225
Telehealth Unbound:  From Home Health Care To Population Based Care
Bonnie P. Britton, MSN, RN-C,  April Hoggard, RN         
Roanoke Chowan Community Health Center, Ahoskie, NC
Roanoke Chowan Community Health Center (RCCHC) implemented a unique and innovative “Patient Provider Community Telehealth Network” in September 2006. The focus of this presentation is to demonstrate heath care links between primary care providers and the continuity of patient care in the private home setting. Continuous care is also given by the way of individual monitoring in three senior centers, a fitness/wellness center, and the county middle school. Also, highlights of an innovative population based disease management prgoram and evaluation of patient data including financial outcomes will be explained. Monitoring patients daily or weekly combined with population based disease management has resulted in the following year 1 outcomes: 152 cardiovascular, diabetes and obesity patients have participated in outpatient case management utilizing in-home daily monitoring and weekly kiosk monitoring, increased self-care, increased compliance to the medical regimen, and the in-home monitoring financial savings are quite significant and encouraging.  To date, patients experienced a 92% decrease in hospitalizations; 67% decrease in emergency room visits, and total health care costs were decreased by 93%. This presentation will discuss clinical and financial outcomes for targeted patients for an 18 month period of time.

154
Resistance to Videophone Adoption: Underutilization of the Telehospice in Mid-Michigan Project
Pamela Whitten, PhD,  Emily M. Meyer, MA,  Bree E. Holtz, MSc       
Michigan State University, East Lansing, MI
INTRODUCTION: The Telehospice in Mid-Michigan project provides videophone services to individuals receiving care from a home hospice program.    Researchers from Michigan State University partnered with two service providers in the Lansing area to promote innovative services for those receiving end-of-life care.  However, major organizational and communication complications emerged, as nurses were not offering videophone services to individuals on their caseload.  The present paper explores the barriers encountered, and provides recommendations for future research in the field, including how to navigate the organizational / communication context in which new technology is introduced to an existing health infrastructure. OBJECTIVE:  The main objective of this paper is to provide an in-depth description of the adoption of videophones in home hospice services.  Researchers cannot determine overall impact until the issues providers face during implementation and application of Telehospice technologies are first addressed. METHODS: Surveys were conducted with both participating organizations.  Two instruments were integrated to document nurses’ technology acceptance, utilization, and organizational climate.  As such, the Unified Theory of Acceptance and Use of Technology (UTAUT) and an adapted version of the Organizational Readiness for Change instruments were administered.  Interviews lasted twenty-five minutes, providing insight into the hospice work environment as well as willingness to accept videophones into existing protocols. RESULTS: Despite nurses’ agreement regarding willingness to incorporate the videophone into their organizational infrastructure, overall behaviors contradict this statement.  Results indicate a tension between verbal acceptance and adoption, thus impacting the eventual implementation and utilization of the device.  Despite willingness to participate in the project, existing tension, fear of change, and hesitance to apply a new technology still exists.  Therefore, implications of this study are significant; as the telemedicine field continues to evolve, researchers must first address challenges at the organizational level.  To begin this process, implications for future work are provided, along with a list of best practices.

377
Universal Service Support for Rural Health Care
William L. England, PhD, JD, PE,  Daniel H. Johnson, MA,  Pamela C. Byrd, MS,  Camelia L. Rogers, MPP     
Universal Service Administrative Company, Universal Service Administrative Company, Rural Health Care Division, Washington, DC
The Universal Service Rural Health Care program supports health care telecommunications and Internet access for eligible rural health care providers, as provided by the Federal Communications Commission’s (FCC) Universal Service Order under the Telecommunications Act of 1996.  Beginning with $3.4 million in support for 483 rural health care providers in 1998, the program has grown 25% annually to support over 2,800 health care providers at nearly $50 million for Fund Year 2006.  That does not include a special “Pilot Program” implemented by the FCC in 2007 to create new rural health care networks, which more than doubled health care provider participation in Universal Service programs.  (A separate report will be given on the Pilot Program).  This presentation will focus on program issues such as provider eligibility, the FCC’s definition of rural eligibility, service coverage, the application process, beneficiary audits, and recent program changes including a Universal Service Fund Management Order adopted by the FCC in 2007 to increase safeguards against program waste, fraud, and abuse and to improve the management, administration, and oversight of Universal Service Funds.  This presentation will also report program statistics and changes to enhance the application and support process.

412
Virtual Visits in General Medical Practice- A Randomized Trial
Ronald F Dixon, MD, MA,1,2,5  James Stahl, MD, MPH,1,3,5  Joseph Kvedar, MD1,4       
1Massachusetts General Hospital, Boston, MA; 2Center for Integration of Medicine and Innovative, Boston, MA; 3Institute for Technology Assessment, Boston, MA; 4Center for Connected Health, Boston, MA; 5Harvard Medical School, Boston, MA
Purpose: The purpose of this study is to investigate the feasibility, effectiveness and acceptability of a virtual visit (patient-physician real time encounter using videoconferencing technology) in comparison to a face-to-face office visit in the general medical setting. The 4 broad aims of the study were: 1) to compare the physician’s ability to diagnose in both settings, 2) to compare the physician’s ability to treat in both settings 3) to examine patient and physician satisfaction with both modalities, and 4) to examine patient attitudes towards payment and insurance coverage for these services. Methods: 130 patients were recruited from a general medical practice to take part in the study.  Four physicians took part in the study. Patients were interviewed and examined in both face to face and virtual settings with the order depending on randomization. Both patients and clinicians were surveyed after each visit type with regard to quality of the history, quality of the exam and satisfaction with the experience. Results: Descriptive statistical analysis using two tailed t-tests and ANOVA were performed. Patient and physician satisfaction of the virtual visit was high. Diagnostic and therapeutic effectiveness was similar in both visit modalities.  Both patients and physicians felt comfortable using the technology. Conclusion: Results suggest that both patients and physicians find the virtual visit a useful alternative to the traditional ooffice visit for many common medical conditions.  This has significant implications for the general medical practice. Patients may benefit from reduced opportunity costs associated with physician visits and clinicians may benefit from decreased overhead costs. This visit modality may provide one of the solutions to the access problems facing many primary care practices.  Integration of this visit modality into an active general medical practice is currently in progress.

263
Effect of Wireless Monitoring on CPAP Adherence and Treatment Efficacy
Carl J Stepnowsky, PhD,1,2  Joe Palau, BA,1  Tania Zamora, BA,1  Matthew Marler, PhD1     
1VA San Diego Healthcare System, San Diego, CA; 2UCSD Department of Medicine, San Diego, CA
Introduction: CPAP is the gold standard treatment for OSA and it is generally accepted that adherence to CPAP can be substantially improved. A key advantage to using CPAP is its ability to objectively measure and store both treatment efficacy and adherence data. Unfortunately, under usual and customary care, there is a time lag ranging from days to weeks between adherence data collection and data availability to care providers. Methods: This was a randomized, controlled trial of usual care compared to a telemonitoring intervention, in which adherence data were wirelessly transmitted directly and accurately to a remote server/database in 24hr cycles. The data were then accessible to system-authorized care providers. Wireless telemonitoring allowed for the increased speed and frequency with which each patient’s nightly CPAP adherence level and efficacy data were available and knowable to care providers, enabling early intervention in the treatment initialization process. Results: Forty-one patients diagnosed with OSA and prescribed CPAP attended were studied. Mean age=59 and mean baseline AHI=39. Nightly CPAP adherence measured over the 2-mo follow-up period was 4.0±1.9 and 3.0±2.4 hrs/night for the telemonitoring and usual care groups, respectively. The telemonitored group had lower mask leak levels than the usual care group (.35±.20 vs .49±.47). Conclusions: Telemonitoring has the potential to be an effective and practical way to improve CPAP adherence and efficacy. Key advantages of telemonitoring CPAP efficacy and adherence data are that the information is objectively measured and easily accessible to providers, enabling them to intervene early in the treatment process to help patients better manage their OSA by helping to establish optimal and enduring patterns of CPAP treatment adherence.

457
Recorded and Reviewed Telepsychiatry Consultations: Improving Diagnosis and Enhancing Teaching
Terry Rabinowitz, MD,1,2 Judith Amour, MA,1 Harry Clark,2 Tara Pacy, MSN,2 Stephen Taylor,2 Michael Wehner2
1University of Vermont College of Medicine, Burlington, VT; 2Fletcher Allen Health Care, Burlington, VT
A primary aim of our Telemedicine (TM) Department is to examine existing technologies or to develop new ones to improve TM consultation, treatment, and outcome quality, or to enhance educational objectives.  To this end, with appropriate permissions, we record and archive most of the initial and follow-up telepsychiatry consultations performed for nursing home (NH) residents.  Recordings include interactions among the resident, psychiatrist, distant care team members, and family/guardian.  Recordings are reviewed by the consulting psychiatrist for quality assurance purposes.  In addition, he or she may request opinions from colleagues for complex cases, and can use the recordings for teaching.  The opportunity to obtain a “second” or more opinion has often led to improved accuracy in diagnosis of many conditions including mood, anxiety, and personality disorders, dementia, delirium, and psychotropic medication-induced side effects, broader differential diagnoses, and has proven very effective in demonstrating the technique to others and to their decreased resistance to adopting a videoconference approach to delivering psychiatric care.  Moreover, it is a very effective teaching instrument that can demonstrate many signs and symptoms (e.g., affect, tearfulness, tardive dyskinesia) at higher magnification or with better resolution than would occur face-to-face.  In addition, the recordings can be reviewed as often as desired, without additional patient or staff burden.  A literature search found few reports describing the use of recorded TP consultations for these or other purposes—a surprise considering the ease, negligible added burden, and relative low cost of recording these sessions.  This talk will discuss the many advantages associated with recorded TP consultations, the equipment used, costs, barriers to implementation, and privacy issues, and will include brief recorded clips to demonstrate the technique, with the expectation that it will lead to more widespread use of this valuable application.

387
An Update on Universal Service Support for Rural Health Care Providers
William L. England, PhD, JD, PE,  Daniel H. Johnson, MA,  Pamela C. Byrd, MS,  Camelia L. Rogers, MPP     
Universal Service Administrative Company, Washington, DC
In August 2007, the Federal Communications Commission adopted an Order for Comprehensive Review of Universal Service Fund Management, Administration, and Oversight.  The Order was written to increase safeguards against program waste, fraud, and abuse and to improve management, administration, and oversight of Universal Service Funds.  This presentation will report on measures created by that Order that pertain to the Rural Health Care program.

97
Measuring the Value of TeleHome/Monitoring Services
Dena S. Puskin, ScD,  Monica Cowan, BA,  Carlos Mena, MBA       
Health Resources and Services Administration, Rockville, MD
In 2006, HRSA awarded grants to three home health agencies to systematically study the cost-effectiveness of tele-monitoring and tele-home health services.  Over the first 18 months of the program, HRSA staff worked with these grantees to develop uniform measures of performance related to the cost and clinical outcomes of the services rendered.  This session will discuss the process that led to the measures adopted, the challenges in data collection, and the preliminary outcomes from the pilot efforts to date.  Implications for reimbursement policies will be discussed as well as the potential for expanding this effort to other home health providers.

269
What Digital Slides Promise to the Education Community
S. Joseph Sirintrapun, MD,1,2  Ann Cecil, MS,2  Thomas Harper,1  Jonhan Ho, MD,1,2 Jeffrey Fine, MD,1,2 Leslie Anthony, MA,2 Anil V. Parwani, MD, PhD,1,2 Drazen M. Jukic, MD, PhD1,2 
1University of Pittsburgh, Pittsburgh, PA; 2University of Pittsburgh Medical Center, Pittsburgh, PA
Background: At the University of Pittsburgh Medical Center (UPMC), there are multiple hospitals located several miles apart.  Because of these geographic logistics, the educational use of glass slides has been difficult.  Capturing glass slides digitally became the solution to providing availability.  The educational slides are viewable at any computer and at any institution associated with UPMC.  Users include medical students, pathology residents and fellows, and pathology faculty.  Design and Technology:  The educational teaching slides were scanned and captured on the Trestle DSM or Aperio ScanScope System and stored on a SAN server.  All digital slides are de-identified.  Digital viewers include Trestle’s Java viewer and the proprietary ImageScope.  Results:  Approximately 5000 digital slide images have been scanned and collected.  Each digital slide has the capability of annotation with case history and diagnosis thus simulating a question and answer format.  Other annotations are possible, marking key histologic features which aid in the training of an inexperienced eye.  Even the distribution of unknown slides can be made available without the need for multiple recuts, loss of material, or transportation hindrances.  Conclusions: Our repository of digital slides provides a superior educational tool to traditional static “snap shot” images that make up the majority of current education anatomic pathology image repositories.  Digital slide images go beyond the traditional static image because the entire slide is captured digitally and therefore simulates the reality of evaluating a glass slide.  Skills such as screening, finding the essential areas of interest, and knowing how to navigate through a slide are simulated on a virtual basis.  With static images, because the areas of interests are immediately shown, these key intangible skills are lost in the learning process.   Our repository of digital slides has proven invaluable and has enhanced our commitment to education in pathology.

459
Home Telehealth's "Second Life": The Role Health AVATARS WILL PLAY IN THE WEB 2.0 WORLD
Susan L. Dimmick, PhD
University of Tennessee Health Science Center, Memphis TN
This presentation reports the results of a survey of health institutions and businesses that live and operate in the virtual world called Second Life. This virtual space is a Web 2.0-enabled world with 8.9 million residents. Avatars are the representations of oneself on the Internet generally and in Second Life specifically. The survey categories institutions and businesses into: government; not for profit; for-profit; healthcare marketing; and innovators, those types of entities that defy typical categorization. Federal government institutions, such as CDC, NASA and NOAA, all reside there. More than 100 education institutions, both land grant (e.g. University of North Carolina at Chapel Hill), and the ivy leagues (e.g., Harvard), have bought space and are using Second Life to host lectures and projects online. Additionally, the National Defense University is putting together a consortium of federal agencies to increase the federal presence in Second Life. Non-profits in Second Life include the American Cancer Society (ACS). Its virtual office “serves a number of purposes including an interactive cancer information resource center, a venue for peer support groups, as well as a headquarters for in-world event planning.” ACS runs its Relay for Life in Second Life. Virtual Hospitals represented include the Ann Myers Medical Center, which “assists students to become more proficient in initial exam history and physicals and to become more proficient in the analysis of MRIs, CTs and X-rays.” Predictions are that there will be “virtual medical homes”; hospital guardians; exercise coaches and health advocates. Telehealth has a role to play in this virtual space, which is predicted to be the way that users will navigate the Web 2.0 world.

205
Introduction and Advantages of Implementing USB Personal Healthcare Device Class
Julie Fleischer1,2,3            
1Intel Corporation, Beaverton, OR; 2Continua Health Alliance, Beaverton, OR; 3USB Implementers Forum, Beaverton, OR
In April 2007, the Universal Serial Bus Implementers Forum (USB-IF) formed a Personal Healthcare Device Working Group whose charter was to enable seamless interoperability between consumer electronic devices and personal healthcare devices via USB.  In support of this charter, the group released a Personal Healthcare Device Class (PHDC) at the end of 2007.  The PHDC targets use cases in three areas.  Health and Wellness use cases enable users to send data from fitness devices, such as exercise watches, to collection and analysis devices, such as PCs or cell phones.  Disease Management use cases allow individuals with a chronic condition to send data from disease management devices, such as blood pressure monitors or glucose meters, to devices such as health appliances.  Aging Independently use cases involve sending information from USB devices that monitor daily living, such as motion sensors, to USB hosts, such as PCs.  In all use cases, caregivers can have access to the data collected on USB hosts in order to help an individual maintain their health.  The PHDC defines a mechanism by which standardized data, such as ISO/IEEE 11073-20601 data, can be transferred over USB.  This presentation will discuss the features of the USB Personal Healthcare Device Class, and it will provide information on how to create a USB host or device that is compliant to the device class.  It will also provide information on the qualification process for USB personal healthcare devices.  Finally, it will provide information on the ecosystem of companies that support the PHDC and discuss the advantages these companies expect with implementing the USB Personal Healthcare Device Class.  These include faster time to market, the ability to focus on core-competencies, and the ability to leverage multi-company expertise, among others.

209
Lessons Learned: Developing a scalable Chronic Disease Model for Ontario
Laurie Poole, Ken McVey, BSee, MBA         
Ontario Telemedicine Network, Toronto, AL, Canada
Ontario has just launched a telehomecare initiative to serve patients with congestive heart failure (CHF) and/or chronic obstructive pulmonary disease (COPD). This 18-month initiative is to be the first phase of a much larger roll-out of telehomecare services. The Program is a time limited intervention designed to enhance patient self-management skills and improve patient health status. Even as a first phase, the initiative was particularly challenging from a technical services perspective as it must be built to support up to 600 patients spread over vast geographical distances. Starting in the fall of 2007, patients are to be cared-for using an integrated care model based on Ontario’s Family Health Teams (FHT). At their homes, patients would use biotelemetry devices such as Peak Flow Meter, Pulse Oximeter, Weight Scale, Blood Pressure Monitor and Heart Rate monitor , in a few cases, videoconferencing, to capture and transmit vital signs and health status to one of  six nurses working at FHT’s. These six nurses would coordinate the tradition care delivery protocols with the new telehomecare protocols. All FHTs would lever the same centralized applications, training services and technical support. The program is based on a a collaborative model of care delivery that focuses on the needs of the patient and the patients capacity to self-care. The family Health Team will play the central role in collaboration with local Community Care Access Centres. The Program includes a comprehensive provider education component, which is designed to ensure that all members of the care team, including the Telehomecare RN have the skills and competencies necessary to delivery quality telehomecare services. The patient will meet with the Telehomcare RN to develop a customized treatment plan. This Project will demonstrate the potential impact to improve quality of care for  CHF and COPD patients.

249
Telepsychiatry Implementation in Rural Geropsychiatric Care
Robert N. Cuyler, PhD        
Diamond Healthcare, Houston, TX
Dr. Cuyler will focus on selection and budget of video conference equipment for hospital and physician office applications as well as on the variety of IP based choices for connectivity.  He will address the advantages and disadvantages of Hospital T-1, DSL, cable internet, and wireless options.   Lessons learned from  multiple installations will include coordination of equipment vendor, hospital IT department, ISP and support team.  Dr. Cuyler will focus on key ingredients necessary to developing a tele-psychiatry program that is sustainable without reliance on grant funding.

471
FEDERAL PUBLIC POLICY UPDATE – THE IMPACT ON TELEMEDICINE
K. Reeder Franklin, 1 Nina Antoniotti, RN, MBA, PhD, 2 Neal Neuberger, CISSP3
1American Telemedicine Association, Washington, DC; 2Marshfield Clinic TeleHealth, Marshfield, WI 3Health Tech Strategies, LLC, McLean, VA
This session will give an overview of what’s going on in public policy regarding telemedicine with an emphasis on how these events will impact telemedicine in the real world.  Discussions will include: potential to expand telemedicine reimbursement, increasing CPT codes reimbursed for telemedicine, and opportunities and challenges with health IT legislation. 

42
Primary Care Telemedicine For Remote Prisons With Chronic Staffing Shortages
Charles D. Adams, MD, MPH,  Stephen Smock, MBA,  Gary J. Eubank, RN, MSN       
University of Texas Medical Branch Correctional Managed Care, Galveston, TX
A major challenge facing many prison systems is ensuring that offenders continue to receive adequate health care despite chronic shortages of correctional physicians and other medical providers. Staffing shortages are especially prominent in prisons located in rural communities. The University of Texas Medical Branch (UTMB) has utilized telemedicine to provide specialty and subspecialty medical consultations for offenders incarcerated in remote units of the Texas Department of Criminal Justice since 1994. Because of the long-term success of the UTMB telemedicine program in providing specialty care, we hypothesized that our extensive correctional telehealth network (UTMB Digital Medical Services) also would be useful in augmenting primary medical care services in prison units experiencing either chronic or short-term healthcare staffing shortages. A 5-month pilot project to test our hypothesis was launched in 2006. Several remote prisons with existing shortages of primary care providers participated in the project. Healthcare personnel at these locations received training in telehealth technology and in serving as “presenters” for the telemedicine clinics. Primary care consultations were provided by UTMB mid-level providers (physician assistants and nurse practitioners) operating from a central telemedicine site. Requests for primary care consultations from the prisons were scheduled via a central coordinator to maximize the number of daily telemedicine visits.  During the project, 941 provider hours were expended in conducting 5,321 telemedicine visits, yielding an average of 6 visits per hour at an average cost of $8.58 per visit. Total cost for the telemedicine provider salaries study was $48,460 (monthly cost of $9,692), in contrast to an estimated cost of $177,348 in salaries for contract providers. The availability of telemedicine services also resulted in more timely access to medical care for offenders.  These preliminary results indicate that telemedicine is an effective means of augmenting primary health care services in remote prisons with on-site staffing shortages.

248
Patient Assessment of Physician-Patient Communication during Telemedicine versus In-Person Consultations
Zia Agha, MD, MS,1,2  Ralph Schapira, MD,3,4  Prakash Laud, PhD,4  Gail McNutt, MD,3,4 Debra Roter, PhD5    
1VA San Diego HSRD, San Diego, CA; 2University of California, San Diego, San Diego, CA; 3VA Milwaukee, Milwaukee, WI; 4Medical College of Wisconsin, Milwaukee, WI; 5Johns Hopkins School of Public Health, Baltimore, MD
Introduction: The quality of physician-patient communication is a critical and predictive factor of treatment outcomes, including patient satisfaction with care. To date, there is little research to document the effect of telemedicine videoconference on communication in the medical setting. Our aim was to determine whether the physical separation and use of technology during telemedicine have a negative effect on physician-patient communication. We conducted a noninferiority RCT of 221 patients at the Milwaukee VA Medical Center. Patients from pulmonary, endocrine, and rheumatology clinics received consultative care with one of 9 physicians, either in person (IP) or via telemedicine (TM). Physician-patient communication was measured using the “Patient Assessment of Communication during Telemedicine” (PACT), a validated self-report questionnaire. Results: We randomly assigned 221 subjects to receive TM (n = 111) or IP (n =110) visits. Noninferiority t-statistics were calculated using a linear mixed model while accounting for any clustering by physician factor. The total patient satisfaction score was higher for TM than for IP visits (192 versus 185.3, p = 0.02). The null hypothesis of inferiority (i.e., TM is inferior to IP), using an inferiority margin of 0.5 SD, was rejected (p = 0.001). Patient satisfaction with physician’s Task-Directed Skills, Interpersonal Skills, Attentiveness, and Emotional Support were similar for TM and IP groups (inferiority null hypothesis rejected p = 0.001). Patients reported higher satisfaction with Shared Decision Making (p = 0.025) and the convenience of TM (p = 0.001) as compared to IP visit.  Conclusions: Telemedicine did not have a negative effect on physicians’ communication skills. Patients were satisfied with their physician’s ability to develop rapport, use shared decision making, and promote patient-centered communication during TM consultations. While encouraging, these results need validation in different populations and settings. Further validation, including correlation of satisfaction data with content analyses of study visits, is underway.

261
Evaluation Results for a Collaborative Digital Slide Quality Assurance Study
Russell Silowash, BS,1  Robb Wilson, MA,1  Dana Grzybicki, MD, PhD,1  Leslie Anthony, MA,2 Robert Zalme, USAF, DC3    
1University of Pittsburgh, Pittsburgh, PA; 2University of Pittsburgh Medical Center, Pittsburgh, PA; 3Keesler Medical Center, Biloxi, MS
Whole Slide Imaging (WSI) is becoming a popular diagnostic tool for pathology. Quality Assurance (QA) practices strive to insure quality in patient care and service. Through funding by the Integrated Medical Information Technology Systems (IMITS) program, the University of Pittsburgh Department of Biomedical Informatics Evaluation Team assessed the feasibility, utility, and effectiveness of WSI-QA within the University of Pittsburgh Medical Center and the United States Air Force Medical Service (AFMS) communities.  Questionnaires were completed before and after the study in order to record participant perceptions and experiences with pathology workflow processes focused on WSI-QA. Case and slide surveys evaluating diagnostic agreement, image quality, case complexity, diagnostic confidence, and other properties were also collected during this study.  Study participants used a novel electronic data collection tool to enter information about 30 randomly selected cases (202 slides).  The Evaluation Team provided a detailed analysis of WSI through qualitative and quantitative data collection techniques.   Findings may facilitate successful implementation of digital technologies into current clinical pathology practices at UPMC and the AFMS.  Results from the questionnaires and surveys will be presented. 

228
Distributing Medical Education with Online Simulations
Kristine M Anderson, BS, MA, ITS-C, PhD,1,2  Kourosh Barati1,2         
1Saint Francis University, Loretto, PA; 2Center of Excellence for Remote and Medically Under-Served Areas, Loretto, PA
The Case Study Method of learning uses technology as a catalyst for change in classroom processes. Instead of the case experience being a text-driven didactic experience, the content is transformed into an interactive case study where any wrong decisions with their virtual patient will have no actual negative implications on to a human life. This safe environment for students to try what they learned in the classroom permits a more eclectic set of learning activities that include knowledge-building situations for students (Sandholtz, 1997).  This Interactive Method of Learning focuses on independent, cooperative and project-based learning opportunities (Land, & Jonassen, 2000; Johnson, Schwab & Foa, 1999). These theories are examples of student-centered learning (John Dewey, Jean Piaget, and Lev Vygotsky’s constructivist learning theories). The presentation will discuss an innovative approach developed by the organization to implement virtual case studies into the medical curriculum. The case study software is an automated system that permits anyone to create, distribute, and evaluate electronic case studies in the medical curriculum.

202
Introduction and Advantages of implementing the Bluetooth Medical Device Profile
Michael Nidd, PhD1,2            
1IBM Research, Zürich, Switzerland; 2Bluetooth SIG, Medical Devices Working Group, Seattle, WA
Although several device manufacturers have decided that Bluetooth® radio communication is a useful mechanism for delivering readings from their sensors, and produced products based on that decision, the results have been necessarily non-standard.  A typical solution uses the Bluetooth Serial Port Profile (SPP) to emulate a cable, with proprietary protocols over that standard connection.  A practical standard for using Bluetooth communication to transfer medical and health & fitness data would improve both interoperability and development time for this category of device.  The Bluetooth Medical Device Profile (MDP) defines the requirements for qualified Bluetooth medical and health & fitness device implementations. This profile defines how to connect data Source devices such as blood pressure monitors, weight scales, glucose meters, thermometers, and pulse oximeters to data Sink devices such as mobile phones, laptops, desktop computers, and health appliances without the need for cables. MDP provides strong application level interoperability by operating with the ISO/IEEE 11073 – 20601 Personal Health Data Exchange Protocol to represent the device data based on international standards. In addition, the profile also provides a standard mechanism by which, the device-type and supported data-types of a device can be determined wirelessly. The presentation will discuss the structure of the profile and explain why it is an improvement over the existing non-standard use of SPP, and briefly review the qualification requirements for claiming Bluetooth MDP compliance.

247
Tracking Care Coordination Interventions for Telehealth Cardiac Patients
Tracking Care Coordination Interventions For Telehealth Cardiac Patients
Sheri E. Kline, MSN,
North Florida/South Georgia Veterans Health System, Gainesville, FL
NF/SG VHS cardiology service is utilizing in home monitoring devices for 300 cardiac patient.  Patient have status post Acute Coronary Syndrome and/or Heart Failure (HF) patients to prevent decompensation.  The telehealth devices greatly impact the care coordination and provision of care for these HF patients.  Daily monitoring is the first step to improving the care of these patients.  Tracking the interventions allows more understanding of the patient’s condition.  Trended data directs the care coordinator to a variety of interventions needed to expedite or optimize cardiac care.  Examples of interventions would be for the care coordinator to call the veteran and do a further phone assessment, expand on education in areas of self-management and reconcile or titrate medications.  Troublesome trended data will spur further detection work to identify labs and cardiac procedures indicated for further assessment.  Ultimately, the problematic issues collected and trended over various time periods will guide discussions in multidisciplinary rounds leading to formulation of a new cardiology led individualized plan of care.  Daily monitoring and trending data alone mean little as compared with combining care coordination and interventions for improved HF management.  Tracking interactions and associated interventions will be summarized and reported to demonstrate significant trends to follow in cardiac patients.

413
Hidden Costs of TeleMental Health
Brian Grady, MD           
University of Maryland, Baltimore, MD
All organizations establishing a telemental health service face a variety of costs, some more apparent than others.  Costs include administrative, operational, training, equipment, communications, technical support and life cycle planning.  It is important to define the needs of the population you want to serve, what is it you would like to accomplish, and what is the scope of the project?  Equipment should be simple to operate if you want to interest providers who are technically challenged.  The equipment should also have potential to add peripherals for those providers who interest is peaked and dynamic.  The clinical champion will need adequate administrative time budgeted to meet with key persons and organizations to market the benefits and understand the limitations of telemental health.  ISDN is easier to install but ongoing charges may make the steeper learning curve and costs of IP to pay for itself over the long term.  Equipment and communications must work from the start or significant costs could be incurred reenergizing discouraged providers.  Orientation and training of staff and providers will take time and money.   Equipment costs have reached a nadir and new technologies on the rise, choosing the appropriate equipment can keep in budget.  Shipping, installation and maintenance agreement costs can also be significant but there are some alternatives to keep these costs under control.  Peripherals such as document readers, video player/recorders and even additional fax machines may have to be purchased depending on service goals.  Should you hire additional staff or negotiate with current staff for the additional work load. 

473
Federal Public Policy Update - The Impact on Telemedicine
K. Reeder Franklin, 1 Nina Antoniotti, RN, MBA, PhD, 2 Neal Neuberger, CISSP3
1American Telemedicine Association, Washington, DC; 2Marshfield Clinic TeleHealth, Marshfield, WI 3Health Tech Strategies, LLC, McLean, VA
This session will give an overview of what’s going on in public policy regarding telemedicine with an
emphasis on how these events will impact telemedicine in the real world.  Discussions will include: potential to expand telemedicine reimbursement, increasing CPT codes reimbursed for telemedicine, and
opportunities and challenges with health IT legislation.

396
LSU Hospitals Telemedicine 4th Room Concept for Provider Access
Tom Winchell, MPA,1  Wayne Wilbright, MD, MS,2  Ted Lambert,1  Michael Butler, MD, MHA, CPE,2 Michael Kaiser, MD,2 Marty Mumphrey,1 Patty Plant,2 Mike Ross2 
1LSU Health Sciences Center, New Orleans, LA; 2LSU Health Care Services Division, Baton Rouge, LA
In 2005 hurricanes Katrina and Rita severely disrupted the operations of the public hospitals within Louisiana.   The current alignment of specialty clinics is significantly different in the post-Katrina environment – displaced clinics, fewer providers, smaller facilities, transportation and even parking constraints are increased challenges for patients seeking services.  As part of the response to those events, the LSU Health Care Services Division and the Department of Corrections have launched an expansion to the existing telemedicine program, deploying over 60  video endpoints in eight public medical centers, including ERs, and 13 state prison institutions.   The objectives of this project are to increase access to care, support educational needs, and facilitate prisoner healthcare.  The initial set of services includes HIV, ENT, Dermatology, Cardiology, Neurology, and Oncology follow-up.  One of the key elements of the expanded telemed program is to move away from the approach of using centralized locations for providers to access the video network, and move toward a more distributed model for delivering services.  This ‘4th room’ concept is designed to allow the providers to interlace telemed patient examinations in the normal workflow of traditional clinic activity.  This distributed framework is feasible due to the advances in LAN/WAN technologies, networking economies, lower price-points for video end points, simpler user interfaces, and advances in monitoring tools.   The key areas of operational and administrative adjustment involve scheduling telemed sessions within traditional clinic settings, workflows for exam room usage and pacing, communications/distribution of documents, records, orders, etc. This approach has increased provider participation in the telemedicine program,  made an impact on the delivery of healthcare in the LSU Hospitals, and reduced prisoner transports - all while enabling flexibility for responding to future disasters that might impact any of the eight public hospitals or state correctional facilities.

423
Physician-Patient Communication During Telemedicine – Analyses of Physician Communication Style
Zia Agha, MD, MS,1,2  Ralph Schapira, MD,3,4  Debra Roter, PhD,5  Prakash Laud, PhD3     
1VA San Diego HSRD, San Diego, CA; 2UCSD, San Diego, CA; 3Medical College of Wisconsin, Milwaukee, WI; 4VA Milwaukee, Milwaukee, WI; 5Johns Hopkins School of Public Health, Baltimore, MD
Introduction: Physician-patient communication is associated with patient satisfaction, patient adherence to medical advice and positive medical outcomes. Whether telemedicine has a negative impact on physician-patient communication is not known. The objective of this study was to compare physician-patient communication during telemedicine and in-person medical consultations. We conducted a RCT of 221 patients at Milwaukee VA hospital. Patients were randomized to in-person (IP) or telemedicine (TM) consultation. Same group of 9 physicians representing 3 specialties (pulmonory, rheumatology, and endocrine) provided an equal number of TM and IP consultations. Each physician-patient consultation was video-recorded and latter analyzed using the Roter Interaction Analyses System (RIAS). The RIAS has been validated in numerous studies and is a reliable and valid measure of physician-patient communication. In this abstract we test differences in physician communication style during TM and IP visits. Results: Of 221 patients enrolled, 14 patients were out of study and 7 were missing video data. RIAS analyses were conducted for 200 patients (TM=100, IP=100). Linear mixed models were used for analyses, with type of visit (TM or IP) as fixed effect and physician as random effect. Patient-centered ratio (patient centered communication categories / physician centered communication) was similar for TM and IP visits (0.95 vs. 1.0, p=0.39). Physician data gathering on biomedical (p=0.45) and psychosocial topics (p=0.27) was similar in TM and IP visits. There was no difference in physician counseling/education (p=0.13) and patient activation (p=0.46) statements between TM and IP visits. Rapport building was higher during TM vs. IP (p=001). For each of these analyses a significant physician effect (p<0.001) was present.  Conclusions: In this study, physician communication style was not affected by telemedicine.  The individual physician factor was a significant predictor of patient- centered vs. physician-centered communication. Physicians with good communication style performed well (i.e. used patient-centered communication) irrespective of type of visit (IP or TM).

