heart rate variability (HRV) uses non-invasive observers to track the beat-to-beat modulation of the cardiac outflow. The HRV of patients was determined from patient electrocardiograms and shared with other physicians on line. The main advantage of this remote method is in the ability to cause minimum disruption or interaction with the patient thus avoiding excessive autonomic responses. Also, the system integrates seamlessly into the clinical environment with minimal, if any, disruption of the procedures related to patient care. This novel
method uses the Lab VIEW programming environment to simplify and economically develop the remote communication features of our heart rate variability acquisition and analysis program. This online system was used to acquire the ECG of 30 patients on-line and carry out the generation of the HRV indices. We successfully met our initial goal of remotely collecting our patient data and sharing it with our colleagues in the hospital in real time. P8 BEST PRACTICES FOR HIGH UTILIZATION OF TELEMEDICINE† David Bangert, PhD University of Hawaii, Honolulu, HI *No abstract available. P9 PAY PER VIEW: THE ARIZONA TELEMEDICINE PROGRAM’S BILLING RESULTS Gail Barker, BA, Elizabeth A. Krupinski, PhD, Tammy Laursen, Kristine Erps, Ronald S. Weinstein, MD Arizona Telemedicine Program, University of Arizona, Tucson, Arizona This presentation describes the results of telemedicine billing and collection activities of the Arizona Telemedicine Program. The program began billing for clinical services in January 1999. In preparation, a letter was sent to all third-party payers in the state informing them of our intention to bill starting in January 1999. Since then 1,135 cases have been billed. We have done an analysis of the telemedicine billing and collection activities and found that 47 individual payers were invoiced. The payer mix was private insurance 29%, Medicaid/state programs 24%, Indian health service 17%, Medicare/Champus 13%, self-pay 9%, and Department of Corrections 8%. Since inception, $41,258 was billed to private payers. $17,607 was collected which represents a 42.6% gross collection rate (GCR.). This compares with the university’s physician group practice GCR of 48.3%. In FY 99/00, the gross collection rate increased to 48.2%. Due to the billing limitations imposed by the Health Care Finance Administration, only four Medicare cases have been billed to date. The State Medicaid program currently pays only with authorization but is in the process of approving a full service contract. We concluded that after a start-up period, billing for telemedicine services parallels a traditional practice. P10 WINDOW’S ACTIVE DESKTOP: A TELEMEDICINE COMMUNICATION PORTAL Jim E. Barrett, EdD,1,2 Robert Brecht, PhD2 1University of Washington, Seattle, WA; 2E-Health Solutions, Inc., Houston, TX Providing a low-cost, easy-to-use-computer interface for busy health professionals has been a major barrier to the adoption of telemedicine. This presentation will demonstrate how the Texas Rural Hospital Telecommunication Alliance, a large rural telemedicine network of 50 hospitals, uses the Active Desktop feature built into Microsoft’s Windows level operating systems to provide easy, fast access to resources and for connections with other members of the network. The Active Desktop portal connects user to a customized collection of Internet Medical Resources, the user e-mail/group-ware application and a networked information and training site all within a single click from turning the machine on. In addition, to these resources and tools the Alliance Desktop contains two active windows providing critical information to every desktop requiring no action on the part of the user. One window is dedicated to the announcement of medical alerts, and the second serves as a com-
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munication channel for news and information. Through this system Public Health emergency alerts can be pushed immediately to all member desktops. An unpublished report will be made on the effectiveness of this desktop portal system in gathering research survey data and disseminating results. P11 OCULAR LOW VISION: ADVANCEMENTS AND APPLICATIONS Wendall C. Bauman, Col, USAF, MC,1,2 Patricia A. D’Amore, PhD3,4 1Brooke Army Medical Center; 2Telemedicine & Advanced Technology Research Center (TATRC), Fort Detrick, MD; 3Center for the Aging Eye; 4Schepens Eye Research Institute A collaborative, multi-disciplinary effort between the Center for Research on the Aging Eye and the Department of Defense is advancing research in low-vision, with direct applications to the military. Areas of interest include: Screening metrics to determine tear film characteristics predictive of poor visual outcomes or complications for Laser in situ keratomileusis (LASIK) surgery. A portable imaging device permitting battlefield evaluation of combat retinal injuries is being constructed. These images will permit military ophthalmologists via telemedicine to recommend treatment options on/near the battlefield. A demonstration that soluble fas ligand can be used to manipulate neutrophil-mediated inflammation will be performed. This cellular manipulation has direct impact on corneal wound healing from chemical burns or trauma. Human corneal endothelial cells transplanted in vitro can be grown to in vivo densities with comparable function. Methods to increase corneal endothelial cell density are being demonstrated. Optic nerve regeneration is possible using a retinal-brain co-culture system using lithium-containing antidepressants. Using a mouse genetic approach, the role of vascular endothelial growth factor (VEGF) will be explored in adult angiogenesis. VEGF leads to loss of vision in diabetic retinopathy and macular degeneration, common problems in the retired military and civilian communities. P12 DEVELOPING A COMPUTER-BASED PATIENT RECORD MAJ Catherine A. Beck, RHIA, MS,1 Mitra A. Rocca, MSc1,2 1United States Army Medical Research & Materiel Commmand (USAMRMC), Telemedicine & Advanced Technology Research Center (TATRC), Fort Detrick, MD; 2AIM Laboratory, University of Pittsburgh, Pittsburgh, PA Whether healthcare is received in person or through telecommunications, it must be documented. The paper record has done well in the past, but it cannot keep pace with the advanced medical technologies used by today’s healthcare providers. Unfortunately, no computer-based patient record (CPR) has kept pace with technology. Paper records and CPRs reside together in many facilities. Many have learned that a CPR is not an easy product to develop or implement. The Medical Informatics Group at the Telemedicine and Advanced Technology Research Center has developed a CPR for use as a research tool to test and further develop the use of voice/speech recognition, handwriting recognition, natural language queries, information extraction, and intelligent agents. Due to their products use with the Personal Information Carrier (PIC), much feedback on the use and functionality of the software was obtained from multiple healthcare providers using the product in different operational settings. The product’s ability to function with other advanced technologies and its ability to be utilized by multiple providers in multiple settings has provided great insight into the development and use of a CPR. The lessons learned from this research tool can influence further development of the CPR.
P13 BIOMEDICAL ETHICS CONSULTATION AND EDUCATION IN RURAL NEW MEXICO VIA TELEMEDICINE David Bennehum, MD, Suzanne N. Shannon, Emily E. Freede, Dale C. Alverson, MD University of New Mexico School of Medicine and Center for Telehealth, Albuquerque, NM Members of the University of New Mexico Health Science Center Biomedical Ethics Committee (UNMHS-BMEC) have been participating in a monthly consultation program via a telemedicine link with the physicians working in a clinic for patients of modest means in Roswell, New Mexico, more than 200 miles from Albuquerque. As their facility had no Ethics Committee, the physicians in Roswell invited our committee to provide consultation and ethics education monthly for the past year over the Telemedicine network. The consulting HNMHSC-BMEC team consisted of two physicians, an internist, and a psychiatrist, a psychiatric nurse from the hospital consultation service, an attorney, the Hospital Chaplain, and occasionally other members of the committee. At the community clinic telemedicine site, the Roswell group would usually present one or more cases for discussion, and occasionally the University group would present their own case. The discussions were quite practical, but for each case it was attempted to extract principles and suggest relevant examples, legal precedents, and useful readings in order to learn from each other. Family residents based in Roswell will also begin to participate as part of their rural community training. This Biomedical Ethics program represents another important application of Telemedicine serving rural communities. P14 USING TELEOPHTHALMOLOGY TO IMPROVE RETINOPATHY SCREENING RATES AMONG CALIFORNIA AMERICAN INDIAN DIABETICS Heather Bernikoff, MS, Priscilla Enriquez, MPH, Bill Halverson, MScNE, MBA California Telehealth & Telemedicine Center, Sacramento, CA The California Telehealth & Telemedicine Center (CTTC) is using telemedicine to increase access to ophthalmology specialty care for California American Indian diabetics. In partnering with technical and cultural experts as well as the Indian Health Program, CTTC has developed a teleophthalmology grant program with the goal of doubling the retinopathy screening rate among Indian Health Program diabetics. The grant program provides funding for the purchase of telemedicine equipment, staff training, staffing, and some telecommunications. Case studies, implementation strategies, program design, and utilization information will be presented. P15 WEB-BASED PEDIATRIC HEART SOUND EDUCATION OVER THE NEXT GENERATION INTERNET Alan E. Branigan, MA,1 Vivian L. West, RN, MBA,1 Michael E. McConnell, MD2 1The Telemedicine Center, Brody School of Medicine, East Carolina University, Greenville, NC; 2Department of Pediatrics, Emory University School of Medicine, Atlanta, GA An online educational application has been developed for educating pre-practice health professionals about pediatric heart sounds. The application incorporates a very user friendly simulated patient interface with high fidelity digitally recorded heart sounds, supporting didactic text, illustrations, and a self-assessment. Instead of hearing just one representative heart sound, the user can listen to four sounds that correspond to the four chest locations most commonly auscultated, thus more closely simulating an actual examination.
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Originally developed for CD-ROM delivery, the application has been ported to a Web interface and delivery via the Next Generation Internet, with funding from the National Library of Medicine. We are also expanding the application to include cardiac ultrasounds. A port of the application to the commodity Internet, with preservation of the high sound fidelity, is also being explored. One of the objectives of this project is to determine if the application can improve auscultation skills. Research indicates that medical students and residents have poor cardiac auscultation skills, with lack of formal training and assessment in medical schools being one contributing factor. Accessibility for training via the Web may help students attain a higher level of pediatric cardiology auscultation skills than is currently being achieved. P16 TELEMEDICINE ASSISTANCE CENTER: TAKING TELEMEDICINE TO THE PHYSICIAN’S OFFICE Samuel G. Burgiss, PhD, Gary T. Smith, MD, David Black, BS University of Tennessee Medical Center, Knoxville, TN When the typical telemedicine barriers of reimbursement and licensure are removed, the remaining barrier is the impact on the physician or other provider to go to a central location for patient consultations. A method has been developed and is being used to provide interactive video conferencing to a virtual exam room in the physician’s office while maintaining support that would typically be available at a central telemedicine location. The Telemedicine Assistance Center (TAC) supports consultations between physicians and other providers, and their patients at spoke telemedicine sites. A nurse at the TAC can connect any spoke site of any bandwidth (T-1 ISDN, or POTS) with a provider’s office at full received bandwidth. In this virtual clinical environment, the TAC nurse can communicate with the patient and presenting nurse, the provider, or both to create a support function as if all were in the same room. Facilities are provided to switch from one patient room to another regardless of the bandwidth, to connect the provider’s room with the patient’s room when both are ready, and for the TAC nurse to support this process in a manner that is considerate of the needs of both the patient and the provider. P17 PROGRAM SATISFACTION AMONG RURAL ARKANSAS ADOLESCENTS IN A CONSUMER HEALTH EDUCATION PROGRAM USING INTERACTIVE VIDEO Ann B. Bynum, EdD,1 Cathy A. Irwin, PhD, RNP,1 George S. Denny, PhD2 1University of Arkansas for Medical Sciences, Little Rock, AR; 2University of Arkansas, Fayetteville, AR Socioeconomic and demographic factors can affect the impact of telehealth education programs that utilize interactive video technologies. This study assessed program satisfaction among participants in the Arkansas School Consumer Health Education Program that uses interactive compressed video. Variables in the one-group posttest study were age, gender, ethnicity, education, community size, and program topics for years 1997–1999. The convenience sample included 3,319 participants in junior high and high schools. Adolescents had high levels of satisfaction regarding program interest and quality. There was significantly higher satisfaction for programs on muscular dystrophy, anatomy of the heart, biology of the skin, tobacco addiction, and heart dissection (p 0.001 to p 0.008). Females, nonwhites, African Americans, and junior high school students had significantly greater satisfaction (p 0.001 to p 0.005). High school students had significantly greater satisfaction with the interactive video equipment (p 0.011). White females (p 0.025) and African American males (p 0.004) in smaller communities reported higher satis-
faction. Findings from the study can be used to improve school telehealth education programs by focusing on increased access in rural areas among ethnic groups, participant’s learning needs, speaker communication, and clarity of program presentation. P18 REMOTE INTERACTIVE MONITORING OF PATIENTS ON ANTICOAGULATION THERAPY TO IMPROVE OUTCOME AND AVOID COMPLICATIONS Jennifer L. Calagan, PhD, MD, Sewnet Mamo Dr.PH candidate, Thomas R. Bigott, Daisy T. DeWitt, MS, Marina N. Vernalis, DO Walter Reed Army Medical Center (WRAMC), Washington, DC Background: Coumadin is used to regulate the clotting times of many cardiac patients. Regulating Coumadin dosages requires close monitoring of the patient’s clotting times. This monitoring requires regular clinical visits and tracking. We are assessing the use of remote testing and monitoring of Coumadin patients using telemedicine technology. Method: 400 patients are equally divided into four groups. The protocol for the groups include: 1) Home measurement of INR and standard assessment 2) Hospital INR testing and home patient assessment, and 3) Home INR measurement and home patient case assessment. 4) These three groups will be compared to a control group that receive standard care. Results: The following parameters are monitored: 1) Quality of care as assessed by: Reduced ER visits, morbidity, mortality, 2) Access to care as provided by daily monitoring and intervention, 3) Acceptance of Care/Patient Satisfaction, and 4) Cost (Travel, Lab Tests, Provider Time, ER Visits) Conclusion: Project will assess the use of a programmable home-monitoring system in association with home testing to allow patients to report changes in condition, problems with therapy, and complications. It is expected that the increased monitoring will enhance the practitioner’s ability to optimize therapy and track, if not avert, complications. P19 BRINGING HEALTHCARE IN THE DEPARTMENT OF DEFENSE INTO THE 21ST CENTURY Col. Dean E. Calcagni, MD United States Army Medical Research & Materiel Command (USAMRMC), Telemedicine & Advanced Technology Research Center (TATRC), Ft. Detrick, MD The U. S. Army Medical Research and Materiel Command has been exploring and implementing telemedicine and other medical advanced technology solutions for over 10 years. The Telemedicine and Advanced Technology Research Center (TATRC), a component of the U.S. Army Medical Research and Materiel Command, is where these solutions are being created. In order to take advantage of rapidly evolving technologies, TATRC uses a rapid prototyping model to develop telemedicine and medical advanced technology products. In this model, technologies are identified, and systems are assembled. They are technically tested and modified based on clinical requirements. These systems are tested operationally and then given to actual deployed medical units to augment their medical care capability. The whole process from identification of technologies to fielding of tested systems can be as short as a few months. In the past 5 years TATRC has deployed telemedicine capabilities with U.S. military medical units in support of operations worldwide. This presentation will explain the TATRC approach toward demonstrating and inserting medical advanced technology into the health care delivery system of the Department of Defense and will give an overview of several current TATRC projects.
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P20 FLATLAND, A TOOL FOR THE CREATION OF VIRTUAL TELE-ENVIRONMENTS FOR INTEGRATED TELEHEALTH APPLICATIONS Thomas P. Caudell, PhD, Ken Summers, John Greenfield, Bob Ballance, PhD, Holly Buchanan, PhD, Dale Alverson, Saiki S. University of New Mexico, Albuquerque, NM Flatland is an open visualization/virtual reality application development tool created at the University of New Mexico. Flatland is one of the core software components of the University of New Mexico TOUCH Project (Telehealth Outreach for Unified Community Health). It allows software authors to construct and users to interact with arbitrarily complex graphical and aural representations of scientific data sets and complex software systems in a distributed manner. Flatland is open software that is written in C/C and uses the standard OpenGL graphics language extensions to produce the 3D graphics. In addition, Flatland supports any type of display technology. Flatland is multithreaded and uses dynamically linked libraries (DLL) to load applications that construct or modify its virtual environment (VE). In addition, Flatland runs in parallel on Linux clusters, and is interactive over the NSF Access Grid allowing users at multiple remote sites to participate in collaborative sessions. This talk will give an overview of the features of Flatland, give examples of the application of Flatland to telehealth, and discuss current research issues. P21 ANTICIPATORY GUIDANCE AS A FRAMEWORK FOR IMPLEMENTING A REHABILITATION TELEMEDICINE PROGRAM Cathy M. Ceccio, MSN, CRRN, CNAA, Mary Jo Roach, PhD, Denise Forster-Paulsen, MSN, CRRN, ANP, Kathleen Murany, RN, CRRN The MetroHealth System/MetroHealth Center for Rehabilitation, Cleveland, OH The use of anticipatory guidance is a well-known strategy in clinical practice to help persons cope effectively with issues that affect health and well-being. At MetroHealth Center for Rehabilitation, anticipatory guidance was used as a framework to direct the implementation of the telemedicine program for persons with acute, complex injuries. Since patients at this institution had generally had little experience with any type of technology pre-injury, staff determined that developing an appreciation for technology was critical to the success and future use of telemedicine. Using vignettes and case discussions, clinicians from several disciplines conducted telemedicine visits, with ten clients and families in the on-site transitional living apartment one week before discharge. Clients were asked to envision the use of telemedicine in their home and to articulate one aspect about the technology that might be useful to them after discharge. Clinicians who conducted the interviews expressed no specific expectations that clients agree to telemedicine visits after discharge. Case reports will be used to describe the encounters and to highlight individuals’ abilities to participate in and articulate the usefulness of telemedicine technology in their lives after discharge. P22 IN-HOME TELEMEDICINE MONITORING OF PEDIATRIC PATIENTS WITH ASTHMA USING STORE AND FORWARD TECHNOLOGY Debora S. Chan, RPh, FASHP, Francis J. Malone, MD, Charles W. Callahan, DO Department of the Army, Department of Pediatrics, Tripler Army Medical Center, Honolulu, HI Objectives: The purpose of this project is to demonstrate the feasibility of in-home asthma monitoring for children with persistent asthma using Internet-based store and forward technology.