381
Shaping a Long-term Strategy for US Air Force Telepathology
Mark D. Lyman, USAF, MD,1 Gary Stokes, USAF, MD,2 Robert Zalme, USAF, DC,3 Derek Mathis, USAF, MD,4 Brian Plasil, USAF, MD,5 Andrew Walls, MD,6 Timothy Lacy, USAF, MC,4 Drazen M. Jukic, MD, PhD,6 Tera Carter,3 Leslie Anthony, MA6
1Offutt Air Force Base, Omaha, NE; 2U.S. Air Force Academy, Colorado Springs, CO; 3Keesler Medical Center, Biloxi, MS; 4Wilford Hall Medical Center, Lackland Air Force Base, San Antonio, TX; 5Elmendorf Air Force Base, Anchorage, AK; 6University of Pittsburgh Medical Center, Pittsburgh, PA
A goal of the Integrated Medical Information and Technologies (IMITS) Telepathology Project is to build a cadre of pathology champions within the US Air Force (USAF) who can help build a long-term telepathology strategy for the Air Force Medical Service (AFMS).  In September 2007, USAF pathologists and Medical Modernization officers convened with UPMC project staff to discuss leadership and technology for the implementation of the telepathology network. Pathologists gained an understanding of available technologies and discussed areas within their current practice and workflow that would benefit from the digital technologies, requirements for implementation, and opportunities and agencies that could support their incorporation.  The needs of Air Force Medical Treatment Facilities (MTFs) vary based on current staffing and case volumes.  Small facilities will benefit from consultation, education and quality assurance (QA) support via telepathology.  Because the volume of cases reaching small bases does not afford unique/rare pathologies, skills could be enhanced and knowledge kept current.  Additionally, the absence of a pathologist would not preclude rapid diagnosis, giving pathologists the freedom to attend enrichment conferences with assurance that cases will be managed.  Mid-size and larger MTFs will likewise benefit from QA resources as it is documented that external QA is more effective in retrospective identification of oversights and errors.  Furthermore, MTFs can distribute high volumes of cases, as needed, to lower volume facilities.  Pathologists concurred on the creation of a charter for the incorporate of telepathology Air Force-wide, whereby supplementing and improving current Air Force pathology standard practice.  Their goals cover development of a strategic vision for USAF telepathology; MTF-based requirements; business case justification; online repositories; education and training applications; workflow reengineering; credentialing and security procedures; and sustainment.  In the USAF, telepathology will keep practitioners current with medical technology, provide improved care to soldiers and optimize case oversight and workflow.  Their charter may provide a model for other small and large institutions working to adopt advanced telepathology.  Methods, challenges, and accomplishments will be presented.

454
COLLABORATIVE TO ENHANCE LEARNING IN 3-D VIRTUAL LEARNING ENVIRONMENTS
Rameshsharma Ramloll, PhD, Jaishree Beedasy, PhD, Neill Piland, DrPh, Beth Hudnall Stamm, PhD, Barbara Cunningham, MPA, MBA
Institute of Rural Health, Idaho State University, Pocatello, ID
The Play2Train Open Content Alliance (POCA), which is evolving from the Play2Train (www.play2train.org) activities, represents collaborative efforts to build a permanent self-sustaining archive of open source virtual worlds, including their content and applications, to support public domain emergency preparedness training and exercises. The virtual content is implemented in the Second Life ™ platform. The powerful user content generation system of Second Life ™ has allowed us to build a sizeable set of virtual environments for emergency preparedness exercises in a fairly short time. We will consider competing platforms as their functionalities begin to match those currently supported by the chosen platform. We believe that this resource will significantly lower the barrier for accessing such virtual environments for emergency preparedness training. The  knowledge network we have initiated during the past 2 years strengthens this collaborative across the computer science, information and communication technologies, health and medical education and other scientific fields allows scholars, scientists and students to work together more effectively, across discipline and distance. The POCA community facilitates access to robust virtual training environments by dramatically reducing the time and financial costs needed for the creation and maintenance of such environments. We demonstrate that this is achievable through the sharing of virtual real estate and reuse of content under open content community standards. This effort opens up virtual environment training research to a larger audience who were previously barred from using massive multiplayer virtual worlds for training purposes because of high costs and technical challenges. By lowering barriers to access virtual environments for training, better opportunities for the evaluation of learning in such spaces will become available. This in turn will help establish a solid evidence based foundation that is necessary to support any scientific enterprise. Our  scientific collaboration made of instructional technologists,  subject matter experts and computer scientists allows us to design, develop, implement, analyze and explore, a blended real and virtual learning environment approach that can augment teaching and learning practices across disciplines and  fields. This effort demonstrates the feasibility of accessible virtual environments for emergency preparedness training at low cost.

217
Implementation of Continua Alliance Certified protocols in Personal Health Devices
Jayant Parthasarathy, PhD           
Nonin Medical Inc., Plymouth, MN
Several experts have testified on the virtues of interoperability amongst devices in the Personal Health space, though, until recently, very few implementable standards existed to realize that vision. Cross-industry efforts at the Continua Health Alliance and various Standards Development Organizations, including the Bluetooth SIG, IEEE, and USB Forum in the past year have led to the emergence of robust, complementary and easily adoptable protocols aimed at enabling interoperability amongst medical, health, and fitness devices. This presentation describes one of the first implementations of the standard protocols which have been adopted by Continua (Bluetooth Medical Device Profile, ISO/IEEE 11073-20601 Personal Health Device Communication Protocol and the ISO/IEEE 11073-10404 Pulse Oximeter Device Specialization) for the Personal Area Network interface communication. These protocols are implemented in a fingertip oximeter (Nonin Medical Inc.) which acts as a Source of Bluetooth and 11073 data. Details of Service Discovery, pairing, set-up & tear down of the Bluetooth control & data channels and the transfer of 11073 data in the streaming & episodic modes are described in this presentation. Additionally, using the Pulse Oximeter as an example, this work provides an insight into the implementation of a Standard data format as described in the 11073 Device Specialization as well as the Extended format which allows for a device manufacturer to innovate and transmit measurements that might be proprietary or unique. The Pulse Oximeter example also helps in understanding the representation of a multi-parameter device as it inherently provides more than a single parameter - Oxygen Saturation & Pulse Rate. Finally, key additions are highlighted which permit a device to be accepted and certified as an inter-operable Personal Health device by the Continua Health Alliance.

129
Efficiency and Effectiveness in Traditional Disease Management vs. Remote Monitoring
Ariel Linden, DrPH, MS,1  Jodie L. Root, MBA,2  Edward J. Kramper, MD2       
1Linden Consulting Group, Hillsboro, OR; 2Cardiocom Multi-Disease Management, Chanhassen, MN
Disease management (DM) programs for individuals at high risk for acute events are traditionally managed through interventions delivered by a nurse making scheduled calls to assess health status and compliance with treatment protocols.  A limitation of this traditional approach is that the nurse does not know, for any given day, which patients most need support to modify risk.  The nurse may therefore call individuals who do not need an intervention that day or may miss intervention opportunities by not calling. Further, one of the weakest points of a scheduled process is that between calls patient signs and symptoms are never static.  Small fluctuations over a day or two can be indicative of serious changes in health, potentially resulting in an acute event.  Remote monitoring of patient vital signs and symptoms may increase the likelihood that intervention occurs at the right time to prevent hospitalization. In order to demonstrate the potential inefficiency and ineffectiveness of a structured call process, actual data from a heart failure population of 852 patients continuously enrolled for 365 days in a remote telemonitoring program was used to create a theoretical nurse intervention model.  Telemonitoring nurse-to-patient case ratios averaged about 1:350.  Scenarios were built to simulate scheduled calls that would have been made in a traditional program.  Based on the telemonitoring data, which triggers an alert when the patient¡¯s health status or biometric data is outside of preset parameters, the theoretical model demonstrates that (1) 1 in 4 patients trigger alerts every day, (2) any given patient triggers an alert once every 4-5 days, (3) DM nurses making a outbound calls every 30 days will identify only 3.5% of total patient health alerts requiring intervention (range = 0 to 33%).  The model demonstrates that incorporating telemonitoring in DM could strengthen the ability to deliver an ROI.

267
Cost Considerations for Telemental Health Services
Ryan J. Spaulding, PhD,  Eve-Lynn Nelson, PhD         
Kansas University Medical Center, Kansas City, KS
The Kansas University Center for Telemedicine and Telehealth (KUCTT) has provided telemental health services for approximately 12 years.  These include adult and child psychiatry and child behavioral health which have been provided to schools, mental health clinics and hospitals.  Budgeting for these activities varies depending on the setting, space issues, clinical preferences and available resources.  Though room-based video systems that cost several thousand dollars can still be used, desktop PC systems that can be purchased for less than $200 provide comparable quality and more flexibility than the older systems.   Migrating from traditional integrated services digital lines (ISDN) lines to internet protocol (IP) transmission also has some cost benefits associated with it, particularly the elimination of hourly charges and improved efficiency for providers.  Determining responsibilities and expense associated with equipment upgrades and maintenance are also important to account for due to the potential high cost of repairing or replacing sophisticated video systems.  Personnel requirements, especially the scheduling coordinator and the video technician, should not be underestimated for mental health consultations that require regular and sometimes frequent follow-up visits.  Clinical fees in the event of limited or absent reimbursement coverage for the consultations should also be budgeted, and originating site costs and revenue should not be overlooked.  A standard return on investment (ROI) analysis is suggested for any proposed telehealth service and a template for performing an ROI procedure will be provided.   Finally, sample cost studies conducted by KUCTT from both the distant and originating site perspectives will be discussed.  Overall, these studies demonstrate a reduction in the average cost-per-consult over time as technology costs have decreased and patient volume has increased.  Additional budgeting considerations and details will be presented.

472
FEDERAL PUBLIC POLICY UPDATE – THE IMPACT ON TELEMEDICINE
K. Reeder Franklin, 1 Nina Antoniotti, RN, MBA, PhD, 2 Neal Neuberger, CISSP3
1American Telemedicine Association, Washington, DC; 2Marshfield Clinic TeleHealth, Marshfield, WI3Health Tech Strategies, LLC, McLean, VA
This session will give an overview of what’s going on in public policy regarding telemedicine with an emphasis on how these events will impact telemedicine in the real world.  Discussions will include: potential to expand telemedicine reimbursement, increasing CPT codes reimbursed for telemedicine, and opportunities and challenges with health IT legislation.

306
Rural Inpatient Telepharmacy from Demonstration to Service
John Grubbs, MS, MBA, RPh,  Thomas S Nesbitt, MD, MPH,  Stacey L Cole, MBA,  Patricia Keast, MS, Cathy Din, PharmD    
University of California, Davis, Sacramento, CA
Rural hospital patient volumes are low, which often challenges the support of a full-time pharmacist, let alone extended hours of pharmacy service.  Further, rural hospitals often lack many of the modern pharmaceutical innovations available to urban hospitals.  To identify and address difficulties faced by rural inpatient pharmacies in Northern California, UC Davis Health System initiated a telepharmacy demonstration project with six independent rural hospital partners.  After meeting with each hospital’s pharmacist and staff, an after-hours medication verification program was designed and implemented.  During the demonstration project aggregate data from 302 telepharmacy patients referred by the six participating hospitals were analyzed. Over the one-year period participating hospitals electively sent after-hours patient medication orders for verification to UC Davis Medical Center’s inpatient pharmacy.  In the subset of study patients, telepharmacists at UC Davis Medical Center screened 2,378 medication orders.  Fifty-eight patients (19.2% of the total patients), had one or more medication errors, which required the telepharmacist to intervene or make adjustments.  A total of 97 errors were found, representing 3.5% of all orders, with some medication orders having more than one error.  The most common types of errors were wrong dose (29.3%), missing route of administration (22%), no amount (e.g. dose, number of tablets, etc.) listed (11%) and allergy (11%).   The most common causes of errors were knowledge errors (62.2%) and unclear orders (51.2%). Some errors had multiple causes. Of the 65 medications reviewed by the telepharmacist using video verification, two medication errors were identified related to incorrect medication strengths.  Our project showed that telepharmacy is an effective means of providing after-hours pharmacy support to rural hospitals that lack 24/7 pharmacist coverage even with challenges related to staffing, technological sophistication, and system compatibility. Based on the experience, the UCD Pharmacy Department has developed the UC Davis Remote Telepharmacy program (RTp).

81
Remote Pharmacy Services:  A Business Plan for Successful Retail Pharmacy
Nina M. Antoniotti, RN, MBA, PhD     
Marshfield Clinic TeleHealth, Marshfield, WI
Rural and remote communities struggle with providing pharmacists and hospital based and retail pharmacy services.  An alarming reduction in the number of available pharmacists to cover the nation’s needs has prompted organizations and communities, as well as state pharmacy boards, to look at innovative ways to provide prescription and sterile products services to patients.  Although remote dispensing units may meet some of the need, often these types of technological solutions are too costly, and do not fill all of the needs.  Many state practice laws prohibit the use of remote dispensing.  Marshfield Clinic has developed an innovative way to provide retail prescription services under the physician dispensing model.  This presentation covers the legal and regulatory aspects of setting up a retail pharmacy under physician dispensing models, the business plan elements required to have a successful, for-profit project, and the operational plan to make a physician dispensing model with pharmacist oversight a reality in your community.  Financial performas, physical plant requirements, and options for dispensing and video technologies will be reviewed.  The participant will learn the critical steps in setting up an alternative retail

258
Building a Business Case for Digital Pathology: The Time is Now
Drazen M. Jukic, MD, PhD,1,2  Jonhan Ho, MD,1,2  Anil V. Parwani, MD, PhD,1,2  Leslie Anthony, MA,1 Drogowski Laura,2 Ann Cecil, MS,1 Jon Duboy,1 Jeffrey Fine, MD,1,2 Aaron C. Yanuzo, MBA1
1University of Pittsburgh Medical Center, Pittsburgh, PA; 2University of Pittsburgh, Pittsburgh, PA
In the past  few years, advances in digital pathology have made the adoption of digital workflow possible. However, as it was with digital radiology, one is often confronted with a question on how can this, rather expensive, transition be made palatable for the financial analysts and hospital administration. In the case or radiology, the savings were projected to be attained from the elimination of the “silver film”.  This, at least in the foreseeable future, is not a strategy than can be followed in pathology, as (at this point) we cannot eliminate the glass slides. In this presentation, we evaluate pro et contra for adoption strategies and assess their viability.

1. Workload distribution – for practices with multiple locations, pathologists do not need to physically travel for “coverage”; this could be addressed by either a robotic microscope or “whole” (digital) slide scanner;
2. Instant and anonymous quality assurance – allowable by using digital slide scanner;
3. Instant digital consult and instant multi-person diagnostic conference by usage of either a robotic microscope or “whole” (digital) slide scanner;
4. Savings by potential elimination of glass slide file, lost slides (currently seen in ~ 10% of cases), and ability to instantly retrieve cases. This would also eliminate the costs associated with storage.
5. Decrease courier and mailing costs – this will be over-viewed in detail, but each pathology department has significant costs associated with this that can be saved with implementation of digital pathology;
6. Increase in pathologists’ efficiency – we postulate that digital workflow will enable pathologists to deliver a diagnosis in shorter time period, with less doubt, less ancillary studies, and create more comprehensive reports. Currently, a large amount of  time is spent on clerical duties, and not diagnostic workup.

With all these models in place, we hope to deliver significant improvements over the usual workflow and provide financial justification for adoption of digital pathology in all segments of pathology practice.  

257
Advantages of implementing the ISO/IEEE 11073-20601 Personal Health Device Communication Profile
Douglas P. Bogia, PhD           
Intel Corporation, Beaverton, OR
In July 2006, under the auspices of ISO/IEEE, 26 motivated organizations got together to define an interoperable profile for a common device data exchange protocol and format in the Personal Health Space. The guiding principle for the work was to define an easily approachable and adoptable standard that would accommodate extremely simple and low cost medical, health, and fitness devices as well as feature-rich monitoring equipment. Since then, the ISO/IEEE Personal Health Devices Working Group has steadily grown to include more than 135 members from 78 organizations.  The group successfully launched the ISO/IEEE 11073-20601 Personal Health Device Communication Protocol and an initial set of 6 Device Specialization documents in early 2008. The protocol is focused on defining the requirements of the application layer and is designed to allow other transport standards, including the Bluetooth Medical Device Profile and USB Personal Health Device Class to define the characteristics of the underlying lower layers. Additionally, the Continua Health Alliance relies on devices using this protocol to define the data payload in order to qualify as an interoperable Personal Health Device. This presentation highlights the various features, operations and state-charts of the ISO/IEEE 11073-20601 protocol as well as provides an insight into how this fits in the larger personal telehealth environment.

178
Low-Cost Web-Based Clinical Decision Support and Case Management for Congestive Heart Failure Patients in Iowa
William Appelgate, PhD,1,2  Nancy E. Brown-Connolly, RN, MSN,2  David Hickman, RN3       
1Des Moines University, Des Moines, IA; 2Iowa Chronic Care Consortium (ICCC), Des Moines, IA; 3Mercy Health Network, Des Moines, IA
The Iowa Chronic Care Consortium (ICCC) is a voluntary collaboration of public, private, academic, and government organizations. Beginning in July 1999, ICCC and Mercy Health Network (MHN), began implementing a program to address congestive heart failure (CHF). Strategic Approach: Deployment of programs for Iowans affected by chronic disease where they live. Designed to use current low-cost telephonic technology with medical oversight. Design: Hospital based case management program with clinical decision support integrated into clinical workflow. Model follows the patient from in-patient (IP) to out-patient (OP) providing continuity of care. Utilizes technology within framework of medical oversight, to provide day-to-day telephonic monitoring and intervention.  Methods: Patients were identified following hospitalization and referrals were accepted by physicians and self-referrals with physician approval. Population: Iowans with CHF (Level I, II, III, excludes Level IV) with history of repeated hospitalizations, self-referral, physician referral and following first hospitalization. Outcome Measures: Clinical effectiveness, patient functionality (Minnesota Living with Heart Disease) questionnaire, satisfaction (Likert 1-5 scale), and cost (IP, OP, ER).  Findings: Clinical effectiveness: (N=569) average reduction in hospital readmissions (86.3%, <16%/year) overall hospitalizations any cause (N=226) decreased (55.8%, 163 admissions), patient functionality improved (physical &#61508;11.2, emotional 5.8, overall 25.0), satisfaction µ= 4.47/5.0, decreased cost  hospitalizations (est. $1,015,050). Conclusion: Low-cost web-based monitoring is effective clinically and cost efficient to implement and support. An integrated model allows continuity of care and contributes to quality bringing resources and expertise already available from the IP to the OP setting and can be integrated into current workflow.

162
TeleMental Health Budgeting: Nuts and bolts for planning and proposals
Robert White, MA, LCPC,1  Brian Grady, MD,1  Robert N. Cuyler, PhD,2  Ryan Spaulding, PhD3     
1University of Maryland Psychiatry, Baltimore, MD; 2Diamond HealthCare, Richmond, VA; 3Kansas University Medical Center, Center for Telemedicine and Telehealth, Kansas City, KS
This panel presentation will be a very practical discussion of budgeting and planning for a telmental health project.  Each member of the panel has many years of experience in preparing budgets and proposals.  Topics for discussion will include: ISDN vs IP, staffing, maintenance agreements, types of equipment, costs, and sources of revenue.

124
Telemedicine Fraud, Abuse, and Regulatory Sanctions—Are You at Risk?
Tara Kepler, MPA, JD           
Haynes and Boone, LLP, Dallas, TX
The purpose of the presentation will be to provide attendees with an overview of the most recent federal and state survey of the rapidly-evolving laws governing telemedicine fraud, abuse, practitioner licensing, and quality of care.  Based on the survey findings, the presentation will also provide general guidance on how to structure interstate and intrastate telemedicine projects so as to avoid violating state and federal Medicaid and Medicare fraud and abuse laws and state healthcare practitioner licensing regulations.  In contrast with prior telemedicine law surveys limited to reimbursement and physician licensing laws, the recent survey revealed that the following issues, when associated with a telemedicine activity, were found to be specifically regulated by law in at least one state: medical malpractice; informed consent; medical records; privacy; quality of care; standard of care; prescriptions; radiology; physician-patient relationships; contracts; advertising; e-mail and Internet usage; conflicts of interest; supervision of care; private insurance payors; Medicaid fraud, abuse, and reimbursement; and physician, nurse, chiropractor, dentist, psychologist, optometrist, physical therapist, and occupational therapist licensing.  The telemedicine laws identified in the survey were primarily found in healthcare practitioner licensing, facility licensing, pharmacy licensing, health insurance, and Medicaid reimbursement regulation.  The survey of telemedicine laws revealed that many states have recently added and modified laws governing telemedicine and that states vary widely in the extent and scope of current telemedicine regulation.  California, Florida, Kentucky, Oklahoma, and Texas are among the states that currently have the most extensive and most recently modified telemedicine statutes and regulations.

323
Electronic Stethoscopes – Reviewing the Options
Chris Patricoski, MD,  A. Stewart Ferguson, PhD,  Sue Clancy, RN, MSN-MPH       
Alaska Native Tribal Health Consortium, Anchorage, AK
The electronic stethoscope is a common peripheral used in telemedicine.  To the clinician, auscultation of sound is a simple concept although interpretation has levels of complexity.  To the technician there are multiple options for electronic stethoscope configuration.  The particular stethoscope and the means of integration both impact sound quality and relative usefulness to the clinician.  Electronic stethoscopes include basic models such as the Stethographics STG Stethoscope, Thinklabs DS32a Digital, Trimline DRG Echo Plus, Welch Allyn Meditron Mater Elite Plus, Andromed Androscope i-stethos, Cardionics E-scope II, and JABES Life Sound System.  These basic models are amplification devices that integrate using a video port.  An instance of application includes the Cardionic E-Scope attached to the audio port of a Tandberg unit to send and receive.  At least one basic electronic stethoscope includes a small simple recording unit. An instance of application includes the 3M Littman Model 4100WS, where the sound file is saved internally and transferred through an infrared port to a laptop computer.  The more complex electronic stethoscopes include the AMD Smartsteth, AMD Ausculette / Simulscope, American Telecare CareTone Ultra and Telehealth Technologies TR-1/EF.  These models both amplify and digitize sound and include digitizing boxes that also serve as sending and receiving stations.   Instances of application include: the Smartsteth attached to the computer serial port and the TR-1/EF attached to a Polycom Unit VSX serial port (via the DB9 connector serial cable).  This presentation discusses the pros and cons of various stethoscopes and configurations.  Discussion includes lessons learned from lab testing and field deployment.  Early results from clinical application are summarized.   For example, certain stethoscopes and configurations appear to be better for lung vs. heart sound pathology.   Implications for technicians and clinicians are discussed.

305
The Development Of An International Telemedicine Training Programme
Maurice Mars, MBChB, MD
University of KwaZulu-Natal, Durban, South Africa
There is widespread acceptance of the benefits of telemedicine, but telemedicine uptake has been poor, especially in developing countries. There is need for widespread training in telemedicine in both developing and developed countries. The International Society for Telemedicine and eHealth has established a Telemedicine Education Committee tasked with producing a basic introductory telemedicine programme for international use. A draft training programme has been developed, aimed at future telemedicine practitioners and key support personnel. The programme’s mission is “To develop a workforce with a practical working knowledge of Telemedicine and competence in the ethical use of Telemedicine and Tele-education.” Key domains in telemedicine were identified, essential knowledge and skills required defined, lists of educational outcomes produced, and training strategies required to achieve these outcomes developed. Currently the program is an intensive two day course of didactic lectures and hands-on practical exercises. It is modular, allowing units to be selected and combined depending on the participating target group. An extra day is required if participants are not computer literate. It is made up of eleven modules covering introductory computing, internet and email use, digital photography, synchronous telemedicine, legal and ethical issues, venue set-up, tele-education and homecare. Additional modules will be developed within specialties such as tele-dermatology, tele-traumatology, etc. It is hoped that this initiative will assist countries in providing basic telemedicine training to large numbers of health professionals. More advanced and specific training programmes can be developed to supplement this introductory course as required.

193
Implementation - Dynamic Workload Allocation within the Air Force Medical Service
Aaron C. Yanuzo, BS, MBA,1  Carlos Betancourt, BS,2  Goran Momiroski, BS, MS,1  Thomas H. Coast, BS,1 Shawn Moroney, BS,1 James Mason, BS,3 Steve Livingston, BS4  
1UPMC - Innovative Medical and Information Technologies Center (IMITS), Pittsburgh, PA; 2UPMC, Pittsburgh, PA;; 3USAF - Wilford Hall Medical Center, San Antonio, TX; 4SAIC - ICDB, San Antonio, TX
Air Force Medical Service (AFMS) and Military Health Service (MHS) have initiated several programs to address improvements in health care through information technology.  One of these initiatives commissioned UPMC Innovative Medical and Information Technology (IMITS) Center to develop a prototype solution for Radiology Dynamic Workload Allocation (DWA) addressing radiology workflow deficiencies.  It has become evident that the DWA prototype solution should also include enterprise clinical imaging workflow efficiency capabilities beyond radiology. Current AFMS staffing constraints, limited system capabilities, and a mobile patient population requires a sophisticated load-balanced distributed imaging workflow model and supporting infrastructure.  These continually changing circumstances within the military healthcare community have identify the need for a sophisticated workflow model that supports an enterprise view.  The prototype solution will result in increased productivity and enhanced patient care across the AFMS regardless of physician staffing constraints, systems capabilities and patient location.  The infrastructure will support a load-balanced distributed workflow model across multiple Major Commands (MAJCOMS) and within a multiple Picture Archiving Communication Systems (PACS) environment. The prototype solution will allow dynamic bi-directional transmission of clinical studies and optimal workflow load-balancing to effectively leverage resources irrespective of location, PACS, or particular local workload demands.  The DWA algorithmically distributes radiology cases throughout AFMS equally depending on radiologist availability, modality type, and location.  Within a mobile patient population, this prototype solution will provide relevant patient history, to the radiologist, enabling an accurate diagnosis.  With regard to workload distribution; these capabilities will allow maximum workload flexibility during radiologist deployments, TDY, on-call support, and the development and availability of subspecialty expertise.  When the DWA proves to be an effective workload allocation tool, not only will patient care improve throughout the AFMS, but radiologists will be able to strengthen their practice by increasing their knowledge in subspecialty experiences.

341
Development of an automatic intervention protocol to aid the long term management of chronic diseases using RPM
Malcolm Clarke, PhD,1  Joanna Fursse, BSc,1  Russell Jones, MBBCH, MRCGP2       
1Brunel University, West London, United Kingdom; 2Chorleywood Health Centre, Hertfordshire, United Kingdom
Remote Patient Monitoring (RPM) has been identified as a tool to manage the ever increasing demand for health care, especially for patients with chronic disease.  Although many projects have evaluated the technology, these have concentrated on managing acute exacerbations arising from chronic disease and have, in contrast, relatively neglected the long term management of the condition itself. The aim of this study is to develop and evaluate methods based on RPM to achieve sustained improvement in disease measurements for three long-term conditions (Chronic Heart Failure (CFH), Type 2 Diabetes and Hypertension) using automatic protocol-based clinical intervention. We describe modelling of vital signs parameters in remote patient monitoring (RPM) of patients with chronic disease. We have characterised the initial response of parameters in patients introduced to RPM and the response following clinical intervention. We have then used this idealised response as the basis of an algorithm for an automatic personalised dynamic threshold envelope that is used to determine patients in need of clinical intervention for long term management of their disease.  The effectiveness of the algorithm and the clinical interventions has so far been evaluated on 29 patients in a RPM pilot project in Chorleywood, UK. To date the algorithm has prompted 17 episodes of clinical intervention in 12 patients. Primarily this includes changes to medication and health advice, and one hypertensive patient was referred for a pace maker after discovering bradycardia.  Our approach provided an effective tool that was found to have several advantages over use of a simple threshold: the number of patients with false alarms for intervention and alerts is much reduced; the specificity of the alarms is much improved; many more patients may be managed by a system; patients not responding to therapy were identified quickly; and new clinical approaches by the primary care team for intervention were developed.

284
Case Management for Congestive Heart Failure Patients in Iowa
William K. Appelgate, PhD,1  Dave Hickman, RN,2  Nancy Brown-Connolly, RN, MSN3       
1Des Moines University, Des Moines, IA; 2Mercy Health Network, Des Moines, IA; 3Iowa Chronic Care Consortium, Des Moines, IA
The Iowa Chronic Care Consortium (ICCC) is a voluntary collaboration of public, private, academic, and government organizations. Beginning in July 1999, ICCC and Mercy Health Network (MHN), began implementing a program to address congestive heart failure (CHF). Strategic Approach: Deployment of programs for Iowans affected by chronic disease where they live. Designed to use current low-cost telephonic technology with medical oversight. Design: Hospital based case management program with clinical decision support integrated into clinical workflow. Model follows the patient from in-patient (IP) to out-patient (OP) providing continuity of care. Utilizes technology within framework of medical oversight, to provide day-to-day telephonic monitoring and intervention.  Methods: Patients were identified following hospitalization and referrals were accepted by physicians and self-referrals with physician approval. Population: Iowans with CHF (Level I, II, III, excludes Level IV) with history of repeated hospitalizations, self-referral, physician referral and following first hospitalization. Outcome Measures: Clinical effectiveness, patient functionality (Minnesota Living with Heart Disease) questionnaire, satisfaction (Likert 1-5 scale), and cost (IP, OP, ER). Findings: Clinical effectiveness: (N=569) average reduction in hospital readmissions (86.3%, <16%/year) overall hospitalizations any cause (N=226) decreased (55.8%, 163 admissions), patient functionality improved (physical &#61508;11.2, emotional 5.8, overall 25.0), satisfaction µ= 4.47/5.0, decreased cost  hospitalizations (est. $1,015,050). Conclusion: Low-cost web-based monitoring is effective clinically and cost efficient to implement and support. An integrated model allows continuity of care and contributes to quality bringing resources and expertise already available from the IP to the OP setting and can be integrated into current workflow. 

66
Maintaining the Youth’s System of Care during Prolonged Psychiatric Hospitalization
Kathleen Myers, MD, MPH,1  Michael Storck, MD,2  Robert George, MD,3  Kimberly Lindsay, MSW4     
1University of Washington School of Medicine, Child Study and Treatment Center, Seattle, WA; 2University of Washington School of Medicine, Children’s Hospital and Regional Me, Seattle, WA; 3Eastern Oregon Children's Multi-Treatment Center (, Pendleton, OR; 4Morrow-Wheeler Behavioral Health Services, Heppner, OR
Background: Child Study and Treatment Center (CSTC) is the long-term, psychiatric hospital operated by the State of Washington that serves children from ages 5 to 18 from across the state. Youth referred to CSTC have an average eight month length of stay during which they are separated from families and their community system of care. This presentation discusses how telepsychiatry has allowed us to integrate a patient’s system of care during hospitalization.  Methods:  We will discuss our telepsychiatry program, its use across disciplines, and how it has impacted clinical care. Vignettes are provided to give clinical relevance.  Results:  Children served via CSTC telepsychiatry have covered a wide diagnostic range. Teleconferencing has allowed us to improve support to our children and families.  We have better appreciated the interactions of temperament, cognition, and mood regulation across the generations, and the ecological aspects of our young patients’ struggles.  Our children are heartened to have contact with their family across the great distances.  They have been comfortable “visiting” through teleconferencing, and are especially intrigued by the ability to scan family members and to show off their new haircuts, dental work, and other signs of development.  Families have been heartened to observe their children’s progress.  Teleconferencing has allowed providers at both sites to meet conveniently and to efficiently plan youths’ follow-up treatment in real time.  A major advantage has been the opportunity for the teams to readily share information, plan ongoing care, and strengthen the system of care.   Conclusion:  Teleconferencing has allowed us to expand our treatment model and to provide more comprehensive, family-focused, culturally competent care. Our team has come to view teleconferencing as an essential component in the treatment of youth within their community’s system of care. Telepsychiatry has cemented our shared mission across treatment teams, family and community.