Methods: Ten patients between 6 and 17 years of age with mild persistent, moderate or severe asthma will be enrolled into a pilot “virtual” study group. Asthma education and case management will be provided for 6-months. Adherence will be assessed by therapeutic and diagnostic monitoring. Therapeutic monitoring parameters include video of patient using MDI spacer technique submitted electronically two times a week using in-home asthma monitoring store and forward technology. Diagnostic monitoring will include asthma symptom diary and video of peak flow use submitted electronically. Parameters used to assess disease control include lung function tests, quality of life tests, utilization of services, rescue therapy use, symptom control, satisfaction, and asthma knowledge retention. The pilot study will also include evaluation and development of software, cameras, and computer systems, as well as the optimal way for patients to record MDI spacer technique and peak flow measurement using the Internet. Conclusion: This pilot will serve as the first step for a controlled trial using Internet store and forward technology for case management of pediatric asthma. P23 SHRINERS PACIFIC TELEMEDICINE PROJECT: PROVIDING PEDIATRIC ORTHOPAEDIC CARE VIA TELEMEDICINE Kent Reinker, MD, Jana Chang, RN Shriners Hospitals for Children, Honolulu, HI The patient base of the Shriners Hospitals for Children—Honolulu extends throughout the Pacific Ocean, encompassing an area of over 1.2 million square kilometers. Since 1999, the hospital has been involved in a telemedicine outreach program whose primary purpose is to provide specialty and subspecialty medical care to children in the geographically isolated island nations of the Pacific. Methods: We have utilized video conferencing to those areas with adequate far end capabilities. The Honolulu Shriners hospital has instituted regular consultation clinics with practitioners in Guam and American Samoa, and have recently also achieved teleconference connections with Palau. During the next year, we expect to establish linkage with the Federated States of Micronesia as well. In areas without real time conferencing capabilities, we have utilized store and forward techniques. Results: Patients and families who have received care via telemedicine have been happy with the results. In many instances, alternative methods of providing consultation would have been impossible. Other patients and families have dramatically saved on travel time and costs. We have encountered two broad classes of problems. Technological problems have related primarily to the limitations of bandwidth. Licensure, credentialling, and patient privacy were the major administrative problems. P24 UTILIZING TELEMEDICINE CONCEPTS AND PROBLEM BASED LEARNING IN THE TEACHING OF BREAST CANCER DISEASE Spyros G. Condos, MD, MBA, Chrysoula Toli, MD, Telemahos Stamkopoulos, PhD Yale Office of Telemedicine, Yale School of Medicine, New Haven, CT Today countless Medical Schools around the world are using Problem Based Learning (PBL) methodology in their programs very successfully. At the same time Telemedicine concepts have been recognized as a very important tool in Medical Education and Distance Learning. We incorporated PBL and Telemedicine concepts (multimedia systems, telecommunication technologies and databases) and
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we developed a Web-Based, PBL model of Learning to teach the Clinical Pathway of the Breast Cancer Disease (BCD). We choose to apply this model to the BCD, because of its complexity and comprehensiveness. To that extent we developed a Clinical Pathway of the BCD, inclusive of screening, projection, early detection, treatment, follow up and clinical trials. The model was intended to be used, by patients, medical students, nurses, residents, primary care physicians and other practitioners. The effectiveness of the model was tested on two medical students over a period of two months and it was proven to be highly successful, user friendly, and easy to follow. We have thus developed an alternative to the various Continuing Medical Education programs that use passive lecturebased activities. In addition we allow the physician to develop the skill of selfdirected learning, an ideal ingredient for Distance Learning. P25 FEASIBILITY OF IN-HOME TELEHEALTH FOR CONDUCTING RESEARCH Carol E. Smith, PhD, RN,1 Jennifer J. Smitka, RN, BSN,1 Susan V.M. Kleinbeck, RN, PhD, CNOR,1 Faye Clements, RNC,2 David Cook, PhD1 1University of Kansas Medical Center (KUMC), Kansas City, KS; 2Skilled Nursing Facility, Topeka, KS The purpose of this study was to determine the feasibility of using in-home audio/video telehealth equipment for administering nursing interventions to families and collecting research data over time. The study design was descriptive with observation data collection and comparison. The subjects were adult patients (n 5) that were monitored using nighttime equipment provided by their caregivers (n 7) for home care. Skin color, vital signs, spirometery, and pulse oximetry and observation of caregiver and patient equipment were reliably obtained. Nursing interventions, equipment demonstrations, visual illustrations, educational videotapes, and audiotape directions were transmitted clearly across telehealth, with the exception of materials that had low contrast in color or small font size. Costs of telehealth home monitoring for data collection were less expensive than traditional data collection via home visits. In-home telehealth transmission via residence telephone lines was reliable for delivering educational nursing interventions and for collecting physiological as well as observational data. P26 RESEARCH APPROACHES TO ESTABLISHING TELEMEDICINE EFFICACY FROM A COMMUNICATION STUDIES STANDPOINT David Cook, PhD, Pamela Shaw, MD, Eve-Lynn Nelson, MA Center For TeleMedicine and TeleHealth, University of Kansas Medical Center (KUMC), Kansas City, KS This project assesses parent satisfaction with an interactive televideo visit with the parent satisfaction with face-to-face visits with the same pediatrician. The questionnaire addresses items specific to parent-physician communication. The face-to-face and ITV parents did not significantly differ on the collected demographic items. Face-to-face questionnaires were compared with telemedicine consultations with the same pediatrician. The preliminary results suggest that the two settings do not differ significantly in parent evaluation. This suggests that the pediatrician is as effective in establishing a relationship with the parent over ITV as in person. This is an important question both in terms of supporting the physician’s ability to establish diagnosis based on history and his/her influence on adherence and follow-up.
P27 SMART CARDS AND HEALTHCARE IN THE 21ST CENTURY Diane Corcoran, RN, PhD,1 Ruth Anderson, RN, PhD2 1Kelly Anderson & Associates, Alexandria, VA; 2Duke University, Durham NC Smart card technology is about to emerge as a major solution to many of the problems currently faced in health care. At a minimum, smart cards will help with security, HIPAA compliance, efficiency, patient safety and privacy, security in the transfer of medical data, accuracy of documentation, access to emergency medical data and overall quality of care. In this presentation, the presenter will describe the technology, its capabilities, and potential uses. In addition, she will describe current Government and private sector programs that are using the technology. P28 DESIGNING A TELEHEALTH BUSINESS DEVELOPMENT PLAN: WHO? WHAT? WHERE? WHY? AND HOW? Jolene A. Davidson, PT, MPT, Mark Hakel, PhD, CCC-SLP Madonna Rehabilitation Hospital, Lincoln, NE Whether beginning a telehealth program or expanding an existing one, a sound business development plan is essential in creating a successful program. It is suggested that programs and projects should have a design/planning component that documents the purpose, need and feasibility. This will insure that those involved in implementing the program and individuals promoting the program have fine-tuned the service and will deliver a high quality, cost effective product. This presentation presents a model on how to develop a successful business plan that addresses the purpose, need and feasibility. Key variables that are necessary in making a financially viable plan will be presented. These variables include discussion on the need for creation of a vision and mission to guide the development of the program. In addition, strategies will be presented on how analyze the target market and need, meet regulatory guidelines (e.g., HIPPA compliance, third party payers) and strategies to examine the success of your program. A sample business plan will be used to illustrate the implementation of this model. P29 WHAT DO PATIENTS THINK OF TELEHOMECARE? George Demiris, PhD, Stuart M. Speedie, PhD, Stanley M. Finkelstein, PhD Department of Laboratory Medicine and Pathology, Medical School, University of Minnesota, Minneapolis, MN The objective was to measure patients’ perceptions of a telehomecare system before and after participation in order to determine a possible change and identify the system’s features that patients perceived differently. The setting was the TeleHomeCare Project, which utilizes videoconferencing and Internet equipment to enable interactions between patients and nurses. Patients viewed videotape that demonstrates a “virtual home visit” and filled out a questionnaire that measures perceptions of telehomecare (pre-test). They were then randomly assigned to a control group receiving standard care or to an experimental group receiving in addition videoconferencing sessions. Both groups filled out the questionnaire again when exiting the system (post-test). The control group consisted of 11 and the experimental group of 17 patients. There was no statistically significant perception change for the control group. The experimental group showed an overall more positive perception after their experience (total score increase by 6.06, P 0.0001). Patients evaluated their experience as positive, felt comfortable with the technology, and convinced that a nurse can assess their status over the television; however,
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there was less agreement with the statement that telehomecare saves them time. The findings indicate that telehomecare has the potential of a widely acceptable care delivery mode. P30 DIFFERENCES IN COMMUNICATION MODE IN A HOME TELEHEALTH PROJECT FOR DIABETICS Susan L. Dimmick, PhD,1 Samuel G. Burgiss, PhD,2 Sherry Robbins, RN3 1University of Tennessee Graduate School of Medicine, Knoxville, TN; 2University of Tennessee Medical Center, Knoxville, TN; 3Telemedicine Manager, Scott County Telemedicine, Knoxville, TN Data from 32 diabetics in a rural county in East Tennessee were analyzed to determine the potential impact of weekly two-way video telemedicine consults versus weekly telephone calls on patient compliance and HgA1C readings over time. Study participants used a digital blood sugar monitoring unit at home to send regular blood sugar readings through their plain old telephone system (POTS). Half of the patients had video consults at home with registered nurses. Half had a telephone call at home from registered nurses that did not include two-way video. Benchmark data for the diabetics included before and after HgbA1C readings in addition to body mass index, functional capacity, demographics and quality of life rankings. Hospitalizations, including emergency department use for the complications of diabetes or diabetes symptoms, were benchmarked as well. Data were analyzed before and after the home telemedicine intervention to determine the impact of video versus non-video nurse follow-up contact and its potential impact on clinical outcomes. P31 PEER REVIEW IN A TELEDERMATOLOGY SERVICE Angela Dingbaum, RN, MPH, William P. Bowman, Jr., AD, Daniel T. Summers, BS United States Army, Center for Total Access, Ft Gordon, GA Policy and peer review activities must be instituted for any healthcare delivery model that is incorporated into the business process of a medical facility, teleconsultation or otherwise. These activities ensure that the service complies with accepted standards that monitor clinical practice, clinical privileges, image security, informed consent and documentation. The Center for Total Access, or CTA, has had oversight of the implementation a regional store and forward web-based Teledermatology program for the military since May 1, 1999. There are seven consulting sites and seventeen referring sites that have generated over four hundred consults since inception. A peer review program has been developed by the CTA as an enhancement to the regional Teledermatology service. Every month, as single consult will be selected, stripped of identifying information, and distributed to an established peer-review network of dermatologists. Each specialist assesses the consult with regard to image quality and appropriateness, adequate history and physical information, supportive information for diagnosis and recommendation, consistency with standards and an overall rating. Implementation of a peer review process marks the evolution of a teleconsultation project from a pilot study into a formalized standard of care for the military healthcare system. P32 EVALUATION OF TELECONSULTATION FOR VETERANS WITH SPINAL CORD IMPAIRMENT IN COMMUNITY SETTINGS Laureen Doloresco, MN, RN, CNAA, Susan Thomason, MN, RN, CS, Judy Trotman, RN, BSN, Diana Weinel, MSN, RN Spinal Cord Injury/Disorder Service, James A. Haley Veterans’ Hospital Tampa, FL
An offshoot of the telemedicine explosion, teleconsultation promises to be a 21st century phenomenon. Teleconsultation links a major SCI/D specialty referral center to non-specialty healthcare facilities, e.g., outpatient clinics. An evaluation of a one-year statewide teleconsultation demonstration project was conducted by the SCI/D Service at James A. Haley Veterans’ Hospital from July ‘99 to July ‘00. Telemedicine units were placed in six VHA satellite outpatient clinics in Florida and linked to the Tampa VA SCI/D Service. Twelve clients participated in this evaluation. Although most teleconsultation visits were initiated for pressure ulcer management, other visits involved teleconsultation for functional evaluation, medication management, urinary tract infections, and other conditions. Three hospital admissions and two rehabilitation admissions were arranged following teleconsultation. Outcomes included healthcare provider and client satisfaction. Benefits and barriers to teleconsultation were identified. Effective telecommunication linked clinical care, education, and administrative systems to ensure client and professional accessibility to specialized SCI/D resources. Teleconsultation did not replace on-site clinical examination by a trained practitioner, but was an adjunctive tool for care delivery for outpatients with SCI/D. P33 RESEARCH APPROACHES TO ESTABLISHING TELEMEDICINE EFFICACY IN A PEDIATRIC SETTING Pamela Shaw, MD, Gary C. Doolittle, MD, David Cook, PhD, Deborah Swirczynski, MA, Eve-Lynn Nelson, MA Center For TeleMedicine and TeleHealth, University of Kansas Medical Center (KUMC), Kansas City, KS This presentation will describe the implementation of an efficacy study comparing face-to-face evaluation and ITV evaluation of the same patient by two pediatricians. Twenty elementary-age children were evaluated over 128 kb/s ISDN technology with otoscope and stethoscope capabilities and face-to-face in the school nurses office. The pediatricians were randomized to either face-to-face or ITV evaluation for a particular patient. The paper will address implementation issues, including recruitment and the human subjects processes. The interrater reliability will be presented as well as design issues. The presenter will summarize what is lost and what is gained in the pediatric evaluation over telemedicine in comparison to the face-to-face acute care exam. This includes both physical exam issues, such as color detection and hearing heart/lung sounds, as well as history taking issues such as abuse history. P34 AN ANALYSIS OF THE SUITABILITY OF TELEMEDICINE TO PROVIDE HOSPICE CARE Gary C. Doolittle, MD,1 Michael McCartney, BS,1 Pamela Whitten, PhD,2 David Cook, PhD1 1Center For TeleMedicine and TeleHealth, University of Kansas Medical Center (KUMC), Kansas City, KS; 2Michigan State University, East Lansing, MI Telehospice® is the use of telemedicine technology to enhance end-of-life care. One year ago, a bi-state project was launched to study the use of home-based telemedicine for routine hospice services. Home based telemedicine units (ViaTV, 8 8 Inc., Santa Clara, CA) were deployed for electronic nursing visits and evaluations by social workers. In order to determine what proportion of home hospice visits could be performed using currently available telemedicine technology, we retrospectively reviewed clinical records for hospice nurse home visits. Clinical notes were obtained from two large hospices (one based in Kansas and one in Michigan). Records were randomly sampled for patients who
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received hospice nursing visits during the month of January 2000. The charts were reviewed for patient demographic information, patient assessments, teaching activities, and interventions. Five hundred ninety-three hospice nursing visit notes were analyzed using an 85-item coding instrument. After careful record review, the observers also made a subjective observation regarding the suitability of each visit for telemedicine. For 61% of these visits, telemedicine could reasonably have replaced the on-site visit. We found that a significant proportion of home hospice nursing visits could be performed using telemedicine, with the potential to significantly reduce the cost of providing hospice care. P35 RESEARCH APPROACHES TO ESTABLISHING TELEMEDICINE EFFICACY IN A CHILD PSYCHIATRY SETTING David Ermer, MD,1 Eve-Lynn Nelson, MA,2 Sharon Cain, MD2 1University of South Dakota School of Medicine, Sioux Falls, SD; 2Center For TeleMedicine and TeleHealth, University of Kansas Medical Center (KUMC), Kansas City, KS *No abstract available. P36 VIRTUAL PRIMARY CARE CLINIC Gregory A. Gahm, PhD, Nhan Do, MD Madigan Army Medical Center, Tacoma, WA The Virtual Primary Care Clinic is a web based e-health research initiative designed to improve access to, and quality of, care while simultaneously controlling costs. Specifically, this project provides patients a secure web site with on-line appointing (booking, reviewing current appointments, cancellation of appointments), review of medication, laboratory, and radiology results, and asynchronous secure communication with providers. It targets health promotion and prevention through directed health information delivery, on-line access to health information, on-line home health monitoring and on-screen graphing, and provider profiling of patients by disease state and clinical needs. It includes specific measurement of total costs of this process to include provider time requirements, impact on workload accounting, and effects on overall healthcare system usage. Cost containment is a goal through appropriate provider level usage (nurses and paraprofessionals when appropriate to handle the information) and targeting high cost/frequency system users. P37 JOSLIN VISION NETWORK (JVN): THE ARCHITECTURE OF JVN-2 W. Kelley Gardner, Sven-Erik Bursell, PhD Joslin Vision Network Research Team, Beetham Eye Institute, Joslin Diabetes Center, Boston, MA The Joslin Vision Network (JVN) is a telemedicine platform designed to facilitate increased access of diabetic patients into a program of annual eye care. The JVN provides remote point of care imaging of the retina with centralized resources to provide the assessment of retinopathy and a suggested treatment plan. A technological drawback to the prior JVN implementation involved a reliance on relatively proprietary hardware and software technologies, making the system difficult and expensive to deploy and maintain. These limitations drove the development of a platform that relies on commercially-off-the-shelf (COTS) technologies and software applications. The server platform uses PACS products from Agfa and Mitra including the IMPAX Basix image archive server, Web 1000 web server, and the Broker interface engine. This is a robust environment providing the required DICOM compliancy and HL7 interfaces to facilitate interaction with existing hospital information systems. New client
applications for image acquisition and display, designed specifically for retinal imaging, were developed on the Windows 2000 platform using this PACS environment. This presentation describes system architecture and application specific features are presented as well as issues involved with developing a retinal imaging application on a system platform originally designed for use in radiology. P38 FROM TELEMEDICINE TO REFERRALS AND ASP’S DISTRIBUTED MEDICAL CASE-NOTE MANAGEMENT ON THE INTERNET Mark Gillett, MB, MIDir eHealthEngines Inc., Cambridge, MA Over the last decade, communications and data processing have evolved beyond all predictions. Computing power has moved from the data-center (mainframe) to the department (mini) and from the host to the desktop and now with the arrival of the Internet is moving back to the commercial data-center within new Application Service Providers (ASP). In many applications, green-screens have given way to a bewildering choice of client-server GUI’s and the same trend toward distributed computing has empowered users and changed business practices. Serial connections to hosts have given way to 1st generation networking protocols and early fixed and dialup networking infrastructures that have in turn been eclipsed by TCP/IP and the Internet. In Telemedicine, slowly a reliance on interactive video has given way to an emerging requirement for solid, legally referenceable consultation records, while applications have moved from specialized workstation to the desktop and more recently to the appliance enabled web. In the main however; outside of large academic institutions, providers have been slow to adopt these new technologies. With the mainstream arrival of the Internet and its accompanying benefits, eReferrals may be set to leapfrog recent reforms and changes in practice to become a significant economic and clinical force in the healthcare environment. The face of medicine will change as clinical communication moves out of its infancy to deliver distributed, multimedia enabled medical records; common, shared and distributed between Physicians, Laboratories, Imaging Centers, Pharmacies and Patients. In this endeavor, Telematics, EPR, Clinical Data Warehousing, Data Mining will come together to drive a new paradigm. Electronic information is now geographically unbounded enabling clinical and organizational boundaries to be crossed from any Internet enabled device. These changes are facilitating a broader continuity in healthcare, increased quality of care and ever decreasing cost. P39 TELEMEDICINE PRECEPTING—PRACTICALITY, FEASIBILITY, ACCEPTABILITY, AND RELIABILITY Kimberly A. Goodemote, MD, Floyd B. Willis, MD Mayo Clinic Family Medicine, Jacksonville, FL Telemedicine is rapidly becoming a valuable tool to enhance and complement health care services. There are several studies on communication with patients via telemedicine. Further studies are needed, however, on the evaluation of the patient, determining diagnoses, and developing management strategies. At Mayo Clinic in Jacksonville, FL, several studies have been done or are being developed to study the various aspects of evaluation and treatment of the patient by telemedicine. Many of these studies have been developed within the Family Medicine Department, which also contains a residency program. The Family Medicine Residency Program staffs an indigent clinic in Jacksonville. Precepting is required for all residents that staff the
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clinic. The precepting is currently done on site. This study was developed to determine the practicality, feasibility, acceptability and reliability of telemedicine precepting. At the completion of this study, the expection is that telemedicine precepting is an adequate and accurate method of supervising residents in an efficient, cost effective manner.
P42 CONSTRUCTING A TELEMEDICINE INFORMATION PORTAL Eric Hanson, MBA United States Army Medical Research & Materiel Command (USAMRMC), Telemedicine & Advanced Technology Research Center (TATRC), Ft. Detrick, MD
P40 THE PREPAREDNESS OF PENNSYLVANIA EMERGENCY DEPARTMENTS TO EVALUATE AND TREAT VICTIMS OF BIO-CHEMICAL TERRORISM Michael I. Greenberg, MD, MPH, FAAEM,1 Sherri Jurgens, MPH2 1MCP-Hahnemann University, Department of Emergency Medicine, Philadelphia, PA; 2MCP-Hahnemann University, Philadelphia, PA
The presenter will articulate the need for an XML-based methodology to describe and communicate information about telemedicine projects and news information required to create an information Portal. The Portal will serve as a central information location for the telemedicine community linking disparate resources from across the Web into one cohesive interface. The presentation will define the open source system and Open Content Syndication (OCS) architecture required to make the proposed Portal successful. OCS is used to mark-up Web pages so that a software engine can collect the data elements and present them to a user through the Portal. Users of the Portal can then read the summary text and drill-down to the actual content. The Portal provides the news aggregation and organization interface that enables the user to customize their experience. An implementation plan will be unveiled and concrete action items will be generated in an interactive discussion to achieve buy-in from the community.
Objectives: To determine the state of readiness of all hospital emergency departments (EDs) in the state of Pennsylvania to evaluate and treat casualties from terrorist use of biological and/or chemical weapons. Methods: A written survey instrument (coded and blinded) intended to assess 38 key points referable to emergency department preparedness was developed and mailed to the physician director of every emergency department (n 202) in Pennsylvania. Results were entered into a computer database and were analyzed using SPSS software. Results: The response rate for this study was 69%. The majority (84%) of ED’s surveyed had no biological or chemical threat agent detection devices available and over 90% did not stock appropriate antidotes needed to treat these casualties. Data revealed an absence of formal training, substantial deficiencies in the ability to decontaminate patients, as well as a lack of cooperative agreements between hospitals and local and federal emergency and public health agencies. Conclusions: This study is the first comprehensive evaluation of emergency department preparedness regarding bio-chemical terrorist threats in a US state. Substantial gaps exist in the current level of ED preparedness in Pennsylvania hospitals. As a result, a comprehensive plan for correcting these deficiencies needs to be developed and implemented promptly. P41 TELEREHABILITATION FOR THE REMOTE ASSESSMENT OF PRESSURE ULCERS IN INDIVIDUALS WITH SPINAL CORD INJURY: A PRELIMINARY REPORT Lauro Halstead, MD, Tom Dang, MSE, Mathew Elrod, PT, MEd, Steven Woods, BA, Rafael Convit, MD, Michael Rosen, PhD National Rehabiltation Hospital, Washington, DC Pressure ulcers represent a major, lifelong health hazard for persons with spinal cord injury (SCI). This health risk is increased when the individual lives in a rural area with inaccessible or nonspecialized health care. The goal of this project is to address this need by demonstrating that teleassessment of pressure ulcers in a remote setting is comparable to assessments made in a specialty clinic. In a pilot study, 20 pressure ulcers were assessed in individuals with SCI in a wound clinic in a metropolitan rehabilitation hospital. Images of each ulcer were obtained using a digital camera and forwarded to a computer monitor in a separate location. A Wound Care Specialist (WCS: a plastic surgeon) completed a questionnaire concerning his “remote” assessment of the wound and treatment recommendations with the option of live video interaction. Using the same questionnaire, then WCS assessed the wound live. A comparison of the two assessment methods showed 60–90% agreement concerning treatment recommendations, the need for referral, and overall satisfaction with teleassessment. Based on our experience with this pilot study, we will discuss the pros and cons of teleassessment for wound management and plans for field-testing in remote settings.
P43 DELIVERING HOME-BASED CARE: EVIDENCE-BASED PRACTICE AND A BEST-FIT APPROACH Roxanne Pickett Hauber, PhD, RN, CNRN Shepherd Center, Atlanta, GA Disabilities resulting from catastrophic injury or disease are life altering. Individuals and their families, dealing with disabilities, face life-long changes in physical and/or cognitive abilities, vocational goals, social roles and other basic aspects of life. Health care reform has resulted in significant reductions in lengths of stay in rehabilitation settings, as well as in the availability of longterm services and support. Technological developments that bridge geographic distances, as well as other barriers, offer new possibilities for meeting this challenge. Since 1995, Shepherd Center in Atlanta, GA has been engaged in research and development of effective and efficient ways to use telecommunications technology to extend the continuum of care after discharge from inpatient rehabilitation. In an environment of rapidly changing technologies and increasing market demands, Shepherd uses an evidence-based practice and “best- fit” approach to it’s use of available technologies. Evidence-based practice is related to proving that a service can be efficiently and effectively delivered via telecommunications technology. “Best-fit” approach is finding the best fit of technology to user, need and environment. The presentation is a discussion of that approach with exemplars. P44 THE SCI TELEHEALTH PROJECT: TELEMEDICINE IMPROVES ACCESS TO CARE FOR VETERANS WITH SPINAL CORD INJURY Michelle Hill, RN, MS, Leonard Goldschmidt, MD, PhD, George Sullivan, MD, Linda Love, CNS, Susan Pejoro, RNP, Inder Perkash, MD Veterans Affairs Palo Alto Health Care System, Palo Alto, CA The Spinal Cord Injury (SCI) Service at the Veterans Affairs (VA) Palo Alto Health Care System is the expert center for care of Veterans with spinal cord injury or dysfunction residing in a large geographic region, including the Hawaiian Islands and parts of Nevada. The expert specialty care is often far from the patients served. Distance and travel are particularly significant barriers to care for patients with spinal cord injury. We developed
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telemedicine consultation to link the local VA medical centers in Fresno, Honolulu, and Reno with the SCI Center in Palo Alto. Our goal was to provide timely, local access to specialty care. During weekly sessions, the local clinicians and the patients consult with the experts in Palo Alto utilizing videoconferencing, electronic patient records, digital radiology, and wound images. An examination takes place with the local clinicians as the “hands”, and the expert consultants offer “eyes and ears.” Clinician surveys indicate that teleconsultation resulted in earlier identification and treatment of clinical conditions. In the first six months, access to care was notably improved; 45% of the patients had never before been seen by the SCI Center. Patient and clinician surveys indicate that they intend to continue to use teleconsultation. P45 DIAGNOSTIC UTILITY OF MPEG1 COMPRESSION OF ECHOCARDIOGRAMS Ernst Hoffstetter, MS, Daniel B. Rayburn, PhD, Marina Vernalis, DO, COL Ronald Poropatich, MD Walter Reed Army Medical Center, Telemedicine Directorate, Washington, DC Digitizing echocardiograms has become standard practice since their resolution is greater than previously used VHS. The resolution of the digitized echocardiograms is comparable or enhanced when compared to the quality of VHS resolution. We therefore assume no loss of diagnostic utility using digitized files. Transferring these large files from remote facilities to distant medical centers is problematic. Data compression using MPEG1 greatly reduces the file size but also reduces the image resolution due to inherent destructive algorithms. The effect of this data compression upon the diagnostic findings has not been previously ascertained. We are currently studying to medical utility of this system by comparing the diagnostic findings of the digitized signal with those of the VHS. Discrepancies of diagnostics between the sources may be attributed to either the loss of resolution or consultant variability. To determine where discrepancies occur, we are assessing the inter- and intra-consultant variability of diagnostic findings from both data sources. The issues, status and data collected from this study will be presented. P46 TARGETING HOME CARE PATIENTS FOR TELE-HOME HEALTH CARE SERVICES Faith P. Hopp, PhD,1 David M. Smith, MD,2 Peter Woodbridge, MD2 1Health Services Research and Development, VA Ann Arbor Healthcare System, Ann Arbor, MI; 2Richard L. Roudebush VAMC, Indianapolis, IN This presentation will describe a three-step process for identifying patients for participation in a tele-home health care program. The first step involves identifying patients at high risk for future health resource use. Our inclusion criterion for patients in a VA home care program included (a) one or more hospitalizations, two or more emergency room visits, or ten or more outpatient visits in the prior six months, and (b) the use of home care services for at least one month. Approximately 45% (n 170) of a recent cohort of VA home care patients met this criterion. Such persons were significantly more likely than other home care patients to have a diagnosis of CHF, COPD or diabetes, and had significantly more hospitalizations, ER visits, and outpatient visits in the six months following their first home care appointment. The second step involves the development of relevant exclusion criteria, which include personal and environmental factors that preclude effective use of the technology, while the final step involves determining patient willingness to participate in telehome health care. We will describe our experiences implement-
ing these three steps, and the opportunities and challenges in targeting and recruiting patients for participation in tele-home health care services.
P47 USING COLLABORATIVE PARTNERSHIPS TO DEVELOP ONLINE ACCESS TO INFORMATION, PROVIDERS, AND SERVICES FOR PEOPLE WITH DISABILITIES Michael Jones, PhD Shepherd Center, Atlanta, GA Advanced telecommunication and information technologies have been proven useful, as a way to bridge the gap between those with specialized care needs living in remote locations and the sources of this specialty care. With the advent of high-speed, high-bandwidth telecommunications networks, telemedicine has emerged as a significant component of the health care delivery system. The Internet already demonstrates the value of interconnected information resources for business, government, education and medical applications. Even at the lowest bandwidth connections, standard Internet protocols support extremely valuable data communications. Advanced network capabilities, such as those available with the Next Generation Internet (NGI), will provide significantly greater access to home and community settings. This presentation describes a project that Shepherd Center and Georgia Institute of Technology, along with their corporate partners Earthlink Inc, CyberCare, Inc and Siemens, Inc, are embarking on to link rehabilitation professionals with patients who have sustained catastrophic brain and spinal cord injuries, their families and caregivers. The test-bed will emulate capabilities of the NGI including high-band width videoconferencing, remote monitoring, environmental control, and high-speed delivery of interactive multimedia instructional materials.
P48 RESEARCH STUDY ON HUMAN PATHOS WITH FLIGHT SIMULATOR 98 Hiroshi Juzoji, MD,1 Isao Nakajima, MD, PhD,1 Yongguo Zhao, MD, PhD,1 Naoshi Kakitsuba, PhD,2 Masuhisa Ta3 1Tokai University Medical Research Institute, Isehara, Kanagawa, Japan; 2Ashikaga Institute of Technology, Ashikaga, Tochigi, Japan; 3Tasada Works Inc., Takaoka, Toyama, Japan This study attempted to quantify mental excitement in a VR environment. Specifically, the study tracked the amount of water evaporating from the palm over time as the subject maneuvering a flight simulator application, engaging in simulations of difficult or dangerous flights. The consumer software application Fight Simulator 98 was used as VR content on a PC running Windows 98. The flight begins at Tokyo Haneda Airport, where a jumbo jet takes off toward the south, rising in altitude. The subject is free to select from several stimulating or dangerous flights in advance, and to maneuver the plane as its pilot. This thrilling flight is not entirely realistic, although the plane takes off and lands in a specified airport with a real-world counterpart. The volume of water measured from the skin of all five subjects increased synchronously with the thrilling flight, though with some individual variations in volume. These phenomena were considered to represent episodes of mental sweating. Thrilling flights in a flight simulator; fear of crashing, neural arousal (rapid responses of visual and motor fields), excitation of hypothalamus, and increased blood flow of capillary arteries of the skin, increased volume of water from the skin. Current game systems are unable to sense the player’s excitement. It has been found that interactive VR systems or game systems with programs capable of detecting player arousal have many potential applications, especially in the case of telemedicine.
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P49 ALASKA FEDERAL HEALTH CARE ACCESS NETWORK Wanda Asta Keller Alaska Native Tribal Health Consortium, Anchorage, AK The Alaska Federal Health Care Access Network (AFHCAN) is a federal telehealth initiative of the Alaska Federal Health Care Partnership to develop a statewide telecommunications network. The project mission is to improve access to health care for federal beneficiaries in Alaska through sustainable telehealth systems. The AFHCAN project has 37 member organizations including IHS/Tribal entities, the Veterans Administration, Department of Defense, US Coast Guard, and the Alaska Department of Public Health Nursing. The AFHCAN project is in the process of developing a statewide telecommunications network to link health care providers at 235 sites including rural clinics, regional hospitals, and medical centers to referring health care providers. P50 TELEMEDICINE TECHNOLOGY IN THE INTERNATIONAL HEALTHCARE ARENA-BROADBAND APPLICATIONS USING IP AND POTS Thomas A. Key, BS, CCNA,1 Raul C. Ribeiro, MD,1 Galen Briggs, PhD,1 Rich House,1 Dan Huss,1 Norman Costa,2 Franscisco Pedrosa, MD,2 Bassem I. Razzouk, MD1 1St. Jude Children’s Research Hospital, Memphis, TN; 2Instituto Materno Infantil de Pernambuco (IMIP), Recife, Brazil St. Jude Children’s Research Hospital Telemedicine Program currently employs a multi-mode, multi-system, and multi-network approach to Telemedicine technology. We have established an International network, using ISDN as the primary protocol. We, also, use H.323 for broadband applications in an IP format to provide Telemedicine videoconferencing capability, to transport high resolution, DICOM compliant radiology and pathology images for diagnostic purposes, and to access patient records with associated diagnostic images, and multimedia files. To accomplish this, we have a Cisco/RAD 3520 Gatekeeper/Gateway behind a Madge M200 hub. Another element that enhances the Distance Education component of the program is the Cisco 3416 videostreaming system. For multiple domestic and international site events, we use the ACCORD Bridge that allows simultaneous 128 Kbs, 768 Kbs, H.323, and audio connections. The backbone for our current network is two ISDN-PRI’s, terminating into a DDM2000 over a SONET/SMARTPATH link. Web enabled Telemedicine applications that allow transmission of DICOM compliant radiology and pathology images over POTS lines are, also, employed. For proctored telesurgery events, we use a Sony DXC-390 3 chip camera system at 768 Kbs in H.323 format. We use this technology for medical consultations, medical conferences, proctored telesurgery, and distance learning applications. P51 SUPER HIGH DEFINITION WITH SCREEN SPLIT WITH MULTI ENDOSCOPIC IMAGES Norio Kimura, MD, Hiroshi Juzoji, MD, Yongguo Zhao, MD, PhD, Isao Nakajima, MD, PhD, Takeshi Miwa, MD Tokai University, Isehara, Kanagawa, Japan We have conducted tests utilizing super high-definition CRTs (hereafter, referred to as a “super high-definition image system,” or “SHD”: 2048 2048 pixels, 24-bit RGB gradation, non-interlace system) for autonomous and distributed medical image database systems. The system is capable of providing 6 times the image definition of a hi-vision television (HDTV). The aim in designing and testing the system is to enable gigabit network con-
nectivity while displaying images on a DOS-V machine. This paper discusses how we can use SHD CRT for clinical image diagnosis, especially screen splitting with multi-endoscopic images. High-definition still images ( SHDs ) such as full color endoscopic images with screen split display are needed to recognize gastro-intestinal conditions of the patient, especially when the patient suffers from some diseases. Additionally, the need to refer to a former patient’s image, or images of similar cases, may arise for reference purposes. For such cases, we require screen split display with high resolution. A standard SHD file size of amounts to approximately 12 MB (uncompressed) or 4 MB (with lossless compression) per file. To ensure accurate diagnoses, we should avoid using compression methods that are prone to data degradation. In over 50 clinical cases displayed on SHD its clinical usefulness has been demonstrated as satisfactory. P52 TECHNOLOGY AND CARE COORDINATION: EFFECTIVE TEAMWORK FOR MANAGING CHRONIC ILLNESS IN GERIATRIC VETERANS Rita Kobb, MS, MN, ARNP, CS, CWS, Robert Lodge, MSW North Florida/South Georgia Veterans Health System, Lake City, FL The Rural Home Care Project in Lake City, Florida, is one of eight clinical demonstration projects in an expansive new technology initiative implemented by the Department of Veterans Affairs, Sunshine Network in Florida and Puerto Rico. The Rural Home Care project has two care coordinators, a nurse practitioner and social workers that are collaborating with primary care providers to target high-risk veterans age 55 and older with diabetes, hypertension, heart failure, and obstructive lung disease. The project uses the Lifeview (telemedicine system and an in-home messaging device called the Health Buddy) to monitor project patients in an effort to reduce hospitalizations and ER visits, and to improve clinical outcomes and patient satisfaction. The evaluation methodology includes interviews with questionnaires, and statistical analysis with an Intranet database tool. Preliminary results show that the use of this technology correlates with increased access to services, reduced health crises, and increased patient satisfaction. P53 ACCESS TO TELECOM SERVICES AND ROUTINE USAGE OF TELEHEALTH APPLICATIONS: A EUROPEAN SURVEY Lutz Kubitschke, MA,1 Kevin Cullen, MA,2 Veli N. Stroetmann, MD, PhD,1 Karl A. Stroetmann, PhD, MBA1 1Empirica GmbH, Bonn, Germany; 2Work Research Centre Ltd., Dublin, Ireland In a European Union wide study to realistically assess the relevance of telemedicine applications in routine service provision, data on national policies and trends as well as on communications between three major players—hospitals, GPs and citizens— and on health telematics applications were collected. The methodological approach was based on an analytical concept of the players’ communications relationships and on health services integration. Besides information on European health system structures and telehealth policy trends, data on access equipment, access to advanced networks (ISDN, leased lines) and advanced services (Internet, dedicated health nets) for 15 countries is presented. Experimental usage for 5 generic telemedicine application types based on surveys and country reports was determined. An analysis of 4 major facilitating and constraining factors—technology, health system structures, medicolegal and efficiency/reimbursement aspects—synthesizes this experience and allows to derive a realistic picture of presently very limited
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routine as well as experimental application of telemedicine. Telecom access for all citizens and health policy implications are outlined.
P54 RECOMMENDED PRACTICES FOR PROTECTING PRIVACY IN TELEHEALTH Joanne Kumekawa, MBA Department of Health and Human Services, Rockville, MD “The Role of the Office for the Advancement of Telehealth in the Development of Policy for Patient Privacy in Telehealth,” This presentation will provide a policy level perspective of telehealth, focusing on emerging policy and legislation that will advance the application of telehealth. Since one of the significant barriers to widespread application of telehealth is concern about the security and privacy of patient information, these recommended practices will be to serve as a starting point for assessing new legislation’s potential impact on telehealth practices and developing meaningful guidance and policy.