57
How important is Hageseth's principle of extraterritorial jurisdiction to international telemedicine?
Thomas R.  McLean, MD, JD,1,2  Pat B. McLean1
1Third Millennium Consultants, Limited Liability Co,  Shawnee, KS; 2Eastern Kansas VA Health Care Center,  Leavenworth, KS
Background: In Hageseth v. The Superior Court of San Mateo County, No. SF345298, filed 5/17/07, the court ruled it had extraterritorial jurisdiction over foreign telemedicine providers who operate without proper licensure. Commentators believe Hageseth significant impact telemedicine in California. Issue: (1) Does Hageseth impact international providers? (2) What alternatives to licensure exist to regulate international trade-in-telemedicine? Methods: Review of the legal and economic literature.  Results: (1) The successful criminal prosecution of Dr. Hageseth occurred because he resided in Colorado. However, unless a defendant is charged with a capital criminal offense, foreign countries rarely cooperate in serving process or extraditing defendants. As violations of licensure laws are rarely capital offenses, it seems unlikely foreign telemedicine providers will be extradited. Doing so may be against a country’s economic policies. For example, because India wants to capture more of the United States’ health care market; a provider who exports millions of dollars of medical services to the United States will be a patriot. India –like most countries- rarely extradites its patriots.  An alternative regulator scheme to licensure is still need for the international telemedicine market. One method with promise involves expanding the Internet transmission protocol to include a credentialing layer. Hospital would be required to turn away services from non-credential providers. A second method involves establishing an international telemedical exchange; and using criminal law to ensure that all telemedical transactions occur on the exchange. Hageseth’s principles of extraterritorial jurisdictions would therefore have a substantial impact if an exchange were established.  Conclusions: (1) Hageseth is likely to encourage telemedicine providers to move offshore to avoid criminal prosecution; and (2) now is the time to think about alternatives to medical licensure to regulate the international telemedicine market. 

375
A solution for remotely monitored patient data – The Remote Monitoring Data Repository
Douglas J. McClure, MIM,  Jeffrey L. Brown, BS         
Center for Connected Health - Partners HealthCare, Boston, MA
Is a blood glucose reading measured in the home and reported through an automatic process the same as patient data measured in the clinic or self-reported patient data?  With the proliferation of connected health technologies, capabilities and programs a mountain of data is beginning to be generated and worse yet it is tending to be stored in different application and data silos.  Generally speaking electronic health record systems lack the capability to store or handle this 3rd type of data – remotely measured - and make it a meaningful part of the care process.  At the Center for Connected Health at Partners HealthCare a rapidly growing number of remote measuring and automatic reporting of patient data programmatic efforts was leading to a chaos of technology solutions and data silos.  In response to this challenge a system was designed, developed and deployed - the Remote Monitoring Data Repository (RMDR).  This common place to store remotely measured and reported patient data has created a single scalable data repository that is a single integration point for the connected health programs.  The RMDR also provides a single integration point to the other enterprise health information systems at Partners Healthcare. The Center for Connected Health now has three connected health programs storing remotely measures patient data into the RMDR with more coming online.  We have developed a series of standard integration points for new programs and for interacting with the different clinical systems around the enterprise.   Further aiding this work is developments in the standards communities to create standard interfaces for sensor data to more easily reach health record systems.  In this presentation the current and future planned programs and integration points at Partners HealthCare will be described as use cases that continue to define the architecture, design and development of the RMDR. 

326
Choosing an Oral Imaging Camera for Medical and Dental Applications
Chris Patricoski, MD,  A. Stewart Ferguson, PhD,  Greg Juchem, RN, BSN       
Alaska Native Tribal Health Consortium, Anchorage, AK
Oral imaging cameras (dental cameras) are used as video display and image capture devices.  The cameras can be used in telemedicine and teledentistry for patient explanation / education, documentation and remote consultation.  A market study of oral imaging cameras reveals multiple vendors with at least 16 current models.  This presentation discusses the rationale for medical device selection using criteria of reliability, quality of image, and ease-of-use.  There are important considerations for selecting a dental camera that fit into each of these categories.  Understanding the basic mechanics of these imaging devices helps to better appraise the specifications and functionality.  Light sources include halogen, other bulbs, and light emitting diodes (LED).  While LEDs are advantageous, they are not necessarily the best light source; and LED quality varies.  Some cameras, based on their optics, require a manual focus rather than a fixed focus, making it more difficult for the user.  Some cameras, because of their optics, display reverse image.  Camera evaluation revealed significant differences in image lighting, color, contrast, and clarity.   Oral imaging devices differ in other important aspects:  size, capture buttons, ergonomics, type of protective sheaths, software compatibility, handle getting hot, letters displaying on screen, quality of instructional manuals, maintenance, cleaning, vendor response and price.  There are important differences in oral imaging cameras that require thoughtful analysis prior to purchase.

196
Evaluation - Distributed Radiology Dynamic Workload Allocation System for AFMS
Russell A. Silowash, BS,  Robb Wilson, MA,  Dana Grzybicki, MD, PhD       
University of Pittsburgh, Department of Biomedical Informatics, Pittsburgh, PA
Because of the growing need of patient services and the desire to improve radiology practices within the Air Force Medical Service (AFMS), a Distributed Radiology Dynamic Workload Allocation System (DRDWAS) has been developed by the UPMC Innovative Medical and Information Technology (IMITS) group. The DRDWAS algorithmically distributes radiology cases throughout the AFMS equally – depending on radiologist availability, modality type, and location. In order to determine the feasibility, effectiveness, and utility of the DRDWAS, IMITS has contracted the Evaluation Team from the University of Pittsburgh Department of Biomedical Informatics to conduct rigorous assessments. There are three phases to the evaluation project. The first phase consists of qualitative questionnaires that record the perceptions, attitudes, and experiences of DRDWAS programmers, radiologists, and support personnel. The second phase is based on the testing of the DRDWAS. Baseline radiology statistics will be collected prior to and after the implementation of the DRDWAS and consist of, but are not limited to the following: number of cases read per day per radiologist, preferred modality types, and workload limits and restrictions. Phase three of the project will consist of questionnaires that monitor final perceptions and attitudes of the AFMS users and support personnel. The Evaluation Team has begun to collect data. DRDWAS programmers have completed questionnaires, and those results have been analyzed. One of the major goals is to improve workflow and communication between developers and AFMS key personnel. The Evaluation Team can use the feedback from completed questionnaires to obtain this goal. Current results will be reported. If the DRDWAS proves to be an effective workload allocation tool, not only will patient care improve throughout the AFMS, but radiologists will be able to strengthen their practice by increasing their knowledge in subspecialty experiences. Results from completed phases will be discussed.

272
Lessons Learned Part 2 (Technical): Developing a scalable Chronic Disease Model for Ontario’s 600- patient Telehomecare Project
Laurie Poole, BScN, MHSA, CHE, Ken McVey, BSc EE, MBA,  Ginny Odette, RN, BScN
Ontario Telemedicine Network, Ottawa, Canada
Ontario has just launched a telehomecare initiative to serve patients with congestive heart failure (CHF) and/or chronic obstructive pulmonary disease (COPD). This 18-month initiative is to be the first phase of a much larger roll-out of telehomecare services. The Program is a time limited intervention designed to enhance patient self-management skills and improve patient health status. Even as a first phase, the initiative was particularly challenging from a technical services perspective as it must be built to support up to 600 patients spread over vast geographical distances. Starting in the fall of 2007, patients are to be cared-for using an integrated care model based on Ontario’s Family Health Teams (FHT). At their homes, patients would use biotelemetry devices such as Peak Flow Meter, Pulse Oximeter, Weight Scale, Blood Pressure Monitor and Heart Rate monitor , in a few cases, videoconferencing, to capture and transmit vital signs and health status to one of  six nurses working at FHT’s. These six nurses would coordinate the tradition care delivery protocols with the new telehomecare protocols. All FHTs would lever the same centralized applications, training services and technical support.  The design of a technical architecture and service solution that could scale to hundreds and eventually to thousands of patients presented a unique challenge. Given that there were few Canadian telehomecare initiatives of this kind and this size to draw from, OTN developed its technical support model levering its existing institutional telemedicine service infrastructure and drawing on the expertise of its chosen telehomecare product vendor. This new integrated architecture will provide the foundation for continued growth of telehomecare services in Ontario harmonized with the existing videoconference-based Telehealth solution already provided.

251
Hospital-Based Case Management of Congestive Heart Failure Patients
William Appelgate, PhD,1  David Hickman, RN, MPH, FACHE,2  Nancy Brown-Connolly, RN, MSN3       
1Des Moines University, Des Moines, IA; 2Mercy Health Network, Des Moines, IA; 3Iowa Chronic Care Consortium, Des Moines, IA
The Iowa Chronic Care Consortium (ICCC) is a voluntary collaboration of public, private, academic, and government organizations. Beginning in July 1999, ICCC and Mercy Health Network (MHN), began implementing a program to address congestive heart failure (CHF). Strategic Approach: Deployment of programs for Iowans affected by chronic disease where they live. Designed to use current low-cost telephonic technology with medical oversight. Design: Hospital based case management program with clinical decision support integrated into clinical workflow. Model follows the patient from in-patient (IP) to out-patient (OP) providing continuity of care. Utilizes technology within framework of medical oversight, to provide day-to-day telephonic monitoring and intervention.  Methods: Patients were identified following hospitalization and referrals were accepted by physicians and self-referrals with physician approval. Population: Iowans with CHF (Level I, II, III, excludes Level IV) with history of repeated hospitalizations, self-referral, physician referral and following first hospitalization. Outcome Measures: Clinical effectiveness, patient functionality (Minnesota Living with Heart Disease) questionnaire, satisfaction (Likert 1-5 scale), and cost (IP, OP, ER). Findings: Clinical effectiveness: (N=569) average reduction in hospital readmissions (86.3%, <16%/year) overall hospitalizations any cause (N=226) decreased (55.8%, 163 admissions), patient functionality improved (physical D11.2, emotional 5.8, overall 25.0), satisfaction µ= 4.47/5.0, decreased cost  hospitalizations (est. $1,015,050). Conclusion: Low-cost web-based monitoring is effective clinically and cost efficient to implement and support. An integrated model allows continuity of care and contributes to quality bringing resources and expertise already available from the IP to the OP setting and can be integrated into current workflow. 

67
A Private Practice Telepsychiatry Model of Medical Directorship for Residential Treatment
Kathleen M. Myers, MD, MPH,1  Michael Storck, MD,2  Robert George, MD,3  Kimberly Lindsay, MSW4     
1University of Washington School of Medicine, Child Study and Treatment Center, Seattle, WA; 2University of Washington School of Medicine, Child, Seattle, WA; 3Eastern Oregon Children's Multi-Treatment Center (, Pendleton, OR; 4Morrow-Wheeler Behavioral Health Services, Heppner, OR
Objectives:  Telepsychiatry is best utilized when integrated into a system of care to build a treatment team and enhance a youth’s care. Few applications have been reported for youth with serious emotional and behavioral disorders that require out of home placement. Applications through private practice are also not well documented. This presentation describes a private telepsychiatry practice for youth in residential care. Methods and Results:  Our private practice in Portland Oregon has served as medical directors and provided care to youth in a residential treatment program 180 miles away in eastern Oregon.   Initially this was done by flying to the site to provide services and supplementing with telephone contact. Over the last ten years we have explored new technologic methods for providing care through computers and telepsychiatry using video-conferencing on large screen television sets.  We are now able to provide new evaluations, neurological examinations, and follow-up visits even with seriously mentally ill patients.  Here we describe our practice, including examples of patient care and system functions that have been successfully improved through telepsychiatry. Conclusions:  Telepsychiatry has allowed us to bring child and adolescent psychiatric expertise to youth in rural residential care while minimizing our time away from family and office. Beyond the benefits to our practice, telepsychiatry has also allowed us to offer the residential program more hours and diverse services, such as more staff consultation and team meetings at a level of frequency required by state agencies and payers. Our work has allowed the community to expand its system of mental health care and to maintain a family focus and cultural perspective by offering residential services within the community. Our success should stimulate others in states where access to care is challenging.

164
Examining Legal & Regulatory Issues
Robert J. Waters, JD,  Melissa Atkinson, JD         
Center for Telehealth & E-Health Law, Washington, DC
This session will provide an overview and update on the legal and regulatory activities facing telehealth programs and companies, including: issues of the 110th Congress, including for example, appropriations, reimbursement, licensure, universal service fund, remote monitoring, e-health;
•  Reimbursement, including findings from a 6-state Medicaid study CTeL conducted in 2006;
•  Licensure, including finding from a national licensure survey conducted in 2006 and issues    related to the use of health care providers in remote monitoring situations;
•  Antikickback and Stark statutes and safe harbors for E-Prescribing; and,
•  Other exciting legal topics to keep you in compliance and out of trouble. 

179
Pregnant and Incarcerated - Telemedicine That Serves and Protects
Gordon Low, APN,  Donna Williams, RN,  Paige Hare, RN,  Terri Imus, ADN, RN, Rachel E. Ott, BA    
University of Arkansas for Medical Sciences, Little Rock, AR
Approximately 6% of incarcerated women are pregnant and many stem from backgrounds that encouraged high-risk behaviors, including drug abuse, smoking, and alcohol use. Traditionally, pregnant inmates were transported for each prenatal visit and procedure to outside providers and hospitals. Through a new telemedicine initiative, the Arkansas Department of Corrections and ANGELS have partnered to provide optimal prenatal care from the state’s only Maternal-Fetal Medicine specialists without ever leaving prison. In 2007, ANGELS launched a telemedicine pilot providing comprehensive prenatal care for the inmates at Wrightsville Prison through an innovative blend of training, in-person guidance, remote subspecialty consultation, and around-the-clock triage support. Implementation followed a series of steps.  First, prison personnel were trained to provide basic obstetrical care, routine lab tests, common obstetrical medications, and technical skills in using a telemedicine-based fetal monitor and cervical exam. Next, the weekly prison clinic was launched weekly, as a nurse practitioner travels to the prison site to partner with prison personnel in administering routine prenatal care.  Utilizing real-time telemedicine, remote Maternal-Fetal Medicine subspecialists, genetic counselors, and obstetrical faculty collaborate with on-site personnel to consult and review ultrasounds and fetal-monitoring strips.  In support, a 24/7, nurse-staffed call center is available for prison personnel and pregnant inmates to triage pregnancy-related complaints and concerns.  For urgent concerns, the call center facilitates on-the-spot consultation with a chief obstetrical resident to the caller by connecting them through interactive telemedicine.  This intervention has already demonstrated promise in providing high quality, cost-effective care to an at-risk group of women whose access to quality obstetrical care is limited.  Further, the collaboration between the in-house and virtual clinic immediately reduced transports for routine care, saving money for the Department of Corrections.  Current studies are evaluating the programs ability to reduce expensive prenatal complications, hospitalization, and unnecessary transports to tertiary centers.

288
How Telemedicine is Transforming Health Care in California
Thomas S. Nesbitt, MD, MPH,1 Barbara Johnston, MSN, 2 Christine Martin, PMP, MBA3
1University of California, Davis, Sacramento, CA; 2Medical Board of California, Sacramento, CA; California Telemedicine & eHealth Center, Sacramento, CA
California has been a leader in the development of telemedicine programs and policy over the past fifteen years.  With nearly a half billion dollars available to advance telemedicine in the State, the environment for telemedicine development is extremely positive. Governor Schwarzenegger has stated that he envisions a digital highway for health care as a key part of his health care reform initiative for the State. This session will tell California’s story and the lessons learned that may be replicated in other states to promote telemedicine and create additional resources for its advancement. In the early and mid 1990s several health care providers in California began experimenting with telemedicine for home care, radiology, remote monitoring, and patient consultations. UC Davis started its telemedicine program in 1992 with remote fetal monitor to address obstetrical needs in rural communities.  In 1996, Kaiser Permanente began developing an innovative home telehealth program to address the needs of its home health patients.  The early pioneers collaborated with the legislature leading California to become one of the first states to pass reimbursement legislation for telemedicine. By the late 90s UC Davis and several rural health centers had received funding through federal and California based foundations to launch pilot projects.  Established in 1999, the California Telemedicine and eHealth Center (CTEC) began raising funds from foundations and recently HRSA, which has led to the development of several regional rural telemedicine networks, the UC Davis Telemedicine Learning Center, and formation of the CTEC Telemedicine Resource Center. The Governor’s administration sought advice from key stakeholders (public and private) regarding how Telemedicine and eHealth could advance healthcare reform. The stakeholders collectively recommended expanding broadband statewide to support an electronically enabled healthcare delivery system. This situation is the result of tremendous collaborative efforts between numerous organizations, foundations, state agencies, universities and committed individuals.

75
Digital images in surgical Pathology: 10 years experience in a private practice in Panama
Juan L. Surgeon C., MD,  Juan R. Arosemena, MD,  Ana I. Porcell, MD       
Servicios de Patología Anatómica y Clinica, Panama City, Panama
The use of images is  key in surgical pathology.  Traditional photography made difficult  the task of illustrating images for the macroscopic and microscopic findings of the histologic studies.  The introduction of equipment for the use of digital images has really changed this objective.  Our private practice group started in 1996 the first attempts to introduce digital images in the surgical pathology reports.  For the macroscopic images we started with a digital camera or a scanner and for the microscopic images we started with a videocamera attached to one of the oculars of the microscope.  With this equipment we were able to incorporate digital images with the other parts of the surgical pathology report.  Through the years the equipments and the programs have improved  and their prices have decreased, which has made our work easier. We will describe the initial process, its initial deployment, development and the implications that digital images have had in our private practice from different points of view:  the incorporation of technology, business, education, legal and communications.

211
Validation of a remote monitoring health platform for Parkinson disease patients
Cecilia Vera-Muñoz, PhD candidate,1  Laura Pastor-Sanz, PhD candidate,1  Maria Teresa Arredondo Waldmeyer, PhD,1  Angel Blanco, MSc2     
1Universidad Politecnica de Madrid, Madrid, Spain; 2SIEMENS, S.A., Madrid, Spain
Emotions play an extremely important role in human’s life and have been deeply studied in the recent years. The AUBADE EU funded project, one of the last initiatives in this field, has developed and validated an innovative system for the automatic detection and recognition of the emotional state of persons, based on the processing of biomedical signals. The system application focuses on the health care sector, more specifically on the neurology area, with particular relevance in Parkinson disease and Huntington disease.
The development of the AUBADE system required the combination of several innovation areas such as wearable systems, biosensors, sensor management techniques, data fusion, medical decision support systems, 3-D animations and telecommunication technologies. The acquisition of multiple biomedical signals from the subject’s body (Facial EMG, ECG, skin conductivity and respiration rate) and the application of advanced data processing techniques result in the automatic recognition of the subjective feeling that a person is experimenting in near real time. The subject’ emotion is identified based on three different parameters: subjective experience, physiological arousal, and behavioural expression. The implemented system is able to detect six different emotional classes, derived from three of the basic emotions (happiness, disgust and fear), specially selected for being relevant for Parkinson disease and Huntington disease.  The system has been tested and validated in a clinical environment, involving 24 subjects and obtaining good accuracy and specificity results: above 70% of correct identifications in all emotional classes’ classification. AUBADE has been proved to contribute to obtain precise diagnosis, to improve disease management, and even to suggest treatment procedures for neurological patients.

113
Customizing Home Teleheath Programs for Remote Areas
Philip W Ginder, MHA, FACHE,  Mark Anaruk, M Ed         
Alaska Federal Health Care Partnership, Anchorage, AK
The Alaska Federal Health Care Partnership (AFHCP) is taking an innovative approach to broadly field home telehealth monitoring to the federal and tribal beneficiaries across the state of Alaska.  While providing centralized program management, planning, procurement, and funding, the AFHCP is also providing customization of each organization’s home telehealth monitoring program to complement their existing disease management processes.  This partnering allows a group of very diverse organizations to work together to reap the benefits of home telehealth monitoring. In most cases program implementation would likely not occur without the centralized aspects of the program.  Deployment of the Home Telehealth Monitoring Initiative has extended the reach of the provider from the clinic into some of the most remote homes in the state of Alaska.  Challenges of deploying this program in rural Alaska have included resolving telecommunications issues, coordinating with small patient populations, and widely scattered health care resources.  Furthermore the care management techniques of our partner organizations are not standardized, so each program required a design with those processes in mind.  Cultural and language considerations played a key role in customizing the home telehealth programs to our diverse organizations.   Anecdotally, our diabetic patients have already noticed a reduction in their HgA1C levels, and have expressed satisfaction with the more frequent, but less burdensome monitoring.  We also were able to identify a significant population that could benefit from Coumadin, but previously were not place on the drug due to their remote locations and inability of providers to monitor their PT/INR levels on a frequent basis.  Now, with a home monitoring device and a hand-held PT/INR meter this treatment is available to those patients.   Finally, our home care providers report that medication management units have allowed our patients to better control their timing of medications, helping optimize their care.  

65
Child and Adolescent Telepsychiatry in Telepsychiatric Consultation to and Collaboration with Primary Care
Kathleen M Myers, MD, MPH,1  Michael Storck, MD,2  Robert George, MD,3  Kimberly Lindsay, MSW4      
1University of Washington School of Medicine, Child Study and Treatment Center, Seattle, WA; 2University of Washington School of Medicine, Child, Seattle, WA; 3Eastern Oregon Children's Multi-Treatment Center (, Pendleton, OR; 4Morrow-Wheeler Behavioral Health Services, Heppner, OR
Background:  Children's Hospital and Regional Medical Center (CHRMC) has operated a successful child and adolescent telepsychiatry service since 2001. Our service provides direct patient care to 4 communities in rural Washington state and to one community in southeast Alaska, with plans to expand into other isolated communities in southeast Alaska. Our service has employed bandwidth of 384 kbits/sec and 1 MB/sec. Here we present findings from our experience. Methods: This presentation comprises a descriptive study of our experience. We also provide a demonstration of the effects of differing bandwidth on the clinical experience. Results: We provide diagnostic profiles, clinical services delivered including medications prescribed, patient and referring providers’ satisfaction with their care, and sustainability of the service. We will also review current research projects. Initial results indicate that most clinical situations can be addressed through telepsychiatry. Parents and referring physicians endorse high satisfaction with their patients’ care, although pediatricians endorse greater satisfaction than family physicians. There are multiple challenges to sustainability of telepsychiatry, but our reimbursement has matched our in-person reimbursement. Conclusions: Telepsychiatry brings valuable services to children and adolescents in distant communities and offers the opportunity to rectify the inequities in access to services. Now that telepsychiatry has demonstrated the opportunity to increase access to care, future work should focus on how to use telepsychiatry to build comprehensive models of care that complement youths’ existing systems of care in their home communities. Future research should focus on outcome studies that demonstrate the efficacy of telepsychiatry in bringing evidence-based services to communities.

99
State-of-THE-art Technologies for Remote Accessibility Assessment of wheelchair user's Home
Jongbae Kim, PhD,1 Yan Wang, PhD,2 Erik A. Porach, BS,1 Heba Hamza, MS2
1University of Pittsburgh, Pittsburgh, PA; 2University of Central Florida, Orlando, FL
We developed a Remote Accessibility Assessment System (RAAS) using three-dimensional (3D) reconstruction technology that enables clinicians to assess the wheelchair accessibility of users built environments from a remote location. Although we demonstrated the potential value of the first phase RAAS through field trials, the method had a few limitations. Even with the guidebook, it was a challenge for novices to take appropriate 2D pictures for the 3D reconstruction. In a follow up, we developed a ®Tele-imaging protocol, that used a high-end IP camera and a high-speed internet connection that allowed the specialist took the high-resolution and wide-angle images of the remote built environment while seeing it via video steaming at distance. In order to provide the efficient and sufficient communication between the consumer and service provider, we built a Web-based Multimedia Decision Supporting System (WMDSS) for accessibility assessment, in which preliminary information, documents, 2D photos, 3D models, and 3D geometry of the built environment can be uploaded. It then allows project members - a technician, a home modification specialist, a clinician, a client, a caregiver and a family member - to share information, exchange ideas, and retrieve documents. We enhanced the system by developing a Virtual Reality Simulation and Measurement algorithm. This technology publishes the 3D models with an embedded cyber wheelchair of the customer’s real wheelchair dimension on the website via the WMDSS. It then enables the evaluator, as well as project members, to try to drive the wheelchair in the virtualized reality environment in their locations, see the measurement of the architectural objects, and figure out which part has the problem for wheelchair accessibility. This algorithm will allow the project members to assess the accessibility more intuitively and efficiently. Now, we are conducting large and randomized studies to access the value of this improved remote accessibility assessment system.

391
New Mexico Medicaid Comprehensive Reimbursement Program for Telehealth Services
Pamela S Hyde, JD,1  Carolyn Ingram,1  Lowell Gordon, MD,1  Dale C Alverson, MD2     
1New Mexico Human Services Department, Santa Fe, NM; 2University of New Mexico, Albuquerque, NM
Starting in August 2007, New Mexico Medicaid began one of the nation’s most comprehensive reimbursement programs for telehealth services. Recognizing the value of using Telehealth to enhance access to covered services for its patients/clients, the NM Medical Assistance Division, Human Services Department, now reimburses for covered services by eligible providers at the same rate as a physical face-to-face encounter.  In addition, reimbursement is made to the originating-site, where the patient is located, for an interactive telehealth system fee; $22.47 per transmission. The reimbursement criteria follow very closely the New Mexico Telehealth Act of 2004. Any approved Medicaid provider is authorized to use Telehealth for their patients/clients. The client/patient receiving the telehealth service can be located at a variety of originating sites, including their place of residence. An interactive telehealth communication system must include both interactive audio and video and be delivered on a real-time basis at the originating and distant-sites. Store and forward interactions are covered. These new regulations are a major step forward in facilitating the use of Telehealth in New Mexico aimed at enhancing the health and wellness of its citizens, particularly the underserved. This program can serve as a model for Medicaid telehealth reimbursement in other states.

474
Telemedicine and the WWAMI (Washington, Wyoming, Alaska, Montana, and Idaho) Region – Future Directions
Richard M. Satava, MD, FACS
University of Washington, Seattle, WA

137
Telemicrobiology and Teleparasitology for mission support in infectious diseases
Patrick L. Scheid, PHD,1  David M. Lam, MD, MPH2,3         
1Central Institute of the German Army Medical Service, Koblenz, Germany; 2US Army Medical Research and Materiel Command, Telemedicine & Advanced Research Center (TATRC), Fort Detrick, MD; 3University of Maryland Medical School, National Study Center for Trauma and EMS, Baltimore, MD
Introduction:  Infectious diseases are among the most common medical conditions identified while serving in foreign military missions or disaster relief operations. The first reported telemicrobiology/teleparasitology system in routine operation worldwide provides a capability to support long-distance diagnosis in both military and civil settings. Methods:  In order to support diagnosis by means of telemedicine, a modification of the German Armed Forces telemedicine workstation was devised. A telemicrobiology/teleparasitology module with special equipment, camera, and software has been designed, validated, and deployed. Results: This module, currently in use in three operational military theaters, has been entered into routine practice after its careful comparative evaluation and validation. Blinded comparative studies of transmitted image interpretation with non-transmitted data have shown a significant improvement in diagnostic species identification (specificity). The currently deployed system allows the transmission and interpretation of high-quality static images of microscopic specimens, overgrown nutrient media, stool preparations, or malaria preparations in a very short time, with consequent improvement in patient care and disease surveillance.  Conclusions:  The inclusion of distant experts in diagnostic analysis through the use of telemedicine improves diagnostic specificity by avoiding false positive results and, particularly in medical parasitology, allows a treatment-essential diagnosis without the dispatch of specimens to Germany. This system can only be used in a well-coordinated overall diagnostic system. The designed telemicrobiology and teleparasitology module has been proven, and is now deployed, providing a higher level of field diagnostic support than previously possible. It has clear potential applicability not only in the military field, but in civilian and multinational disaster relief operations.

296
The Impact of Format and Interactivity on Learning and Retention
Gordon F. West, DMin, PhD,1 George Hurrell, Jr., MBA,1 Donna Rane-Szostak, EdD, APRN, BC2
1Annenberg Center for Health Sciences at Eisenhower, Rancho Mirage, CA; 2California State University San Bernardino, Palm Desert, CA
Introduction: This research protocol was designed to answer three questions about continuing medical education:

1. Is one educational format more efficacious than others in healthcare provider learning?
2. Is one educational format more efficacious than others in healthcare provider retention of learned material?
3. Does participant interaction increase either learning or retention?

Methods: To address these, educational content was developed for a variety of topics within the field of biopreparedness. That content was presented in various formats: live meetings, print, personal digital assistant, and online. Within the live and online formats, participants were assigned to a traditional passive or an interactive educational activity presenting the same information. The print and PDA formats did not offer alternatives to passive learning. Learning was assessed with pre- and post-tests; retention was measured by follow-up tests at 3 and 6 months. Demographic data were collected for the statistical analysis. Results: Currently, only the data from the live meetings have been analyzed. Other data will continue to arrive and be analyzed into 2008. In didactic and interactive meetings, knowledge increased significantly from pretest to posttest. In both cases, there was an expected erosion of knowledge from posttest to 3 month follow-up, with little change to 6 month follow-up. The two groups were sufficiently incompatible to not allow cross comparisons. Data on other formats is currently being collected. Further analysis on those data will be completed and presented at the meeting. Conclusions: In preliminary results, we see that live activities do increase healthcare provider knowledge in topics related to biopreparedness. However, that knowledge is not retained over time. There are currently tendencies that will become clearer as data arrive and are analyzed.

186
The Next Generation of Disease Management
Julie Cheitlin Cherry, RN, MSN, PHN
Digital Health Group, Intel, Beaverton, OR
Abstract Summary: Advances in at-home patient monitoring technology promise to be a catalyst for the next generation of disease management, especially by supporting truly personalized healthcare regimens for patients. Technology will create a new, interactive conduit to allow for more appropriate and timely interventions, real-time and integrated data reporting, and dynamic two-way communication between patients and health professionals. Additional benefits to disease management programs include the ability to provide personalized care plans that can integrate patients’ monitoring regimens with educational content and behavior modification techniques so patients can become more engaged in managing their own chronic conditions. Intel has conducted groundbreaking research into the technology usage, habits, and needs of this population and this talk will include relevant outcomes from this research. 
Objective 1: To understand the importance of designing technology for a targeted population.
Objective 2: To examine the components of a telehealth solution that can improve the likelihood of successful outcomes for people with chronic conditions.
Objective 3: To explore the impact personalized care plans can have on the following: on the ability to enable patients to more actively manage their own health; on the relationship between patients and their healthcare providers; and on patient health through sustained lifestyle changes.

74
Improving Adherence to an Exercise Program: A Personalized Virtual Coach
Abby Cange,1  Timothy Bickmore, PhD,2  Kimberly Harris, MM,1  Deirdre Neylon, MA,1 Joseph Kvedar, MD,1,3,4 Jeffrey Brown,1 Alice Watson, MD MPH1,3,4  
1Center for Connected Health/Partners Healthcare, Boston, MA; 2Northeastern University, Boston, MA; 3Massachuetts General Hospital, Boston, MA; 4Harvard Medical School, Boston, MA
Over 65% of US citizens are currently overweight or obese.  Poor adherence to exercise and diet are cited as major barriers to losing weight.  Although motivational coaching, personalized feedback and patient education are effective tools, to deliver all these elements using traditional methods requires a level of manpower that is both costly and in short supply, leaving many patients without access.  In order to address this problem we developed an automated coaching platform designed to provide personalized feedback to change behavior.  The platform has two key components: a wearable activity monitor and a computer avatar designed to provide exercise coaching.  The activity monitor tracks daily step totals and can be worn in a number of different locations on the body (on belt, in pocket, around neck), allowing it to be a ‘wear and forget’ device. The monitor transmits information about a patient’s daily activity level through a “black box” console to a computer server.  The step counts are then sent to the ‘Virtual Coach’; an animated, embodied computer agent designed to run on a patient’s home computer.  The coach uses verbal and non-verbal relationship building behavior to create an effective working alliance with a patient, offering educational information, feedback on performance and strategies to overcome barriers.  By creating interoperability between the coach and the activity monitor, we allowed interactions to be tailored to the patient’s step count.  This platform offers patients access to scaleable, low-cost personalized coaching.  This is a valuable form of motivational support to help overweight patients improve their adherence to an exercise regime.  Furthermore, by basing the coaching interactions on measured step counts we eliminate the common errors seen when patients self-report this information.  We believe this platform offers an effective approach to increasing patient activity and positively impacting overall health.

363
Telemental Health Guidelines: Disorder-Specific Perspective
Peter Yellowlees, MBBS, MD           
University of California, Davis, Sacramento, CA
Many articles and reports call for the need for telemental health guidelines, but no guidelines are consistently used in the practice of mental health. Leaders from four different organizations will address telemental health guidelines from the perspective of 1. a telemedicine organization special interest group; 2. a psychiatry organization; 3. a state psychology committee; and 4. a NIH-sponsored, disorder-specific panel.  More specifically, the panelist will discuss the National Institute of Mental Health supported project “Enhancing Mental Health Services to Children with Autism in Rural Communities.” The project produced guidelines intended for professionals at tertiary care centers specializing in the care of children with autism who are interested in expanding the scope of their service delivery to rural and remote communities through the use of telecommunications technology.  Especially in rural communities, care of children with autism is marked by a lack of access to autism-specific expertise and lack of coordination among the key public agencies.  This often results in fragmented service delivery, unmet needs, high levels of family stress, and children who do not progress adequately.  The guidelines were developed collaboratively based on experts across telehealth, child psychiatry, autism diagnosis and treatment, bioethics, education, economics, sociology, human development, distance learning, mental health, and cultural studies. In addition to pooling findings from across these disciplines, the project integrated information from the community as it developed guidelines.  The panelist will emphasize the need for continued research to build telemedicine’s knowledge base both in autism care and general telemental health practice.