P55 THE PEARLS AND PITFALLS IN ESTABLISHING A DIABETIC RETINOPATHY SURVEILLANCE PROGRAM USING TELEMEDICINE Mary G. Lawrence, MD, MPH,1,2 Gary S. Michalec, BS, CRA, COA,1 Sandra K. Schmunk, BS, MA, HHSA1 1VA Upper Midwest Network, Minneapolis, MN; 2University of Minnesota, Department of Ophthalmology, Minneapolis, MN The purpose of this project was to establish an innovative diabetic retinopathy surveillance program in a large Veterans Health Affairs (VHA) Network. The technical, scientific and administrative issues that were addressed will be presented. Treatment for diabetic retinopathy (DR) is optimal if given early in the course of the disease, so annual retinal examinations are the recommended standard of care in the USA. Compliance with annual retinal exams, however, has been reported to be between 18%-65%. The Upper Midwest Network of the VHA extends across approximately 700 miles of sparsely populated area. At one remote site in the network, only about 48% of diabetics received an annual eye evaluation. A pilot program was established using telemedicine technology to provide retinal exams to the diabetic patient population in one remote site within the network. Digital Retinal images were taken by staff at the patient’s primary diabetic care site. The digital images were transmitted electronically from the remote site to the reading center, where ophthalmologists skilled in retinal evaluations looked for diabetic retinopathy. Implementation of this project required extensive planning to include technical, organizational, and personnel issues. We demonstrated an increased compliance rate with annual retinal examinations standards for the remote site. Other outcomes, such as technical settings and utility analysis will be presented. In conclusion; telemedicine technology provides a viable alternative to “face to face” examinations for the presence of retinopathy in the diabetic population. Organization and operational issues need to be considered in addition to questions regarding costs and technology. P56 OPERATIONAL CHALLENGES AND OUTCOMES OF STORE-AND-FORWARD TELEMEDICINE EVALUATION OF DIABETIC RETINOPATHY IN A PRISON HEALTH CARE SYSTEM Helen K. Li, MD,1 Minh Dang, MS,1,2 Sami Uwaydat, MD,1 John Horna BS,1 Douglas J. Appel, OD,3 John S. Pulvino PA,3 Owen J.
Murray, DO,3 Larry Johnson, PhD,3 Grace C. Chao, MD,3 Leon M. Clements,3 Ben G. Raimer, MD3,4 1Department of Ophthalmology & Visual Sciences, University of Texas Medical Branch, Galveston, TX; 2Department of Health Informatics, University of Texas Health Science Center, Houston, TX; 3Correctional Managed Care, University of Texas Medical Branch, Galveston, TX; 4Community Outreach, University of Texas Medical Branch, Galveston, TX Store-and-forward telemedicine evaluation of diabetic retinopathy is seen by many as an ideal application for remote eye care delivery in a variety of patient populations. However, store-andforward telemedicine presents many implementation challenges. Additionally, remote delivery of health care in a correctional care setting includes unique considerations compared to telemedicine in general populations. Store-and-forward teleophthalmology was used to evaluate diabetic retinopathy in a prison population. This study analyzes the results of teleophthalmology at a remote regional medical facility and the University of Texas Medical Branch tertiary care center. Analysis of teleophthalmology experience for approximately 200 diabetic patients includes: Data management, including storage, file compression, record retention duration and transmission factors related to computer text and imagery data; Operator training requirements for data acquisition; Review of factors related to diabetic patients who could not be evaluated by store-and-forward telemedicine; Delineation of special considerations and issues related to implementing a telemedicine system in prison setting. P57 INCREASING ACCESSIBILITY OF BREAST CLINICAL TRIAL INFORMATION Ana Maria Lopez, MD, MPH, FACP, Sarah Frances Kurker, MSW, Michael Talley University of Arizona, Arizona Cancer Center, Tucson, AZ Objectives: Clinical trials (CT) represent an important but underutilized treatment option in the management of women with breast cancer. The goal of this intervention was to develop, implement and evaluate a demonstration project to increase access to breast cancer CT information via telemedicine. Methods: The Arizona Telemedicine Program (ATP) provides teleconsultations to rural communities in the state of Arizona. The ATP sites were targeted to receive the CT information. Potential users were introduced to the web-based CT information site via press releases, newsletters, personal letters and teleconferences with on-line demonstrations. Access to the web site was not limited to medical personnel; therefore, technical language was not employed. Questions were encouraged via an interactive format. Once referred to a CT, screening and evaluation would take place via teleconferencing. Results: After 10 months of operation, the web-site has received 312 hits. Thirteen screening questions have been received. Statement of Impact: Access to the Internet provides unprecedented access to information. This intervention increased provider and patient knowledge about CT and state of the art therapies for breast cancer. P58 TUMOR BOARD PRESENTATIONS VIA TELEMEDICINE Ana Maria Lopez, MD, MPH, FACP,1,2 Katherine Scott, MD,2 Jay Fleishman, MD,3 Sydney Lazarus, BS, BA,2 Herbert Schwaeger, PhD,2 Ronald Weinstein, MD2 1Arizona Cancer Center, Tucson, AZ; 2The University of Arizona, Tucson, AZ; 3Verde Valley Medical Center In 1999, the Arizona Telemedicine Program (ATP) initiated a Tumor Board with a community in rural Arizona. Real-time inter-
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active videoconferencing was employed to review oncology cases on a monthly basis. Approximately 2 cases were reviewed per session. Participants included oncologists, surgeons, radiologists, primary care physicians and pathologists. Approximately, 12–15 physicians were present at each session. In addition, to the transmission of clinical information, histology and radiology images were transmitted. Telecommunication was bi-directional. Cases reviewed included a broad spectrum of cancer cases including breast (2), bladder (2), lung (2), brain (1), thyroid (1), bone (1), tongue (1), uterine (1), pancreatic (1), endometrial (1), testicular (1), esophageal (1), and undifferentiated carcinoma (1). Reasons for the case presentations included diagnostic pathology review or clinical management concern. Over 80% of participants present at the rural sites agreed that new knowledge was gained, that the educational objectives were met, and that the experience was intellectually stimulating. Tumor Board presentations are feasible, well accepted and provide an example of successful multidisciplinary teleconferencing available to facilitate patient care that would otherwise be difficult to coordinate. P59 DELIVERY OF PAIN MANAGEMENT CONSULTATIONS VIA TELEMEDICINE Ana Maria Lopez, MD, MPH, FACP,1,2 Sydney Lazarus, BS, BA,2 Bennet Davis, MD,2 Nancy Cross, MD,2 Ronald Weinstein, MD2 1Arizona Cancer Center, Tucson, AZ; 2The University of Arizona, Tucson, AZ The Arizona Telemedicine Program (ATP) has provided patient consultations on pain management to rural communities in the state of Arizona. A chart review of nineteen teleconsultations in the area of pain medicine demonstrated that all consultations utilized real-time technology. Three required follow-up teleconsultations. Demographics: age 29–73 years, average of 45.1 years; men (7), women (12); White, non-Hispanic (7), Hispanic (4), unknown (8). The pain diagnoses were low back pain (8), fibromyalgia (2), abdominal pain (2), constant headache with low back pain (1), rheumatoid arthritis with low back pain (1), radicular pain with low back pain (1), hip pain with headache (1), shoulder pain (1), scoliosis (1), and restless leg syndrome (1). The majority of patients (11) received recommendations that allowed for local management. These recommendations included medication adjustments and/or physical therapy or further diagnostic evaluations. Eight required in-person care for further evaluation and specialized pain therapy. Satisfaction was uniformly high with the real-time technology and ease of communication with the teleconsultant. Based on these findings, it appears that pain care consultations via telemedicine result largely in allowing patients to continue care locally. Further study is necessary to delineate the role of telemedicine its efficacy and cost-effectiveness in patients with pain. P60 THE USE OF TELEMEDICINE IN THE CARE OF CANCER PATIENTS Ana Maria Lopez, MD, MPH, FACP,1,2 Sydney Lazarus, BS, BA,2 Ronald Weinstein, MD2 1Arizona Cancer Center, Tucson, AZ; 2The University of Arizona, Tucson, AZ The Arizona Telemedicine Program (ATP) provides telemedicine consultations to rural communities in the state of Arizona. A chart review revealed 13 adult Medical Oncology teleconsults: real-time (1), store-forward (12). Demographics: age 37–78, average 61 years; men (4), women (9); White, non-Hispanic (7), Hispanic (1), Native American (5). Diagnoses: cancer of the breast (2), colon (2), rectum (2), duodenum (2), esophagus (1), kidney (1), diffuse large cell lymphoma (1), sarcoma (1) and cancer of unknown primary (1). Four were new cancer diagnoses. One pa-
tient underwent an initial teleconsult for a mass, a teleradiology consult for the recommended CT scan, a telepathology consult for the biopsy and a telesurgical-oncology consult once the diagnosis was made. Eight were second opinions for difficult clinical presentations. One was a follow-up to an Arizona Cancer Center consultation. Four required management at a tertiary care center. Nine received detailed clinical recommendations that allowed care to be provided locally. Patients were uniformly satisfied with the clinical outcome and agreed that telemedicine increased accessibility of clinical care. Teleconsultants (93%) expressed a high level of satisfaction with the telemedicine technology and confidence with their telemedicine diagnosis. Based on these findings, it appears that oncology care consultations are feasible via telemedicine. P61 DYNAMIC COTS COMPONENT CONFIGURATION FOR INTERNATIONAL TELEMEDICINE SYSTEMS INTEGRATION Allen A. Izadpanah,1 David C. Kushner, MD, FACR,2 Kenneth Lucas1 1Visual Telecommunications Network Inc., McLean, VA; 2Chairman, Diagnostic Imaging and Radiology, Children’s National Medical Center, Washington, DC Emerging information and communications technologies have made it possible to enable a physician’s clinic office to become truly virtual. Physicians in the future will be have a digital office at their finger tips wherever they may be, inclusive of medical records, high resolution images, full motion video, and wireless communications that provide access to on-line medical knowledge bases and clinical data repositories, all enabled on a pocket-sized personal digital assistant (PDA). The major obstacle to this vision has been the inability to easily and dynamically integrate legacy hospital informatics systems with the various proprietary telemedicine software and hardware tools now flooding the market. Our MedVizerTM telemedicine open systems software enables a physician to quickly construct a complete digital clinic using virtually any telemedicine system components available in the market place. Last year at the ATA we introduced the same technology in both Windows CE and Windows NT for pocket PC PDAs. Here we discuss our wireless telemedicine interoperability research being carried out with the US Army, the University of Minnesota, and military and industrial partners in Norway. Our research is aimed at providing these collaborators with the capability to quickly and dynamically configure COTS telemedicine components with both military and civilian informatics systems to enable the same full service digital office we now provide for use in the fixed clinic or hospital for the physician on the move. P62 OPERATIONAL CONSIDERATIONS WHEN STARTING A TELE-HOME CARE PROJECT: LEGAL ASPECTS Susan G. Slater, RN, BSN,1 Holly Russo, MS, BS,2 Robert MacDonnell, Esq.1 1Telemedicine Solutions in Healthcare-Pittsburgh, PA Regional Office, Corporate, Atlanta, GA; 2Tele-Health Consultant, Juno Beach, FL Initiating a Telemedicine project within a home care setting takes many hours of research and planning. There are many details, which must be thought through, in order to have a telemedicine program run smoothly. Telemedicine is a great tool to augment the care traditionally provided by the home care agency. The staff will find that the patients are very receptive to this tool, and will love the flexibility telemedicine offers the staff to manage their care. All members of the home care agency team; from the non-clinical support staff to the clinical staff and administrators, need to work together to make this type of project work. It is
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very important to have a telemedicine philosophy within the organization, to get all of the staff to embrace the project. The program implementation issues that will be discussed are: equipment selection, tracking, and maintenance; staff training, patient training, peripheral device use, documentation, outcome measurements, and coordination of care using a (TCM) telemedicine case manager.
P63 TELEPHONE TRIUMPH: USING A NURSE-LED CALL CENTER TO IMPROVE THE COORDINATION OF MEDICAL CARE John Ross Maclean, MD, MBA, Brian Armour, PhD, Robert Cook, RPh, Jeff Etchason, MD, Adrianne K. Holmes, Jennifer L. Waller, PhD, Ellen Clements, RN Medical College of Georgia, Augusta, GA Objectives: To determine the effectiveness of a nurse-led call center in (a) improving access to healthcare services and (b) reducing medical center costs by improving the coordination of care. Methods: The evaluation used administrative data from a retrospective study of patients at the Augusta VA medical center facility between April and September 1999. Results 1. Access A survey of a random sample of callers (n 63) revealed that the call center increased veteran access to pharmacy services and that most callers were satisfied. The Augusta VAMC primary care clinic average no-show rate for appointments scheduled through conventional methods was 21% (3,433/16,607) compared to an average no-show rate of 5.5% for appointments scheduled by Call Center nurses (24/436). 2. Cost of service provision Given the average variable cost per no-show ($65.13), the potential cost-savings that could be realized if all primary care clinic visits were coordinated through the Call Center is estimated to be $328,134 if aggregated to fiscal year 1999. Conclusions: This study provides evidence that the implementation of a call center increases the coordination of medical care and reduces no-show rates at VA medical center primary care clinics. This reduction in no-show rates could potentially save Network-7 $328,134 per annum.
P64 TRAINING FOR INTERNATIONAL TELEMEDICINE Lori Maiolo, David C. Balch, MA Telemedicine Center, East Carolina University, Greenville, NC Advances in distributed medical care require highly trained medical, emergency, civil, and defense personnel. Twenty-first century disasters and threats require Americans be ready to respond both at home and abroad. Distributed Medical Intelligence (DMI) is a health care model developed at East Carolina University (ECU) to focus on the use of technology to improve accessibility and quality of care in the areas of greatest need. DMI will achieve its full potential when well-trained first responders and well-trained physician consultants can provide on-demand care around the globe. The Telemedicine Center at ECU has developed International training programs on both the technology and organizational aspects of telemedicine in humanitarian response. The curriculum emphasizes the need to train personnel in the use of telemedicine equipment and protocols and to develop practical models for delivery of care any where in the world. New components of the International training program include the use of simulations, case studies, and hands-on experiences.
This presentation will provide an overview of International Telemedicine Training program and the importance of training for successful applications in emerging international models. P65 ACUTE CARE PROVIDED VIA HOMETELECARE Frances S. Mair, MBChB,1 Robert Angus, MBChB,2 Mark Wilkinson, MBChB,2 Sandra Bonnar, RN,3Richard Wootton, PhD4 1University of Liverpool, Liverpool, England; 2Aintree University Hospitals NHS Trust, Liverpool, England; 3North Mersey Community Trust, Liverpool, England; 4Centre for Online Health, Australia This study examines the feasibility of using home telecare technologies to provide a safe alternative to admission for patients with mild to moderate exacerbations of chronic obstructive pulmonary disease (COPD). In this study a team of specialist nurses, an Acute Chest Triage Rapid Intervention Team (ACTRITE), provide home care (via an analogue video telephone) for patients that would otherwise be accepted for hospital admission with exacerbations of COPD. This project represents the first trial aimed at examining the utility of providing home telecare to those experiencing an acute exacerbation of their chronic illness, who would otherwise have merited acute hospital admission. COPD is a disease that is a major contributor to rising rates of emergency medical admissions. Thus this project examines the use of new technology to address an issue of immense economic significance and of great practical importance to patients. Thus far 20 patients have participated in the project. Preliminary results have demonstrated the feasibility of using home telecare in this context. The study findings particularly focusing on health care providers’ views and patient satisfaction and will be presented. P66 DEVELOPMENT AND DEPLOYMENT OF A WEB-BASED ASTHMA TELEMEDICINE CONSULT SERVICE TO THE WESTERN PACIFIC Francis J. Malone, MD,1 Mark D. Ching, BS,1 Morgan S. Mandeville, MD,2 Karen L. Fitzgerald, RN, CPNP, MS,3Sharon P. McKiernan, MD,4 Scott T. Maurer, DO,5 Debora S. Chan, FAHSP6, Scott J. Sheets, DO,6 Charles W. Callahan, DO6 1Pacific e-Health Innovation Center, Tripler Army Medical Center, Honolulu, HI; 2United States Naval Hospital, Guam; 3374th Medical Group, Yokota Air Base, Japan; 4121 General Hospital, Seoul, Korea; 5United States Naval Hospital, Okinawa; 6Department of Pediatrics, Tripler Army Medical Center, Honolulu, HI Military providers in Okinawa, Japan, Korea, and Guam are participating in a Web-based consultation study of children with asthma. Consults are submitted using Internet “store and forward” technology to the pediatric pulmonologist at Tripler Army Medical Center in Hawaii. The consult includes a history and physical, a digital chest radiograph (optional), digital spirometry, a video clip of the patient’s MDI technique, and a quality of life questionnaire. Fifteen patients (ages 6–18) with persistent asthma will be enrolled from each site and followed on a clinical pathway for one year. Patient’s MDI scores, utilization of resources, acceptance of telemedicine consultation, and quality of life will be measured. Practitioner acceptance of the technology will also be assessed. RESULTS: To date, 4 male and 1 female patient, aged 10.96 2.99 years (mean age SD) have been enrolled. Three had moderate and two had severe asthma. All children had insufficient MDI scores ( 70%) at time of consult. Average MDI technique score was 42% 20.37%, range 12.5–66.7%. Other data points are pending. CONCLUSION: This study will demonstrate the utility and effectiveness of telemedicine consultation to assist providers in
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caring for children with asthma. Funding provided by a grant from Pacific e-Health Innovation Center. P67 TELEDERMATOLOGY THROUGH PROTOTYPE INDEPENDENT VERIFICATION AND VALIDATION (IV&V) SUPPORT Ronald Marchessault, Jr., MA, MBA Candidate,1 Cheryl A. Merritt, MA2 1Information Systems Support, Inc., Bethesda, MD; 2SRA International, Inc., Fairfax, VA The Walter Reed Army Medical Center has developed a working Teledermatology prototype using Commercial-Off-The-Shelf and government developed applications which supports Dermatology patient encounters, patient consultations, and physician referrals. The prototype has undergone fielding to Regional Medical Centers in Europe and CONUS where user feedback has been positive. The deficiencies of the current practices are documented in the Operational Requirements Document for the Medical Equipment Set, Telemedicine dated 12 FEB 98. The Teledermatology System uses digital cameras and web technology to provide a consult service, using store-and-forward methodology. It is being proposed as an Acquisition Category IV system. To build on the success of the Teledermatology application it is necessary to move the project from a research and development effort into a formal acquisition program. This begins with a two-step process: 1) Determine the telemedicine programmatic and technical requirements; 2) Assess the prototype application’s compliance with current US Army and DOD technical standards and software development practices. P68 INTERNET-BASED TELEDERMATOLOGY PEER REVIEW QUALITY IMPROVEMENT ENHANCEMENT OF TELEDERMATOLOGY SYSTEM Mary K. Mather, MD,1 Thomas R. Bigott, BS,2 Zhengyi Sun, MS,2 COL Ronald K. Poropatich, MD,2 Paul Benson, MD1 1Dermatology Service, Walter Reed Army Medical Center (WRAMC), Washington, DC; 2Telemedicine Directorate WRAMC Background: The Walter Reed Army Medical Center (WRAMC) has been using a store-and-forward Web-based telemedicine system for Dermatology consultation since May 1998 and has over 1,500 consultations to date. No outcome assessment has been done and no outcomes measures have been instituted to track quality of care. Methods: WRAMC Dermatology Service is currently tracking all TeleDermatology consultations received and answered by WRAMC Dermatology Providers. The current study will continue for a 6-month period. The current system tracks patientoutcomes using telephone contact at 2 days and 30 days following their TeleDermatology consultation. Results: The following outcomes measures are currently being recorded: time from consultation to patient contact for follow-up, time between initial telemedicine consultation and patient visit to Dermatologist (when recommended), number of patients who fail to comply with the initial electronic recommendations for treatment or biopsy, the number of provider visits required to resolve the patient’s chief complaint, and the percentage of patients who are successfully managed through the electronic consultation alone. Conclusion: This study should provide a meaningful assessment of the outcomes of the current system. Data suggesting modifications to the current system will be studied in order to improve patient outcomes and ultimately patient care.