462
Standards and Guidelines: ATA and Telemedicine's New Frontier
Nina M. Antoniotti, RN, MBA, PhD,6 Brian Grady, MD,3 Elizabeth Krupinski, PhD,5 Anne Burdick, MD,6 Lisa Carnahan, PhD,4 Lynn Rosenthal, PhD,4 Jerry Cavallerano, OD, PhD2
1Marshfield Clinic TeleHealth, Marshfield, WI; 2Beetham Eye Institute, Joslin Vision Network, Boston, MA; 3Sheppard Pratt Health System, Baltimore, MD; 4National Institute of Standards and Technology, Washington, DC; 5University of Arizona, Tuscon, AZ; 6University of Miami Miller School of Medicine, Miami, FL
At no time has it been more important than today to develop national standards and guidelines for TeleHealth/Telemedicine. Payers, regulators, legislators are asking for standards. There is no other entity in a better position to do so that the American Telemedicine Association.  Government regulatory bodies have longed questioned – “Where are your standards?” and now ATA is in a position to answer that question.  The Standards and Guidelines Committee, one of the three Board appointed committees of ATA, has developed a Standards Framework, a Workplan for Standards and Guidelines, a common list of Definitions and Terms, and has finalized two sets of standards – one for Diabetic Retinopathy and the other for TeleDermatology.  This presentation will outline the historical development of these two important documents, the current projects underway, and the overall process for development of standards and guidelines for TeleHealth/Telemedicine. The participant will gain knowledge in the process of standards development and will leave the presentation with tools to begin the process of specialty and role specific standards and guidelines development. 

151
Effectiveness and Replicability:  Providing Healthcare to Uninsured and Underinsured Employees
Michael Bourdeau, MS,2  Maria Wellisch, BBA, RN,1  Oscar W. Boultinghous, MD, FACEP,2  Alexander H. Vo, PhD2     
1Morningside Ministries, San Antonio, TX; 2University of Texas Medical Branch at Galveston, Galveston, TX
Effectiveness and Replicability:  Work-based telemedicine works because it can be cost-effective for both employees and employers. New technological innovations in telemedicine continue to improve prospects for both lowering costs, improving health outcomes for employees, and increasing worker productivity in the workplace.  User fees and co-pays can be kept relatively low making telemedicine an affordable health care alternative for employees. Because work-based telemedicine is easily accessible to employees at times convenient to them, they can reduce the amount of wages lost to make doctor's appointments. Telemedicine also appears to improve health outcomes for employees, again reducing both lost wages and out-of-pocket health care costs for workers. For employers, improving employee and family health outcomes and less sick-time off, results in lower labor costs (less sick time paid) and increased worker productivity (fewer absences). Better health outcomes can also help to reduce health insurance claims resulting in lower health insurance premiums for employers. In addition, because employees perceive that access in the workplace to otherwise unaffordable heath care for the entire family is an attractive fringe benefit, telemedicine helps employers both recruit motivated workers and retain valued employees. How could it be made to work in other communities?  To implement a successful work-based telemedicine program, an organization must have:
1. Strong commitment to employee health from the CEO and Board.
2. Effective marketing to employees of the benefits of telemedicine.
3. Strong collaboration with a health care provider for physician services.
4. Support of local funders to defray technology development costs.
See Other Panelist Abstracts for Complete Description of Proposed Presentation.

316
The African Rural Clinic of the Future.
Maurice Mars, MBChB, MD,1  Chris Morris, BEng2         
1University of KwaZulu-Natal, Durban, South Africa; 2Meraka Institute, Pretoria, South Africa
Africa has a major burden of disease, a significant shortage of health professionals and insufficient funding to meet its health needs. Adding to its woes is the prediction that its population will double by 2050. Most African countries will not achieve their Millennium Development Goals, which include the reduction in infant mortality and improvement of maternal health. While the World Health Assembly and the Global Observatory for eHealth see telemedicine as a means of addressing the problem, connectivity and internet access in Africa is still poor, bandwidth costs are high and telemedicine uptake low. In Africa, telemedicine is usually seen as an additional burden as it adds extra tasks to the already overworked health professional. For telemedicine and medical informatics to play a role in alleviating the African health crisis, innovative ideas and solutions are required. Fundamental to the African health systems is the rural clinic which provides primary healthcare and education, antenatal and maternity services, paediatric care, basic trauma support, services relevant to the disease profile of the area and homecare. It also collects epidemiological data. These clinics are often run by nurses who may or may not have occasional support from visiting doctors. A model of a rural clinic incorporating telemedicine and medical informatics and based on mHealth, with integrated open source platforms, will be presented. The proposed solution includes mesh and cellular telephone based connectivity and mobile technologies for patient care, data collection, home care, monitoring of patient drug compliance, education and surveillance. The use of existing homecare telemedicine solutions to improve services in the rural setting will be described. Ground based surveillance needed to meet the new International Health Regulations is incorporated in the model. This model may serve as an alternative starting point in the discussion on meeting Africa’s healthcare problems at clinic level.

475
Army Teledermatology: More than just patient care!
Tom Hirota, OD
Dermatology Services, Madigan Army Medical Center, Fort Lewis, WA
Since 2000, the US Army has deployed and operated a web-based teledermatology system. During this time, several lessons were learned regarding setting up the business model for military treatment facilities. More important, in the last 2 years, the dermatology residency program in San Antonio has incorporated Teledermatology as part of the training program. The intent of this presentation is to highlight the business model for use of the program, and to highlight the benefits of incorporating teledermatology into the residency program.

174
Desperate Measures: Using Colposcopic Telemedicine to Benefit Rural Women
Gordon Low, APN,  Delia James, APN,  Wilbur C. Hitt, MD,  Rachel E. Ott, BA     
University of Arkansas for Medical Sciences, Little Rock, AR
Between 1999 and 2003, Arkansas averaged 148 cases of invasive cervical cancer and 52 deaths annually, ranking 4th in the nation in cervical cancer mortality.  Arkansas’ women suffer from a healthcare system unsupportive of colposcopy.  In the sixth poorest state in the nation, Arkansas Medicaid does not cover colposcopic exams and only provides reimbursement and treatment for women with colposcopic biopsies showing moderate dysplasia or worse.  ANGELS pioneered a telecolposcopy clinic combining the expertise of local and remote specialists to predict moderate to severe dysplasia, while administering telemedicine-based monitoring and follow-up for women with less severe conditions.  An APN at a rural Arkansas county health unit performs colposcopic exams using a telemedicine colposcope broadcasting real-time images of the cervix to an ANGELS gynecologist. Through interactive telemedicine, these experts visually assess the cervix to identify the existence and severity of dysplasia to merit biopsy.  ANGELS seeks to determine the sensitivity of telecolposcopy in identifying severity of dysplasia to help build a better system in securing Medicaid reimbursement for Arkansas’ rural women. By reviewing the cervix through telemedical scope, experts at UAMS have had success in positively identifying moderate to severe dysplasia requiring biopsy.  Among 111 women receiving telecolposcopy and biopsy, the visual assessment agreed with the biopsy result in 84.  Among the cases where there was disagreement 15 women were initially suspected to have moderate to severe dysplasia, but biopsy determined this impression was overestimated; whereas,12 women were underestimated in their severity.  Telemedicine can achieve an accurate, sensitive assessment of colposcopies comparable to traditional colposcopic exams through simple interactive imaging, which serves as an essential intervention for Arkansas’ rural women facing Medicaid reimbursement restrictions.  When combined with gynecological specialist expertise, telecolposcopy can help assess severity, guide biopsy, and provide follow-up for rural cervical cancer patients without access to specialty care.

243
Clinical Grand Rounds and Corporate Training Trials Across the Borders.
Giselle Ricur, MD, Gabriela Batiz, IT Eng, Alfredo Romano, José Arrieta, MD, Andrés Valdivia
Instituto Zaldivar, Mendoza, Argentina
This presentation reports on the trial use of web-based applications and VoIP technologies during clinical grand rounds and corporate training seminars between the Institution’s local and international branches. In order to enhance the personnel’s access to formal medical and corporate institutional training, web meetings and on-demand collaborative applications together with VoIP solutions were deployed between the Argentinean branches of the Instituto Zaldivar in Mendoza and Buenos Aires and its international site in Asunción, Paraguay. By means of different desktop applications (Webex, Live Meeting, etc) trail web meetings were performed on a weekly basis, targeting two different segments: the medical personnel during their clinical grand rounds and the executive staff during their corporate training seminars. These new tools allowed for the sharing of information and multimedia presentations, facilitated decision making, and enhanced mutual collaboration between the staff in a confidential and secure manner. In consequence, the Institution’s auditorium in Mendoza was converted into an online live classroom linked to the desktops or videoconferencing equipments of the other sites. VoIP telephony systems were used as backup when critical technical factors such as insufficient bandwith, network “congestion”, etc. challenged a noiseless transmission.  These trials demonstrated that the new on-demand web-based conferencing tools are becoming an attractive communication medium for e-learning. The interaction between instant desktop audio and video conferencing capability enhances training regardless of the geographic locations and transforms the learning process into a real-time class room experience. These trials also proved that operational training costs were also decreased by eliminating the need of transporting the personnel to the main site in Mendoza. Troubleshooting the technical factors mentioned above resulted as critical as organizing the adequate network right from the beginning of the program. 

158
A Wireless Wearable Reflectance-Based Forehead Pulse Oximeter
Yitzhak Mendelson, PhD,1,2  James R Duckworth, PhD1,2          
1Worcester Polytechnic Institute, Worcester, MA; 2Advanced Body Sensing, Worcester, MA
A wireless wearable pulse oximeter has been developed based on a small forehead-mounted optical reflectance sensor. The battery-operated device can operate for several days. It employs a lightweight sensor comprised of a large area photodetector to reduce power consumption. Dedicated signal processing algorithms are utilized to reduce the effects of motion artifacts. The system also has short range wireless communication capabilities to transfer arterial oxygen saturation, heart rate, respiration rate, body acceleration, and posture information to a PDA or to a USB-based receiver for connection to a PC that can be carried by military and civilian first responders. The PDA or PC can monitor multiple wearable pulse oximeters simultaneously and allows medics to collect vital physiological information to enhance their ability to extend more effective care to those with the most urgent needs. The system can be programmed to alert on alarm conditions, such as sudden trauma, or physiological values out of their normal range. It also has the potential for use in combat casualty care, such as for remote triage, and for use by first responders, such as firefighters. This paper describes the results from initial field testing of this wearable system, and compares its performance with that of conventional pulse oximeters and other physiological wearable devices.

334
Testing the reliability and accuracy of a preventative telecare system
Steve J. Brown, BSc (hons),1  Blaise F. Egan, BSc, MSc, MPhil,1  David Adamson, MSc,2  Paul A. Bowman, BSc, Msc,1 Martin Salter,2 Tian Loh,2 Trevor Esward2  
1British Telecom Research, Ipswich, United Kingdom; 2National Physical Laboratory, United Kingdom
Reductions in the cost of data processing, storage, broadband communications and sensor hardware, together with an increase in the performance of these technologies and components, has led to the development of some new and exciting telecare applications. It is now possible to develop telecare systems capable of helping prevent dangerous incidents from occurring to individuals rather than simply detecting when they have occurred. In general, these ‘preventative’ systems are attempting to identify specific human activities in order to spot unusual or dangerous patterns, and to alert carers accordingly. However, such systems vary in their accuracy and reliability in detecting human activities, and the level of detail they can provide to the carer about those activities.  We believe the success of preventative telecare systems will largely depend on the quality and reliability of the data provided by the system sensors and on the algorithms used to process this data.  The algorithms will be intended to detect specific complex human activities and require verification and validation. This paper describes the methods we have employed in testing a preventative telecare system. The results provide an indication of the accuracy of the system, as well as the reliability of the sensors and sensor transmission system for the system being tested.

361
Telemental Health Guidelines: Professional Organization Perspective
Kathleen Myers, MD, MPH, MS1,2           
1Department of Psychiatry and Behavioral Sciences,, Seattle, WA; 2Children's Hospital and Regional Medical Center, Seattle, WA
Many articles and reports call for the need for telemental health guidelines, but no guidelines are consistently used in the practice of mental health. Guidelines are “systematically developed statements to assist practitioners and patients make decisions about appropriate health care for specific clinical circumstances.” There are various choice-points in guideline development, implementation, dissemination, and evaluation. Voluntary guidelines will be contrasted with mandatory standards. Guidelines will be placed within the context of evidence-based medicine.  Leaders from four different organizations will address telemental health guidelines from the perspective of 1. a telemedicine organization special interest group; 2. a psychiatry organization; 3. a state psychology committee; and 4. a NIH-sponsored, disorder-specific panel.  More specifically, the panelist will address the guideline or parameter development for the American Academy of Child and Adolescent Psychiatrists (AACAP).  Telepsychiatry services are growing rapidly in child and adolescent psychiatry due to severe workforce shortages.  The telepsychiatry practice parameters have taken over three years to refine and draw on the expertise of both telehealth researchers and practicing telepsychiatrists.  The parameters address strategies for establishing a telepsychiatry service and optimizing clinical practice within that service.  The panelist will present the twelve parameter principles, based on existing scientific evidence and clinical consensus.  The panelist will emphasize the integration of telepsychiatry within other AACAP practice parameters. The panelist will discuss strategies for integrating recommendations across the different guidelines presented by the panel.

463
Standards and Guidelines: ATA and Telemedicine's New Frontier
Nina M. Antoniotti, RN, MBA, PhD,6  Brian Grady, MD,3  Elizabeth Krupinski, PhD,5  Anne Burdick, MD,6 Lisa Carnahan, PhD,4 Lynn Rosenthal, PhD,4 Jerry Cavallerano, OD, PhD2  
1Marshfield Clinic TeleHealth, Marshfield, WI; 2Beetham Eye Institute, Joslin Vision Network, Boston, MA; 3Sheppard Pratt Health System, Baltimore, MD; 4National Institute of Standards and Technology, Washington, DC; 5University of Arizona, Tuscon, AZ; 6University of Miami Miller School of Medicine Miami, FL
At no time has it been more important than today to develop national standards and guidelines for TeleHealth/Telemedicine. Payers, regulators, legislators are asking for standards. There is no other entity in a better position to do so that the American Telemedicine Association.  Government regulatory bodies have longed questioned – “Where are your standards?” and now ATA is in a position to answer that question.  The Standards and Guidelines Committee, one of the three Board appointed committees of ATA, has developed a Standards Framework, a Workplan for Standards and Guidelines, a common list of Definitions and Terms, and has finalized two sets of standards – one for Diabetic Retinopathy and the other for TeleDermatology.  This presentation will outline the historical development of these two important documents, the current projects underway, and the overall process for development of standards and guidelines for TeleHealth/Telemedicine. The participant will gain knowledge in the process of standards development and will leave the presentation with tools to begin the process of specialty and role specific standards and guidelines development. 

140
Significance and Innovation:  Providing Healthcare to Uninsured and Underinsured Employees
Jose Loera, MD,2  Maria Welisch, BBA, RN,1  Glenn G. Hammack, OD, MSHI, FAAO,2  Alexander H. Vo, PhD2     
1Morningside Ministries, San Antonio, TX; 2University of Texas Medical Branch at Galveston, Galveston, TX
Significance and Innovation:  Many employers and workers in the elder care industry cannot afford to pay premiums for even the lowest-cost health insurance available or to pay the out-of-pocket costs of primary, private care. Lacking access to affordable health insurance or private care, workers in the elder care industry experience poor health outcomes, higher health care costs relative to their income, and the loss of wages for unpaid time off due to frequent illnesses. Indeed, many workers do not receive healthcare until their health problems have become chronic or acute, requiring expensive treatment and a significant time off and loss of wages. Telemedicine technology makes it possible to provide lower-cost healthcare to a large number of employees and family members who otherwise have little or no access to healthcare. The long-term goals of the Morningside Telemedicine Project are to:

1. Improve the quality of healthcare available to employees at Morningside Ministries, as well as other older adults and their professional caregivers.
2. Reduce the costs of healthcare to employees at Morningside and other similar facilities.

The use of work-based telemedicine technology at Morningside Ministries has shown to improve employee health outcomes, increase worker productivity, and be a useful tool in employee recruitment and retention. Employees "see" a doctor at one of three Telemedicine Clinic via a high-speed data transmission line or an Internet connection. The Telemedicine Clinic has specialized medical devices such as a stethoscope, otoscope, and dermascope that allows doctors to hear a patient's heart and lungs, see into their ears, and take a "close-up" look at a patient's skin. Telemedicine provides employees and their families work-based, medical care using telemedicine technology and physician services made available by the University of Texas Medical Branch located in Galveston.   See Other Panelist Abstracts for Complete Description of Proposed Presentation.

386
Introduction of Cellular Phone-based Call-Centers in Bangladesh: Impact on Access to Health care Information
Mohammad A. Rahman, PhD           
California State University, Fresno, Fresno, CA
The Health-Line initiative undertaken in Bangladesh is a unique call-center program that connects patients with doctors for instant medical advice and serves as the clearing house for health information and health related services. The program is jointly undertaken by Grameen Phone cellular phone service and Telemedicine Research Center Limited, a health technology firm. This study was conducted to understand the viability of using cellular phone-based call-center in a developing country like Bangladesh and its impact on the level of access to health information, particularly the rural areas. It is to be noted that the land phone system in Bangladesh is city-based while cellular phone service has penetrated the rural countryside thanks to micro-credit loans to poor women in the villages. This study conducted interviews of 250 cell phone subscribers randomly sampled from the cellular phone company’s subscribers list. The study finds that there is evidence of a tremendous response to such initiative throughout the country and has provided marked improvement in the access to modern health care information. The majority of the callers is of low income and located in remote rural areas; a significant number of them are women who are usually confined indoors with little access to modern allopathic medical health information. It appears that the call-center service has been successful to bring down the barrier of economic and social disparities to access to health information to some extent. The callers were mostly satisfied with the service and recognized its value in terms of money saved from travel cost to the nearest doctor, wait time and doctors’ fees. The study also points out some drawbacks of such services and identifies the lessons learned from such initiatives that can be useful not only in other developing nations with similar situations, but also in under-served areas in many developed countries.

476
Continuous, Ambulatory Remote Monitoring of Vital Signs for Improved Life Quality
Frode Strisland, Dag Ausen, Ingrid Svagård, Ole Christian Bendixen
SINTEF Information and Communication Technology, OSLO, Norway
Sensor systems for home vital signs monitoring are mainly focused on discrete point measurements (weight, blood glucose, short period ECG trace), during which time the patient is constrained to be at rest next to the monitoring station.  However, several user groups would benefit from continuous remote monitoring that ensures their freedom of movement. Temporary continuous monitoring can provide better safety of patients discharged from day care surgery procedures and allows more efficient medication adjustments. Permanent monitoring is an alternative for patients with serious cardio-vascular diseases that otherwise would have been trapped in a hospital bed.  Similarly, soldiers or workers in hostile/harsh environments can benefit from vital signs monitoring in assurance that injuries will cause alerts and a prompt rescue.

Vital signs monitoring is challenging in several respects, for example obtaining reliable sensor data and interpretation models for the data, achieving user acceptance and ease-of-use, and integration the existing health care system and care processes.

We report on work carried out to do continuous remote monitoring of vital signs.  Parts of the work have been carried out within the US-Norway Medicom telemedicine research program, in which also a soldier vital signs monitoring demonstrator system has been developed. This system allows live monitoring of a user’s heart rate, respiration rate, body posture, activity, temperature and pulse oximetry, and transmission of data to an internet-accessible data storage using cell phone technology. In addition, we report on work to implement increased use of wireless monitoring and tracking systems in the Norwegian civilian health care sector.

194
Creative Use of Telemedicine in Radiation Oncology in a Multi-site Setting
Lon Marsh, BS, RRT(T), CMD.,  Steve Jordan, BBA,  Joe Meyer, BBA,  Marc Halman, MSW     
University of Michigan Health System, Ann Arbor, MI
The radiation oncology program at the University of Michigan Health System (UMHS) has designed and implemented a virtual private network (VPN) connecting seven delivery sites throughout the State of Michigan. The network is coordinated by its hub center at the Department of Radiation Oncology of the UMHS. The network was established to obviate the need for patient travel to receive daily radiation therapy for up to 8 weeks that conform to standardized protocols to assure optimal health outcomes.  Telemedicine technologies have been integrated into the routine daily practice to produce a “virtual” clinic throughout the network.  This service brings professional expertise to areas underserved by medical specialties. Connectivity is employed daily for a wide range of activities.  While these include the more typical clinical interactions such as consultation between medical professionals, it also provides a unique opportunity in the areas of quality assurance and resource management.  Radiation Oncology is a heavily image guided practice.  It relies on the creation of 3-dimensonal models of patient anatomy for a more precise and accurate dosage of radiation with minimal damage to surrounding structures and organs.  Videoconferencing is used for weekly and ad hoc peer review and consultation between providers to assure accurate definitions of these critical 3-D datasets.  In addition, it provides educational and staff development opportunities through direct instruction and participation in lecture series. All eight clinics function as a single “virtual” clinic. The infrastructure consists of Polycom VSX7000 codec and GoToMeeting image sharing over an IP and ISDN backbone, all operating within a secure virtual network. Conference rooms are equipped with two 40” flat panel monitors that are connected to a codec and PC for high resolution images. Experience to date suggests that telemedicine tools have improved efficiency, quality, and system integration of radiation oncology service in a multi-site delivery setting.

407
Design of a teleoperated robotic manipulator for battlefield trauma care
Pablo Valdivia y Alvarado, PhD,1  Chu-Yin Chang, PhD,1  David Askey, MSc,1  Kullervo Hynynen, PhD,2 Ronald Marchessault, MBA3    
1Energid Technologies, Cambridge, MA; 2Brigham and Women’s Hospital, Boston, MA; 3US Army Medical Research and Materiel Command, Telemedicine & Advanced Research Center (TATRC), Fort Detrick, MD;
The purpose of this research is the development of a rugged, portable, and teleoperated robotic manipulator for use in battlefield trauma care. Several medical procedures of interest in battle field trauma care require high positioning accuracy of an instrument or sensor, while keeping contact forces with the patient within a safe threshold.  A challenge lies in making a system that is both precise and safe, as high precision can translate into a rigid and hence potentially dangerous operation. Another challenge lies in creating a teleoperation system that enables the application of a physician’s expertise without the need of physical presence. Previous studies have investigated devices for achieving these features and presently several systems exist. However, these systems require large support infrastructures and cannot easily be deployed in harsh environments. Our group has developed a portable teleoperated robotic manipulator system for use in noninvasive High Intensity Focused Ultrasound (HIFU) applications. Its unique design allows for both position and force control through the use of series-elastic actuation. In addition, the system is rugged and portable, enabling its deployment in harsh environments. In this article, the novel architecture, design, and construction of the system are described. In addition, we present details of the hardware and software features that ensure safe human-robot interaction and proper position and force control. Delays and bandwidth limitations in the communication links are also addressed. The performance in terms of position and force resolution, accuracy, and bandwidth are presented, and the relevance of this performance to the HIFU application is discussed. The system our group is developing demonstrates the feasibility of precise and safe human-robot interaction for battlefield trauma care. This work is sponsored by TATRC.

92
Sociotechnical Influences on Outcomes in Telehomecare
Kimberly Shea, PhD, RN           
Arizona State University, Phoenix, AZ
Telehomecare utilizes electronic communication technologies to support care when distance separates nurses from their patients. Successful home health care outcomes depend on social and technical interactions within diverse patient, caregiver and nurse triad groups. No theory or analysis method for evaluating complex multi-level relationships in telehomecare service delivery exists. Therefore, it is not known if characteristics of interpersonal relationships influence outcomes. This research examined interdependence, communication and technology integration influence on outcomes of satisfaction and self-care. The Sociotechnical Systems Theory and Social Relations Model served as guides to explore individual, dyad and triad effects on patient quality outcomes. The purpose of this research is to examine the relationships among patients’, caregivers’ and nurses’ social and technical characteristics and quality outcomes in telehomecare. Three western U.S. VHA sites participated in this descriptive, multi-level, correlational study. Forty-three groups comprised of patient, nurse and caregiver provided survey data. Results show statistically significant bivariate correlations demonstrating associations between characteristics and outcomes at multi-levels: interdependence with satisfaction at individual and dyad levels; communication with satisfaction at all and simple self care at individual levels; technology integration with satisfaction at group as wells as simple and complex self care at individual levels. The principle of joint optimization states that service delivery systems function optimally only if the social and technical characteristics of the groups fit the demands of each other and the environment.  A measure of joint optimization was computed and analyzed for outcome predictability. Joint optimization for three social and one technical characteristic had significant influences on the patient’s perception of being well cared for. This research demonstrates that telehomecare requires unique combinations of social and technical characteristics to produce desirable outcomes.  By understanding the multi-level nature of telehealth in home health care, nurses can engage in effective best practices specific to the patient’s environment. 

362
Telemental Health Guidelines: State Professional Organization Perspective
Kenneth Drude, PhD           
Ohio Psychological Association, Columbus, OH
Many articles and reports call for the need for telemental health guidelines, but no guidelines are consistently used in the practice of mental health practice. Guidelines are “systematically developed statements to assist practitioners and patients make decisions about appropriate health care for specific clinical circumstances.” There are various choice-points in guideline development, implementation, dissemination, and evaluation. Voluntary guidelines will be contrasted with mandatory standards. Guidelines will be placed within the context of evidence-based medicine.  Leaders from four different organizations will address telemental health guidelines from the perspective of 1. a telemedicine organization special interest group; 2. a psychiatry organization; 3. a state psychology committee; and 4. a NIH-sponsored, disorder-specific panel.  More specifically, the panelist will address Telepsychology Guideline Development by the Communication and Technology Committee of the Ohio Psychological Association.  These guidelines are based on the 2002 American Psychological Association (APA) Code of Ethics as well as Reed, McLaughlin, and Milholland’s (2000) interdisciplinary principles for professional practice in telehealth.  The telepsychology guidelines provide a framework for the type of recommended conduct and practices psychologists need to be aware of when providing psychological services using electronic communication. The guidelines address categories of legal and regulatory issues, public benefit, and professional guidelines.   Telemedicine concerns are included within the wider context of technology-based service delivery and patient communication.  While focused on the needs of Ohio, many of the same concepts apply to psychologists across the nation and the panelist will address lessons learned that other states may consider.

464
Standards and Guidelines: ATA and Telemedicine's New Frontier
Nina M. Antoniotti, RN, MBA, PhD,6  Brian Grady, MD,3  Elizabeth Krupinski, PhD,5  Anne Burdick, MD,6 Lisa Carnahan, PhD,4 Lynn Rosenthal, PhD,4 Jerry Cavallerano, OD, PhD2  
1Marshfield Clinic TeleHealth, Marshfield, WI; 2Beetham Eye Institute, Joslin Vision Network, Boston, MA; 3Sheppard Pratt Health System, Baltimore, MD; 4National Institute of Standards and Technology, Washington, DC; 5University of Arizona, Tuscon, AZ; 6University of Miami Miller School of Medicine Miami, FL
At no time has it been more important than today to develop national standards and guidelines for TeleHealth/Telemedicine. Payers, regulators, legislators are asking for standards. There is no other entity in a better position to do so that the American Telemedicine Association.  Government regulatory bodies have longed questioned – “Where are your standards?” and now ATA is in a position to answer that question.  The Standards and Guidelines Committee, one of the three Board appointed committees of ATA, has developed a Standards Framework, a Workplan for Standards and Guidelines, a common list of Definitions and Terms, and has finalized two sets of standards – one for Diabetic Retinopathy and the other for TeleDermatology.  This presentation will outline the historical development of these two important documents, the current projects underway, and the overall process for development of standards and guidelines for TeleHealth/Telemedicine. The participant will gain knowledge in the process of standards development and will leave the presentation with tools to begin the process of specialty and role specific standards and guidelines development. 

138
Telemedicine: Providing Healthcare to Uninsured and Underinsured Employees
Maria Wellisch, BBA, RN,1  Oscar W. Boultinghouse, MD, FACEP,2  Glenn G. Hammack, OD, MSHI, FAAO,2  Vo H. Alexander, PhD2     
1Morningside Ministries, San Antonio, TX; 2University of Texas Medical Branch at Galveston, Galveston, TX
Introduction and Overview of Presentation:  Telemedicine technology has proven effective in improving employee health outcomes, lowering employee healthcare costs, and improving employee recruitment, retention and productivity in an elder care setting. Morningside Ministries provides 650 employees and their families with low-cost healthcare services using telemedicine technology. Physician services are provided by the University of Texas Medical Branch in Galveston and made available to employees located 250 miles away visiting Telemedicine Clinics at all three Morningside facilities in San Antonio. Employees using the Telemedicine Clinic have personal contact with a nurse, visit a physician using distance technology, and receive a prescription for medications, if needed.  For the elder care industry, the lack of healthcare results in more frequent absences, lower employee productivity, and increased labor costs. In addition, because of the inability to provide employer-sponsored health insurance, the industry faces increasing difficulty recruiting & retaining professional caregivers. An effective, work-based telemedicine program can addresses many of these challenges.  Work-based telemedicine works because it because it is cost-effective for both the employer and employees, and it improves health outcomes for employees and their families. After completing the session, attendees will be able to:

1. Identify the technological, financial and organizational resources needed to develop and operate a telemedicine Clinic.
2. Specify the requirements of a successful collaboration and business partnership with a healthcare provider.
3. Evaluate the opportunities provided by telemedicine, as well as the technological, organizational, financial, and marketing challenges.
4. Determine the feasibility of developing and operating a workplace telemedicine program in their organization.

131
Follow-up of patients managed by store-and-forward telemedicine in developing countries
Richard Wootton, PhD, DSc,1  Paula Ferguson, MBBS,2  John Menzies, MBBS3       
1Centre for Online Health, University of Queensland, Brisbane, Australia; 2Ok Tedi Mining Limited, Tabubil, Papua New Guinea; 3JTA International, Brisbane, Australia
Telemedicine can be used to support doctors working in developing countries.  Most of the longer-running programmes have employed relatively 'low-tech' methods, based on email and/or web messaging.  Presumably the referring doctors find such services useful or they would not continue to participate.  Nonetheless, almost no published data exist about the outcomes of patients treated in this way.  Our hypothesis is that useful advice can be provided by telemedicine in a low resource setting.  Over a two-year period, eight medical students from four U21 universities spent their electives at hospitals in Pakistan, Papua New Guinea and Sri Lanka.  They made a total of 49 e-referrals which resulted in 67 queries in a wide range of specialties.  The major categories of the 67 queries were internal medicine, paediatrics and surgery.  The case-mix was similar to the 785 queries managed by the Swinfen Charitable Trust over the same period. Follow-up data were obtained in 14 of the 30 cases from one hospital (47%) after a median period of 17 weeks (IQR 10-29).  The cases were reviewed by an independent doctor.  Telemedicine was considered to have assisted with the diagnosis in all cases (median score 5 on a five-point scale from 1=not helpful at all to 5=very good/excellent).  The advice to the referring doctor for further action was considered helpful in all except one case (median score 4.5 on the same scale).  The outcome for the patient was considered to be good in all but two cases (median score 4 on the same scale). Medical students were able to facilitate e-referrals by relieving the pressure on the local doctor to undertake the necessary clerical and technical work.  The students reported a rewarding elective experience.  Low-cost telemedicine can provide useful advice in a low resource setting.

199
Onconet - An Effective Cancer Telemedicine Network For Remote Population
Baljit Singh Bedi, MTech, Joseph T. Rajan, BTech, S. Sudhamony, BScEngg
Centre for Development of Advanced Computing, Thiruvananthapuram, India
Cancer is an important public health problem in India with about 800,000 new cases detected every year and about 2.5 million existing patients.  As majority of the patients require regular follow-ups, use of Tele-medicine to support the patient care remotely offers an attractive alternative.  In its role to promote ICT applications in healthcare a major pilot program was supported by Department of Information Technology and implemented by Centre for Development of Advanced Computing (C-DAC), Thiruvananthapuram to see its efficacy and impact with a view to benefit  cancer patients in remote areas and a possible subsequent roll-out for large scale coverage .    The project of Telemedicine in Oncology was undertaken in the State of Kerala in southwest India. The Regional cancer centre, Thiruvananthapuram (RCC-T) is a tertiary referral cancer hospital catering to South India. The RCC-T has established peripheral centres with essential infrastructure in remote areas in Kerala. ‘ONCONET- Cancer Care for Rural Masses’ telemedicine project was launched at RCC-T. This system is the first Tele-Oncology system in India with Hospital Information System tightly integrated with it and experimented with different available communication infrastructure. This system provides telemedicine services for cancer detection, patient follow-up, palliative treatment and, thereby, continuity of care in remote site hospitals. During the last two years, approximately 7000 patients have undergone tele-consultation through ONCONET.  This article throws light on the technical details and the status of telemedicine services through this system. Success of this ongoing project has spurred the user Ministry of Health & Family Welfare to contemplate covering the whole country by establishing Tele-Oncology network  connecting 25 Regional Cancer Centres and 100 peripheral centres (4 for each RCC) across the country and provide Telemedicine Services like Early Cancer Detection, Follow up Consultation, Cancer awareness, Continuing Medical Education.

318
Deployment of a Robotic Tele-Presence Capability in the US Army
Ronald K. Poropatich, MD,1  Cynthia Barrigan, RN, MS,1  Kevin K. Chung, MD,2  Kurt W. Grathwohl, MD2     
1US Army Medical Research and Materiel Command, Telemedicine & Advanced Research Center (TATRC), Fort Detrick, MD; 2United States Army Institute of Surgical Research, San Antonio, TX
Introduction: Robotic Tele-Presence (RTP) is a capability that refers to a commercially available wireless mobile robotic telemedicine technology that consists of a desktop or laptop control station and a robot (RP-7; InTouch Health, Santa Barbara, CA). Brooke Army Medical Center (BAMC) in San Antonio, TX deployed the first robot in the U.S. Army in 2006 and demonstrated effectiveness in managing critically ill patients remotely from a Burn ICU setting.  The ability to leverage surgical and critical care specialty consultations globally among the distributed medical resources in the U.S. Army is essential in meeting the health care needs of deployed and garrison based hospitals. Methods: In CY07, four additional robots will be deployed, three under Institutional Review Board (IRB) investigation: 1) Madigan Army Medical Center, Tacoma, WA; 2) Ryder Trauma Center, University of Miami, in collaboration with U.S. Army providers that rotate routinely through the facility for team trauma training; and 3) BAMC. Research protocols will address the role of RTP in the effectiveness of surgical simulation training, family counseling sessions, and comparing the accuracy in writing a trauma note using RTP vs. on-site care. An additional robot will be deployed to Landstuhl Regional Medical Center in Germany to support neurocritical care ICU tele-consultations from Landstuhl to the National Capitol Area Neurosurgery Center in Washington, DC. Results: Contracts for the four additional robots have been processed and deployment to these additional four sites will be completed by the end of CY07. Investigational research protocols and IRB approval is also scheduled for completion by the end of CY07.  Conclusions: The U.S. Army Medical Department is fully leveraging its medical resources through the use of advanced medical technology in establishing a global RTP for operative surgical mentoring, ICU and Emergency Room consultations. Plans to deploy this capability in austere military medical facilities in Iraq and Afghanistan are planned for CY08 based on Lessons Learned from earlier deployments.

64
Describing obtrusiveness for telehealth and smart home technologies
Karen L. Courtney, PhD, RN,1  George Demiris, PhD,2  Brian K. Hensel, PhD, MSPH3       
1University of Pittsburgh, Pittsburgh, PA; 2University of Washington, Seattle, WA; 3University of Missouri- Columbia, Columbia, MO
With the anticipated growth in the older adult population in the next few years, information designers are examining new ways for information-based telehealth and smart home technologies to support independent living and quality of life for adults as they age.  Telehealth technologies, such as videoconferencing, the Internet and monitoring devices, allow for communication between residents and care providers as well as monitoring of vital signs when participants are separated by geographic distance. A smart home is a residence equipped with technology that enhances safety of patients at home and monitors their health conditions. These applications are often referred to as information-based assistive technologies.  Central to the role of information-based assistive technology to support and enhance quality of life is the development of non-obtrusive technologies.  Despite the importance of non-obtrusiveness to the design of assistive technologies, there remains no standard definition of obtrusiveness or measurement instrument.  A recently proposed conceptual framework for obtrusiveness in home telehealth technologies has not yet been tested empirically.  The study presented was a secondary analysis of focus group and interview data from two studies (n = 14 and n = 15) and was designed to explore the presence of the dimensions of the obtrusiveness framework in older adults’ responses to information-based assistive technologies in residential care facilities.  Overall the conceptual framework for obtrusiveness seemed well represented in prior study participants’ descriptions of factors influencing their technology acceptance.  We found the existing data contained examples of each dimension (physical, usability, privacy, function, human interaction, self-concept, routine and sustainability) and sixteen of the twenty-two subcategories proposed by the obtrusiveness framework.   These results provide general support for the framework, although further prospective validation research is needed.  Potential enhancements to the framework are proposed.

365
Telemental Health Guidelines: Special Interest Group Perspective
Brian Grady, MD, MS           
University of Maryland School of Medicine, Baltimore, MD
Many articles and reports call for the need for telemental health guidelines, but no guidelines are consistently used in the practice of mental health. Guidelines are “systematically developed statements to assist practitioners and patients make decisions about appropriate health care for specific clinical circumstances.” There are various choice-points in guideline development, implementation, dissemination, and evaluation. Voluntary guidelines will be contrasted with mandatory standards. Guidelines will be placed within the context of evidence-based medicine.  Leaders from four different organizations will address telemental health guidelines from the perspective of 1. a telemedicine organization special interest group; 2. a psychiatry organization; 3. a state psychology committee; and 4. a NIH-sponsored, disorder-specific panel.   More specifically, the panelist will address guideline development for the American Telemedicine Association’s special interest group (SIG).  The SIG guidelines have been a consensus process through clinical and administrative workgroups. The guidelines are meant to address the overarching question “What are the clinical, administrative, and technical effects of providing mental health care, via various interactive video technologies in place of traditional face to face care, on the client/patient, their caregivers and the health system?”  The panelist will address the development of evidence tables related to telemental health research across disciplines (psychiatry, psychology, social work, and nursing) and the process of narrowing the evidence search to relevant sources.  The panelist will address translating evidence into practical guidelines.  The panelist will describe challenges to guideline dissemination across SIG members and to wider audiences as well as challenges to guideline development with continually evolving technologies.

76
Standards and Guidelines: ATA and Telemedicine's New Frontier
Nina M. Antoniotti, RN, MBA, PhD,6  Brian Grady, MD,3  Elizabeth Krupinski, PhD,5  Anne Burdick, MD,6 Lisa Carnahan, PhD,4 Lynn Rosenthal, PhD,4 Jerry Cavallerano, OD, PhD2  
1Marshfield Clinic TeleHealth, Marshfield, WI; 2Beetham Eye Institute, Joslin Vision Network, Boston, MA; 3Sheppard Pratt Health System, Baltimore, MD; 4National Institute of Standards and Technology, Washington, DC; 5University of Arizona, Tuscon, AZ; 6University of Miami Miller School of Medicine, Miami, FL
At no time has it been more important than today to develop national standards and guidelines for TeleHealth/Telemedicine. Payers, regulators, legislators are asking for standards. There is no other entity in a better position to do so that the American Telemedicine Association.  Government regulatory bodies have longed questioned – “Where are your standards?” and now ATA is in a position to answer that question.  The Standards and Guidelines Committee, one of the three Board appointed committees of ATA, has developed a Standards Framework, a Workplan for Standards and Guidelines, a common list of Definitions and Terms, and has finalized two sets of standards – one for Diabetic Retinopathy and the other for TeleDermatology.  This presentation will outline the historical development of these two important documents, the current projects underway, and the overall process for development of standards and guidelines for TeleHealth/Telemedicine. The participant will gain knowledge in the process of standards development and will leave the presentation with tools to begin the process of specialty and role specific standards and guidelines development. 

141
Employee Health Outcomes:  Providing Healthcare to Uninsured and Underinsured Employees
Alexander H. Vo, PhD,2  Maria Welisch, BBA, RN,1  Oscar W. Boultinghouse, MD, FACEP,2  Glenn G. Hammack, OD, MSHI, FAAO2     
1Morningside Ministries, San Antonio, TX; 2AT&T Center for Telehealth Research & Policy, University of Texas Medical Branch at Galveston, Galveston, TX
Employee Health Outcomes:  From August 1, 2006 through April 30, 2007, 364 patients have been seen at the Morningside Telemedicine Clinics. The mean age of the patients was 39.4 years, ranging in age from 2 to 65 years.  Approximately 80% were female and 20% were male (reflecting the sex of workers in the elder care industry).  Primary diagnoses were  allergies 26%, hypertension 10%, dermatitis 6%, bronchitis 5%, urinary tract infection 5%, and depression 3%.  Secondary diagnoses included:  morbid obesity 25%, hypertension 25%, and diabetes 15%.   In May 2007, the AT&T Center on Telehealth Research and Policy at UTMB reported the preliminary findings on the effectiveness of the use of telemedicine technology to provide primary health care to workers in the elder care industry employed at Morningside Ministries.  The study included a random selection of 300 clinical encounters.  Data for the study was extracted from patient clinical notes.  The study included partitioning and analysis of demographic characteristics and diagnostic codes.  The researchers identified the most salient diagnostic assessments.  Finally, they conducted a preliminary inferential analysis of the status of one selected chronic condition—hypertension—at two points in time (between telemedicine clinic visits).   A key finding of the study showed that blood pressure levels of patients diagnosed as hypertensive decreased significantly between early visits to the telemedicine clinic and later clinic visits.  Specifically, systolic blood pressure (upper number on the scale) fell from an average of 150 (range 145 to 160) to an average of 140 (range of 130 to 150).  Diastolic blood pressure fell from an average of 95 (range 90 to 110) to an average of 85 (range 80 to 90).  These changes in blood pressure during the treatment period were statistically significant, as measured by UTMB.

450
Swinfen Charitable Trust Telemedicine System
Lord Roger Swinfen, Lady Patricia Swinfen, Richard Wootton, BSc, MSc, PhD, DSc, IMA, FSS
The Swinfen Charitable Trust, Cantervury, United Kingdom; University of Queensland, Brisbane, Australia
The Swinfen Charitable Trust (SCT) has operated a low cost email Telemedical System to support doctors in developing countries since mid 1999. SCT uses email to connect remote hospitals and doctors with expert medical opinion and advice. Many of these hospitals are understaffed and have no highly qualified doctors, some operating with lone general practitioners in charge, and could be a days travel or more away from other hospitals with better facilities. The network has been operational for nearly nine years, making it one of the longest running such telemedical systems, i.e. operated for charitable purposes and dealing mainly with clinical work. Over 1500 referral have been managed during this time. For the first three years, email messages were handled manually; subsequent operations have benefited from an automatic message-handling system. This unique system was developed for SCT by the Centre for Online Health at the University of Queensland, Australia. It archives all messages and ensures that a request for advice and the Subsequent response pass between the remote hospital and the relevant specialist. The system operators, situated in the UK and Australia, ten time zones apart, provide a 24 hour service 365 days a year. Some of the countries utilizing these links, such as Iraq and Afghanistan, are passing through conflict and post-conflict situations. Other countries using SCT links include Bangladesh, Nepal, Cambodia, Sri Lanka, Sierra Leone, The Solomon Islands, Uzbekistan, east Timor, Ethiopia, Sudan, Tristan da Cunha, Zambia and most recently Pakistan, Tibet, and the Gambia. SCT can obtain specialist advice in 130 specialties and sub-specialties. SCT is in the process of setting up a telecolcoscopy diagnostic and teaching service using our links for a number of hospitals. SCT anticipates participating in the exciting initiative of Dr. Hon Pak, the ATA`s President to promote a telemedicine outreach program to the developing world. 

61
Patient and Doctor Satisfaction with an Electronic Visit (E-Visit) Program for the Management of Acne
Hagit Bergman, MD,1,2,3  Christy Williams, MD,1,2,3  Regina Nieves, RN,1  Abby L. Cange, BSc,1 Brian D. Hammond, BA,1 Alice J. Watson, MBChB MRCP MPH,1,2,3 Joseph C. Kvedar, MD1,2,3  
1Center for Connected Health, Partners Healthcare, Boston, MA; 2Department of Dermatology, Massachusetts General Hospital, Boston, MA; 3Harvard Medical School, Boston, MA
Introduction:  Internet technology offers new ways to increase access to care for dermatology patients.  We conducted a randomized controlled trial comparing asynchronous electronic visits (e-visits) consisting of online surveys and digital images with conventional office care for the management of mild-moderate acne. We report efficiency and satisfaction for 100 trial subjects. Results:  The mean age of subjects was 28.1 (SD 8.70, range 13-60) years old; most were  white (70%) and female (77%). Usual care subjects spent an average of 22 min (range 15-35 min) in the physician’s office, of which only 4:37 min was spent with the dermatologist. In addition, almost half (45%) of this group spent 30-60mins traveling to the office. In contrast, 91% of e-visit subjects were able to complete their e-visit, in less than 20 minutes. Dermatologists took comparable lengths of time to complete e-visits and office visits (4:42min vs. 4:08 min, p= 0.552).
Subjects in the office and e-visit groups reported similar levels of satisfaction with their care (98% vs. 89% respectively) and improvement in their acne (88% vs. 89%). Of the e-visit patients, 90% would consider using e-visits to receive acne care in the future and 73% believed that the dermatologist could assess their acne using an e-visit system as well as they could have in person. Dermatologists’ satisfaction with the improvement in their patients’ acne was similar in both office and e-visit groups (94% vs. 91%). In 91% of cases, dermatologists were satisfied with their ability to assess acne using digital images. Conclusions:  E-visits appear to be well-received by patients and physicians.  Patients in particular benefit from considerable time savings when using this method of care delivery.   We anticipate increased uptake of the e-visit platform as dermatologists seek efficient and effective ways to conduct follow-up visits for non-urgent conditions. 

443
443
eICU IMPACT In A Large Health NETWORK
Teresa Rincon, RN, CCRN1,2,3,4,5,6
1American Association of Critcal Care Nurses (AACN), Aliso Viejo, CA; 2Society of Critical Care Medicine (SCCM), Des Plaines, IL; 3SCCM Remote ICU Task Force, Sacramento, CA; 4VISICU Sepsis Workgroup, Baltimore, MD; 5Eli Lilly Medical Advisory Board, Indianapolis, IN; 6Eli Lilly Speaker Bureau, Indianapolis, IN
This segment is part of a series of presentations, from different types of organizations, that illustrate sustainable business models for critical care telemedicine utilizing eICU® Programs.  In an environment of growing critical care requirements due to an aging population and shrinking intensivist and nursing workforce, these presentations will provide alternative solutions to a growing crisis.Panelists will provide a brief overview of their specific implementation in a large health network, rural health system, rural community hospital, academic medical center and in the military along with key clinical and financial results being realized.  These results focus on improved survival rates, length of stay reductions, reduced complications, and reduced operational costs.

227
Consumer Telehealth – Are We Nearing The Tipping Point?
Scott C. Simmons, MS,1 Bernard A. Harris, Jr., MD, MBA, FACP,2 Michael Robkin,3 David L. Whitlinger,4 Sam L. Grogg, PhD5
1University of Miami Miller School of Medicine, Miami, FL; 2Vesalius Ventures, Houston, TX; 3Kaiser Permanente Information Technology Kaiser Foundation Hospitals, Pasadena, CA; 4Continua Health Alliance, Intel Corporation, Beaverton, OR; 5School of Communications, University of Miami, Coral Cables, FL
Consumer telehealth involves fundamentally different transactional and business models from traditional telehealth programs and services. In consumer telehealth models, patients will pay out-of-pocket expenses for service, equipment, software, and/or telecommunications. Consumer telehealth transactions will occur in an on-demand, ad-hoc manner rather than the highly structured delivery models in traditional telehealth.  Furthermore, consumer telehealth will be focused on customer service and convenience, delivering services at the time and location that are most convenient for the patient. This revolutionary change in telehealth is presaged by several factors. Today’s “wired” consumers routinely purchase many products and services at any time of day from almost any location. This is enabled by continual developments computing, consumer electronics, virtual collaboration, and telecommunications technologies. Patients are also paying more directly for health care – either through increased premiums for their employer-provided plan, participation in Health Savings Account programs, or self-pay. As consumers pay an increasing share of their health expenses, they are less likely to tolerate the inconveniences and inefficiencies of today’s health care system – delays in getting appointments, travel time and expense, time spent in waiting rooms, duplicative form completion, and lack of after hours care options. However, there are several challenges that must be addressed in order to reach the vision for consumer telehealth.  Consumer-priced devices and software must be available and interoperable. Registries and directory services for devices, patients, services, and health care personnel must be devised and implemented. Finally, consumer telehealth marketing, promotion, and advocacy activities are required. This panel involves presentations and discussions about the many promises and issues related to consumer telehealth from the perspectives of academia, industry, marketing, and finance in an attempt to determine whether consumer telehealth is nearing its tipping point.

356
The Telemental Health Development Guide: An Interactive Resource for Programs
Elizabeth Brooks, MS,  Jay H. Shore, MD, MPH,  Rhonda Dick, MS,  Douglas Novins, MD     
University of Colorado at Denver and Health Sciences Center, Aurora, CO
The creation of new telemental health programs is often a slowly evolving process.  Several reasons exist for this (such as the time it takes to acquire administrative and funding support) however, even after the necessary backing has been secured, the actual clinic development is a daunting task.  One avenue that can be used to support new programs’ entrance into telehealth is to offer tools that enable them to understand and prepare for telehealth activity.  The American Indian and Alaska Native Programs (at the University of Colorado at Denver Health Sciences Center), is in the process of creating a Telemental Health Development Guide that will provide critical information regarding start-up procedures and maintenance of telemental health programs.  While other guides are currently available, they generally are not targeted to the needs of administers, consumers and policymakers.  This project speaks to this gap by offering a guide that addresses the unique issues surrounding each group.  For example, for administrators, we offer technological and infrastructure requirements; for policy-makers we provide economic and outcome program data; and for consumers we explain the basics of a telehealth encounter.  In addition, we will take advantage of the ever-growing technological innovations by presenting educational content in a highly interactive, entertaining manner.  In an effort to widen the viewing audience, the guide will be offered in two formats: online and cd-rom.  If successful, the Telemental Health Development Guide will provide important information on the use of telemental health services and hasten the creation of new telemental health programs.   In this presentation, we will present the guide and discuss the process of its creation. 

392
Internet Intervention System for Overweight Children & Adolescents: Obstacles & Solutions
Robert A Pretlow, MD           
eHealth International, Seattle, WA
Current healthcare resources are grossly inadequate to treat the estimated 25 million obese/overweight children and adolescents in the U.S.  Technology offers a solution.  An Internet-based weight loss system was therefore created, by which overweight children and adolescents may: 1) be educated on healthy eating and exercise, 2) receive support from overweight peers, and 3) self-monitor weight with online support and guidance from their healthcare provider.  This presentation will describe technical and regulatory obstacles encountered and some solutions. Obstacles included: 1) minimal computer knowledge by providers, 2) lack of time by providers to check client data and post supportive messages, 3) lack of reimbursement for care delivered via the Internet, 4) lack of time for children to access the site, especially at school,  5) lack of Internet access by children, e.g. students at schools, 6) licensure issues when delivering care to children in another state, 7) HIPAA concerns by providers that personal information may be stolen from the database, 8) liability concerns by providers, e.g. that a hacker or predator may break into the database, obtain a provider’s password, and spoof or prey upon a child.  Solutions found include: 1) automatic notification to providers of weight gain, or when a child has weighed-in or not weighed-in, within the provider specified time frame, 2) automatic weigh-in reminders to children, if not weighed-in within the provider specified period, 3) pre-written, secure weight control messages (templates) sent automatically to children at the provider specified interval (e.g. weekly), including the provider’s photo and signature, which saves providers substantial time (only 4.2 minutes per week per child required from a provider, on average), 4) Internet-connected scales.  Two years of school and clinic data will be presented.  Internet technology has potential to impact on childhood obesity, if the regulatory, liability, and technology availability obstacles can be solved.

469
Key Business, Clinical and IT Considerations in Building a Sustainable MultI-specialty Cyber-Hospital Telemedicine Program
Sandeep Krishnan, 1,2 Cynthia Gordon, 1,2 Ralph Pennino, 1,2 Amy Craib, 1,2 John Valvo, 1,2 Ralph Madeb1,2
1Via Health System, Rochester General Hospital, Rochester, NY; 2Newark Wayne Hospital, Newark, NY
ViaHealth - one of the leading healthcare systems in the western New York State has created an Office of Telehealth. Rochester General Hospital in Rochester, NY is the primary facility within ViaHealth with 526 beds and includes all specialists and sub-specialists in both medical and surgical fields. Newark Wayne Hospital is a smaller subsidiary hospital within ViaHealth with primary care practices and a handful of specialists. We describe the technical considerations needed to build a static and dynamic telehealth system between a primary and subsidiary hospital.  The ViaHealth Office of Telehealth supports in-patient and out-patient telemedicine consultations at Newark Wayne Hospital using specialists located at Rochester General Hospital, as well as specialists located in private practices.  This requires a robust, flexible, and expandable IT (information technology) infrastructure to support the multi-vendor telemedicine network architecture incorporating wireless and wired telemedicine end-points, without compromising network security and privacy of information.   The enhancements in the design and implementation of the wireless infrastructure at Newark Hospital to support the wireless telemedicine end-points are noteworthy; specifically in routing of wireless traffic between the available A, B and G wireless radio channels. Multiple vendor systems have been evaluated to determine the effectiveness of a particular system to the type of telemedicine consult, as well as the ease of use by the end-user. The core telemedicine network infrastructure designed at ViaHealth takes into consideration the need to connect to rural hospitals outside the ViaHealth system to provide telemedicine consults.  As a result, firewall traversal systems and techniques to connect to telemedicine end-points at non-ViaHealth facilities have been successfully implemented and tested.

303
International and comparative law considerations in cross border ehealth regulation
John D. Blum, JD, MHS           
John D. Blum, Chicago, IL
This presentation will provide an overview of key regulatory issues that affect cross border ehealth arrangments, broadly covering international law principles, trade law considerations and related  telecommunications law. The presentation is designed to offer generic legal/regulatory perspectives on developing and maintaing an ehealth relationships, which involve principals from two or more countries.The presentation will be broken into three parts, first a review of relevant international law principles developed by the World Medical Association, the EU, and to a lesser extent the World Health Organization, will be provided that can be referenced for overall guidance in this arena. Secondly,  will be a consideration of how trade law elements such as the TRIPS agreement or the free movement principles of regional trading arrangments, such as the EU, impact ehealth. Third, the presentation will center on the law which affects telecommunications technologies, from satellites to cell phones, with a strong focus on the developing world, where Information Communication Technologies (ICT) hold great potential for transforming health care. The goal of the presentation is to provide attendees with a floor of information which can be used as a foundation for more detailed inquiries into this complex area. 

329
Improvement in Primary Provider Diagnostic Acumen Using a Teledermatology Network
Roy M. Colven, MD,1  Mi-Hyun Mia Shim, BS,1  Gail Todd, PhD, FFA (Derm)2       
1University of Washingonton, Seattle, WA; 2University of Cape Town, Cape Town, South Africa
INTRODUCTION. Teledermatology is a promising tool for improving the delivery of scarce dermatological care, which can directly reduce the burden of skin disease and improve the quality of health-care practice in remote areas.  However, data that demonstrate the extent of sustainable benefits derived from teledermatology support are currently insufficient.  In this pilot study, we report the impact of teledermatology service in underserved areas of South Africa by evaluating primary-care provider (PCP) satisfaction and assessing change in diagnostic concordance between referring providers and teledermatologists over time.  METHODS.  A network was established to link University of Cape Town dermatology consultants to providers from six underserved primary-care sites using asynchronous store-and-forward technology between October 2004 and January 2007.  For trend analysis, 120 patient histories, digital images, and corresponding consultant responses were used to analyze the agreement of primary diagnoses between six PCPs and teleconsultants.  Provider satisfaction was also assessed using questionnaires collected at the time of referral and at patient follow-up.  RESULTS.  The mean primary diagnostic concordance trend between PCPs and teledermatologists showed a baseline of 13% for the first four referrals sent per provider, then 25% by the fifth to eighth referrals, 50% by the ninth to twelfth referrals, and 36% for the combined subsequent referrals.  An evaluation of satisfaction surveys resulted in a high level (100%) of provider overall satisfaction, convenience, improved patient outcome, and enhanced learning from the teleconsultation.  In 28% of surveys, PCPs would have preferred a face-to-face consultation.  CONCLUSION/LESSONS LEARNED.  If a simple and inexpensive teledermatology solution is carefully implemented in a resource-limited setting, a high level of provider satisfaction and improvement of primary provider diagnostic acumen can be achieved.  The lessons learned from this pilot study are now being applied to similar systems domestically.

445
445
eICU IMPACT IN A Rural Health SYSTEM
Pat Herr
Avera Health, Sioux Falls, SD
This segment is part of a series of presentations, from different types of organizations, that illustrate sustainable business models for critical care telemedicine utilizing eICU® Programs.  In an environment of growing critical care requirements due to an aging population and shrinking intensivist and nursing workforce, these presentations will provide alternative solutions to a growing crisis. Panelists will provide a brief overview of their specific implementation in a large health network, rural health system, rural community hospital, academic medical center and in the military along with key clinical and financial results being realized.  These results focus on improved survival rates, length of stay reductions, reduced complications, and reduced operational costs.

207
Framework for Information Technology Infrastructure for Health-Indian initiative
Baljit Singh Bedi, MTech           
Centre for Development of Advanced Computing, New Delhi, India
In India healthcare is delivered by a multitude of providers’ public and private, currently working in isolation. There is limited networking among doctors or hospitals and they function as independent entities. In this scenario, the need for a standard health information system across the country that meets the requirements of diverse groups and to be able to offer value to the most important stakeholder - the patient, is paramount today. As part of this Endeavour, the Department of Information Technology (DIT), had undertaken the initiative for defining the framework for an Information Technology Infrastructure for Healthcare (ITIH) in India. Simultaneously, under a high level Committee and a Technical Working Group, a set of Standards and Guidelines were suggested for the practice of Telemedicine in India. These efforts, among other things, go a long way in proposing standards which are crucial for consideration in development of Indian Health Information Network. As its pioneering project, the major stakeholders in the industry were consulted to define the standards for health information in the country with a primary aim to define an acceptable Electronic Health Record (EHR).  Suggested framework covers Billing Formats, Clinical Standards, Data Elements, Health Identifiers, Minimum Data Set, Legal Framework and Messaging Standards.  A number of National initiatives for standardization in IT enabled services for Healthcare, including Telemedicine are drawing substantially from this pioneering effort. These include initiative of National Knowledge Commission, a national Apex policy making body, to set up Working Group for suggesting Indian Health Information Network Development (I-HIND).  National Task Force for Telemedicine in India, set up under Ministry of Health & Family Welfare through Subgroup on Telemedicine Standards including Electronic Medical Record (EMR) has also drawn substantially from the reported efforts done in this regard in the field of EMR. 
  
467
Consumer Telehealth - Are We Nearing the Tipping Point?
Scott C. Simmons, MS,1 Bernard A. Harris, Jr., MD, MBA, FACP,2 Michael Robkin,3 David L. Whitlinger4, Sam L. Grogg, PhD5
1University of Miami Miller School of Medicine, Miami, FL; 2Vesalius Ventures, Houston, TX; 3Kaiser Permanente Information Technology Kaiser Foundation Hospitals, Pasadena, CA; 4Continua Health Alliance, Intel Corporation, Beaverton, OR; 5School of Communications, University of Miami, Coral Cables, FL
Consumer telehealth involves fundamentally different transactional and business models from traditional telehealth programs and services. In consumer telehealth models, patients will pay out-of-pocket expenses for service, equipment, software, and/or telecommunications. Consumer telehealth transactions will occur in an on-demand, ad-hoc manner rather than the highly structured delivery models in traditional telehealth.  Furthermore, consumer telehealth will be focused on customer service and convenience, delivering services at the time and location that are most convenient for the patient. This revolutionary change in telehealth is presaged by several factors. Today’s “wired” consumers routinely purchase many products and services at any time of day from almost any location. This is enabled by continual developments computing, consumer electronics, virtual collaboration, and telecommunications technologies. Patients are also paying more directly for health care – either through increased premiums for their employer-provided plan, participation in Health Savings Account programs, or self-pay. As consumers pay an increasing share of their health expenses, they are less likely to tolerate the inconveniences and inefficiencies of today’s health care system – delays in getting appointments, travel time and expense, time spent in waiting rooms, duplicative form completion, and lack of after hours care options. However, there are several challenges that must be addressed in order to reach the vision for consumer telehealth.  Consumer-priced devices and software must be available and interoperable. Registries and directory services for devices, patients, services, and health care personnel must be devised and implemented. Finally, consumer telehealth marketing, promotion, and advocacy activities are required. This panel involves presentations and discussions about the many promises and issues related to consumer telehealth from the perspectives of academia, industry, marketing, and finance in an attempt to determine whether consumer telehealth is nearing its tipping point.

367
School-Based Telehealth Weight Self-Management Program for Adolescents
Patricia Lindley, PhD, RN,  Kim Urbach, MS, RN, PNP,  Donna Tortoretti, MS, RN       
Center for Entrepreneurship, University of Rochester School of Nursing Center, Rochester, NY
In upstate New York, 28% of high school students are overweight or obese, compared to the Centers for Disease Control rate of 17% for American adolescents aged 12 to 19 years. Interventions aimed at fostering healthy eating and activity are needed to reduce the prevalence and subsequent emotional and physical burden of obesity. Consistent with the CDC Health Protection Goal for adolescents, "Achieve Healthy Independence," one strategy is to empower adolescents for weight self-management. "Knowledge Needed for Owning Wellness" is a school-based telehealth program for adolescents to gain requisite knowledge and skills in order to self-manage their weight through healthy choices in eating and physical activities. Adolescents used a kiosk to measure their weight, blood pressure, and pulse. They also used web-based course software to access health information, respond to questions on their health behaviors, and evaluate their use of the kiosk and the course software. Health promotion topics consisted of nutrition, physical activity and exercise, sleep, and body image. Clinical data (insulin, glucose, and lipid profile) were available from participants' clinic records. At an urban high school school-based health clinic in upstate New York, 10 females and 9 males, aged 12 to 19 years and predominately African American, completed at least two measurements on the kiosk during a 10-week period. Adolescent participants averaged a five pound weight loss and a small decline in insulin level. They reported increased mean hours of exercise and decreased mean hours of sedentary activities. Nutrition results were mixed; beverage consumption improved, but not fruit and vegetables. Overall, the adolescents engaged effectively with the technologies and enjoyed success with self-managing their health. While there were challenges with using the kiosk and course software, the participants offered positive evaluations of their both technologies and of the health education.

461
THE CREATION OF A CYBER-HOSPITAL: A Healthcare Strategy and Delivery Network for Regionization of Specialty Care
Ralph Madeb,1,2 Sandeep Krishnan,1,2 Cynthia Gordon,1,2 Ralph Pennino,1,2 Amy Craib,1,2 John Valvo,1,2
1Via Health System, Rochester General Hospital, Rochester, NY; 2Newark Wayne Hospital, Newark, NY
To date the implementation of telehealth systems in New York State have been site or specialty specific. ViaHealth is one of the two leading medical systems in the Western part of New York State with a newly formed Department of Telehealth. Rochester General Hospital in Rochester, NY, is the primary facility with526 beds and includes all specialists and sub-specialists in both medical and surgical fields. Newark Wayne Hospital is a smaller subsidiary hospital with primary care practices and a small number of specialists. Our objective was to determine the feasibility of extending specialty care to our smaller hospital in over 10 fields of medicine and surgery in both an in- and out-patient model.  This was accomplished by implementing both static and dynamic telehealth systems. The outpatient department was formulated by designating a site in both respective hospitals with wall-mounted Tandberg 880 units with HD capability. The spoke hospital at Newark has a dedicated nurse practitioner and the specialist consults vary by day. This setting allows for controlled, non-acute consults that are referred by the patient’s primary care providers. The dynamic model uses the RP-7 robot manufactured by In-Touch Technologies. It is allows for specialists to have the freedom needed  to give consults all around the hospital environment including the operating room, medical/surgical floors, ICU, emergency room, and the attached nursing home in both the acute and non-acute setting. All administrative work is coordinated through the dedicated office of telehealth in the spoke hospital. Small pilot tests have been done in dermatology, urology, cardiology, vascular and plastic and reconstructive surgery. All have been proven to be feasible. Objective outcomes are pending.

430
The Development and Maintenance of an International Telemedicine Pediatric Program
Kevin S. Hopkins, MD            
Driscoll Children's Hospital, Corpus Christi, TX
Background: This paper will present in detail, the 4 year development of an international pediatric telemedicine network between South Texas, Mexico and several other countries. Our hospital is the only Regional, Pediatric Tertiary Care Hospital in South Texas. Geography and shared cultural roots have played a strategic role early on in establishing this network initially for distance learning and Grand Rounds; however a strong marketing plan has propelled it forward to now involve physician and patient consultations, nursing education and even job interviews. Methods: The network consists of videoconferencing systems with plug-ins over ISDN, the Internet, and Internet 2 with bridging from our hospital. Connectivity is to state children’s hospitals as well as other teaching hospitals in Northern and Central Mexico and Venezuela. We have also supported remote consultations via satellite and videophone for specific projects in Central and South America. Results: Telemedicine is the driving force for our International Outreach. It has allowed us to measurably increase our presence in Mexico and South America and directly compete with larger, university-based children’s hospitals for market share, while providing for much-needed physician and nurse education and patient consultations.  Conclusions: Currently, this project is supported by private funding and government grants. A thorough discussion of pitfalls, lessons learned, funding and sustainability will be presented.