P69 TYPES OF TELECONSULTATIONS AND THEIR FACILITATION Jerrold H. May, PhD,1 Luis G. Vargas, PhD,1 COL Ronald K. Poropatich, MD,2,3 William G. Jacobs,1 Gary R. Gilbert,1,2 Linda R. Youngblood Sales, BS,3Mitra A. Rocca, MSc1,2 1AIM Laboratory, University of Pittsburgh, Pittsburgh, PA; 2United States Army Medical Research & Materiel Command (USAMRMC), Telemedicine & Advanced Technology Research Center (TATRC), Ft. Detrick, MD; 3Walter Reed Army Medical Center, Washington, DC The study analyzed the consultation records from a U.S. Army teledental system as part of the design and construction of the Consult Broker part of the Global Grid Telemedicine System. As presented at ATA 2000, teledental consultations appeared to fall into three categories: (1) patient referral; (2) information request, but the requester will continue to treat the patient; and (3) information request in which the requester will treat the patient if routine but will refer if treatment is beyond his/her competence. In extending the Consult Broker prototype to general medical problems, we are studying data from the Ask-a-doc systems at Walter Reed Army Medical Center. The Ask-a-doc data includes other categories of consultations, such as administrative questions and drug therapy questions. In systems such as Ask-a-doc, the person who requests the consultation chooses a particular consultant specialty, but sometimes a different specialty would have been a better choice and sometimes expertise from more than one specialty is required to answer the question. We discuss the patterns we found in Ask-a-doc, compare them with teledentistry, and propose frameworks for the Consult Broker that could provide assistance for different types of teleconsultation systems. P70 WIRELESS TRANSMISSION OF TELEMEDICINE APPLICATIONS TO THE PATIENT BEDSIDE James Mayrose, PhD, David G. Ellis, MD, James O. Whitlock State University of New York at Buffalo, Buffalo, NY Telemedicine is concerned with ways in which computers and telecommunication can be combined to improve the quality of health care by linking remote sites with centers of expertise. We have developed a system that allows us to not only deliver this technology to a remote site but to go one step further and deliver it to the bedside of any patient within that facility. We achieve this through the use of wireless network technology. Wireless networking refers to technology that enables two computers to communicate using standard network protocols, but without network cabling. The wireless network developed here uses an access point that acts like a hub, which provides connectivity for the wireless computers to the wired LAN. LAN resources and Internet connectivity are then available to the wireless endpoints. A mobile PC-based telemedicine system, which utilizes the H.323 standard for the transmission of real-time video, audio and data over packet-based networks was developed. The high performance video and small footprint of this equipment allows this system to be easily integrated into any healthcare facility. The system developed here allows small, remote healthcare facilities to deliver the expertise of medical professionals at other facilities directly to the patients’ bedside. P71 PROMOTING TELEMEDICINE TO GOVERNMENT POLICY MAKERS Don McBeath, BA; Shannon Kennedy, MBA Texas Tech University Health Sciences Center, Lubbock, TX While telemedicine has gained support in the medical field in recent years, general public support of this technology has lagged.
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Increasing awareness is crucial since support by government and community policy makers is vital to the growth of telemedicine. The Texas Tech University Health Sciences Center (TTUHSC) telemedicine program developed an informational direct-mail newsletter, written to provide basic knowledge about the operations and benefits of telemedicine. This quarterly Telemedicine Report targets policy makers in the TTUHSC service area who are in a position to support telemedicine at a funding and regulatory level. The audience includes mayors, county judges, school superintendents, and hospital administrators. The Texas Governor, Lt. Governor, members of the state legislature, the Commissioner of Health, members of the Texas congressional delegation, and various state officials in adjacent New Mexico are also sent a newsletter. The newsletter is designed to be a generic informational piece about telemedicine, rather than a promotional piece for the TTUHSC telemedicine program (although Texas Tech is clearly identified as the source). Because telemedicine is an integral component of health care, the newsletter also features some general health information. This presentation will outline marketing strategies as well as sample newsletter designs. P72 HIV CARE FOR INMATES: A COMPARISON OF TELEMEDICINE AND FACE-TO-FACE CLINICS Donnie McGrath, MD,1,3Kathy Lasch, PhD,2,3 Jennifer Chung Lee, PhD2,3 Therfena Green, BA,1,3 James Stahl, MD,4 Joseph Bakan, MA,3 Joseph Cohen, MD1,3 1Lemuel Shattuck Hospital, Boston MA; 2The Health Institute, Clinical Care Research Division, New England Medical Center, Boston, MA; 3Tufts University School of Medicine, Boston, MA; 4Massachusetts General Hospital-Harvard Medical School, Boston MA Infectious disease care is a common application of telemedicine in the US. However data describing the nature or effectiveness of this application is limited. We compared HIV telemedicine clinics in 3 Massachusetts prisons with traditional onsite face-toface clinics over a two-year period. This is part of the Massachusetts Telehealth Access Project (MASSTAP), a prospective quasi-experimental study evaluating telemedicine cost-effectiveness and health outcomes amongst inmates who participate in telemedicine. Clinics are performed via interactive videoconferencing over ISDN lines (384kbs). Methods: Clinical and technical data was prospectively collected about telemedicine clinics using a structured data collection instrument. Patients and providers were interviewed to assess satisfaction and acceptance. Clinical data was prospectively collected about face-to-face clinics. Results: We collected data on 50 telemedicine clinics and 15 onsite clinics. There were no significant differences in average consultation time, percentage of routine visits (no new symptoms/ signs, no medication changes) or complicated visits (involved medication changes and/or involved new symptoms/signs). Patient and provider satisfaction rates were high with the telemedicine clinics. Conclusion: HIV patient management using telemedicine is similar to traditional care. In addition both patients and providers express high levels of acceptance and satisfaction with telemedicine clinics. P73 USE OF A VIDEOSTREAMING SERVER FOR THE DELIVERY OF CONTINUING EDUCATION OVER A TELEMEDICINE NETWORK TO RURAL HEALTHCARE PRACTITIONERS Richard A. McNeely, MA, John R. Hall, PhD, Cynthia A. Frank, MS, Richard A. Collins, BFA, Kenneth E. Umphrey, BFA, Ronald S. Weinstein, MD
Arizona Telemedicine Program, Arizona Health Sciences Center, University of Arizona, Tucson, AZ Established in 1996, The Arizona Telemedicine Program is a multidisciplinary clinical program of The University of Arizona Health Sciences Center. The program operates telemedicine clinics in 14 communities and is linked for distance learning to 31 affiliated organizations at 38 sites. The programs broadband ATMT1 network simultaneously delivers real time video, data, and Internet services to these sites. Continuing education via conventional interactive real time video began in 1999, in collaboration with the centers Division of Biomedical Communications, which provides video origination services from the centers primary teaching facilities. To date, over 200 continuing education sessions have been delivered to over 2,200 attendees. Sessions include grand rounds in internal medicine, pediatrics, psychiatry, public health and surgery. A videostreaming server allows this programming to be viewed over the Internet. Currently, all real time distance learning sessions are simultaneously videostreamed and past sessions are available through the videoserver’s archives, along with digitized collections of presenters’ teaching slides. The server also provides curriculum-based presentations for review by students on rural rotations and at home in urban areas. Our analysis shows that videostreaming educational programming can be an important offering of a telemedicine program. P74 TECHNOLOGY ASPECTS OF ESTABLISHING A PHOTOGRAPHIC TELEMEDICINE DIABETIC RETINOPATHY EVALUATION PROGRAM Mary Gilbert Lawrence, MD, MPH, Gary S. Michalec, BS, CRA, COA, Sandra K. Schmunk, BS, MA, HHSA. VA Upper Midwest Network, Minneapolis, MN This presentation will discuss issues that need to be addressed when establishing a photographic diabetic retinopathy evaluation program utilizing telemedicine. Diabetic retinopathy is the most frequent cause of new cases of blindness among adults ages 20–74. Clinical trials have shown that laser photocoagulation can reduce the risk of severe visual loss, but effectiveness of this treatment requires early detection. Unfortunately, well over half of the diabetic patients do not visit a qualified eye care provider as recommended. It has been proposed that this under served population can be evaluated in the primary care setting utilizing digital retinal photographs. These images can then be transmitted to a centralized reading center where they will be evaluated for degree of retinopathy and need for referral. It is hoped that this evaluation will serve in lieu of an annual retinal exam that is performed by a qualified eye care provider. In establishing such a program many technological obstacles need to be overcome. Selection of imaging equipment, image storage and transmission, and efficacy of new imaging technology in identification of retinal pathology are a few of these items. This presentation will address these obstacles and the evolution of the Minneapolis VAMC diabetic retinopathy evaluation program. P75 MANAGING TERMINAL CANCER PATIENTS VIA TELECONFERENCE Glenn M. Mills, MD,1 JoAnne Alley, MD,2 Victoria Ratts, RN, MS,1 Richard Mansour, MD,1 Ravindra Patil, MD,1 Benjamin Li, MD,1 Gary von Burton, MD,1 Federico Ampil, MD1 1Louisiana State University Health Sciences Center, Shreveport, LA; 2E. A. Conway Hospital, Monroe, LA The aim of the study was to improve terminal cancer patient management at an outlying facility, 100 miles east of our University, through a consensus-based decision making process via a Tumor Board teleconference.
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Materials and Methods: Weekly multidisciplinary teleconferences, explored options for patient management identifying those with end-stage disease. Attendees met in respective videoteleconference rooms. Surgeons, oncologists, internists, pathologists, radiation oncologists, nurses, clinical research associates, fellows, residents and medical students participated. The chief oncological surgeon at the affiliate hospital and a University oncologist moderated the teleconferences. Case descriptions faxed from the affiliate prior to the teleconference identified other consultants needed. Pathology and radiological images were transmitted for correlating diagnosis with stage. Each case discussed rendered decisions by a consensus-based approach. Results: Over 3-1/2 years, (32%) of patients were determined to have end-stage disease. Recommendations for palliative care were proposed, such as radiation therapy for pain, enteral nutritional support, hospice services, etc. Conclusions: Patients benefited from this teleconference approach in decision making by reducing the time, discomfort and cost of traveling to the University. The teleconference forum resulted in more rapid implementation of terminal care, providing improved patient management and providing an educational tool for trainees regarding ethical decisions for end-stage disease management. P76 INTERACTIVE VIDEO CONFERENCE EDUCATION IN A FAMILY PRACTICE CENTER Orlando F. Mills, MD, MPH,1 Vicki Pendleton, RN,1 James F. Bates, PhD,2 Kathleen Lese, MA, MLIS,3Michael Tatarko, MD1 1Conemaugh Memoral Medical Center, Johnstown, PA; 2Center of Excellence for Remote and Medically Underserved Areas, Loretto, PA; 3Southcentral Area Health Education Center, Loretto, PA Residencies are required to conduct weekly lectures for residents, often a time-intensive process. Two-way videoconference technology may be a useful adjunct in Family Practice education by expanding the possible lectures available for residents. Methods: Live videoconferences were arranged between our site and other sites. Participants at our site completed standard evaluation forms and rated the technical quality and perceived educational value. We performed a quantitative and qualitative analysis of the evaluations. Results: We conducted 30 videoconferences between our residency program and other sites and analyzed 382 evaluation forms. Overall the quality was good. Our worst conferences suffered from poor sound or video transmission. In our best conferences there was good sound and video, speakers gave clear handouts in advance and showed slides that were not overly wordy or complicated. Conclusions: Two-way videoconference education was a useful adjunct for our Family Practice Residency over the two year period of operation. In the future there may be a role for this technology to help programs share their medical expertise with other programs without leaving their site.
clients, and the seriously mentally ill in outpatient, residential, and in-patient settings. With a 62,000 square mile area, NARBHA faced numerous difficulties in delivering care. In 1996, NARBHA began its Telemedicine operation and has two video-conferencing sites Flagstaff, two Phoenix sites, Show Low, St. John’s, Page, Prescott, Springerville, Holbrook, Kingman, Lake Havasu, Winslow, Bullhead City. NARBHA connected the network sites of Community Partnership of Southern Arizona, with six Tucson sites, Benson, Douglas, Nogales, Sierra Vista and the Pinal Gila Behavioral Health Authority site in Apache Junction. NARBHA established a permanent network connection to the University of Arizona’s Telemedicine Program for continuing medical education and specialty consultation. This year, the four RBHA, 43 site network will become centralized by adding The Excel sites from Yuma and LaPaz counties, forming the largest state-wide behavioral health network in the country. P78 TELEHEALTH IN THE ASIA PACIFIC (1999–2000) Isao Nakajima, MD, PhD,1 Hiroshi Juzoji, MD,1 Yongguo Zhao, MD, PhD,1 Norio Kimura, MD,2 Yuhwsuke Sawada, MD, PhD,2 Yoshihiro Takashima, MD, PhD3 1Tokai University Medical Research Institute, Japan; 2Tokai University School of Medicine, Japan; 3International Medical Center of Japan, Japan From the summer of 1999 to the spring of 2000, a study was focused on the management and operational status of telehealth in the Asia Pacific. The writers gathered materials upon returning to Japan to provide as detailed a report as possible on the current status and analysis of telemedicine in this region. There are numerous medical support activities currently operating in the Asia Pacific region as follows; 1) Fiji School of Nursing: working in cooperation with the Fiji Ministry of Health, the Fiji School of Nursing has been providing monthly nursing education, under guidance from WHO’s Office of the Representative for the South Pacific, since 1991. Offered continuously over this period, the weekly program centers around three main sites: the 2) WPHNet (Western Pacific HealthNet) is a web-based medical consultation site managed and operated by the Pacific Basin Medical Association. 3) PACNET is also an Internet project, it is a more looselytied network that relies on e-mail running on autonomous distributed systems supported by the SPC (Secretariat of the Pacific Community), located in Noumea, New Caledonia. 4) Indonesia video telemedicine: With analog public circuit line, two-way video conferencing telemedicine are performed on clinical medicine. 5) TAMC (Tripler Army Medical Center) Telemedial operation. 6) STAN (State of Hawaii Telehealth Access Network)
P77 STATEWIDE BEHAVIORAL HEALTH NETWORK IN ARIZONA Catherine Romeo-Woff, MA, Susan Morely, MSW, Sara Gibson, MD Northern Arizona Regional Behavioral Health Authority, Flagstaff, AZ
P79 HEALTHY STEPS INTERVENTION FOR ADOLESCENT PARENTS OVER INTERACTIVE TELEVIDEO David Cook, PhD, Eve-Lynn Nelson, MA, Pamela Shaw, MD, Gary C. Doolittle, MD Center For TeleMedicine and TeleHealth, University of Kansas Medical Center (KUMC), Kansas City, KS
Northern Arizona Regional Behavioral Health Authority (NARBHA) was founded in 1967 and is under contract with the Arizona Department of Health Services for providing behavioral health services to the northern region of the state. Since its inception, NARBHA placed a high priority on developing community based behavioral health services with provisions to provide services to adults, children, families, alcohol and drug
The Healthy Steps for Young Children Program is a national initiative focused on enhancing the physical, emotional, and intellectual development of children from birth to age three. The local project links Healthy Steps Specialists with adolescent parents at an urban high school using telemedicine. The presentation will address collaboration among the telemedicine department, the multiple granting agencies, the Healthy Steps specialists, and the
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school system in implementation. The quantitative design compares adolescent parents who receive Healthy Steps care face-toface with those who receive Healthy Steps care over ITV. In addition to general demographic information, outcome measures for prenatal care include: attendance and knowledge of Healthy Steps information presented in lecture and handouts; adherence to prenatal visits and recommendations; and use of external agencies. Outcome measures for postnatal care include: parent measures (completion of school; feelings of competency; etc.); adherence measures (immunizations; car safety; home safety; etc.); and infant developmental measures. Information concerning implementation and initial data will be presented. P80 TELEMEDICINE PROVIDER PERCEPTIONS OF DIAGNOSTIC AND TREATMENT EFFICACY IN A PEDIATRIC POPULATION Eve-Lynn Nelson, MA, Pamela Shaw, MD, Gary C. Doolittle, MD, Georgina Peacock, MD, David Cook, PhD Center For TeleMedicine and TeleHealth, University of Kansas Medical Center (KUMC), Kansas City, KS Ten telemedicine providers completed a structured interview concerning reasons for telemedicine use and diagnostic and treatment efficacy. The median provider profile was a female pediatrician in her mid thirties. Pediatricians identified a number of barriers to care and reasons for use of telemedicine in this urban population (lack of insurance, transportation difficulties, work conflicts, childcare barriers, language barriers, etc.) Providers emphasized the importance of experienced on-site nurses in the development of rapport with the family and in equipment use. The majority of providers (8 of 10) reported preference for faceto-face visits but view telemedicine as an acceptable alternative. On a Likert scale from 1 (very positive) to 7 (very negative), the average physician rating of comfort with equipment, reliability of equipment, audio quality, and video quality was between 2 and 3. Diagnoses based on history were viewed as the best evaluated over telemedicine. Technology (128 kb/s ISDN technology) enhanced some visuals, such as the ear TM is magnified on the screen. Pediatricians expressed concerns around treatment availability (as with asthma breathing treatment) and concerns around adherence (as with antibiotic pills versus injection for acute infections) using telemedicine. An ongoing study compares the perceptions of telemedicine providers with non-telemedicine providers. P81 RESEARCH APPROACHES TO ESTABLISHING TELEMEDICINE EFFICACY IN A BEHAVIORAL PEDIATRICS SETTING Eve-Lynn Nelson, MA,1 Martha Barnard, PhD,1 Sharon Cain, MD,1 David Ermer, MD2 1University of Kansas Medical Center (KUMC), Kansas City, KS; 2University of South Dakota Medical Center, Sioux Falls, SD Research in traditional, face-to-face clinic settings consistently supports the efficacy of cognitive behavioral therapy (CBT) in the treatment of childhood depression. The researchers adapted a CBT protocol for childhood depression in the ITV context. Their ongoing research compares an eight-week CBT intervention over 128 kb/s ISDN to face-to-face care at the medical center. The project is recruiting thirty families over 2 years. After meeting the childhood depression criteria as assess by the Kiddie Schedule for Affective Disorders and Schizophrenia, families complete the Childhood Depression Inventory and the Behavior Assessment System for Children. The preliminary data suggest child improvement from pre- to post-assessment from the parent perspective and the child perspective at similar rates
for both groups. The attendance and attrition rates did not significantly differ between the ITV and the face-to-face groups. The ITV equipment worked consistently across the visits but some issues to consider include adequate lighting to see facial expressions, ITV rooms that are wheelchair accessible, supervision at distant sites, and privacy issues secondary to room control at distant sites and to technology. Cognitive behavioral therapy appears well suited to the ITV context because its structured, goal-oriented sessions fit the strict scheduling demands of ITV line use. P82 TELEPSYCHIATRY IN A RURAL JAIL POPULATION Charles Zaylor, MD,1 Eve-Lynn Nelson, MA,2 David Cook, PhD2 1Lansing Correctional Facility, Lansing, KS; 2University of Kansas Medical Center (KUMC), Kansas City, KS The psychiatrist conducted a telepsychiatry clinic with a rural jail population over 20 months. The clinic followed a quadratic growth trend, moving from crisis intervention care (approximately 10 inmates/month) to intervention with chronic disorders (approximately 70 inmates/month). The most common diagnoses were affective disorders (44%) and adjustment reactions (22%). Substance dependence, abuse, or withdrawal was diagnosed in over half the consults, again consistent with the high percent of drug use in other correctional settings. The study asked inmates and the psychiatrist to complete ratings of improvement over time. The patient rating of improvement (Symptom Rating Checklist-90-Revised) and the provider rating of improvement (Clinical Global Impression Scale Severity Index) correlated significantly, validating the clinical impression that inmates respond the same to telemedicine services as face-to-face services. P83 TELEMEDICINE EVALUATION OF RESPIRATORY SYMPTOMS IN PATIENTS PRESENTING TO THE EMERGENCY ROOM: A COMPARISON STUDY Mark A. Novas, MD,1 Robert L. Bratton, MD,1 Theodore Szymanski, MD,1 Peter O’Brian, PhD,2 Patrick Healy, MBA1 1Mayo Clinic Jacksonville, FL; 2Mayo Clinic Rochester, MN Objectives: To access the reliability of telemedicine examination on patients presenting to the emergency room with respiratory symptoms and to compare the efficacy, efficiency and cost-effectiveness of telemedicine examination compared with the conventional examination. Methods: 500 telemedicine visits will be conducted from the emergency room setting. Patients in no acute distress will be identified in triage and directed to the telemedicine unit. Patients will connect with the physician on-call and be evaluated via telemedicine using the otoscope, electronic stethoscope, oxygen saturation monitor, thermometer, and peak flow meter. The physician linked via telemedicine will then record their assessment and plan. The patients will then be evaluated by the onsite physician. The diagnosis and treatment plans will then be compared. Results: This is a study in-progress. Results are pending. Conclusions: (anticipated) Based on the observations and methods used, a basis for the reliable use of telemedicine to evaluate patients with respiratory symptoms was established. Compared with a formal visit to the emergency room, the cost of a typical telemedicine evaluation would be x, this compares with the ER cost of providing care to the population studied of y. All out-liers will be identified and discussed, i.e. those patients that in the estimation of the EM physician ultimately required evaluation and treatment in the ED. Additionally, a cost comparison will be carried out.