456
Putting Fires Out through Telemedicine: Burn Triage and Management
Jimmy C. Park, MS, RN,1 Kathryn Blackman, MSN, APN, RNP,2 William W. Henry, Jr, MD,2 William R. Dougherty, MD, FACS,1 William L. Hickerson, MD, FACS, 1 Michael Manley, RNP,3 Rachel E. Ott, BA,3 Cathy Flanagin, MS4
1The Burn Center at Arkansas Children’s Hospital, Little Rock, AR; 2St. Bernard’s Regional Medical Center, Jonesboro, AR; 3University of Arkansas for Medical Sciences, Little Rock, AR; 4Arkansas Department of Health and Human Services
In a state with the seventh highest rate of fire mortalities, Arkansas’ only Burn Center and Department of Health have combined expertise and telemedicine resources to triage, consult, and appropriately transport burn victims seen in emergency departments at outlying, rural hospitals.  The Arkansas Children’s Hospital (ACH) treats approximately 475 burn patients yearly, many of which are transported from every corner of the rural state.  A number of these patients are transported based upon the burn expertise of the outlying hospital, resulting in a number of transports that could be treated locally with co-management and guidance from burn specialists.  Recognizing the need for strengthened burn support at rural hospitals, ACH paired with the Arkansas Department of Health in 2007 to utilize existing disaster preparedness T1 lines to connect to emergency departments statewide for the purpose of triaging burn patients. Upon implementation, a house fire resulted in seven adult and pediatric burn admissions to one of these small emergency departments.  Using Tandberg MXPs at ACH and the pilot site, Burn Center specialists assessed, consulted, and recommended treatment and/or transport for each burn patient.  Through interactive video and innovative graphing software, ACH surgeons measured the severity and expanse of burns on each patient, thereby determining which victims required treatment at the Burn Center.  This telemedicine intervention facilitated the appropriate and prompt transport of one of the seven burn victims.  Without telemedicine consultation, at least two victims would have most likely been transported to ACH, unnecessarily expending several thousand dollars in treatment costs. As this pilot project continues, the integration of telemedicine and clinical assessment and management of burn victims shows distinct promise in cost effectiveness, replicable ability, and quality of care.  Through a simple telemedicine setup and software, other Burn Centers could deploy pilot programs to build a statewide telemedicine burn network. 

447
eICU IMPACT IN a Rural Community Hospital
Terry Siek, RN,1 Robert Cox, MD,1,2 Jodi A. Schmidt, MBA/HA1
1Hays Medical Center, Hays, KS; 2Kansas Foundation for Medical Care, Topeka, KS; 3Saint Luke's Health System, Kansas City, MO
This segment is part of a series of presentations, from different types of organizations, that illustrate sustainable business models for critical care telemedicine utilizing eICU® Programs.  In an environment of growing critical care requirements due to an aging population and shrinking intensivist and nursing workforce, these presentations will provide alternative solutions to a growing crisis. Panelists will provide a brief overview of their specific implementation in a large health network, rural health system, rural community hospital, academic medical center and in the military along with key clinical and financial results being realized.  These results focus on improved survival rates, length of stay reductions, reduced complications, and reduced operational costs.

197
Network Reliability and Reach: No Longer Mutually Exclusive
Richard J. Carroll,  Ruth Hough,  Dorothea H. Henderson       
ARINC, Inc., Annapolis, MD
Essential to the effectiveness of any telemedicine technology solution is the quality of the network infrastructure on which it operates—the more advanced the technology, the more it is impacted by network limitations.  There is a long-held belief that IT directors must make a trade-off between network reach and high reliability and this assumption restricts the success of telemedicine applications. Telemedicine can achieve greater advancements by exploring the communications network models of other industries that deal with safety-of-life and mission-critical applications. Industries such as aviation and defense have embraced the concept of outsourcing their networks to Virtual Network Operators (VNO). A VNO manages the collective capabilities of many commercial telecommunications providers to design and implement customized network architectures to meet customer requirements for reliability, availability, cost-effectiveness, and global reach. To ensure requirements are met, the VNO provides its customers with customized, risk-based service level agreements (SLAs). The VNO business model differs from the traditional commodity-based telecommunication model in that it is not based upon owning a “heavy” network infrastructure and therefore does not carry the traditional constraints and challenges such as restricted technology choices, rigid price points, and limited global coverage.  The VNO is able to “broker” network solutions on behalf of its customers to select the most appropriate technology for the application, taking into consideration cost, locations, bandwidth, throughput, latency, and performance.  Telemedicine is creating a need for communications access across the globe and in remote rural areas. The objective is to make quality healthcare available to everyone everywhere. By implementing a highly reliable network that uses the VNO business model to support its mission-critical applications, the healthcare industry will have the choice, flexibility, and cost effectiveness to achieve its telemedicine objectives successfully.

466
CONSUMER TELEHEALTH – ARE WE NEARING THE TIPPING POINT?
Scott C. Simmons, MS,1 Bernard A. Harris, Jr., MD, MBA, FACP,2 Michael Robkin,3 David L. Whitlinger4, Sam L. Grogg, PhD5           
1University of Miami Miller School of Medicine, Miami, FL; 2Vesalius Ventures, Houston, TX; 3Kaiser Permanente Information Technology Kaiser Foundation Hospitals, Pasadena, CA; 4Continua Health Alliance, Intel Corporation, Beaverton, OR; 5School of Communications, University of Miami, Coral Cables, FL
Consumer telehealth involves fundamentally different transactional and business models from traditional telehealth programs and services. In consumer telehealth models, patients will pay out-of-pocket expenses for service, equipment, software, and/or telecommunications. Consumer telehealth transactions will occur in an on-demand, ad-hoc manner rather than the highly structured delivery models in traditional telehealth.  Furthermore, consumer telehealth will be focused on customer service and convenience, delivering services at the time and location that are most convenient for the patient. This revolutionary change in telehealth is presaged by several factors. Today’s “wired” consumers routinely purchase many products and services at any time of day from almost any location. This is enabled by continual developments computing, consumer electronics, virtual collaboration, and telecommunications technologies. Patients are also paying more directly for health care – either through increased premiums for their employer-provided plan, participation in Health Savings Account programs, or self-pay. As consumers pay an increasing share of their health expenses, they are less likely to tolerate the inconveniences and inefficiencies of today’s health care system – delays in getting appointments, travel time and expense, time spent in waiting rooms, duplicative form completion, and lack of after hours care options. However, there are several challenges that must be addressed in order to reach the vision for consumer telehealth.  Consumer-priced devices and software must be available and interoperable. Registries and directory services for devices, patients, services, and health care personnel must be devised and implemented. Finally, consumer telehealth marketing, promotion, and advocacy activities are required. This panel involves presentations and discussions about the many promises and issues related to consumer telehealth from the perspectives of academia, industry, marketing, and finance in an attempt to determine whether consumer telehealth is nearing its tipping point.

182
INNOVATIVE COMPETENCY TRAINING FOR PROVIDERS DELIVERING TELEBEHAVIORAL HEALTH SERVICES
Britton A. Niles, M.A.,1  Valerie M. Gifford, MSW,2  Jodi Polaha, Ph.D,3  Catherine Koverola, PhD,4 Inna Rivkin, PhD5    
1Univeristy of Alaska, Fairbanks, Fairbanks, AK; 2University of Alaska, Fairbanks, Fairbanks, AK; 3East Tennessee State University, Johnson City, TN; 4Antioch University, Seattle, WA; 5University of Alaska, Fairbanks, Fairbanks, AK
Background:  As two-way video conferencing capabilities become widespread, mental health professionals are increasingly able to provide services to clients in rural communities.  It is essential that urban-based or off-site therapists and rurally-located, on-site telehealth site-coordinators understand the ethical considerations involved in telebehavioral health service.  Indeed, the ethical code of the American Psychological Association (APA, 2002) stipulates expectations that psychologists uphold the code in the context of telehealth. However, no specific APA guidelines exist regarding ethical considerations specific to telebehavioral health.  Rees and Haythornwaite indicated the importance of psychologists addressing ethical and legal consideration in telehealth to include confidentiality, informed consent, and client safety (2004). Objectives:  The Alaska Rural Behavioral Health Training Academy provided a telebehavioral health training, for providers, with a strong focus on ethical practice.  The main objective of the study is to assess the effect of training using video vignettes and problem-solving on therapist and coordinators knowledge of 14 specific competencies unique to telebeheavioral health practice.  Methods:  A training video was produced depicting a therapist, client, and coordinator engaged in a behavioral health consult.  The video image depicted the therapist’s point of view, with her image appearing in the Picture in Picture box, and the client and on-site coordinator on the full-screen.  The scenes highlighted errors made across 14 specific ethical competencies (i.e. client safety, confidentiality, and cultural awareness).  A second video was produced with similar vignettes used to assess the participant’s knowledge of the 14 competencies as a pre and post test measuring participant improvement.  Findings/Conclusion:  Results of this study support that participants effectively integrated knowledge and competencies related to the 14 competencies.  Results support the need for therapists and site-coordinators to continue education regarding ethical competencies required to appropriately provide telebehavioral health services.  Video vignettes appear to be an effective means for providing such training.

359
Evolution of a School-Based Telemedicine Program
Eve-Lynn Nelson, PhD           
KU Center for Telemedicine and Telehealth, Kansas City, KS
The school-based telemedicine service TeleKidcare has completed over 4,000 consults during the last nine years, with 529 consults completed in 2006-2007 alone.  The presenter will describe the trend toward mental health consultations and lessons learned in the developmental process of the program. TeleKidcare originally focused on ambulatory concerns, but the program has shifted to over 85% mental health presentations in both urban and rural schools.  This trend reflects access barriers to mental health services and severe shortages of child specialists.  TeleKidcare’s mental health services include psychiatry (253 consults), psychology (171 consults), and developmental medicine (30 consults).  Just as in face-to-face behavioral clinics, the majority of TeleKidcare patients are male (60%) and three-quarters have co-morbid mental health concerns.  One founding TeleKidcare school completes approximately 30% of total consults (161 of 529 consults), while three-quarters of schools (13 of 17 schools) complete less than 30 consults/year.  Although most TeleKidcare schools are elementary schools, patient age has increased (mean age=11 years) over time, with many adolescent TeleKidcare patients returning to their original TeleKidcare elementary school.  Many early lessons learned in TeleKidcare have been magnified over time and with increased volume, including the importance of a school champion, the need for administrative buy-in across participating institutions, and the importance of centralized scheduling. Ongoing training for new and returning school presenters remains essential for technology, protocol, and mental health specific information. As the program has evolved, consults require more school presenter preparation and follow-up time with paperwork consisting of multiple consent forms, HIPAA forms, intake forms, and behavioral questionnaires. School presenters assist in follow-up recommendations related to medical care and adherence, school accommodations related to the illness’ impact on learning, and family-related recommendations and referrals.  Compliance with telemedicine service guidelines across providers and presenters in the school setting will be addressed.

470
THE CREATION OF A CYBER-HOSPITAL: Incorporation of Private Practice Specialists' Into the Telehealth Arena
Ralph Madeb,1,2 Sandeep Krishnan,1,2 Cynthia Gordon,1,2 Ralph Pennino,1,2 Amy Craib,1,2 John Valvo,1,2
1Via Health System, Rochester General Hospital, Rochester, NY; 2Newark Wayne Hospital, Newark, NY
Incorporation of private practice medical and surgical specialists into a developing telehealth program can prove to be a difficult task. To date the implementation of telehealth systems in New York State have been site or specialty specific. Via Health is one of the two leading medical systems in the Western part of New York State with a newly formed office of Telehealth. Rochester General Hospital in Rochester, NY is the primary facility with 526 beds and includes all specialists and sub-specialists in both medical and surgical fields. Newark Wayne Hospital is a smaller subsidiary hospital with primary care practices and a smaller number of specialists. Our objective was to determine the feasibility of incorporation of private practice specialists in both the surgical and medical arena. We have already shown (1st abstract) that implementation of both a static and dynamic telehealth system is feasible. A virtual medical group was created through Rochester General Hospital comprised of various private practitioners in various specialties. As mentioned, two respective offices have been designated in both the hub and spoke sites. The telehealth coordinator is located at the spoke site and coordinates two sessions per day for two different specialties (an AM and PM session).  There is a nurse practitioner at the spoke site taking histories and physicals while the specialist evaluates and delivers the specialty consult.  Patients are scheduled into the specialist’s normal clinic or office hours.  An electronic medical record is available via a web enabled system. A validation period demonstrated 98% physician satisfaction.   Small pilot tests have been done in dermatology, urology, cardiology, vascular and plastic and reconstructive surgery. All have been proven to be feasible. Objective outcomes are pending.

390
Development of a Collaborative Telehealth Network in Ecuador
Ricardo Hidalgo, MD,1  Dale C. Alverson, MD,2  Gonzalo Cartagenova, PhD,1  Luis Maldonado3     
1Universidad Tecnologica Equinoccial, Quito, Ecuador; 2University of New Mexico, Albuquerque, NM; 3Fuerza Aérea Ecuatoriana, Quito, Ecuador
In conjunction with Universidad Tecnologica Equinoccial in Quito, the Ministry of Public Health and in consultation with the Center for Telehealth at the University of New Mexico, the Ecuadorian Air Force is providing broad-band satellite connectivity throughout the country for a national telemedicine program. The national network can also be linked to international networks, such as Internet2.  This telehealth network is already establishing links between universities in Ecuador and remote communities in the Ecuadorian jungle, Andes and the Galapagos, as well as New Mexico. Telehealth links connect medical experts in Ecuador and anywhere in the world through these wireless telecommunication connections and provide exciting opportunities for cultural exchange and knowledge sharing, between health professionals, faculty and students in many disciplines. Continued advances in telehealth information communication technologies, computing and wireless networks are enabling improved access to healthcare information, health services, research and education independent of distance on an international level. In turn, Telehealth is allowing an enhanced means of sharing knowledge and expertise, “leap-frogging” over the barriers of distance and time on a global level. Telehealth is far more than a communication infrastructure but constitutes a platform for collaboration between healthcare providers and educators, public health workers, investigators, both in-country and across borders with other international organizations and partners.  As the world continues to “shrink”, international telehealth “network of networks” offers an opportunity for cooperation, collaboration, knowledge sharing and improving the health of every individual. Mounting concerns related to the HIV/AIDS epidemic, the emergence of tuberculosis, increasing issues related to hepatitis C, malaria and other tropical diseases, as well as  and the threat of pandemic influenza, highlight the importance and value of telehealth and international collaboration. These programs can promote international understanding and mutual respect in a manner the can improve the health of the entire global community.

130
The Impact of Teledermatology on Skin Cancer Diagnosis and Treatment
Jennifer L. Hsiao, BS,1,2  Dennis H. Oh, MD, PhD1,2         
1Dermatology Research Unit, VA Medical Center, San Francisco, CA; 2Department of Dermatology, University of California, San Francisco, CA
Although the diagnostic accuracy of teledermatology has been extensively studied, relatively few studies have examined whether teledermatology in practice translates into improved, objective patient outcomes.  We retrospectively examined the hypothesis that store-and-forward teledermatology referrals are associated with earlier diagnosis and definitive treatment of malignant skin cancers in comparison with conventional clinic-based referrals for remotely located patients.  A chart review was performed of all patients who had been treated for skin cancer over a 4.5 year period in a VA medical center’s dermatologic surgery clinics as a result of either a conventional dermatology referral or a teledermatology referral from one of three remotely located primary care clinics.  169 patient cases met the study criteria:  45.6% were identified as conventional clinic-based referrals (mean age 66.9 years, range 50-98; 98.7% male), and 54.4% were identified as teledermatology referrals (mean age 68.1 years, range 23-98; 98.9% male).  The overall mean time to initial consult completion was 50 days for a clinic-based referral and 4 days for a teledermatology referral (p<0.00001).  The mean time to biopsy was 57 days for a clinic-based referral and 38 days for a teledermatology referral (p=0.012), and the mean time to surgery was 125 days for a clinic-based referral and 104 days for a teledermatology referral (p=0.036).  Mean times for these three outcomes were also shorter for teledermatology referrals from each outpatient clinic site itself, though the times to biopsy and surgery were statistically significant for only one remote site.  These data indicate that clinical outcomes in skin cancer management, specifically the time intervals to diagnosis and surgical treatment, via teledermatology are comparable to if not better than management by conventional referrals for remotely located patients.

444
eICU Impact in an Academic Medical Center
Patrick Kim, MD
Trauma and Surgical Critical Care Division, University of Pennsylvania, Philadelphia, PA
This segment is part of a series of presentations, from different types of organizations, that illustrate sustainable business models for critical care telemedicine utilizing eICU® Programs.  In an environment of growing critical care requirements due to an aging population and shrinking intensivist and nursing workforce, these presentations will provide alternative solutions to a growing crisis. Panelists will provide a brief overview of their specific implementation in a large health network, rural health system, rural community hospital, academic medical center and in the military along with key clinical and financial results being realized.  These results focus on improved survival rates, length of stay reductions, reduced complications, and reduced operational costs.

465
Consumer Telehealth - Are We Nearing the Tipping Point?
Scott C. Simmons, MS,1 Bernard A. Harris, Jr., MD, MBA, FACP,2 Michael Robkin,3 David L. Whitlinger4, Sam L. Grogg, PhD5           
1University of Miami Miller School of Medicine, Miami, FL; 2Vesalius Ventures, Houston, TX; 3Kaiser Permanente Information Technology Kaiser Foundation Hospitals, Pasadena, CA; 4Continua Health Alliance, Intel Corporation, Beaverton, OR; 5School of Communications, University of Miami, Coral Cables, FL
Consumer telehealth involves fundamentally different transactional and business models from traditional telehealth programs and services. In consumer telehealth models, patients will pay out-of-pocket expenses for service, equipment, software, and/or telecommunications. Consumer telehealth transactions will occur in an on-demand, ad-hoc manner rather than the highly structured delivery models in traditional telehealth.  Furthermore, consumer telehealth will be focused on customer service and convenience, delivering services at the time and location that are most convenient for the patient. This revolutionary change in telehealth is presaged by several factors. Today’s “wired” consumers routinely purchase many products and services at any time of day from almost any location. This is enabled by continual developments computing, consumer electronics, virtual collaboration, and telecommunications technologies. Patients are also paying more directly for health care – either through increased premiums for their employer-provided plan, participation in Health Savings Account programs, or self-pay. As consumers pay an increasing share of their health expenses, they are less likely to tolerate the inconveniences and inefficiencies of today’s health care system – delays in getting appointments, travel time and expense, time spent in waiting rooms, duplicative form completion, and lack of after hours care options. However, there are several challenges that must be addressed in order to reach the vision for consumer telehealth.  Consumer-priced devices and software must be available and interoperable. Registries and directory services for devices, patients, services, and health care personnel must be devised and implemented. Finally, consumer telehealth marketing, promotion, and advocacy activities are required. This panel involves presentations and discussions about the many promises and issues related to consumer telehealth from the perspectives of academia, industry, marketing, and finance in an attempt to determine whether consumer telehealth is nearing its tipping point.

226
Increasing Access to Evidence-Based Mental Health Services through Technology
Lisa J. Roberts, PhD           
Viterion TeleHealthcare, LLC, Bellevue, WA
There is increased focus in providing integrated medical and psychiatric services,   and “promoting health care for the whole person.”  There is also continued emphasis on applying three pillars of evidence-based practice: 1) research evidence, 2) clinician expertise, and 3) patient preferences, values and culture in a reformed health care system in which health care provider’s team up to treat the whole person.  Technology is a mechanism that can be used to support the pillars of evidence-based practice, integrating services for both physical and psychological health.  The first goal of this presentation is to describe innovative applications of home telehealth technology for individuals with co-occurring medical and psychiatric disorders, including multiple sclerosis, depression and posttraumatic stress disorder.   Not only do these populations have tremendous health services needs, but also they often have difficulty accessing services due to insufficient resources (transportation, time, urban and rural obstacles), insufficient providers (especially for specialty services), and limited functioning due to their health conditions.  The second goal is to provide an overview of the state of the home telehealth literature for medical and psychiatric.

320
Diabetes Care in Adolescents: An Innovative Approach to School-Based Management
Janet L. Grady, DrPH, RN,  Jane Getsy, RN, BSN,  Robin Stern, RN       
Henry M. Jackson Foundation for the Advancement of Military Medicine, Cresson, PA
The American Diabetes Association estimates that in the US alone, over 176,000 individuals less than age 20 have diabetes.  Many are adolescents attending schools served by school nurses facing an increasing workload of student needs.  Adolescence is a difficult time for diabetics because glycemic control can deteriorate, leading to an accelerated risk of developing long-term complications.   Diabetes management must balance the need for independence with adherence to therapeutic regimens.  This presentation describes an innovative approach to diabetes care for adolescents, implemented in a rural area of west-central Pennsylvania as part of a federally-funded telehealth grant program.  Using telehealth technology and computerized educational resources to encourage better diabetes control, fifty high school students and fifteen school nurses are participating in a pilot program examining alternate approaches to diabetes care in adolescents.  The intervention includes educational seminars and web-based modules to deliver current diabetes content to school personnel.  In addition, student participants download weekly glucometer readings to an established database, using a device compatible with a wide range of glucometers.  Once data from the glucometers are transferred to the database, a variety of reports and graphs are generated by school nurses to better understand when and what care is needed, and to help students self-manage their chronic condition.  Students also have access to a web-based educational program with content tailored to their needs and based on ADA and CDC materials.  The presentation will provide an update on student and school nurse satisfaction with the innovative program, as well as lessons learned during program implementation that serve as guidelines for future programs.  Discussion will also address hypothesized improvements in diabetes knowledge of program participants and in outcomes related to diabetic control that result from access to technology-enhanced education and telehealth monitoring tools in a sample of high school students and school nurses. 

468
THE CREATION OF A CYBER-HOSPITAL: DEVELOPMENT OF A ROBOTIC RAPID RESPONSE TEAM
Ralph Madeb,1,2  Sandeep Krishnan,1,2 Cynthia Gordon,1,2 Ralph Pennino,1,2 Amy Craib,1,2 John Valvo,1,2
1Via Health System, Rochester General Hospital, Rochester, NY; 2Newark Wayne Hospital, Newark, NY
To date the implementation of telehealth systems in New York State have been site or specialty specific. Via Health is one of the two leading medical systems in the Western part of New York State with a newly formed office of telehealth. Rochester General Hospital in Rochester, NY is the primary facility with 526 beds and includes all specialists and sub-specialists in both medical and surgical fields. Newark Wayne Hospital is a smaller subsidiary hospital with primary care practices and a smaller number of specialists. The Rapid Response team is the opportunity for critical care experts, to bring their skills to patients at the bedside.  Oftentimes, patients deteriorating condition is failed to be noted.  This is a fundamental problem that leads to failure to rescue patients from untowardly events.  Rapid Response outcomes show that there has been a major reduction in patients deteriorating and unnecessary deaths. . Incorporation of the Rapid Response team at Rochester General has proven to be feasible and effective with no need for overhead emergency bells for patients warranting resuscitation. We set out to determine the possibility of incorporation of a robotic rapid response team at Newark Hospital using the RP-7 robot manufactured by In-Touch Technologies. By using the same principals we hypothesized that the rpaid response team can be extrapolated to our subsidiary hospital using advanced Telehealth systems, specifically, the RP-7 robots. The same ICU staff responding to the emergency calls at RGH performed the rapid response consults. Incorporation of this system has been expected to advance care and serve as a quality control measure. Additionally, this allows for specialty nurses to extend their capabilities to smaller peripheral hospitals that cannot afford to develop these systems. Outcomes are being collected and are pending.

431
Integrating Cross-Cultural Indigenous and Western Healing with Modern Technology Update
Kevin S. Hopkins, MD,5  Dale C. Alverson, MD,2  Ricardo Hidalgo Ottolenghi,, MD,3  Gonzalo, Cartagenova, PhD,3 Star Johnsen-Moser4    
1Driscoll Children's Hospital, Corpus Christi, TX; 2University of New Mexico School of Medicine, Albuquerque, NM, Costa Rica; 3Universidad Tecnológica Equinoccial Facultad de Ci, Quito, AL, Ecuador; 4Cahokia Mysteries School for Cosmic Education, St. Joseph, MO; 5Driscoll Children's Hospital, Corpus Christi, TX
Indigenous healers around the world have used non-traditional practices and techniques for centuries that, though poorly understood by western physicians, clearly have a role in the well-being and healing of their patients. Slowly, some of these same practices are gaining popularity in western society. In 2004, the National Center for Complementary and Alternative Medicine (NCCAM) reported survey results that 62 percent of respondents used complementary and alternative medicine in 2002. Indigenous healers around the world have used non-traditional practices and techniques for centuries that, though poorly understood by western physicians, clearly have a role in the well-being and healing of their patients. Slowly, some of these same practices are gaining popularity in western society. This paper is an update on our progress in initiating and sustaining  the integration of cross-cultural healing practices between the United States and Ecuador. Plastic Surgeons and Physicians from the US and Ecuador working with indigenous and alternative healers from both countries have established protocols for pre and post-operative management of children with cleft lips and palates in Ecuador’s Amazon region. Telemedicine, in the form of videoconferencing is used to augment the entire process from pre-operative evaluations to post operative treatments which incorporate both western and indigenous healing practices. Both patient to physician and peer to peer healer consultations are used extensively.  Reciprocal presentations by healers in both countries are also used to foster a better understanding and respect of each other’s culture and techniques. Surveys report a high level of satisfaction and a low complication rate.

299
Compared to face-to-face: Wheelchair seating teleassessment, a pilot study
David W. Jordan, BScOT           
Sunny Hill Health Centre for Children, Vancouver, Canada
Background:  Sunny Hill Health Centre in Vancouver, British Columbia, Canada, provides pediatric development outreach services. One component of outreach services is adaptive seating, providing custom wheelchair seats to improve the posture and function of children with muscular impairments. The level of sitting scale (LSS) is a routine part of initial assessments. This ordinal scale measures the level of sitting support required to maintain an upright posture. The observational nature of the scale makes it promising for teleassessment. Validity and reliability of the LSS is known in face-to-face but unknown in videoconferencing conditions. This created the opportunity for a pilot study: Is the LSS teleassessment equal to one made in person? Design:  A sample size of thirty children aged 6 months to 18 years are being recruited. Each subject participates in two LSS assessments. The first assessment is done via videoconferencing and the second assessment face-to-face, at least three weeks after the first session to control for clinicians’ memory. Evaluation:  Inter-rater reliability is used to establish confidence that different therapists can perform the LSS and achieve the same result. Test retest reliability determines confidence that the test can be performed with the same results across conditions; in this case, over time and through different media (face-to-face vs. teleassessment). Intra-class correlation coefficient (ICC) will be used to measure both inter-rater and test retest reliability. An ICC value of .75 is determined to be acceptable and a Kappa value of .75 thought to be excellent for correcting the proportion of agreement due to chance.  Results:  The results of this ongoing pilot study (N = 6, as of Aug, 2006) are too small to quantify, but trends observed  are expected to be further substantiated.

216
The Impact of Emerging UAV Technology on EMS Operations
Frederick W. Piasecki, BS           
Piasecki Aircraft Corporation, Essington, PA
Advances in telemedicine enable early and specialized pre-hospital patient management, resulting in the saving of countless lives.  However, the advances are limited by the ability to transport critical enabling capabilities to remote areas.  Aircraft accidents and ground accidents involving hunters, hikers, climbers, and other off-road sports enthusiasts often occur in remote areas, where obstacles and obscurants limit access to both ground and air ambulances.  TATRC has been sponsoring research into unmanned aerial vehicle (UAV)-related technologies needed to transport telemedical and other supplies to wounded soldiers in urban or wooded terrain.  These technologies can also enhance manned aerial vehicles’ ability to deliver telemedicine capabilities to remote areas.   Recently, one of these technologies, Landing Zone Selection, was used in experiments with a manned medical evacuation helicopter.  The capability was initially developed to allow UAV’s to select safe areas for their landing, but it is also proving to be valuable as a tool for the pilots of manned helicopters.  Use of sensors combined with software can advise medical evacuation pilots of hazards which are difficult to see with the naked eye and provide the pilot with more confidence to land in areas he might otherwise avoid.  Even in good visibility obstacles such as wires and objects buried in high grass can be difficult to spot from above.  This presentation summarizes the tests and demonstrations conducted in 2007 to show the LZ evaluation capability and its applicability to manned medical helicopter operations.

446
eICU Impact in the Military
Eric A. Crawley, LTC MC
Critical Care Services, Tripler Army Medical Center, Honolulu, HI
This segment is part of a series of presentations, from different types of organizations, that illustrate sustainable business models for critical care telemedicine utilizing eICU® Programs.  In an environment of growing critical care requirements due to an aging population and shrinking intensivist and nursing workforce, these presentations will provide alternative solutions to a growing crisis. Panelists will provide a brief overview of their specific implementation in a large health network, rural health system, rural community hospital, academic medical center and in the military along with key clinical and financial results being realized.  These results focus on improved survival rates, length of stay reductions, reduced complications, and reduced operational costs.

88
Patient-centered telehealth: a theoretical framework
George Demiris, PhD           
University of Washington, Seattle, WA
New design approaches that support health care delivery and patient education emerge due to advances in information technology and a shift from institution-centric to patient-centric applications. This panel focuses on key principles and challenges of the design, implementation and evaluation of patient-centered telehealth technologies. This study will review the recommendations of the American Medical Informatics Association Knowledge in Motion Working Group for “Patient-centered applications: use of information technology to promote disease management and wellness” in the context of telehealth.  We will provide a review of current and emerging trends, highlight challenges related to design, evaluation, reimbursement, and usability of patient-centered telehealth tools and introduce the theoretical framework for the applications and studies discussed by the other panel presenters. We will hereby analyze the concepts of patient empowerment and shared decision as they relate to telehealth.

104
Telepsychiatry : Our experience with Compliance and Satisfaction
Salim Chowdhury, MD,  Nancy Parrotta, LPC, NCC         
Community Care Behavioral Health Organization, Pittsburgh, PA
Telepsychiatry has been rapidly gaining interest and is viewed as an effective means to enhance access in psychiatric care. Community Care Behavioral Health Organization is a behavioral health MCO that manages behavioral health services for approximately 600,000 members under Health Choices Medicaid contracts in 35 of the 67 counties in Pennsylvania. To improve access to and the quality of behavioral health services   Community Care initiated a telepsychiatry program in 2005 in one of the counties it works in and in August’2006 expanded this program to sites in an additional county. This service includes providing initial psychiatric evaluations and medication management follow-ups for adult and child members in outpatient settings where they have been receiving traditional psychotherapy services. Since this modality of treatment is still in its early phase, Community Care monitors patient and provider satisfaction with the program and patient adherence to initial and follow-up appointments. Review of our collected data since the inception of this program have been encouraging and these results in this presentation.

290
Applying Advocacy to Increase Access to Child Healthcare Through Telemedicine
Jenny Kattlove, MSSA,  Terri Shaw, MPH         
The Children's Partnership, Santa Monica, CA
The Children’s Partnership (TCP) has implemented a project to increase access to health care for California’s children, especially underserved children, through telemedicine. TCP is accomplishing this goal by: 1) researching the benefits of and barriers to telemedicine for children; 2) educating policy makers and other key stakeholders about telemedicine for children; and 3) implementing a policy agenda to foster optimal deployment of telemedicine for children. Through the child advocacy model of research, convening stakeholders and building consensus, translating lessons learned into a policy framework, and pursuing policy solutions, TCP has increased awareness of the potential of telemedicine to meet the health care needs of children and has advocated for improvements to telemedicine policies through the state  policy making process. Specifically, TCP developed the report, Meeting the Health Care Needs of Children: The Role of Telemedicine (http://www.childrenspartnership.org/Report/Telemedicine) to inform leaders and the public of how telemedicine can address the health care needs of California’s children. This report provides an overview of the benefits of telemedicine; outlines challenges to successful adoption of telemedicine; and provides recommendations for ensuring that telemedicine reaches its full potential in meeting the health care needs of California’s children. TCP is using the report, along with presentations, to educate policy makers and other stakeholders about telemedicine. TCP has also successfully advocated for inclusion of policy recommendations regarding telemedicine for children in various advisory reports to the Governor of California and will continue to pursue policies through the administrative and legislative processes. While policy change is gradual, TCP has taken the necessary steps to ensure enactment of policy solutions.   This unique project, demonstrating the role of advocacy in moving policies to ensure that telemedicine reaches its full potential in meeting children’s health care needs, can be used as a model in other states and nationally.

59
Human Factor Issues with State-of-the-Art Emergent Care
Gina L. Litzinger, RN, MSN,  David M. Wolfe,  Jay B. Roberts, MA,  Barbara R. Demuth, RN, MSN     
Saint Francis University's Center of Excellence for Remote and Medically Under-Served Areas, Loretto, PA
Human factors and the willingness to accept change play key roles in implementation of technologies into medical practice. As with any innovation, meaningful change comes slowly. Successful moves towards the use of new technologies require those in that organization to establish different working relationships, along with a readiness to use the technology itself. Researchers at the Center of Excellence for Remote and Medically Under-Served Areas (CERMUSA) were faced with numerous human factors in the implementation of a state-of-the-art ambulance known as FREC-M (First Responder Emergency Communications-Mobile). Key personnel involved in the projected cited time constraints, increased patient case loads, unfamiliarity the technology, increased time between use, actual and perceived work flow changes, and technology mindset of the end users as reasons for lack of data in this project. Despite the potential for success in providing state-of-the-art emergent care, CERMUSA closed this research study early. This paper will further expand on the human factor issues CERMUSA faced while implementing this project.

78
Measuring Change in Function Following the Provision of a Wheeled Mobility and Seating Intervention via Telerehabilitation
Richard M. Schein, MS,2  Mark Schmeler, PhD, OTR/L, ATP,2  David Brienza, PhD2       
1University of Pittsburgh: Department of Rehabilitation Science and Technology, Pittsburgh, PA; 2University of Pittsburgh: Department of Rehabilita, Pittsburgh, PA
Remote areas often experience shortages of professionals and technical resources crucial
to the delivery of services related to specialized medical fields.  This impacts both the health care providers and the patients. There are more people in need of the services of assistive technology specialists than there are regional clinics to serve them. The objective of this study is to investigate the ability of the Functioning Everyday with a Wheelchair (FEW) outcome tool to measure the difference and magnitude of user perceived change in function following the provision of a new seating and wheeled mobility device via Telerehabilitation (TR). The Rehabilitation Engineering Research Center on Telerehabilitation has assisted two remote hospitals set-up wheelchair clinics modeled after the Center for Assistive Technology at the University of Pittsburgh Medical Center to support this research project as wheelchair provision and service delivery for individuals with mobility impairments is a complex and challenging clinical intervention. Data collection is in progress and preliminary findings will be reported based on pre post measures of the ten specific related tasks measured by the FEW and the average FEW total score. Finally to examine the clinical or practical significance of the wheeled mobility device intervention provided, effect sizes for the individual FEW item grand means will be calculated using Cohen's d. It is anticipated that TR has the potential to provide evaluation, treatment intervention, and follow-up as needed to a client at a local clinic with a generalist practitioner with remote consultation from an expert practitioner.

287
Expert System For Remote Monitoring And Control Of Intensive Care Units
Javier Pereira, PhD,1 Miguel A. Pereira, MD,2 Alberto Curra, MSc,1 Celia Teijeiro, MSc,1 Gerardo Banos, PhD, MD,2 Jorge Teijeiro, PhD, MD,1 Alejandro Pazos, PhD, MD1 
1Centre of Medical Informatics and Radiological Diagnostic, University of A Coruna, A Coruna, Spain; 2Service of Anesthesia, Resuscitation and Intensive, Vigo, Spain
When a patient in critical condition is admitted into the ICU, his/ her vital signs must be constantly observed, and a continuous analysis of these signs must be maintained to determine the appropriate choice and administration of specific medications. This continuous decision-making process requires the involvement of medical specialists.  In this work, we describe a system capable of monitoring the patient, acquiring his/her vital signs obtained by the ICU monitors, storing the data, and --through an expert system--, presenting the information to the medical specialist while also proposing possible treatment courses. In addition, once the decisions are determined by the specialist, the system is also capable of remotely controlling the infusion pumps through which the chosen medications are to be administered to the patient.  The methodology used by the expert system is CommonKADS. The system has been implemented in JAVA and JESS using the architecture pattern Model-View Controller. The architecture is designed using six modules: (a) Communications, to carry out all the transmissions; (b) Acquisition, to access the data obtained by the monitors; (c) Control, to manage the infusion pumps, and integrate the different modules; (d) Intelligence, based on production rules; and (e) Storage, to store all the information. The communication with the devices is achieved through serial connections controlled by a computer located at the patient's bedside. From here, the data are sent to a server via CORBA communications. The medical specialist or physician can access the date from a laptop that communicates with the server through a standard browser; the physician can access the data in real time for each patient and control the medications to be administered by the pumps. The system has been installed in the ICU at the Hospital do Meixoeiro (Spain) with ten beds; thus far the tests have been carried out with one patient.  The physician users have utilized the first version TabletPCs and an interface is currently under development to permit the appropriate visualization using PDAs.

159
Remote Detection of CBE Agents at or Near Medical Casualties
Charles W. Gardner, PhD,1  Parag H. Batavia, PhD,2  Gary Gilbert, PhD3       
1ChemImage Corporation, Pittsburgh, PA; 2Applied Perception Incorporated, Cranberry Township, PA; 3US Army Medical Research and Materiel Command, Telemedicine & Advanced Research Center (TATRC), Fort Detrick, MD
Bringing a chemical, biological or explosive (CBE) contaminated casualty into a medical treatment facility can result in additional loss of life or at the least, cause the loss of that facility to treat additional casualties.  Therefore, the need exists to detect CBE agents on casualties, preferably prior to evacuation and treatment. We describe the development of a robot-deployed surface detection system for CBE agents that does not require the use of antibodies or DNA primers.  The detector is based on Raman spectroscopy, a technique that has the ability to simultaneously identify multiple hazardous chemical and biological hazards.  Preliminary testing showed the ability to identify CBE simulants in 10 minutes or less. This detector was successfully integrated on a highly agile robot platform capable of both high speed and rough terrain operation.  The detector is mounted to the end of six-axis arm that allows precise interrogation of the environmental surfaces near a casualty.  The robot, arm and Raman detector are JAUS compliant, and are controlled via a radio link from a single operator control unit (OCU). Results from the integration testing as well as from limited field trials will be presented.  Plans for future development and testing will also be presented. This study confirmed the feasibility of remote detection of CBE agents on environmental surfaces using Raman Spectroscopy.  The reagentless nature of Raman, coupled with the proven ability of robots in battlefield and emergency response situations results in a powerful and deployable system for the protection of emergency medical personnel.

87
User-Centered Telehealth Designs for Community-Based Projects
Karen L. Courtney, PhD, RN,1  Jennifer H. Lingler, PhD, FNP,1  Shikha Iyengar, PhD,1  Richard Schulz, PhD,1 Ellen Olshansky, DNSc, RNC, FAAN2    
1University of Pittsburgh, Pittsburgh, PA; 2University of California-Irvine, Irvine, CA
Senior congregate housing communities, often inhabited by poorer, older adults with low health literacy and multiple co-morbid conditions, typically provide little on-site access to health information, clinical care, and health monitoring. Telehealth interventions hold great potential for maintaining or improving the health of older adults with chronic illness by virtue of their capacity to facilitate health information seeking, enable self-monitoring of health maintenance behaviors, and support virtual office visits across geographic distances. Given the limited personal resources available to many of these individuals, exploration of new telehealth models for maintaining or improving the health of older adults and improving their health  resource utilization is warranted.  Flexible solutions to support individual health maintenance, such as the use of community-based telehealth technologies, can facilitate aging in place and respect the relationship between older adults and their communities.  User-center design of telehealth models and applications for communities rather than individuals as end-users requires participatory design approaches which specifically include the community. This presentation will discuss how the principles of community-based participatory research can be applied to designing telehealth applications for communities.  Telehealth design challenges for community-based projects will be presented.  Unique ethical design concerns arising from the community as end user will also be reviewed and discussed.  Data from the RAND-University of Pittsburgh Health Institute telehealth kiosk feasibility study in senior congregate housing will be used to illustrate the benefits and challenges of using a user-centered approach.   This study is using the Viterion 500 telehealth kiosk to assist older adults in a naturally occurring retirement community with chronic disease management through telemonitoring.  This project is a collaborative effort between a community service provider, UPMC Living at Home and the University of Pittsburgh Institute on Aging and academic researchers at RAND and the University of Pittsburgh.

285
10-Year Analysis of Telepsychiatry Cases at an Academic Medical Center
Elizabeth A. Krupinski, PhD,  Gail P. Barker, PhD,  Ana Maria Lopez, MD,  Ronald S. Weinstein, MD     
Arizona Telemedicine Program University of Arizona, Tucson, AZ
We addressed the question of whether there were significant changes in types of cases referred to an academic telemedicine program for telepsychiatry over a 10-year period. During the 10-year period there were 531 pediatric consults (majority Native American) and 1729 adult consults (majority Caucasian) at 6 rural sites. Cases for each year were classified into according to the primary diagnosis assigned by the telepsychiatrist. Approximately 40% of the adults and 20% of the pediatric patients had multiple diagnoses. The diagnoses of depression and PTSD were most common in adults and ADD/ADHD and depression were most common in pediatrics. Approximately 20% of consults were initial and 80% follow-up. Nearly 80% of the pediatric patients were seen only once, but 75% of the adults were seen multiple times. The percentage of consults in which a pediatric patient with ADD/ADHD and/or depression was seen ranged from 50% to 75% over the 10-year period. There were no significant changes from year to year (X2 = 9.78, p > 0.05). The percentage of consults in which an adult patient with depression and/or PTSD was seen ranged from 41% to 86%. There were significant changes over the years (X2 = 25.62, p < 0.01), with a drop occurring when one telepsychiatrist left the program and another joined. Analyses are underway to determine if the change is due to the new telepsychiatrist revising diagnoses on patients previously seen by the former telepsychiatrist or whether there was a change in the patients being seen. Our program sees a great diversity of telepsychiatry cases although the top diagnostic categories have been generally unchanged over 10-year service period.

201
Improving Pediatric Asthma Care with a Home-Based Interactive Website  Teamwork
John M. Wiecha, MD, MPH,1  William Adams, MD2         
1Department of Family Medicine, Boston University Medical Center, Boston, MA; 2Department of Pediatrics, Boston University Medical Center, Boston, MA
Introduction: To achieve modern and effective management of patients with chronic disease in the primary care setting requires a reengineering of health care systems and relationships to create interdisciplinary teams of professionals providing evidence-based patient-centered care. Asthma has long been recognized as the most common chronic disease of childhood. It has become increasingly prevalent and severe in recent decades despite effective medical therapy. In urban areas and among the disadvantaged, these trends are particularly marked. Proper use of effective medications, environmental control interventions, teamwork among health care professionals, and patient education for self-management each independently, and even more powerfully when employed in combination, can reduce asthma morbidity and associated health care costs. Project and Hypothesis: The BostonBreathes (BB) system is an interactive website enabling physician-physician and physician-patient communication, monitoring (peak-flow, medication use, symptoms) of asthma patients in the home, and patient and family asthma education. Patients and families can interact with their health professionals online as members of the care team. Using a randomized clinical trial design, this project is testing the hypothesis that the BB website will improve patient knowledge and medication adherence, and teamwork among individuals caring for pediatric asthma patients, resulting in improved quality in the process and outcomes of asthma care. This presentation will describe design and results of a new method of promoting each of these factors to achieve improved outcomes.  Results to date: The system is currently functional with 55 study patients from underserved areas of  Boston and 41 physician users.  Conclusions: BB uniquely combines patient education, monitoring, and clinical teamwork functions into one integrated web environment. This session will be the first to present final results of this project, including patient demographics, utilization patterns, and impact on asthma symptoms, medication adherence, and quality of life measures.   Supported by The Commonwealth Fund, NYC.

90
Can videoconferencing effectively replace in-person presentations, and if so, how?
Gail P. Barker, PhD,  Janae Cooley,  Elizabeth A. Krupinski, PhD,  Richard A. McNeely, MS, Ronald S. Weinstein, MD    
Arizona Telemedicine Program, Tucson, AZ
Overview: The Arizona Telemedicine Program, based in Tucson, Arizona, holds bi-monthly telemedicine training conferences. As part of the curriculum the Associate Director, Finance gives a 30-minute lecture on the business of telemedicine. In July 2006, the finance director moved to Phoenix, 120 miles northwest of Tucson, and began giving lectures by videoconference. Six in-person lectures were compared to 6 videoconference lectures and 3 modalities within the videoconference lectures were evaluated. Materials and Methods: Six in-person lectures from the period 6/05 through 6/06 were measured against 6 videoconference lectures performed 11/06 through 8/07. The identical material was presented for all lectures. Five categories were measured using a scale from 1-5, with 5 being best. The 5 and 4 category results are detailed below.

Within the video conferencing sessions, three modalities were compared: PowerPoint presentation only, picture in picture (PiP) and split screen (both speaker and presentation shown). The 5 & 4 category results are detailed below.                

Results: As expected the in-person sessions received the highest scores and all categories were statistically different. We found the best videoconferencing result was accomplished using a split screen. The PiP was the least well received because the picture blocked out some of the presentation which frustrated the audience. It should be noted that for one of the lectures (PiP) handouts were not distributed in time for the lecture; this is reflected in the “handouts” score and does affect the overall score.  Conclusion: Our preliminary data show there are approaches using videoconferencing that compare favorably with in-person sessions.

187
Effectiveness of the LSVT online: A randomized control trial
Deborah G. Theodoros, PhD,  Gabriella Constantinescu, BSpPathHons,  Trevor Russell, PhD,  Elizabeth C. Ward, PhD, Stephen Wilson, PhD, Richard Wootton, PhD   
University of Queensland, Brisbane, Australia
The Lee Silverman Voice Treatment (LSVT&#61650;) is an effective evidenced-based treatment for the speech disorder associated with Parkinson’s disease (PD). Despite this finding, patient access to this treatment remains limited due to the restricted availability of speech-language pathologists (SLPs) trained in the LSVT®, the mobility issues associated with PD, and distance to health care facilities. The delivery of the LSVT® via telecommunications rather than face-to-face (FTF) has the potential to provide a more readily accessible treatment option for people with PD. The study aimed to determine the effectiveness and validity of the online delivery of the LSVT® by comparison with FTF treatment. Thirty-eight participants with PD, and hypokinetic dysarthria ranging in severity from mild to severe were randomly assigned to either an online or a FTF LSVT® treatment group. A telerehabilitation application consisting of a customized Internet-based videoconferencing system was used to deliver the LSVT® online. Pre and post treatment assessments recorded sound pressure levels (SPLs) for sustained phonation, reading, and conversational speech, maximum phonation time (MPT), pitch range, percentage sentence intelligibility, and perceptual speech features. Paired t-tests revealed significant improvements in SPLs for the online group post-LSVT® for sustained vowel phonation (p=0.0001), reading (p=0.0001), conversational speech (p=0.0001), and several perceptual parameters. Similar improvements were determined for the FTF group (p = 0.001). No significant pre to post treatment improvements were found for % sentence intelligibility and some perceptual parameters in either the online or FTF group. Analyses of variance revealed no significant differences (p>.05) in treatment effect for SPL measures, pitch range, MPT, sentence intelligibility and several perceptual parameters. Participants with mild to moderate dysarthria in the online group were more responsive to treatment than persons with more severe dysarthria. This study demonstrated the effectiveness and validity of online LSVT® indicating that telerehabilitation offers an alternate mode of delivery for this treatment.

214
Integrated Intelligence for Continuous Care During Emergency Medical Response
Kyle Snyder,  Emanuel Lowe         
Applied Systems Intelligence, Inc., Roswell, GA
In 2007, Applied Systems Intelligence, Inc. (ASI) developed the MobileCARE (Mobile Coordination Associates for Resupply and Evacuation) concept to provide a common software application for distributing a shared mission picture and planning system across medical response assets.   Combat medics, trauma care specialists, emergency management professionals, and other health care specialists spend their lives in dangerous, threatening environments trying to save lives.  These medical professionals use a variety of methods (helicopters, ambulances, etc.) as evacuation and supply vehicles to provide expedited care to the seriously injured.  The MobileCARE architecture emphasizes the value of integrating artificial intelligence software technology for sharing situational data, resource tasking, field medical requests, and continuous emergency response status.  By providing a common language for sharing response plans and situational context, the MobileCARE software will allow combat medics and civilian medical response personnel to focus on their primary task: safely treating injuries.  Although designed for combat health support services, the MobileCARE concept also directly applies to state and local emergency management services (EMS).  The integration of MobileCARE software throughout a medical response system that includes dispatch operations (e.g. coordination with 9-1-1 systems), on- scene first responder units, emergency care hospital staffs, and evacuation units, demands a high degree of coordination and management of patient health information.  MobileCARE components residing in each of the emergency response assets will allow medical teams to quickly adapt to dynamic and unpredictable environments, such as evacuation through dense ground or air traffic.  As a result, the MobileCARE system will help to reduce the mortality rate and severity of patient injuries by increasing the efficiency of emergency medical response processes and by increasing the situational awareness of each of the members of the medical response teams.  ASI will present the objectives, design, and market analysis for justifying the development of the MobileCARE concept.

86
User-centered telehealth design:  The patient as user
Stuart M Speedie, PhD           
University of Minnesota, Minneapolis, MN
In a number of telehealth applications, the patient receiving  care is the only user or one of two or three users of the system.  Most of these applications have originated in the area of home telehealth.  In this presentation we will describe our experiences and observations with patients and their families in using various technologies in the home for  health care.  The TeleHomeCare project used a combination videophone and web browser to allow a nurse to interact with a patient at home.  The VALUE project expanded this to a computer system using a web portal and videoconferencing over broadband access to support frail elderly at home.   Both projects have yielded valuable insights concerning application design for  the elderly at home.  These insights range from the common sense such as making sure that screen type is sufficiently large to be readable to those with impaired eyesight, to the more subtle such as that mastering the necessary eye-hand coordination to use a mouse is a more difficult task for the elderly to the technical such as older homes occupied by the elderly may not have the necessary telephone wiring to support a remote monitoring device.   Based upon these insights, this presentation will put forward a set of design principles for consideration that could make home-based telehealth applications more user friendly for the patients who must use them daily.

304
Telepsychiatry Client Satisfaction After 10 Years of Network Operation
Sara F. Gibson, MD,1,3  Nancy Rowe, BA,1  Susan Morley, MSW, LCSW,1  Elizabeth A Krupinski, PhD2     
1Northern Arizona Regional Behavioral Health Authority, Flagstaff, AZ; 2Arizona Telemedicine Program, Tucson, AZ; 3Little Colorado Behavioral Health Centers, St. Johns, AZ
Northern Arizona Regional Behavioral Health Authority implemented a telepsychiatry network over 10 years ago; it received positive Client reviews in its first year. Since November 1996, clients in Apache County (two clinic locations) have been receiving psychiatric services exclusively through NARBHA’s telemedicine network. We recently surveyed current Apache County clients to determine their attitudes toward telemedicine after a longer term of use. All Apache County telemedicine clients over a 4-month period (228 clients) were given the survey; 76 responded, a one-third response rate. Overall results included:
• 64% had been receiving telepsychiatry services for 2 years or less, 25% for 3-6 years, and only 4% for 7 years or more.
• 74% had experienced 5 or more telemedicine sessions. Number of sessions experienced correlated to number of years receiving telemedicine services.
• 86% said the quality of medical care through telemedicine is the same as or better than the quality of medical care in person.
• 60% did not express a preference between seeing their psychiatric practitioner in person or via telemedicine; 20% prefer telemedicine.
• 92% said that a clinician in the room either had no effect on their comfort level or made them feel more comfortable.
• 76% agreed or strongly agreed that a clinician in the room helped them feel that they had a team of people contributing to their treatment.
• 71% said they are now more at ease with telemedicine compared to their first sessions.
Survey results were also broken down by age, gender, and number of telemedicine sessions experienced.
Conclusions: Results are generally very positive. The most striking responses and comments were about the presence of a clinician in the room, leading us to consider whether, after initial sessions, clients should be given the option to be accompanied by a clinician or not.

344
6,000 Pediatric Tele-echocardiography Transmissions: Impact on Practice and Lessons Learned
Craig Sable, MD,  Mary Donofrio, MD,  Russell Cross, MD,  Deneen Heath, MD, Christopher Spurney, MD, Susan Cummings, MD, Sarah Clauss, MD, Gail Pearson, MD, Molly Reyna, BA, Gerard Martin, MD
Children's National Medical Center, Washington, DC
BACKGROUND:  Real-time telemedicine transmission of echocardiograms is used to evaluate infants with suspected heart disease. We report the largest experience to date of a pediatric telecardiology practice. METHODS Telemedicine systems (desktop computers or stand alone videoconferencing units) capable of transmitting live echocardiograms over ISDN lines or internet protocol, were installed in 10 hospitals in Washington, DC and suburban, a tertiary care children’s hospital in Washington, DC, and 6 physicians’ homes. Sonographers who routinely scanned adults, but received extra training in pediatric cardiology, performed the echocardiograms. Studies were interpreted and management recommendations were made by a pediatric cardiologist during the videoconference. Sonographers were given the choice of performing the study live or recording and playing back during the transmission. MPEG digitization of the study was performed at the receiving end. RESULTS:  Over 6,000 telemedicine transmissions were performed between 1998 and 2007. No significant diagnostic errors related to telemedicine occurred. Heart disease was detected in over 40% of studies, including over 100 patients with life threatening defects. Over 150 patients were transported for surgical, catheter based, or medical intervention. Critical heart disease was ruled out over 75 patients, preventing unnecessary transport. Medical management and/or outpatient follow up was recommended in over half of the studies. The average from time from request to completion of the tele-consultation was under 30 minutes. Over 90% of the echocardiograms were performed during the videoconference in the first two years of the program. This fell to under 60% during the two most recent years of the program without impact on diagnostic accuracy. CONCLUSIONS:  Tele-echocardigraphy is an efficient way of delivering care to infants with suspected heart disease allowing for appropriate delivery of medical care, avoidance of unnecessary transports, and augmentation of sonographers skill level in performing pediatric echocardiograms.

421
A Study to Assess the Knowledge, Attitude and Practice of E-Health among the Hispanic Population in the San Joaquin Valley of California: Findings from a Telephone Survey
Mohammad A. Rahman, PhD           
California State University-Fresno, Fresno, CA
This study assesses the knowledge, attitude and practice of the Hispanic population in the San Joaquin Valley of California towards their use of internet (website, email) and other communication mediums such as land phones and cell phones, in accessing and seeking medical care and health information, which can vary from disease management to receiving reminder for taking pills, access prescription, drug information and remote home monitoring. A majority of the Hispanic community, which constitutes about half of the population in the region, have limited access to care because of economic hardship and/or remote location of their workplace in the farmlands. Knowing whether they have access to the internet, land or cellular phones and whether they are willing to use these mediums as vehicles of exchanging personal health data, medical care and receiving remote home care can provide useful information regarding the usefulness of telemedicine and e-health as an alternative channel of care for this population. The data for this study comes from a telephone survey of randomly selected 894 Hispanic households in four counties of the central San Joaquin Valley. The study sorts the major communication mediums used by the Hispanic population and how it varies by factors such as income, education, age, gender and location. The study found that more than 65 per cent of the respondents are willing to use at least one medium as a channel of receiving medical care and personal health information, which also varied by age and gender. It was found that there was a significant relationship between age and willingness to seek certain medium and services as source of medical care. The findings from this study have major implication regarding e-health policies and strategies of the private health care sector, local health departments and the state and federal governments.

424
Design and evaluation of a broadband telemedicine system for supporting ICUs in regional hospitals
Laurie S. Wilson, PhD, Susan K. Hansen, BSc, BSocSc, Marcus W. Skinner, MD, FANZCA
CSIRO ICT Centre, Sydney, Australia
Intensive care units in regional hospitals cannot offer the full range of specialist backup services, such as echocardiography, available in major centres. Decision making in intensive care is a complex, multifactorial process requiring access to considerable amounts of information, and decisions need to be made on a time scale measured in hours. This information is generated at the bedside, and patients cannot easily be moved. Provision of specialist services in the ICU clearly requires mobile systems capable of being easily activated, and capable of conveying the complex information required to manage patients. One approach is to re-create the patient’s data set at the referral hospital, as exemplified in the eICU. However, the present project is aimed at assisting the local ICU specialist with specific expertise (particular echocardiography) which mimics a personal specialist consultation. The technology has been specifically developed for this project, based on CSIRO’s broad band system for emergency medicine, the Virtual Critical Care Unit. The technology has been simplified for mobility, and for diagnosis based on real time echocardiography. The system was developed in a participatory design process using specialists and other workers from the two hospitals: Royal Hobart Hospital (RHH) and the North West Regional Hospital (NWRH), located in the remote North West of Tasmania, Australia. An evaluation process was devised and closely linked to the design process; for example, a baseline study established success criteria for the project as well as design criteria. Success criteria are based on clinical outcomes, cost benefit, technical suitability, and social and organisational issues such as the development of collegiate and other relationships between the two hospitals. A clinical trial began in August 2007, with 3 nodes (2 at RHH and one at NWRH). Early impact of the system includes management of complex patients, joint case discussion meetings and interactive education.

223
Telerehabilitation in Employment/Community Supports Using Video-based Activity Recognition
Michael McCue, PhD,1  Jessica Hodgins, Ph.D.,2  Edmund F LoPresti,3  Adam Bargteil2     
1University of Pittsburgh, Pittsburgh, PA; 2Carnegie Mellon University, Pittsburgh, PA; 3AT Sciences, Pittsburgh, PA
A telerehabilitation-based “in vivo” intervention is being developed to support consumers with cognitive disabilities. We are implementing activity recognition using video and sensors to monitor specific work behaviors and, ultimately, to deliver cues and instruction in response to problem behaviors. The system is trained using live video of a given task being performed.  A model is then developed to automatically recognize components of the task (or errors) during real time task performance and provide task guidance feedback to a client as needed via headphone. Based upon a series of focus groups, we identified food preparation as an appropriate application for this technology, with grilling hamburgers in a fast food setting as an initial application. In institutional settings this task requires a long series of actions that must be performed in sequence to create a high quality product. Results of video captured and analyzed by a machine learning technique used to automatically identify features in the person’s movement patterns by which the system could automatically recognize components of the task (e.g. flipping, salting, placing on or taking burgers off the grill) indicated that none of the complex movements were mislabeled and a set of common errors were identified and labeled. Thus, our initial work has yielded a model that is able to correctly identify component tasks for a single subject. We have also developed a user interface that is able to utilize logged data to recognize and deliver task guidance cues remotely to the user in real time. Next steps include broadening the subject base, developing technology to create a portable system using off-the-shelf video cameras rather than motion capture cameras, and developing an interface to share a summary of the data (e.g. success rate, types of errors) with a job coach or other support person.

343
Autonomous Medical Resupply and Evacuation Collaborative System
Christian Hans Debrunner, PhD           
PercepTek, Inc., Littleton, CO
86% of all battlefield deaths occur within the first 30 minutes after injury. Therefore immediate treatment to stabilize a patient and rapid evacuation of the patient from the point of injury to a treatment facility is critical to saving lives. Unmanned rotorcraft carrying a patient Life Support for Trauma and Transport litter have the potential for rapid recovery and evacuation of wounded personnel without placing a rescue pilot at risk. However, several challenges remain: the unmanned rotorcraft must operate safely within controlled airspace while avoiding tactical no-fly zones and other aircraft in its vicinity; the unmanned rotorcraft must select a landing site and land safely at unimproved locations in urban and wooded environments and in the presence of untrained personnel; and a combat medic operating in a forward position must interact with and control the rotorcraft without significant specialized training and with minimal impact on their medical activities. PercepTek's Autonomous Medical Resupply and Evacuation Collaborative System (AMRECS) system addresses these issues and will enable autonomous re-supply and evacuation. AMRECS is being built upon the capabilities of Boeing's Unmanned Little Bird, which has demonstrated waypoint-based takeoff, landing, and navigation. This project focuses on the sensing and planning capabilities needed to provide the appropriate waypoints. AMRECS uses LADAR for mapping the ground for landing site selection, and visual imaging for obstacle detection, tracking, and avoidance. Earlier PercepTek projects have developed route planning capabilities that allow it to navigate autonomously from a staging area to the location of the casualty, and finally to a medical treatment facility.  Initial experiments show that landing sites can be reliably identified and that moving people can be reliably detected and tracked using the proposed sensors.  This presentation will present the AMRECS concept, as well as an overview of experimental results establishing the feasibility of the approach.

85
Telehealth as a tool to empower patients and informal caregivers
Debra Parker Oliver, PhD, MSW,1  George Demiris, PhD,2  Elaine Wittenberg-Lyles, PhD,3  Karla Washington, MSW, LCSW,1 Michele Day, MSW1    
1University of Missouri, Columbia, MO; 2University of Washington, Seattle, WA; 3University of North Texas, Denton, TX
Informal caregivers play an essential role to the delivery of hospice services. This caregiving experience, however, is not without adverse effects on caregivers themselves.  A usability study with 12 seniors and focus group sessions with 14 hospice providers indicated that videophones are easy to use and can enhance hospice services. As a follow up, a pilot study was conducted with 12 caregivers and their patients of two hospice agencies. Subjects received a videophone that was installed in their home. The study demonstrated the feasibility of a videophone based intervention and indicated its potential on reducing caregiver anxiety. In the current phase of the Telehospice Project we use commercially available POTS-based videophones as tools that allow patients and caregivers to "virtually" participate in hospice interdisciplinary team (IDT) meetings. This application enables patients and their caregivers to be actively involved in the discussions and decision making. Telehealth is used in this context to empower informal caregivers and support shared decision making. IDT meetings where patients and caregivers participate “virtually” and IDT meetings without patient and caregiver involvement are video-taped and transcribed for analysis and comparison.  Preliminary findings of 81 taped IDT case discussions without patient involvement and 45 IDT case discussions with virtual participation of patients and caregivers indicate that the patient and caregiver participation changes the nature of these meetings, improves their overall efficiency and improves discussions about pain management.

325
No-Show rate for TMH compared to Face-to-Face Mental Health
John Chardos, MD,1,3  Zia Agha, MD, MS,2,3  Jim Fiedler1        
1VAMC San Diego, San Diego, CA; 2VAMC San Diego HSR&D, San Diego, CA; 3University of California San Diego, San Diego, CA
INTRODUCTION: Nonattendance for appointments has a significant impact on both patient care and productivity. The use of video teleconferencing to provide telemental health (TMH) in place of face-to-face (FTF) visits is often met with reluctance by the patient, and this may lead to a higher no-show rate. We compared the appointment no-show (NS) rate for TMH clinic and FTF clinics at the VA San Diego. The VA San Diego Telemedicine program consists of a hub site in La Jolla and 3 remote clinics, each located roughly 30 miles from La Jolla.  The FTF clinics are located in La Jolla, CA.  We defined the NS rate as appointments that were missed and not cancelled prior to the appointment. We collected data for 6 providers (3 psychiatrists, 2 pharmacists, and 1 nurse practitioner) who performed both TMH and  FTF visits over a 13 month period. RESULTS: From July 1, 2006 to July 31, 2007, 6 providers performed 511 TMH and 2617 FTF patient visits. The NS rate for all TMH visits was 15.0% while the NS for all FTF visits was 16.1% (p value not significant). CONCLUSION: This study data implies that TMH and  FTF visits have similar NS rates. This finding points towards patient preference and acceptability of telemedicine. Whether  NS rates for certain patient populations would improve after starting TMH due to easier access to mental health care needs exploration.

452
Rural Pediatric Critical Care Telemedicine: SummAry of the Vermont Experience
Barry Heath, MD,1 Richard Salerno, MD,1 Amelia Hopkins, MD,1 Michael Caputo, MS2
1Division of Inpatient and Critical Pediatrics, Department of Pediatrics, University of Vermont College of Medicine and Vermont Children’s Hospital at Fletcher Allen Health Care, Burlington, VT; 2Central Information Technology Services, Washington University in St. Louis School of Medicine, St. Louis, MO
Introduction: A disparity in access to health care exists between rural and urban areas.  In an attempt to address this, we initiated a program of pediatric critical care telemedicine in rural underserved emergency departments.  Methods: We performed a prospective analysis of pediatric critical care consultations between March 2006 and July 2007 in 10 rural hospital emergency departments in Vermont and upstate New York. Results: 44 consultations were performed in 10 rural emergency departments.  The average number of consultations was 4.4 (range 1-12).   Minor technical issues were identified in 9 consultations (20%).  There were 16 primary diagnoses.  Telemedicine was used to supervise the critical care transport team on 36 occasions (81%).  Consulting intensivists made a total of 159 recommendations and found that telemedicine consultations improved patient care 86% of the time; were superior to telephone consultations 89% of the time; and provided good to very-good provider-to-provider communications 93% of the time.  Referring providers found that telemedicine consultations improved patient care 89% of the time; were superior to telephone consultations 57% of the time; and provided good to very-good communications 100% of the time. Conclusions: It is feasible to provide urgent subspecialty critical care for children in underserved rural emergency departments with a high degree of provider satisfaction.  Pediatric critical care telemedicine may help to address the disparities in distribution of pediatric critical care subspecialists in rural areas.