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P84 A NOVEL TREATMENT PARADIGM FOR FRAGILE PSYCHIATRIC OUTPATIENTS: COMBINING OFFICE BASED CARE AND TELEPSYCHIATRY—RX FOR SUICIDE PREVENTION AND LOWER COSTS Ann Oberkirch, MD Yale School of Medicine, New Haven, Connecticut, Woodbridge, CT
drinking and rainwater can be obtained. By application of scintillation counter, Gamma camera, study of radioactive emission can be made which in turn can be stopped by appropriate scientific methods that will help to remove the human health hazards particularly in India and to the world in general.
*No abstract available.
P87 EFFICIENTLY MANAGING NONTRADITIONAL ADVANCED MEDICAL TECHNOLOGY R&D—THE TATRC BUSINESS MODEL Jan M. Patterson, BA, Katherine Eltzroth, MHA, Conrad Clyburn, MA United States Army Medical Research & Materiel Command (USAMRMC), Telemedicine & Advanced Technology Research Center (TATRC), Ft. Detrick, MD
P85 A CLINICALLY DRIVEN, TECHNICALLY BASED CARDIAC TRIAGE SYSTEM Krisan Palmer, RN,1 Robert MacDonald, MD,1 Richard Scott, PhD,1 David Garnett2 1Atlantic Health Sciences Corporation, Saint John, New Brunswick, Canada; 2Aliant Telecom. Inc, Saint John, New Brunswick, Canada The New Brunswick Heart Centre (NBHC) receives over 1200 hospital-to-hospital transfers per year. Recognizing the value of getting the right patient to the right place at the right time to best utilize scarce resources and to ensure a high quality of patient care for this population, the NBHC initiated a single entry point for the referral process. Prior to this successful research and development project, patient data relayed was often inconsistent and unreliable. Referrals were received in any one of eleven different ways and assessed by one of as many cardiologists. In conjunction with remote physicians, NBHC cardiologists developed a standardized triage assessment tool. Technology partners automated the process and it was implemented in December 1998 on a provincial basis. The process now has clinical information entered, ECG’s scanned and patients automatically scored, reviewed and the priority for transfer assigned. To date, remote clinicians are satisfied with the increase in clinician accessibility and information flow. This objective, systematic approach to cardiac triage (c-triage) has proven its worth within the provincial healthcare system by markedly decreasing repeat laboratory testing, the need for internal transfers, and inappropriate transfers. It has provided an avenue for interactive, real time, online consulting. This has enhanced the medical management of patient’s prior to transfer. Quality patient care, increased accessibility, acceptability and cost effectiveness have facilitated the use of c-triage on an interprovincial basis. P86 HEALTH CARE PROMOTION OF THE CANCER PATIENT WITH TELEMEDICINE Hemendra Pathak, MSc, MD AEDC Limited, Guwahati, Assam, India The technically backward and geographically isolated North Eastern part of India is getting worldwide connectivity through VSAT from block level Community Information Centre (CIC). Now the problem of surface transport communication hindered by hills and forest will be partly solved through the CIC’s network. Unfortunately, this part of India is full of cancer patients. So if a coordinated telehealth effort connecting the medical professional and telecommunication can be established then the health services can be provided to the rural residents including medically underserved and isolated area by the round-the-clock access to the medical care facility. By interlinking different healthcare providers through a broadband infrastructure for consultation between physicians and specialists, the long distance travel of the rural patients can be eliminated. Again with the help of this telemedicine network information of cancer patient from remote location in respect of their type of cancer, suffering duration, environmental condition including
Management of advanced medical technology research and development (R&D) programs and projects are a significant component of the Telemedicine and Advanced Technology Research Center’s (TATRC) operational mission. These programs and projects are administratively and technically complex, unique, and often cut across (the TATRC’s) traditional organizational lines. Therefore, the TATRC has developed a detailed, complete program/project planning and control framework in order to successfully manage a program/project from inception to completion. The framework is characterized by five interrelated lifecycle phases: Inputs, Controls, Mechanisms, Execution, and Outputs. In short, science is sought (e.g. through announcement vehicles) and received (e.g. proposals) in the “Inputs” phase; subjected to rigorous functional and scientific review in the “Control” phase; if approved, matched with the optimal funding source and/or program in the “Mechanisms” phase; monitored/managed through technology review in the “Execution” phase; and finally transformed into an end or transferable product in the “Outputs” phase. P88 TELEMEDICINE GUIDELINES: MANAGING A DYNAMIC PROCESS Lorraine Pellegrino, RN, MHA, Thomas S. Nesbitt, MD, MPH University of California, Davis Health System, Sacramento, CA Patients are frequently and inappropriately referred for specialist care by their primary care physicians. To reduce the potential for this occurring in telemedicine clinics, guidelines were prepared to indicate which clinical conditions are best suited for telemedicine. Both primary care physicians in the community and specialists within the UC Davis Health System were consulted to determine the amount of time needed for initial and follow-up evaluation, training required to operate medical peripheral devices (ie, examination camera, nasopharyngoscope), and clinical information needed by the specialist to complete the patient assessment. The specialists at the UC Davis Health System provide constant monitoring of appropriate conditions for telemedicine based on thorough medical record review of patients referred for telemedicine. When patterns of inappropriate care arise, the guidelines are modified to reflect standards of ‘best practice’. Specialists also report to a clinical nurse manager who serves the important function of liaison between specialty and primary care; in this role, the nurse tracks improvements needed in examination skills, technical problems with the equipment, and the availability of all required clinical information prior to the video consultation. The result of this process has been fewer inappropriate referrals and a greater understanding of the clinical data needed to diagnose, treat, and monitor complex medical conditions over video-based telemedicine. A case study will be presented to illustrate the process developed.
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P89 STANDARDIZATION OF DERMATOLOGY CASE PRESENTATION FORMS FOR TELEDERMATOLOGY M. A. O’Reilly, MD,1 A. E. Burdick, MD, MPH,2 J. Lauman, BS,3M. E. Goldyne, MD, PhD,4 A. Papier, MD,5 Marta J. Petersen, MD1 1Department of Dermatology, University of Utah, Salt Lake City, UT; 2Department of Dermatology, University of Miami, Miami, FL; 3EMERG, Department of Dermatology, University of Utah, Salt Lake City, UT; 4Department of Dermatology, University of California, San Francisco, CA; 5Department of Dermatology, University of Rochester Teledermatology presents great promise for improving patient access to specialized skin care. The need to establish standards for case presentation with respect to content as well as images has been discussed by many of the leaders in teledermatology. Multiple objectives could be met with an appropriately adaptable format for these interactions. A minimum standard content for encounters and images would help ensure consistent quality of care. A uniform approach to case presentation may also help advance future research by facilitating data acquisition. Archives of teaching cases could also be extrapolated from such a format. A subgroup of the ATA Special Interest Group in Teledermatology (SIGT) proposed reviewing established protocols with the aim of creating a document for use in teledermatology consults. We subsequently reviewed protocols from military and civilian academic programs, as well as those used in community and correctional settings. A list of minimum components required was synthesized. A “Short Form” for routine cases and a “Long Form” for more complex cases or for teaching cases are presented. P90 TEACHING THE BASICS OF TELEMEDICINE Don McBeath, BA, Shannon Kennedy, MBA, Jon Phillips, BS Texas Tech University Health Sciences Center, Lubbock, TX Over the last few years, telemedicine has become an extremely complicated scenario of technical, clinical, and regulatory interactions. Many health care policy makers and administrators lack the basic knowledge to make informed decisions regarding telemedicine. Seeing a need for a “basics” course on telemedicine, the Texas Tech Telemedicine Training Center developed a “Telemedicine 101” course to address the needs of people interested in getting involved in telemedicine but not ready for some of the other more advanced technical and clinical courses available. The eight-hour course, which spans two days, targets: 1) Clinical personnel who would like to utilize telemedicine as a tool for practicing medicine, 2) Health care administrators who see telemedicine as a means for enhancing service offerings, and, 3) Community leaders and policy makers who want to learn how telemedicine can be a strategy for addressing health care access. The course serves as an excellent precursor for the level of presentations at meetings of the American Telemedicine Association. This presentation describes how the course was developed to meet the educational needs of the targeted audience, as well as strategies for marketing the course. P91 ELECTRONIC TRANSMISSION OF ECHOCARDIOGRAM STUDIES BETWEEN THE CLEVELAND CLINIC FOUNDATION (CCF) AND HILLCREST HOSPITAL Daniel Murphy, MD, Bob Mobley, Sharon Plona, RN, Neil Mehta, MD The Cleveland Clinic Foundation, Cleveland, OH Managed care has led to development of cost-efficient health care networks with fewer sub-specialists in one central location. A
Cleveland Clinic Health System hospital lacks a pediatric cardiologist despite busy obstetric practice. Neonates with suspected congenital heart defects (CHD) had echocardiograms done which were sent via courier to main campus for review resulting in a delay in diagnosis / treatment. If special views were required, neonate needed to be transferred for further testing. Neither physicians nor technicians were satisfied with this arrangement. The 2 sites were linked using an Intel Team Station and triple Basic Rate Interface lines of 384 Kbps. Neonatal echocardiograms are now reviewed in real-time by a pediatric cardiologist who directs the study, instructs the sonographer via voice link. We evaluated this program using the first 90 neonatal echocardiograms transmitted. All cardiac diagnoses made via telemedicine were subsequently confirmed by follow-up echocardiography. There were no unnecessary hospital transfers and no transfers for diagnostic purposes. Physician satisfaction and the expertise of the echocardiographic technician were enhanced due to live interaction. Transmitted ehocardiogram quality was satisfactory. Conclusion: Telemedicine is a useful tool for evaluation of suspected CHD: Current managed care climate is ideal for extensive use of this technology. P92 PRELIMINARY DATA ANALYSIS OF AVIATION MEDICINE Jeanette Rasche, MS, LTC Joe McKeon, MD, MPH, Colonel Warren Whitlock, MD, Colonel James McGhee, MD, MPH Center for Total Access, Fort Gordon, GA While it is intuitive that distance-learning is an economical alternative to resident-based training, the effectiveness of a computer-based distance-learning program for medical education has not been studied. A study conducted by the Center for Total Access (CTA) and U.S. Army School of Aviation Medicine (USASAM) objectively determines the effectiveness of web-based training for aviation medicine. In phase one, classes of flight surgeon and flight medic students at USASAM were split into two groups, one receiving a didactic lecture, and the other received on-line training. Preliminary data revealed no statistical difference in mean test scores between the two groups, however, the distance learning group achieved greater than a two-fold savings in contact time. Based upon this data, specific medical modules are as effective as classroom lectures and appear to be less time intensive. The CTA and USASAM are committed to continuing a methodical approach to the development of a successful distance-learning curriculum. Utilizing the scientific method, the lessons that can be effectively delivered on-line, and which courses require hands-on training at USASAM will become apparent. Lessons learned from Aviation Medicine Training online may be applied to other medical distance learning initiatives. P93 REMOTE INTENSIVIST CONSULTATIONS TO CARE SPECIALIST TO TREAT CRITICALLY ILL AND UNSTABLE PATIENTS Thomas T. Carmody, MAJ, MC, MD,1 Daniel B. Rayburn, PhD,2 Ernst A. Hoffstetter, MS,3COL Ronald K. Poropatich, MD3 1Thoracic Surgery Service, Department of Surgery, Walter Reed Army Medical Center, Washington, DC; 2Telemedicine Directorate, Walter Reed Army Institute of Research, Washington, DC; 3Telemedicine Directorate, Walter Reed Army Medical Center, Washington, DC A limited number of intensive care specialists are available to treat critically ill and unstable patients who present to smaller medical facilities. Previous research documents the importance of the intensivist consultation in the intensive care units. Consultations by an intensivist have been shown to reduce mortality, decrease lengths-of-stay, and improve resource management.
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Through the use of TeleMedicine Technology, we will determine the efficacy of using a remote intensivist for medical consultations of critically ill patients. In the current study, an intensivist, who is uninvolved in on-site care of the patient, conducts remote rounds from a central observation point. Real-time physiologic signals, laboratory data and video are displayed at a central observation room remotely located from the intensive care unit. The “remote intensivist” maintains a record of diagnostic findings and therapeutic recommendations. Following the patient’s discharge, the diagnostic findings and therapeutic recommendations of the “remote intensivist” are compared to those prepared on-site. Preliminary results comparing “remote rounding” with traditional, on-site, care suggest strong diagnostic and therapeutic concordance. The results of this study are to be presented. P94 USE OF SATELLITE TECHNOLOGIES FOR HUMANITARIAN PURPOSE Antonio Guell, MD, CNES, Nicolas Poirot, MD, René Rettig, PhD Medes, Toulouse, France Humanitarian purposes are first aims for practitioners educated and trained to give accuracy response to health need of human being. But for victims of crisis or disaster, they have to be able to practice in very bad conditions. Satellite technologies seem better than others for crisis and disasters because they can be operated anywhere, anytime. But biomedical industry and healthcare organizations must be strongly involved to develop new practices using space technologies. MEDES is involved now to develop new applications as experimental practices to assess efficiency of new products processed by combined team of laboratories, industrial and practitioners: a) Tele-epidemiology, merging different kind of data, is able to support health care management and public health care policy against epidemia related to environmental conditions. In health field it’s a real breakthrough. b) With tele-expertise we are confronted with new tools, depending on special know how to combine telecommunication, biomedical device and medical practice. The two applications are working with mobile tele-medicine station interfaced with multiple biomedical devices associated to palm technologies. P95 SUCCESS AND FAILURE OF A VA-COMMUNITY TELEMEDICINE NETWORK Edward D. Renner, PhD, MPH, Cynthia Dubord VA Medical Center, Fargo, ND The Fargo VAMC evaluated the use of telemedicine for delivery of health care services to rural areas of North Dakota by utilizing a community health providers network and clinics. The cooperative project involved two-way fully interactive electronic communication between geographically strategic rural clinics and the VA Medical Center. Although health care providers and patients were very satisfied with the interactive system in eighty percent of the three hundred conferences completed, the system did not meet expedited cost-effective utilization. The major obstacles were physician reluctance to utilize the telemedicine opportunity and lack of administrative support. Lessons learned were that to initiate a successful telemedicine program the interactive video equipment must not be separated geographically from the clinic area and must be integrated into patient care clinics. In addition adequate and trained personnel must be assigned to the program rather than telemedicine being assigned as ancillary duty. Authority must be obtained to schedule patients into telemedicine clinics if they meet established criteria and consent to telemedicine care. Do not rely on physician scheduling. It is
strongly advised a Telemedicine Advisory Committee consisting of key personnel from high application areas be established and charged with obtaining realistic goals of telemedicine utilization. Establishment of a successful telemedicine program requires a commitment from administrative and medical services. Providing telemedicine services without a clear understanding of the requirement it involves will not be cost-effective. P96 OPERATIONAL CONSIDERATIONS WHEN STARTING A TELE-HOME CARE PROJECT: FUNDING ASPECTS Susan G. Slater, RN, BSN,1 Holly Russo, MS, BS,2 Robert MacDonnell, Esq.1 1Telemedicine Solutions in Healthcare-Pittsburgh Regional Office, Corporate, Atlanta, GA; 2Tele-Health Consultant, Juno Beach, FL Legal and regulatory implications of initiating a telemedicine project in a home care setting are complex and varied, as they are in telemedicine programs generally. These implications involve not only the legal and regulatory structure generally applicable to telemedicine activities, but also varied and unique implications for the home care organization’s relationship with its patients. The practical effect of these implications, the home care organization’s design and operation of its program, are the key to solutions to many of the issues raised by a telemedicine project. These solutions, however, require creative thinking and organization patterns which vary from the norm. The presentation will discuss the legal and regulatory aspects of licensing, multistate practice, reimbursement, and liability. In addition, practical solutions to organizational and operational aspects of a telemedicine program within the legal and regulatory context will be explored. Telemedicine can offer significant economic advantages to home care organizations; however, the design and implementation of a telemedicine program to comply with legal and regulatory requirements must be viewed critically and creatively in order to capture the full economic benefit of this new technology. P97 IMPACT OF TELEMEDICINE ON THE PRACTICE OF PEDIATRIC CARDIOLOGY IN A COMMUNITY HOSPITAL Craig Sable, MD, David Kushner, MD, Melissa Fromm, Gail Pearson, MD, ScD, Eric Quivers, MD, Russell Cross, MD, Lorraine Schratz, MD, Susan Cummings, MD, MPH, Gerard Martin, MD Children’s National Medical Center, Washington, DC Real-time telemedicine transmission of neonatal echocardiograms is used to evaluate newborns with suspected heart disease. Methods: Desktop computers (ViTelNET, Inc. McLean, VA), capable of transmitting live echocardiograms over 3 ISDN telephone lines, were installed in the neonatal units of 2 community hospitals. Studies were interpreted, additional views suggested, and management recommendations made by a pediatric cardiologist 15 miles away. Accuracy, patient care, echocardiography utilization, referral patterns, time, and revenue were analyzed prospectively. Results: 500 telemedicine transmissions were performed in 364 patients over 2 years. Diagnoses included congenital heart disease (n 123) and patent ductus arteriosus (n 86). Videotape review confirmed diagnoses in all studies. Telemedicine had an impact on patient care in 252 studies. Utilization of echocardiography before (36/1,000 births) and after (42/1,000 births) telemedicine installation was similar. The percentage of neonatal echocardiograms that were interpreted by our practice increased from 53% to 84% (p 0.001). Teleconference time averaged 20 7 minutes and resulted in an estimated timesaving of 4.2 person-hours/week. Hospital charges from echocardiograms
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and patient referrals ($3,000,000) greatly exceeded the total cost of telemedicine. Conclusion: Neonatal teleechocardigraphy is accurate, improves care, increases referral of patients, improves cardiologist time management, is cost-effective, and does not increase utilization of echocardiograms. P98 TRAINING TELEMEDICINE CONSULTANTS Stan Saiki, MD, David Huhta, Michael Van Platen, Jana Hall, PhD, Richard Friedman, MD University of Hawaii School of Medicine, Honolulu, HI Clinician buy-in and investment is central to the success of any telemedicine system. Clinicians must be comfortable that findings achieved during a telemedicine consultation are the same as those that would occur during a real-time face-to-face encounter. The University of Hawaii Telemedicine Group has developed a telemedicine orientation program held within a clinical laboratory environment. The program places the clinicians and other members of the telemedicine team in “orientation” clinical encounters. Telemedicine sending and receiving systems are set up in different rooms within the clinical laboratory. Trainees playing the role of “consultants” are located in the consultation room. They practice their skills at communicating over telecommunications links, assessing clinical information provided by the telemedicine peripheral devices and directing extenders in the examination room to assist in the examination of standardized patients. Upon completing the teleconsultation the trainee moves into the examination room with the “patient” to confirm that his or her impression over the telecommunications links are validated in the faceto-face visit. Most participants require only two or three such exercises to become comfortable using the technologies. Disciplines such as psychiatry, where there is less physical contact with patients, predictably require less training. Disciplines, such as cardiology and gastroenterology, which require more intensive use of telemedicine peripherals, require more training time. P99 PERCEPTUAL DISABILITY SCREENING IN AN URBAN UNDERSERVED ELEMENTARY SCHOOL CLINIC VIA TELEMEDICINE Jade S. Schiffman, MD, Jerome Rosner, OD, Gina G. Wong, OD, Laura Kennedy, RN, MSN, LPNP, Laurel Marshall, OD, Regina Adams, CMA, Rosa A. Tang, MD, MPH, Maria Castillo University of Houston, Houston, Texas Perceptual Disorders in children are common. Once a screening exam detects a disability, it can be further analyzed by additional testing. Specialists in interpretation of these tests can then discuss the findings with both the teacher and parents and create a teaching strategy best suited for the individual student. Our experience with the analysis of test results through telemedicine and the interview between parents, teacher and child on-line with the perceptual disability specialist will be presented. Examples of teaching modifications that can be implemented will be discussed. P100 TELENURSING AND TELEMEDICINE: FINDINGS OF A US STUDY OF THE EMERGING PROFESSIONAL ROLE Loretta Schlachta-Fairchild, PhD iTeleHealth Inc., Frederick, MD Telenursing is the use of telehealth technology to deliver nursing care and conduct nursing practice (Schlachta & Sparks, 1999). Telenursing is emerging as a new role. Role stress asociated with new nursing roles impacts individual patients and the larger healthcare organiation, causing turnover, burnout, loss of conti-
nuity of care and loss of operational expertise. As with many emerging technologies, nurses assume increasingly complex roles and responsibilities. As telemedicine proliferates, the role of nurses in operationalizing and improving the telemedicine process will take on more and more importance. It is important to identify issues related to use and integration of telemedicine into nurses’ roles in order for telemedicine to flourish. This presentation reports findings of a descriptive research study, which used a web-based survey of US telenurses (N 196) during Summer 2000. The purposes are to: 1) Describe to telenurses’ professional role(s), characteristics, and US strategies for nurse competence and patient safety. 2) Measure & Predict—telenurses’ characteristics, work satisfaction, role stress, role ambiguity and role conflict. 3) Recommend—strategies for selecting and retaining telenurses for telemedicine programs, companies and healthcare organizations. P101 HOW TO DEVELOP SOUND PARTNERSHIPS FOR SUSTAINING COMMUNITY-BASED TELEMEDICINE SERVICES Deborah E. Seale, MA, Sally Sue Robinson, MD, FAAP, Alexia Green, RN, PhD, Glenda Walker, RN, PhD, Bobby Berg, RN, MSN, PNP, Christina Esperat, RN, PhD, CSFNP, Patty Ellison, MSN, RN, CFNP, Michael Chalambaga, BS, BA University of Texas Medical Branch, Galveston, TX Telemedicine is inherently a collaborative enterprise. There has to be someone on each end of the line willing to place the call and/or answer it. Consequently, the success of telemedicine rests on sound relationships and effective communication. An expert with over seven years experience in developing collaborations and partnerships for telemedicine will share proven techniques for identifying the necessary champions to develop, operate and sustain telemedicine services. Techniques will be shared for building “grassroots” support at the organizational and community levels as well as gaining the support of upper level leadership in the organization and community. This “ground-up,” rather than “top-down” approach assures that once the “deal is sealed,” the leadership understands the risks and the opportunities and the people on the ground floor have the resources and dedication to succeed. Three case studies will be presented in which these techniques were applied and succeeded. One case study involves a regional network of 7 rural hospitals linked to a community college and regional hospital. The second is an academic health center linked to the nursing components in two universities. The third involves an academic health center, two universities and five public schools. P102 TELEMEDICINE IN RURAL GUATEMALA: A CASE STUDY James M. Shanahan, BS, Gerardo Cabrera-Meza, MD, Yadin David, PhD, Larry Jefferson, MD, John E. Kenna, BS, Doug Suell, MD, Nancy Wang, MEd, MA The Center for TeleHealth, Houston, TX One of the great promises of telemedicine is the ability to enhance patient care in rural areas where subspecialty medical resources are less likely to be available. In September, 1999 Texas Children’s Hospital in Houston, Texas, the Fundacion Semillas de Esperanza and the Hospital Infantil de Dr. Gustavo Casta eda Palacios, near Zacapa, Guatemala initiated a telemedicine project in which local physicians at the rural hospital site could submit complex patient cases to sub specialists at the academic medical center. This presentation examines the planning, logistics, opportunities and results of this initiative. Using PC based hardware, store-and-forward software, a digital camera and clearly defined operational protocols, this initiative demonstrates how expertise typically found only at academic medical centers can
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be effectively and economically conveyed to rural and underserved areas where such expertise is sorely needed. P103 RESEARCHING THE FEASIBILITY OF TELEMEDICINE TECHNOLOGY FOR USE IN EMERGENT AND NONEMERGENT ENVIRONMENTS Martha Sheely, RN, BSN, CCM,1 Randall Spears, BS2 1Mercy Home Health Services, Springfield, PA; 2Center for Disaster & Humanitarian Assistance Medicine, Bethesda, MD A rapid response is vital to a patient’s recovery, especially in the first hour after a trauma. Having the ability to fully assess a patient’s condition during that time enables a medical provider to make an expedient decision regarding the provision of care. However, patients are often in remote locations with limited access to onsite health care professionals. Mercy Home Health Services conducted a research project funded by a Federal grant from the Department of Defense to examine the use of remote physiologic data monitors in the non-emergent home care setting. The patient population included CHF and open-heart surgical patients. Medical devices collected vital signs, pulse oximetry, heart and lung sounds, and an ECG. A two-way video camera provided visual contact. Data and video were transmitted through the patient’s phone line using a laptop computer. The research includes an evaluation of the accuracy of data collected compared to the actual home care visit made that day. The level of training required and teaching tools needed for nurses and volunteers will be reviewed. Additionally, the acceptance of this technology by the community and medical profession as an integral part of health care will be discussed. P104 CENTER FOR NATIVE AMERICAN TELEHEALTH AND TELEEDUCATION James (Jay) Shore, MD, MPH University of Colorado Health Sciences Center Department of Psychiatry, Denver, Colorado The Center for Native American TeleHealth and TeleEducation (CNATT) is the telecommunications component of the Division of American Indian and Alaska Native Programs at University of Colorado Health Sciences Center (UCHSC) Department of Psychiatry. CNATT organizes and focuses technological resources for Native American Health from an array of telecommunications services at the UCHSC to offer education, resources, and training. CNATT also monitors impact assessment of these telecommunications services. CNATT facilitates these activities through two services. The first is the Indian Telehealth Network, which is composed of 9 sites in Indian Communities throughout the Western United States. This telehealth network provides consultation/liaison services, distance learning programs, and helps to facilitate rapid communication and linkage between these Indian Communities and the UCHSC. The second is the World Wide Web sites of the American Indian and Alaska Native programs, which offer information dissemination and archive retrieval. These programs are directly relevant to the culturally informed diagnosis, epidemiology, treatment, and prevention of physical, alcohol, drug, and mental health problems that commonly occur among American Indians and Alaskan Natives. The CNATT programs provide an important model of utilizing telehealth to improve services for under served populations. P105 IDENTIFYING UNDIAGNOSED DEMENTIA IN WASHINGTON STATE VETERANS HOMES VIA TELEMEDICINE ASSESSMENT Molly Shores, MD,1,2 Elaine Peskind, MD,1,3 Rhonda WilliamsAvery, PhD,1 Peggy Ryan-Dykes, ARNP,1,4 Bless Mamerto, MD,5
Mercedes Zweigle, MD,5 Pat Palmer, RN,5 James Petrulli, RN,6 Tom Lampe, MD,1 Paul Nichol, MD1 1VA Puget Sound Health Care System, Seattle, WA; 2Geriatrics Research, Education and Clinical Care (GRECC); 3Mental Illness Research, Education and Clinical Center (MIRECC); 4Geriatrics and Extended Care (GEC), Washington Veteran’s Home at Orting; 5Washington Veteran’s Home at Retsil; 6Washington Veteran’s Home at Orting Overview: Dementia is a significant problem in aging, which is frequently unrecognized. Telemedicine assessment for dementia would make specialty consultation available to remote sites, which would likely improve the diagnosis/management of dementia. This study will compare telemedicine and clinical examinations to estimate the reliability of telemedicine in diagnosing dementia and the acceptability and costs of telemedicine versus usual care. Methods: Veterans at two Washington State Veterans homes, who screen positive for dementia and consent to participate, will have a telemedicine examination for dementia. The reliability of the telemedicine assessment will be estimated by comparing it to a clinical examination by a geriatrician who is blinded to the telemedicine assessment. Patients with dementia will be randomized to follow-up via telemedicine or usual care. Referring staff from the outside facility will have access to the computerized medical record system (CPRS) at the tertiary care facility, which includes progress notes, laboratory and imaging data. Results: Reliability of telemedicine diagnosis, staff satisfaction with telemedicine and CPRS, and time and cost of patient care. Baseline data on attitudes of referring staff indicates that 53% have never used CPRS and that 80% have had no experience with teleconferences. Staff expressed frustration with the current referral process, mean score of 2.17 (where 10 high satisfaction) and expressed positive attitudes towards telemedicine, mean score of 3.9 (where 5 most favorable). Outcome data on telemedicine dementia assessments, costs and satisfaction will subsequently be presented. P106 TELEMEDICAL REHABILITATION: AN EMERGING TECHNOLOGY Gordon Silverman, PhD,1 Joseph Brudny, MD,2 Paulette Gage, PhD3 1Department of Electrical & Computer Engineering, Manhattan College, Riverdale, NY; 2Clinical Associate Prof. of Rehabilitation Medicine, New York University School of Medicine, New York, NY; 3PhysMed, Inc., Somerset, NJ Remote delivery of neuromuscular re-education aided by biofeedback has recently become feasible with the confluence of high-speed network technology and low cost computers (PCs). A Local Area Network (LAN) or Internet-based network including a teleconferencing communication channel are configured to enable a therapist to remain in concurrent contact with several patients, supervising their rehabilitation in real time, and provides resources for detailed patient records quantifying functional gains. An array of sensors collects information from each patient and relays it to the local PC for integration and display of attempted, as well as desired movement patterns. The infrastructure includes capability to provide real time feedback for shaping a patient’s motor control of a dysfunctional limb. Feedback facilities include: virtual images of the patient’s limb that mirrors actual movement; oscilloscopic traces depicting target (response goals) and actual responses; and auditory feedback to supplement graphical information. In addition, the system software can be extended to determine the nature of movement disorders, select an appropriate training protocol, and assist in the shaping of the patient’s functional level of performance. The system addresses the challenges faced by the delivery of rehabilitation services—improved evidencebased outcomes at reduced cost.
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P107 OPERATIONAL CONSIDERATIONS WHEN STARTING A TELE-HOME CARE PROJECT: CLINICAL ASPECTS Susan G. Slater, RN, BSN,1 Holly Russo, MS, BS,2 Robert MacDonnell, Esq.1 1Telemedicine Solutions in Healthcare-Pittsburgh Regional Office, Corporate, Atlanta, GA; 2Tele-Health Consultant, Juno Beach, FL Initiating a Telemedicine project within a home care setting takes many hours of research and planning. There are many details, which must be thought through, in order to have a telemedicine program run smoothly. Telemedicine is a great tool to augment the care traditionally provided by the home care agency. The staff will find that the patients are very receptive to this tool, and will love the flexibility telemedicine offers the staff to manage their care. All members of the home care agency team; from the non-clinical support staff to the clinical staff and administrators, need to work together to make this type of project work. It is very important to have a telemedicine philosophy within the organization, to get all of the staff to embrace the project. The program implementation issues that will be discussed are: equipment selection, tracking, and maintenance; staff training, patient training, peripheral device use, documentation, outcome measurements, and coordination of care using a (TCM) telemedicine case manager. P108 CARDIOLOGY NETWORK—PEOPLE AND TECHNOLOGY IN CONCERT Mark Starling, MD VA Ann Arbor Health Care System, Ann Arbor, MI The Michigan VA hospitals recognized the need for significant changes in the care delivery model for cardiac services. With a central tertiary referral site in Ann Arbor, three other major VA hospitals several hundred miles away, and remote clinic locations, roadblocks to streamlined care exist. The lack of information flow, access to care, information, expertise, scheduling, management of reports and images, referrals, consults and transfer processes are problematic. Procedures are often not done at remote sites due to lack of technical expertise, or are repeated at the referral center due to poor image quality, requiring patients to travel. Referral processes are disjointed. Schedules are not widely available. There are problems with availability of images and reports. Inadequate mechanisms are in place for return of patients and appropriate follow-up care and no utilization of clinical pathways or disease management algorithms. Six of the top ten DRGs at the central site are for cardiac conditions. Demographic profiles of the areas surrounding the facilities demonstrated a large underserved population of patients at high risk for cardiac disease. Solutions being implemented: 1) Care navigation: referral procedures, clinical pathways, and disease management algorithms to streamline the continuum of care; 2) Digital connectivity for all cardiac laboratory modalities: ECG, catheterization, echocardiography, electrophysiology, Holter monitor, stress test; 3) Information systems for network-wide use to accommodate scheduling, reporting, image management, notes, CPT coding, billing; 4) Telecommunication systems: telementoring, teleclinic, teleconferencing and telereferral/teleconsultation. P109 TELEMEDICINE IN GREENLAND—PRELIMINARY EVALUATION RESULTS Thomas Stensgaard, MD Nuuk Primary Health Care Clinic, Greenland Home Rule, Nuuk, Greenland In the spring of 1999 a business plan for telemedicine in Greenland was approved. This business plan includes an evaluation
plan describing the extent and kind of evaluation that should be incorporated in the project. The evaluation includes the following criteria: expectations and reactions of the users, satisfaction among patients, logistics, organization and technology, medical outcome, waiting time, travel activity among patients, economy, transferring of competence and recruiting/retaining of staff. The parameters were defined with a view to what answers it seems possible to obtain in the Greenlandic environment, i.e. factors like geography, staff, economy etc. So was also the case with the methods chosen to collect data: questionnaires, logs and interviews. Evaluation appears as a health technology assessment and was developed by an economist, a sociologist and a medical doctor in cooperation, with great an valuable help from the National Center for Telemedicine in Tromsø, Norway. The first results from the evaluation will be presented.
P110 PROTOCOLS FOR E-MAIL TELEOPHTHALMOLOGY: HOW TO ESTABLISH GUIDELINES Rosa A. Tang, MD, MPH, Jade S. Schiffman, MD, Gina G. Wong, OD, Sonali Singh, MD, John Horna, BA, Regina N. Adams, CMA University of Texas Medical Branch at Galveston, Houston, TX Surfing the web for health care information is so common. Use of the Internet in the U.S.A. increased at a rate of 60% from 1998 to 1999. As patients come to rely on e-mail as an essential component of communication, the doctor-patient relationship faces new challenges and new risk exposures. A comprehensive e-mail policy with protocols has been devised and tested in over 50 cases and found to be a useful tool for patient communication strategies to ensure that this technology is used optimally for health care queries is discussed.
P111 RETINAL SCANNING DISPLAY FOR THE MILITARY MEDICAL INFORMATICS PERSONAL DATA ASSISTANT Christine M. Thero, BSEE, MSEE, MBA,1 Gary R. Gilbert, PhD,2,3 John R. Choate, BA1 1Microvision, Inc., Bothell, WA; 2United States Army Medical Research & Materiel Command (USAMRMC), Telemedicine & Advanced Technology Research Center (TATRC), Ft. Detrick, MD; 3University of Pittsburgh Katz Graduate School of Business Force medical protection is the collective effort of the military to improve the survivability of its forces through health services support. Access to immediate information can enable informed medical decisions, reduce the number of errors, and improve health care. Likewise, a medical informatics tool that captures, transmits and analyzes patient information at the point of care can potentially improve immediate diagnosis and treatment, as well as follow up care during evacuation, hospitalization, and convalescent care. Telemedicine technology research aimed at the wireless Personal Data Assistant (PDA) is intended to provide health care providers with real-time access to critical healthcare data via a wireless, personal display, medical informatics tool and to collect more accurate and more timely patient data even at the first responder point of encounter. We present our work in miniaturizing and integrating a daylight readable laser retinal scanning display as a hands-free user visual interface to a military medical PDA. The retinal scanning display system is a very high brightness, “see-through,” highresolution human wearable computer display system. This head worn display enables the user to view electronic information from precise measurement and graphic data to patient records in all lighting conditions without blocking the user’s normal field of vision, and it leaves the user’s hands free to perform patient care.
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P112 USING TELEMEDICINE AND WIRELESS TECHNOLOGY TO IMPROVE DIABETIC OUTCOMES IN POORLY CONTROLLED PATIENTS Robert A. Vigersky, MD,1 Donna Thomas-Wharton, MPA, Doctoral Student,1 Wendy Biddle, PhD, CFNP,2 Amy D. Filmore, CRNP3 1Walter Reed Army Medical Center, Department of Medicine, Endocrinology Service (7D), Washington, DC; 2Old Dominion University, School of Nursing, Norfolk, VA; 3Diabetes Institute, Walter Reed Health Care System Endocrinology Service (7D), Walter Reed Army Medical Center, Washington, DC There are currently over 16 million diabetics in the United States. Diabetes is particularly difficult to control because of frequent fluctuations in blood glucose, requiring frequent (often daily) adjustments in insulin and/or other diabetic medication because of variation in diet, physical activity, and stress. Hemoglobin A1C levels reflect the three month average of blood glucose and are used as clinical markers of effective therapy. We propose using telemedicine technology to more frequently monitor blood glucose levels, make daily therapeutic adjustments, and assess these effects upon hemoglobin A1C levels. Diabetics will record and clinicians will monitor daily blood glucose levels, diet, and physical activity. Clinical responses are specific to current conditions and include menu suggestions and medication adjustments. We are currently studying the efficacy of this telemedicine technology on 600 diabetics from the Diabetes Institute at the Walter Reed Army Health Care Center. Diabetics are randomly assigned to one of three technology groups or a standard care group, which serves as the control. Patients are to be studied for 6months. Patient compliance, Hemoglobin, the number of major and minor hypoglycemic episodes, emergency room visits, hospital admissions, and the development of new diabetic complications will be statistically analyzed for each group. P113 EVALUATING PRACTITIONER ATTITUDES TO TELEDERMATOLOGY John Togno, MBBS FRACGP, Joe Hovel, RN Monash University Centre for Rural Health, Bendigo, Victoria Australia Teledermatology is a technically proven method for supporting remote practitioners in the diagnosis and management of skin conditions. However, there is relatively little evidence of the acceptability of teledermatology by family medical practitioners, dermatologists and their patients. This paper presents preliminary findings on the attitudes of family medical practitioners, dermatologists and their patients based on an evaluation of teledermatology consults in rural areas of Victoria, Australia over a period of three months. These regions have very poor access to face-to-face dermatology services, and the development of teledermatology services that are acceptable to all users is the key to improving access to dermatology services in rural areas. The evaluation takes into account issues including ease of use of digital cameras, the software and hardware required to transmit images, image quality, response times for dermatology opinions and patients’ attitudes to the use of the service for management advice for their skin conditions (with a particular emphasis on cost and time effectiveness). P114 EXTENDING THE GGTS CONSULT BROKER Luis G. Vargas, PhD,1 Jerrold H. May, PhD,1 William G. Jacobs,1 Gary R. Gilbert1,2 1AIM Laboratory, University of Pittsburgh, Pittsburgh, PA; 2United States Army Medical Research & Materiel Command (USAMRMC), Telemedicine & Advanced Technology Research Center (TATRC), Ft. Detrick, MD
At ATA 2000, we described a prototype decision aid to support matching up someone requesting a teleconsultation with someone who could provide the desired assistance. That decision aid, the Consult Broker, was built using data from a teledental system maintained at TATRC. The Consult Broker is to be part of the Global Grid Telemedicine System (GGTS). A key part of the Consult Broker is its naive Bayesian classifier, which extracts from technical medical text information that can be used for the administration and management of the teleconsultation. The naive classifier worked quite well for most areas of dentistry. In this talk, we discuss our experience in extending the Consult Broker’s classifier to general medical problems, using a large (55,000) surgical database. Certain areas of medicine are well served by the same approach that we used for dentistry, but a multi-level approach using the knowledge inherent in the ICD9 and CPT hierarchies is particularly promising. P115 A VIRTUAL SURGERY MODEL: FUNDAMENTALS ON ELECTRONIC ENDOSCOPIC OTOLARYNGOLOGY WEBBASED SCENARIO Jorge Alberto Velez B., MD, SHM, Carlos Alberto Gamboa M., MD Asociacion Internet Salud Y Medicina, Colombia *No abstract available. P116 CONFRONTING COGNITIVE ISSUES IN PHARMACY: CARING FOR DIABETIC PATIENTS Marcia Walker-Guy, RPh, MED Medicognitive Solutions, Inc., Norcross, GA The organization of healthcare has changed over the past two decades. The goals of Pharmacy education have been contoured to meet this change. Historically, the pharmacist’s role consisted of the compounding and dispensing of pharmaceuticals. In response to the demand for a more skilled and knowledgeable pharmacist, the profession embraced the new philosophy and practice of Pharmaceutical Care. Despite this achievement, graduates from most accredited pharmacy schools were equipped with an abundance of facts, but very few skills to apply these facts. According to Spiro et al (1992), cognitive and instructional neglect of problems, related to content complexity, irregularity and patterns of knowledge use leads to learning failures that take common, predictable forms. A feasible instructional strategy that supports the cognitive demands in pharmacy education and practice will transcend those of traditional education. P117 ACCURACY OF STORE-FORWARD TELEDERMATOLOGY FOR DIAGNOSIS OF SKIN NEOPLASMS Erin M. Warshaw, MD, Sandra K. Schmunk, BS, MA, HHSA VA Upper Midwest Network, Minneapolis, MN We report the interim results of a study designed to assess the diagnostic accuracy of store-forward digital images of skin neoplasms as compared to clinic diagnoses using histopathologic findings as a gold standard. While preliminary studies have shown the diagnostic agreement of teledermatologists and clinic dermatologists regarding most dermatologic conditions to be comparable to traditional, clinic-based visits, diagnostic accuracy and agreement of transmitted images of skin neoplasms may be sub-optimal. This project is a comparative study of store forward teledermatology and traditional, in-person encounters using a repeated measures design. Primary endpoint is diagnostic accuracy of skin neoplasms via store forward teledermatology as compared to traditional clinic encounters. Secondary endpoints include diagnostic agree-
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ment and appropriateness of management. In addition, we will evaluate present preliminary findings on teledermatoscopy, the transmission of digital images obtained through a relatively new skin magnification device, for accurate diagnosis of pigmented lesions. Malignant melanoma is one of the most common and deadly forms of skin cancer. Patient survival depends on the identification and removal of early, thin lesions. Any method, which improves patient access to dermatologists or increases the accuracy of melanoma diagnosis, should enable earlier diagnosis, thereby enhancing survival. Evaluation of technological parameters, efficiency, cost-effectiveness and patient satisfaction will also be reviewed. Potential benefits include improving and expediting dermatology consults, reduction of direct and indirect costs, and improved access to dermatology services.
analysis, medical application problem solving, and training data collection methodologies. In addition to being on-demand, the training package must be multi-modality, and capable of customization for specific military mission requirements. The application server design utilized for telemedicine training during medical missions can be applied to civilian telemedicine training efforts.
P118 PATIENT SATISFACTION WITH TELEPSYCHIATRY VS. TRADITIONAL OUTPATIENT PSYCHIATRIC CARE Lydia E. Weisser, DO, Rhonda G. Vought, MD Medical College of Georgia, Augusta, GA
Historically, routine patient encounters accomplished in a deployed tactical environment are undocumented or not properly documented. Inadequate documentation of patient encounters does not provide an accurate visibility for disease surveillance. If all patient encounters were documented during the Persian Gulf War a more complete picture of Gulf War Illness would be available today. The MedSurv module, a component of the Special Operations Medical Diagnostic System (SOMDS) is designed to collect specific data elements at the point of care. MedSurv operates on a hand-held device functioning both synchronously and asynchronously with a centralized database. The utility of a wireless technology platform will increase the likelihood for medics to record field encounters. Once recorded and downloaded to the centralized database, data mining can be easily accomplished. This approach will provide increased disease surveillance during field conditions that effect military readiness. The development of disease surveillance and medical threat analysis in a wide variety of deployed field environments provides a rapid and accurate assessment of the field health care delivery process. Lessons learned can be applied to civilian healthcare: health clinic, nursing homes, home health and patient transport.
Patient satisfaction with outpatient treatment is often a concern even with traditional methods of healthcare delivery. Over the past 3 years, the Georgia Statewide Telemedicine Program has developed an on-going relationship with several rural sites to provide continuity telepsychiatry clinics. These sites are located in Wrightsville, Athens and Warrenton, Georgia, where the populations served are primarily adult; however, there is also a Child/Adolescent clinic based in Waycross. Although patients have directly and indirectly expressed a high degree of satisfaction with the level of care received, until now no formal attempt has been made to measure patient satisfaction with telepsychiatry vs. conventional psychiatric outpatient care. A questionnaire was developed by incorporating elements from the Mayo Clinic Patient Satisfaction Survey and the McLean Hospital Perceptions of Care Survey. Additional elements specific to the telemedicine experience were added. This survey was administered to approximately 50 outpatients (or their parents) at the various sites. Although data collection is on-going at this time, preliminary results indicate that patients perceive their care to be at least equal to that delivered by more traditional methods. New patients as well as returning patients were included in this survey. P119 ON-DEMAND TRAINING FOR DEPLOYED TELEMEDICINE APPLICATIONS Col. Warren Whitlock, MD, FACP, LTC Phylanne Prince, RN, Ed Kensinger; Gary Gilbert, PhD Center for Total Access, Fort Gordon, GA In a deployed military environment, telemedicine provides information management for essential tasks of medicine, including clinical documentation, medical evacuation and identification of medical threats. The use of medical applications within a deployed environment has a demonstrated need for integrated training of military medical personnel. Cobra Gold 2000, a joint military exercise simulation of a humanitarian relief effort, utilized a 6-point network where hardware, communications, and software applications were evaluated under field conditions. Prior to deployment, training on the telemedicine applications took place at four different locations and was rated highly successful. During the exercise, problems were encountered included configuration and incompatibility errors. These errors resulted in limited WAN and LAN access. Only 14% of the participating medical personnel completed pre-deployment training of telemedicine equipment. Telemedicine skills require training for topics including: network security, authentication, network applications, technical
P120 SPECIAL OPERATIONS MEDICAL DIAGNOSTIC SYSTEM (SOMDS): SYNCHRONOUS DISEASE SURVEILLANCE USING A WIRELESS APPLICATION Col. Warren Whitlock, MD, FACP, Ron Packard, Gary Gilbert, PhD, COL Stephen Yevich, MD Center for Total Access, Fort Gordon, GA
P121 HOME-BASED PILOT PROGRAM MONITORS: EFFECT OF AN INTERACTIVE TELEHEALTH DEVICE ON MANAGEMENT OF HEART FAILURE Neil Mehta, MD, Sandra Wilkinson, RN, Christine Pierce, RN, CS, MSN, Robert W. Mobley, Sharon Plona, RN Cleveland Clinic Home Care, Valley View, OH Heart failure is the nation’s most rapidly growing cardiovascular disorder and places a substantial financial burden on the health care system. Home health care has become an increasingly popular venue of care for the management of this chronic illness. Statistics published by the National Association of Home Care identify Heart Failure as the most common admission diagnosis for patients age 65 and older. Non-compliance with the medical plan of care is a well-documented factor in exacerbation of symptoms and rehospitalization. This pilot will utilize a home-based, interactive, electronic device as a supplement to usual patient care, to address key areas of the patients’ self-care. Data entered by the patient is viewed remotely by the nurse. The pre-programmed, portable device electronically communicates with the patient to integrate: patient teaching, symptom recognition and reporting, and timed medication administration reminders. In addition to numerous pragmatic observations, the intervention group will minimally be compared to patients receiving standard care for the following empirical data: 30 and 60 day rehospitalization rates, compliance with weight monitoring, and reported medication compliance. This pilot is designed with a limited
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sample size to evaluate the feasibility and potential value of implementing a large-scale study of statistical significance. P122 STEREOSCOPIC DIGITAL IMAGING AND ITS IMPACT ON GLAUCOMA SCREENING AND MANAGEMENT VIA TELEMEDICINE Gina Wong, OD, Jade S. Schiffman, MD, OD, Regina Adams, CMA, Rosa A. Tang, MD, MPH University of Houston, Houston, TX Glaucoma is one of the most common causes of blindness and often does this silently until the disease is end stage. Screening for glaucoma is difficult because to do so, one needs an excellent stereoscopic image of the nerve that can be done reliably and be performed by a non-eye care professional in underserved sites. A new digital stereoscopic camera, the Discam, allows this to happen. This camera will be compared with standard 35 mm stereoscopic images as well as the face-to-face exam. Stereoscopic digital images with the Discam, allow screening and management of glaucoma through telemedicine. P123 BRINGING MEDICAL INFORMATION ASSURANCE INTO FOCUS FOR YOU Willie Wright, MBA1,2 1United States Army Medical Research & Materiel Command (USAMRMC), Telemedicine & Advanced Technology Research Center (TATRC), Ft. Detrick, MD; 2SRA International Inc., Ft. Detrick, MD What happens when we come face-to-face with unlimited information and computing power at the same time that the very notion of knowledge as an intangible is being challenged? The Department of Defense Medical Services finds itself answering this question as it pertains to information assurance, after identifying that the nation’s critical infrastructure needs protecting. Although the process and the connections that convert information to knowledge reside principally in people’s minds, the tools they use to make those connections—and the way in which they organize the information necessary to support their decisions—reside at the desktop. Therefore, these tools can easily be made part of a corporate memory. While not a panacea, the aggregation of information sources provides added value by capturing the connections that make up the value basis for most knowledge workers’ environments. Risk Management Information Resource (RIMR) then become the foundation for starting to reverse the brain drain process. The RIMR project expects to be proactive and make knowledge accessible to all and not await the fate of the silent brain drain. What’s RIMR? RIMR—knowledge management system that provides a systematic process for acquiring, creating, synthesizing, sharing, and using information, insights, and experiences to achieve organizational goals. P124 TELEPATHOLOGY FOR ORGAN TRANSPLANTATION* Yukako Yagi University of Pittsburgh Medical Center, Pittsburgh, PA *No abstract available. P125 E-PUBLISHING—THE PROVISION OF HIGH QUALITY HEALTH INFORMATION ON THE INTERNET Peter Yellowlees, MD, BSc, MB, BS, FRANZCP, MRC (Psych) MAPsS, MRACM University of Queensland, Brisbane, Queensland, Australia
One of the many revolutionary aspects of e-health concerns epublishing on the internet. The author has published two ebooks, one by self publishing at www.mightywords.com, and the other through a traditional academic publisher, The University of Queensland Press at www.uqp.uq.edu.au. This paper will review various aspects of e-publishing, including the process of writing for the internet, which is very different from conventional writing, the need for a strong customer focus, the inclusion of multi-media into text, and the extra flexibility allowed by the facility to change publications, and update them easily. The implications of the e-publishing revolution in health will be discussed from a perspective of patients, clinicians, authors and publishers and the way in which e-publishing will become a vital part of e-healthcare delivery in future years will be described. P126 TELEMEDICINE IN BANGLADESH: A COMPREHENSIVE APPROACH TO OVERCOME BARRIERS TO INTERNATIONAL TELECONSULTATION Sikder Zakir, MB, BS Telemedicine Reference Center Ltd., Dhaka, Bangladesh Bangladesh is under-served both medically and technologically, which is further worsened by lack of telecommunication infrastructure. The introduction of telemedicine system and services is occurring in four phases. Phase I was completed with extensive research of the system keeping in view the barriers those exists in developing countries. Phase II included detailed study, appropriate configuration and outsourcing of telecommunication, equipment and medical resources. Phase III concluded by educating concerned professionals in the systems and its outcome. Phase IV involves setup of the system and start of USBangladesh teleconsultation. This presentation gives a clear picture of every phase with definition of barriers and possible cost-effective solutions. The detail study report was prepared for Telemedicine Reference Center Ltd., which includes: 1) technology assessment and evaluation, 2) telecommunication infrastructure deficiencies and solutions, 3) equipment outsourcing, 4) response of medical professionals, 5) needs assessment, 6) defining categories and types of international teleconsultation and costing, 7) response of the government machineries, 8) development of US-Bangladesh joint physician teleconsultation programs, 9) reimbursement methods, 10) business plan and 11) implementation procedures for rural and international teleconsultation systems. Based on the report Telemedicine Reference Center Ltd. is introducing cost-effective telemedicine system in Bangladesh on January 25, 2001. P127 A COMPARISON OF THE IRREVERSIBLE DCT AND WAVELET COMPRESSION ALGORITHMS APPLIED TO MEDICAL IMAGES Yongguo Zhao, PhD, Isao Nakajima, MD, PhD, Hiroshi Juzoji, PhD Tokai University Medical Research Institute, Nakajima Laboratory Boseidai, Isehara, Kanagawa, Japan Objective: JPEG 2000, the next ISO/ITU-T standard for still image coding, is about to be finished. Wavelet transform is the core strength of the new standard. This paper evaluates the performance of JPEG 2000 irreversible compression algorithm by comparing with the original JPEG standard. Image quality properties including the NMSE and PSNR were assessed, and the impact of JPEG 2000 coding algorithm was analyzed. The principles behind the wavelet-based JPEG 2000 were briefly described and an outlook on the application in medical imaging was discussed. Material and Methods: Ten grayscale radiographs and ten color pathologic images were digitized, compressed, and decom-
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pressed by both the original JPEG standard and by using a java implementation of JPEG2000 encoder/decoder developed by the JJ2000 group. The NMSE and PSNR of the images compressed by JPEG and JPEG 2000 algorithms were calculated at various compression rates. The results were plotted respectively and compared with each other. Results and Conclusion: It was found that JPEG 2000 irreversible compression algorithm can achieve higher compression efficiency with less error rate. There is a true improvement in the performance of the new standard. The results of this initial experience pave the way for further observer performance studies.
P128 TELEMEDICINE IN DEVELOPING COUNTRIES: ACTIVITIES OF STUDY GROUP 2 OF THE IUT DEVELOPMENT SECTOR (IUT-D) Yongguo Zhao, PhD, Isao Nakajima, MD, PhD, Hiroshi Juzoji, PhD Tokai University Medical Research Institute, Nakajima Laboratory Boseidai, Isehara, Kanagawa, Japan
The International Telecommunication Union (ITU) has been actively promoting the wide application of telecommunication solution in areas such as healthcare and education. It has set up a number of pilot projects involving telemedicine throughout the world. The ITU also sponsored the First World Telemedicine Symposium for Developing Countries in Cascais, Portugal on 30 June–4 July 1997, and the Second Symposium held at Buenos Aires, Argentine on 7–11 June 1999. Both were with great success.Within the ITU-D Study Group 2, the Rural Application Focus Group (Topic 7) headed by Mr. Yasuhiko Kawasumi and its Tele-Health and Tele-Medicine Discussion Group chaired by Professor Leonid Androuchko is working on providing recommendations and guidelines on telemedicine for developing countries. This paper highlights current activities with regard to telemedicine in and for developing countries. It reviews the current agendas on telemedicine of the Rural Application Focus Group within Study Group 2 of the ITU. The special features and obstacles to deploy telemedicine in developing countries are analyzed and the feasible approaches based on successful cases are suggested.
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