206
Guidelines for addressing Human Factors in Telecare Solutions
Steve J. Brown, BSc (Hons),1  Bruno von Niman, MSc,2  Torbjørn Sund, PhD,3  Alejandro Rodríguez-Ascaso, PhD4     
1British Telecom Research & Development, Ipswich, United Kingdom; 2Vonniman Consulting, Stockholm, Sweden; 3Telenor ASA, Fornebu, Norway; 4UNED, Madrid, Spain
Evidence suggests that the unsatisfactory or negative experiences end users often have when interacting with telecare systems are preventing those systems from becoming mainstream alternatives to nursing homes or sheltered housing. In order for telecare to break through this barrier, we believe it is necessary for stakeholders involved in the development, manufacture and service provision of telecare services to improve the end user experience by properly addressing the associated human factors issues. Since the beginning of 2006, a team of European Telecommunication Standards Institute (ETSI) experts have been developing a set of guidelines to be used by telecare stakeholders. The guidelines are designed to advise stakeholders of what they should do to ensure that human factors issues are adequately addressed. The guideline document (ETSI Guide EG 202 487) will be published and made freely available by December 2007/January 2008, and addresses three main themes: trust, user interaction and service aspects. Within these themes all of the major issues relating to human factors are addressed (e.g. security, privacy ethics, usability etc.). The guideline document has been structured in a user-friendly way, with short, easy to read guidelines aimed at either telecare service/equipment developers, service providers or both. Industry response to early drafts of the document has been positive.

393
Wireless Techniques for Expert Remote Management of Acute Cardiac Events
Max E. Stachura, MD,  Elena V. Khasanshina, MD, PhD,  Guy L. Reed, MD       
Medical College of Georgia, Augusta, GA
Acute myocardial infarction is a public health priority, especially in rural communities with limited access to rapid intervention.  Although early, appropriate lytic therapy can improve patient outcomes, logistical challenges exist, including geographic distance from patient to cardiologist, and first responder need to quickly capture and transmit accurate and reliable data for specialist evaluation.
Time to treatment initiation could be shortened by linking patients and mobile cardiologists through first responders.  With advanced wireless interfaces and 12-lead electrocardiogram (ECG) capability, required information could be captured and transmitted, enabling correct decision-making within limited-time treatment windows. The potential for appropriate lytic intervention outside hospital settings depends on both the quality and transmissibility of field ECGs.  Several currently available FDA-approved portable devices can capture and transmit tracings to hospital computers.  However, the ability to send readable ECGs directly to a fully mobile handheld device could dramatically reduce time to patient assessment.
We defined three challenges: (1) First responder capture of digitized ECGs without restriction to field location, (2) Diagnostically lossless ECG transmission to cardiologists over commercial wireless networks, and (3) ECG access by mobile specialists using wireless hand-held multi-purpose devices whose displays have the clarity and resolution required for diagnostic interpretation, are easy to use, and comfortably portable. Initial work on Challenge 1 explored how forgiving of first responder lead placement are portable ECG capture devices.  We examined first responder lead placement latitude before transmitted data risk diagnostic errors by comparing ECG data obtained after proper lead placement with data obtained using controlled lead placement deviations. In Challenge 3 we focus on validating diagnostic clarity of 12-lead ECG images displayed on devices carried by the cardiologist, as well as on ease with which devices are used.  Issues include, but are not limited to device size, screen size, screen resolution, device multi-functionality, and navigational ease.

241
Telementoring in Ophthalmology: Using IP technologies to enhance training in biomicroscopic corneal assessment
Giselle Ricur, MD,  Gabriela Batiz, IT Eng,  Adriana C. Lotfi, MD,  Andres Valdivia, Hugo Micarelli    
Instituto Zaldivar, Mendoza, Argentina
Introduction:  This presentation reports on the use of new applications over IP that have impacted on the way our physicians train and communicate with each other regardless of their geographical location. In order to facilitate instant communication (audio-video) between the attending (trainees) and consulting physicians (mentors) at the different Institutional sites, the use of slit-lamps with video network cameras and digital cameras attached, remote computer access software (RCAS) and computer video conferencing software with USB cameras was implemented.  Description:  Conventional slit lamps were fitted with dynamic IP video cameras and 10Mpx digital cameras, and both the MPEG-4 and still images captured were projected onto the PC’s screen. The RCAS enabled trainees and mentors to have complete control of the PCs involved and observe the videos or images, regardless of their location. Trainees were telementored in corneal assessment by means of the video images captured with the modified slit-lamps, while the transfer of still images was designed to ensure diagnostic accuracy. Videoconferencing capability was assured by computer video conferencing software and standard USB cameras. Therefore, real-time discussions between users could take place on-demand at each one’s desktop, with conference room performance, avoiding unnecessary patient or physician transfer between rooms, floors or buildings. Conclusions:  These applications have empowered our continuous medical educational programs and the fact that these tools run over IP has also helped bring down the operational costs of training the new medical staff at the different sites. Therefore, they have enabled us to continue providing high quality eye care services for our patients, regardless of the geographic or time barriers.

144
Remotely-Operated Robotic HIFU Cauterization System For Battlefield Trauma Care
Ralf Seip, PhD,1 Narendra T Sanghvi, MS,1  Artur Katny, BS,1 Wohsing Chen, PhD,1 Clint Weis, BS,1 Stephen P Buerger, PhD,2 Clint Hobart, BS,2 Kris Dines, PhD,3 Ronald Marchessault, MBA4
1Focus Surgery, Inc., Indianapolis, IN; 2Sandia National Laboratories, Albuquerque, NM; 3XDATA Corporation, Indianapolis, IN; 4 US Army Medical Research and Materiel Command, Telemedicine & Advanced Research Center (TATRC), Fort Detrick, MD;
The design for a remotely-operated robotic high-intensity focused ultrasound (HIFU) system for vessel cauterization in battlefield trauma care and disaster response was presented last year at this conference. It is to be compatible with the US Army’s Critical Systems for Trauma and Transport (CSTAT) initiative, and consists of a robotic manipulator, a HIFU and ultrasound imaging applicator, and a cauterization planning and control strategy. A prototype is currently being constructed with key components of the system that have already been implemented. These include: a custom annular HIFU array operating at 2.2 MHz (capable of generating intensities exceeding 1000 W/cm2 from the tissue surface to a depth of 75 mm), a 8-5 MHz Doppler-capable curved imaging array for laceration detection and cauterization monitoring, a backdriveable manipulator arm for transducer positioning, patient registration hardware, and remote operation capability. Current efforts are focusing on system and hardware/software integration and phantom evaluation activities, as part of an ongoing Phase II effort. Implementation details for the HIFU and imaging applicator, robotic manipulation, remote operation, user interface, and cauterization strategy will be presented. Design challenges, including the power budget, applicator/patient registration, system weight and transportability, and operation within a battlefield framework will also be described. Other than its currently intended battlefield trauma care application, the developed technology has great potential to also be used within an operating room or in a first-responder setting due to its non-invasive applications and remote operation capabilities.

354
The Diffusion of Rurally-Based American Indian Telemental Health Clinics
Elizabeth Brooks, MS,  Jay H. Shore, MD, MPH,  Spero Manson, PhD       
Univerisity of Colorado at Denver and Health Sciences Center, Aurora, CO
American Indians who live on rural, reservation communities suffer from high rates of mental health problems, such as Posttraumatic Stress Disorder (PTSD) and co-morbid substance abuse, compared to their non-Native counterparts; yet, help-seeking behavior for these problems has been relatively low.  A primary reason for this is due to the lack of specialized mental health services on and near reservations.  To address the need for care, the American Indian and Alaska Native Programs (at the University of Colorado at Denver and Health Sciences Center) established a series of telemental health clinics to provide PTSD treatment to American Indian veterans.  The goal of this study was to understand the diffusion and adoption of these telemental health clinics, as well as the implications for treating American Indian veterans.  Data for this research project was obtained by conducting semi-structured interviews with over 40 key players involved in the creation and operation of the telemental health PTSD clinics.   The data was analyzed using both qualitative and quantitative research methodology.   The results will be used to examine factors that impeded and facilitated the diffusion and adoption of telemental health within and between tribal, state, and federal organizations.   This presentation will discuss how the data informs research strategies regarding cultural issues and outcomes related to telemental health services.   Finally, the next steps in this process will be discussed, including the implications for developing telemental health programs and policies among American Indians specifically, and among rural populations in general.  This information helps to address critical gaps in our understanding of the diffusion of technology-based, innovative mental health practices.  

340
Can Telemedicine Be Integrated in the Primary Care Medical Home?
Neil E. Herendeen, MD, MBA,  Kenneth McConnochie, MD, MPH         
Universtiy of Rochester Medical Center, Rochester, NY
Background/Objectives: A child s acute illness accounts for > 50% of primary care pediatrician (PCP) office visits and 40% of work absence for parents using childcare. Families find the convenient access of retail-based clinics (RBCs) compelling, but RBCs threaten continuity of care.  Telemedicine (TM) in childcare provides easy access yet preserves potential for continuity.  Acceptance and integration of TM in PCP offices requires scope and quality of care that enables clinician confidence in medical decisions. From its inception in May 2001, the Health-e-Access Telemedicine Network (HeA) has enabled 4239 telemedicine visits from 5 childcare centers in Rochester s (NY) inner city. A 63% reduction in absence due to illness followed introduction of TM in these centers.   We assessed hypotheses that using HeA (1) high levels of continuity with PCP would be achieved and (2) clinicians would complete >85% of visits. Design/Methods: 18-month descriptive study of feasibility and acceptability of HeA visits beginning May 2005 when new funding enabled expansion to 5 urban and 5 suburban PCP offices,.  The HeA model uses both real-time videoconference and store-and-forward information exchange.  Childcare staff trained as telehealth assistants digitized clinical observations for examination by remote-site physicians.  Ear, eye, mouth, throat and skin images were captured with an all-purpose camera, and lung sounds were captured with an electronic stethoscope.  Visit completion criteria were diagnosis decisions and treatment without subsequent, in-person evaluation.  Results: Among 1530 TM visits attempted, 1474 (96.3%) were completed by 43 different clinicians. The 587 participating children averaged 182 TM visits/100 children/yr. TM visits the PCP was unable to accommodate were seen by a default clinician. Continuity averaged 86.5% (range 50% - 93%) among the 10 PCP offices.  Conclusions: HeA can be integrated in practices serving urban children, enabling exceptional access, completion of almost all illness visits and, unlike RBCs, continuity of care.

56
Is fear of the "India price" for teleradiology justified?
Thomas R. McLean, MD, JD,1,2  Patrick B. McLean1         
1Third Millennium Consultants, LLC, Shawnee, KS; 2Eastern Kansas VA Health Care Service, Leavenworth, KS
Background: In the global market, Indian teleradiology providers have an absolute price advantage. This advantage raises fear of the “India price” for teleradiology; a price analogous to the “China price” in manufacturing. Various American medical societies are now seeking protective legislation; which would deny patients the lowest price for health care. Issue: Is fear of the India price in teleradiology justified when international trade is driven by comparative advantage and not absolute price advantage? Methods: Ricadian and Heckscher-Ohlin (H-O) analysis of international trade-in-teleradiology.  Results: Ricardian theory states that comparative advantage is determined by opportunity costs; and that a country with the lowest opportunity costs will export to countries with a higher opportunity costs. Teleradiology opportunity costs are those expenses associated with decreased access to radiology services in the domestic market. India’s opportunity costs are expected to progressive increase as: (1) knowledge of available health care diffuses into the country; (2) 700,000 rural Indians demand better health care; and (3) all Indians see their out-of-pocket health care expense increase because only 10% of Indians have medical insurance. H-O theory states that a country that produces services from factors it has in relative abundance will have a comparative advantage over its trading partner. Teleradiology is produced from technology, physician labor, and language skills. Only one-third of Indian physicians have some English-languages skills. Compared to the United States, on a per capita basis, India has one-twelfth the number of English-speaking physicians. Indeed, it has been estimated that as few as 15 radiologists do all of India’s exporting to the United States. Conclusions: (1) The United States’ health care market should not live in fear of the India price for teleradiology services; and (2) because consumer can benefit from lower prices governmental agencies should balance the benefits of provider protectionism against consumer interests. 

327
"Who Moved My Telehealth Scheduling Application?": Managing Large-scale Software Adoption
Simon Cheesman, MA           
Ontario Telemedicine Network, Toronto, Canada
The Ontario Telemedicine Network encompasses hundreds of organizations spread over thousands of miles, carrying out tens-of-thousands of telehealth consults each year. OTN relies on the efficient scheduling of these clinical encounters, educational events and administrative meetings to sustain the scale of its operations, as well as the rapid growth it continues to experience. OTN recently deployed an online, self-service scheduling application to hundreds of users to establish a unified scheduling regime across the province. OTN was formed from the merger of three independent videoconference-based telemedicine networks, each with its own well-established procedures, tools, culture and customers. The need to move to a single scheduling framework (one online tool, one set of rules, one set of definitions) was obvious, but would require our members and partners to change – in many cases, dramatically – the way they carried out their work. Faced with existing scheduling practices that ranged from completely autonomous to entirely centralized, from all electronic to exclusively pencil-and-paper, OTN opted for a scheduling tool that would accommodate a mix of self and assisted scheduling services, allowing for a hybrid centralized/decentralized service model. This tool – based on an existing custom software application – was developed over the course of 2006, and went live in 2007. During this and last year, OTN has been moving local coordinators onto the new scheduling tool and into one of several defined channels for scheduling, initiating and monitoring telehealth activity. This paper will review the scope and design of the technical solution and the strategies and resources brought to bear on its successful deployment and adoption. The results of this exercise in change management have profoundly altered, expanded and improved the organization's capacity to enable telehealth services in terms of both scale and scope.

399
Evaluating The Evidence Base For Home Telehealth And Remote Monitoring
Stuti Dang, MD,1  Susan L. Dimmick, PhD,2 Rita F. Kobb, MN, GNP-BC3
1University of Miami Miller School of Medicine, Miami, FL; 2University of Tennessee Health Science Center, Memphis, TN; 3Sunshine Training Center, VHA Care Coordination Services, Lake City, FL
Introduction: Home telehealth and remote monitoring (HTRM) has been shown to facilitate both patient education and the effective self-management of specific diseases and can potentially decrease the economic burden of chronic diseases. Three major chronic diseases are responsible for disproportionately high health-care costs in the elderly population: congestive heart failure (CHF), diabetes mellitus (DM), and chronic obstructive pulmonary disease (COPD).Objective: To review the best evidence for HTRM interventions in the management of DM, COPD, and CHF. Evidence: Systematic literature review of all English-language articles, retrieved using a keyword search of MEDLINE (1966 through May 2007), EMBASE, Cochrane Collaboration, and the National Institutes of Health Clinical Trials Database, and followed by manual searches of reference lists of selected major review articles. All English-language randomized controlled trials with more than 100 subjects were included. Results: The results of the use of HTRM for DM, CHF, and COPD will be discussed based on the literature review. There are several questions that need to be answered. Which chronic disease population benefits most from remote monitoring? Is it possible to quantify the additional benefit of technology over and above care coordination, which usually forms a major component of the HTRM programs? In terms of utilization benefit, it is difficult to quantify the relative values attributable to care coordination and to technology. Which technology attributes are most useful and cost effective for each specific disease in each different setting? What are the relative contributions of interpersonal contact versus the technological components of the HTRM model? Since resources are limited, future larger and more carefully designed randomized controlled trials with longer observation periods are needed to determine cost- efficiency and efficacy.

347
Distance Monitoring in Heart Failure Management: what’s in the horizon?
Krishnaswami Vijayaraghavan, MD, MS, FACP, FACC,1,2  Nancy Wood, MS, RN,1  Leslie Barnet-Avery, PA-C,2  Sue Eike, RN2     
1Scottsdale Cardiovascular Research Institute and Heart Failure Center, Scottsdale, AZ; 2Scottsdale Cardiovascular Center, Scottsdale, AZ
Congestive Heart Failure (CHF) is a complex syndrome associated with high rates of hospitalization, poor quality of life, increasing mortality and an exponential rise in economic burden. The reasons for worsening mortality and morbidity range from underutilization of lifesaving therapies, lack of knowledge base of patients and physicians, noncompliance, lack of physical activity, inadequate monitoring of physiological parameters, and lack of coordination between patient care coordinators and clinical decision makers. Attempts have been made to bridge this “quality chasm” utilizing disease management strategies. Multidisciplinary approach, optimizing discharge medications, frequent telephone follow ups, clinic visits, and home visits have shown variable outcomes. Automated telemonitoring that allows collection of biometrics and transmission to a server reviewed by a healthcare provider and intervened may improve their symptoms. In CHF patients who receive an Implantable Cardioverter Defibrillator or Cardiac Resynchronization Therapy, the ability to monitor fluid status  provides additional insight into management of these patients. Intrathoracic impedance monitoring is a new, device-based method for detecting fluid accumulation in the lungs. OptiVol fluid status monitoring feature (Medtronic, Inc) uses impedance data obtained by  interrogation of the device in an office setting or in patient’s home and transmitted via a standard telephone line to a password-protected Web site where it can be reviewed by a clinician for intervention. Noninvasive impedance cardiography that measures cardiac hemodynamics from a distance will add value in earlier detection of decompensation.  Beyond body weight and blood pressure, parameters such as Thoracic fluid content, Stroke volume , Systemic vascular resistance and systolic time ratio will help in predicting decompensation 14 days in advance of hospitalization. Distance monitoring of these parameters  with alert signals can lead to interventions that may prevent hospital readmissions  with positive impact on economic outcomes. Prospective, randomized trials are underway to evaluate their clinical utility.

403
Telemedicine Diabetic Retinopathy Assessment in a Remote Underserved Population
Ingrid E. Zimmer-Galler, MD,1  James Handa, MD,1  Mark Wieland, MD,2  Victor Yano, MD, Minister of Health,3 Kevin Quinn, BS,4 Ran Zeimer, PhD1   
1Johns Hopkins Wilmer Eye Institute, Baltimore, MD; 2Retina-Vitreous Associates, San Mateo, CA; 3Belau National Hospital, Koror, Palau; 4EyeTel Imaging, Inc., Columbia, MD
Introduction:  The Pacific island nation of Palau has a population of approximately 20,000.  As a more western life-style is being adopted, the incidence of diabetes is rising at an alarming rate.  Health care services are limited and there are no retina specialists in Palau to treat the complications of diabetic retinopathy.  Methods:  Two retina specialists (JH, MW) travel from the United States to Palau for several weeks each year to provide humanitarian eye care including laser and surgical treatment of retinal diseases.  A telemedicine program has been implemented to assess patients remotely to identify those patients who will most benefit from intervention by the visiting retina specialists.   The program utilizes an easy to operate automated retinal camera, the DigiScope, to image patients with diabetes.  Images are obtained throughout the year by local health care providers.  The images are reviewed at a reading center in the United States to identify patients requiring treatment.  This allows optimal triage of patients throughout the year.  Efforts can then be focused on patients who will most benefit from intervention when the retina specialists return annually to Palau.  Results:  The retinal camera was implemented in Palau in January 2007 and is being used to image patients with diabetes.  To date, 39 patients have been imaged.  Six patients were identified as requiring intervention (5 with diabetic macular edema and 1 with a macular hole).  An additional 10 patients were noted to have mild to moderate nonproliferative diabetic retinopathy and will be re-imaged in one year.  Images from 7 patients were ungradeable. Conclusions:  A telemedicine program has been successfully implemented in the remote island nation of Palau.  Patients requiring specialist care can be identified remotely to maximize the limited time of retinal specialists during a brief annual visit to Palau.

134
Real-Time Patient Vital Sign Data Collection Network For Trauma Care
Peter F. Hu, MS, CNE,1,3,5 Colin Mackenzie, MD,2,3  Richard P. Dutton, MD,1,3,5 Grant Bochicchio, MD,1,4 Kelly Bochicchio, RN, MS,1,4 Yan Xiao, PhD,1,3 John Spearman, MBA,5 Thomas Scalea, MD1,2,4,5 
1Program in Trauma, University of Maryland School of Medicine, Baltimore, MD; 2National Study Center for Trauma and EMS, Baltimore, MD; 3Department of Anesthesiology, University of Maryland, Baltimore, MD; 4Department of Surgery, University of Maryland School of Medicine, Baltimore, MD; 5R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD
Introduction:  There is a lack of detailed physiological data on trauma victims during pre-hospital (field) and in-hospital management. We designed a continuous vital signs data collection (VSDC) network to gather real-time patient vital-signs data from the field and from the patient’s bed-side. Methods: After IRB approval, we developed a PDA-based VSDC system that captures real-time patient vital signs from the Propaq-Encore206EL monitor. The VSDC system allows capture of life saving interventions (LSI) by medics during patient assessment and transport. After patient arrival at the trauma center, an in-hospital VSDC system continues collecting patient VS from the GE-Marquette-Solar-7000/8000 monitors during the patient’s Trauma Resuscitation Unit stay.  The VSDC system collects over 80-VS variables including both waveform (ECG/SpO2/CO2/Respiration) and numerical (HR/SpO2/NIBP/Temp/etc.) data. Collected data sets are stored on a secure server along with study patient outcome data obtained from the trauma registry and medical records. Results: During two and a half months of VSDC operation, we collected 127 field transfer cases from two-medevac helicopters and one-ambulance. The pre-hospital VSDC system captured waveforms at 181Hz (ECG) or 90Hz (SpO2/ETCO2) and numerical data every second. The in-hospital VSDC captured waveforms at 240Hz and numerical data every 6 seconds. The average pre-hospital VS data collection duration was 27.1 min (std-dev +/-9.17 min) with data file size of 1.28MB (std-dev +/-0.44MB). In-hospital VS data collection result in average of 76.4 KB/hour for numerical and 12.3MB/hour for waveforms. Discussion:  The real-time continuous VSDC system for both pre- and in-hospital VS data collection provides a unique opportunity for understanding what occurs in the field, including the relationship between LSI’s, real-time vital signs, and outcomes. Decision support algorithms based on the captured data may improve pre-hospital care, while the ability to capture this data in real-time will facilitate medical consultation and telemedicine applications.  Supported by DoD-TATRC#W81XWH-05-0374, SBIR-W81XWH-06-C-0034

266
Resident Telepsychiatry Training Service: Improve Care for Rural Veterans
Jay H. Shore, MD, MPH,1,2  Michael Thurman, MD,1,2  Herbert Nagamoto, MD1,2       
1University of Colorado at Denver and Health Sciences Center, Aurora, CO; 2Denver Veterans Affairs Medical Center, Denver, CO
Veterans living in rural areas often face significant barriers to receiving mental health care.  These barriers include not only geographic distance but a scarcity of available psychiatrists in rural locations with expertise in veterans’ mental health issues.  This is particularly salient for OIF/OEF veterans given their high rates of mental health conditions and disproportionately rural backgrounds. To address these concerns, the Denver Veterans Affairs Medical Center (DVAMC) created a psychiatric resident telepsychiatry training service in 2003.  The service has three major goals:  1) To improve access for rural Colorado veterans to mental health care; 2) To train psychiatric residents in the use of telepsychiatry and sensitize them to work with veteran populations from rural areas; and 3) To increase recruitment of psychiatrists into the VA system with interest and expertise in using telepsychiatry to provide care to this population.  Data will be presented from 4 years (2003-2007) of clinic operations including number of patients served, types of diagnoses seen, care provided, number of residents trained, and recruitment rate of trained residents into the VA system.  Additionally the service development, implementation, organizational structure and the formal and informal training received by the residents about telepsychiatry and rural populations will be described.  The DVAMC resident telepsychiatry service illustrates several important lessons for improving the mental health care for rural veterans including: 1) Exposure to a training service is critical in helping residents develop skills in telepsychiatry and psychiatric treatment of rural populations; 2) A resident telepsychiatry service can increase recruitment into the VA of psychiatrist with both the skills and interest to provide telepsychiatric care to rural veterans; and 3) In addition to the products of a telepsychiatric training service, the service itself improves both access to and quality of care available for rural veterans.

295
Impact of Pediatric Telemedicine Consultations on Diagnostic and Therapeutic Outcomes
James P. Marcin, MD, MPH,1,2  Madan Dharmar, MBBS,1  Nathan Kuppermann, MD, MPH,1,3  Emily Andrada, MD,1,3 Candace Sadorra,1,2 Stacey Cole,2 Patrick Romano, MD, MPH1  
1Department of Pediatrics, University of California, Sacramento, CA; 2Center for Health and Technology, University of California, Sacramento, CA; 3Department of Emergency Medicine, University of California, Sacramento, CA
Introduction - Hypothesis:  The standard means of assisting rural Emergency Departments (EDs) in the care of critically ill children is by telephone consultation.  However, advice can be limited by the fact that the consulting specialist is unable to see the patient and/or talk to the parents.  The goal of this study was to compare the frequency of change in medical diagnostic and therapeutic advise and the quality of care provided to acutely ill and injured children presenting to rural EDs to the same measures (using implicit review) in matched controlled EDs.  Our hypothesis was that telemedicine consultations would result in more frequent changes in diagnostic and therapeutic advice, and result in higher measures of quality of care compared to telephone consultations or no consultations (non-telemedicine consultation). Results:  In patients who had received telemedicine consultations (N=47), the consulting physician making more changes to the medical diagnostic studies (51.3% vs 7.7%; p-value = 0.02) and therapeutic advise (40.5% vs 14.3%; p-value = 0.08).  Physician plan for disposition and follow-up and overall quality of care (measured on a 7 point Likert scale) were higher (6.02, 5.38, respectively) than for non-telemedicine consultations (5.74, 5.28, respectively).  Conclusion:  When telemedicine is used to provide critical care consultations to acutely ill and injured children in rural EDs, telemedicine consultations resulted in more changes in the diagnostic and therapeutic advise and also better quality of care scores for the care plan and patient follow-up, as well as the overall quality of care. Pediatric telemedicine consultations provided to rural EDs may improve the quality and satisfaction of care provided to acutely ill and injured children.

451
Telemedicine After Dark: A $1 Billion Business
Howard Reis, MBA
Imaging On Call, LLC, Poughkeepsie, NY
One form of Telemedicine has evolved into a profitable successful business model.  Teleradiology is in fact a $1 Billion business and is growing at an exponential rate. Hypothesis:  The business of Teleradiology is here to stay and will grow from a sub-specialty into a main line practice which will provide a model for future profitable telemedicine businesses. Results: The primary business for Teleradiology providers is the provision of preliminary reads of radiological images for domestic U.S. based hospitals in an after-hours environment.   Here’s a quick look at the numbers for basic after-hour radiology reading:

Teleradiology providers have found several additional sources of revenue to significantly increase this fundamental line of business. There is one publicly traded teleradiology company, Nighthawk Radiology which estimated to have a 25% market share. Nighthawk reported $92 Million in revenue in 2006.  In 2007 acquired The Radlinx Group and has raised its guidance for full year revenue to be over $150 Million.   To address the business of teleradiology, the following questions need to be asked and answered.

• Basic business model for hospitals and radiology groups
• Technology and necessary business processes
• Quality of service
• Barriers to entry
• Reimbursement
• Life-style challenges
• Off-shore implications
• Additional Revenue Opportunities

Conclusions: Teleradiology is an existing, accepted component of the health care industry and will only continue to grow into yet unforeseen areas.  The profitable commercial teleradiology companies will lead the way for other medical specialties using similar technology.

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A Database for Managing Telemedicine Activities
Richard C. Evans           
Utah Telehealth Network, Salt Lake City, UT
Like most organizations, the Utah Telehealth Network (UTN) started small.  With few rural clinics and hospitals, support of the network was simple and straightforward.  As UTN grew, it began to develop challenges in supporting its own growth and operations.  These challenges included coordinating and centralizing information, managing inventory, maintaining an accurate map of its network, and being able to easily glean accurate quantitative data about its operations.  In addition, creating and maintaining a schedule for using UTN resources, especially video teleconferencing, became onerous. To meet these challenges, UTN determined that a centralized database was required to automate its business processes and information. The database’s goals include:

• a scheduling system for telemedicine providers
• daily conference setup reports that include meeting participants, contact info, and configurations
• automated telemedicine utilization reports
• business accounting and equipment maintenance history
• a database of all contacts, equipment, and relationships

These goals needed to be met with the condition that people would still be involved in the decision-making process of resource allocation and that the solutions was both maintainable and extendable to meet future needs. To that end, the database is built so that a telemedicine provider may adapt it for its own business purposes. Customization is easy. The presentation will highlight the functions of the database, especially the videoconferencing scheduling system. At the end of the presentation, UTN will announce the database’s open source availability to all telemedicine providers. An FTP Site with a copy of the Database, User and Technical documentation will be provided, free of charge.

312
Prevalence of EKG Brugada pattern: experience in Chile
Edgardo Escobar, MD,  Patricia Adriazola, MD,  Francesca Bello, MD,  Mirta Orellana, MD, Pamela Trejo, MD    
ITMS, Telemedicina de Chile, Santiago, Chile
Tele-electrocardiography system in Chile was initiated in 2004. Tracings, are received by telephonic trasmision from all over the country including rural areas and Eastern Island.Analysis of tracings is made with a computarized system. Until Sept ,007 we have a data base of 402947 tracings,permitting us to approach the prevalence of different EKG patterns. For this presentation we have analyzed the prevalence of Brugada´s pattern to alert chilean physicians about its importance as a potential cause of severe arrhytmias and/or sudden death. Out of the total we selected at random 122000 tracings. Incomplete right bundle branch block(iRBBB) was present in 5.9% of the tracings. Brugada pattern was observed in 6.4% of the iRBBB, and 0.37% of the total tracings. Type 1 was 12.4% of the Brugada patterns and type 2 the 87.6%. Brugada pattern was prevalent in men and average age was below 50 years in both groups,coincident with data of other populations. In conclusion, Brugada pattern is not infrequent in Chilean population, and follow up of these patients and their families is important to prevent sudden deaths.   

242
Integration of Ocular Telemedicine in an Asian American Diabetes Program
William Hsu, MD,  Sophia Cheung, MS, RD,  Nancy Hong, MS,  Ann Marie Tolson, BA, Taniya Francis, BA, Sharon Eagan, OD, Jerry Cavallerano, OD, PhD, Joslin Vision Network Clinical Team 
Joslin Diabetes Center, Boston, MA
Introduction: The Joslin Vision Network (JVN) Diabetes Eye Care Telemedicine Program was introduced in Joslin’s Asian Clinic, which provides culturally oriented diabetes care and education with emphasis on needs of Asian Americans with diabetes.  Linguistically appropriate programs are designed to enhance quality of life and health outcomes for Asian Americans with diabetes.  The Joslin Asian Clinic provides appointments with physicians, dietitians and diabetes educators who are culturally sensitive to Asian Americans.  A care coordinator schedules appointments, handles prescriptions and is a liaison for patients with Joslin Clinic; providers and coordinators speak Chinese (Cantonese and Mandarin), Vietnamese and Hindi. Results: Of the 89 patients imaged to date, 47 (52.8%) were women; age ranged from 27-85 years (mean 59.0, median 59.0).  Duration of diabetes ranged from newly diagnosed to 28 years (mean 9.3; median 7.5).  One patient (1.1%) had type 1 diabetes, 83 (93.3%) had type 2 diabetes, 1 had gestational diabetes (1.1%) and 4 (4.5%) had impaired fasting glucose; 33 patients (37%) reported no eye examination within the past 12 months. Gylcosylated hemoglobin A1C ranged from 5.0%-15.1% (mean 7.5%, median 7.1%) and body mass index ranged from 16.99-37.27 (mean 25.2, median 24.2). Of the 89 patients imaged, 21 (23.6%) were ungradable for level of diabetic retinopathy (DR).  Of the 68 patients with gradable images, in the worse eye 52 (76.5%) had no DR, 11 (16.2%) had mild nonproliferative DR (NPDR), 3 (4.4%) had moderate NPDR, 1 (1.5%) had severe NPDR, and 1 (1.5%) had proliferative DR. Conclusions: Retinal evaluation using the JVN expanded eye care in Joslin’s Asian Clinic, provided opportunity for diabetes eye care and education in patients’ native languages, accessed 33 patients who had not had recent eye examination, and has the potential to be sufficient for retinal evaluation for 63 (70.8%) patients who had no or mild NPDR.

23
Participatory Evaluation of a Telehealth application for Aging in Place
George Demiris, PhD,1  Debra Parker Oliver, MSW, PhD,2  Marilyn Rantz, RN, PhD,2  Marjorie Skubic, PhD2     
1University of Washington, Seattle, WA; 2University of Missouri-Columbia, Columbia, MO
Older adults are living longer more fulfilled lives aiming to maintain their independence for as long as possible. Telehealth applications can be utilized to enhance residents’ safety and monitor their health condition and well-being. While the premise is that such “smart home” technology can help keep older adults independent while controlling costs, it is essential that the solution be driven not by the technological possibilities alone but also by the needs of the older adult population. This requires a participatory evaluation approach, namely a process that leads to collective knowledge production and cooperative action. The aim of this study was to conduct a participatory evaluation within an actual smart home project. The study setting was an independent retirement facility in the Midwest that includes 32 apartments. The implemented technology uses sensors (motion, stove, pressure and bed sensors and a gait monitor) to track potential problems in mobility and cognition of elders. A total of 75 interviews with nine residents who had the technology installed in their apartments were conducted over a period of one year. We also employed observations, where residents were asked to carry out certain activities while being observed by research assistants. Findings indicate three stages in the adoption of smart home technologies: 1) adjustment, 2) familiarity and curiosity, and 3) full integration. Specific issues were raised by residents (e.g., suggestions about size and texture of a bed sensor, different locations for installation of sensors) that were addressed by the engineering team. The belief that a balance needs to be struck between the benefits of such monitoring, determined by level of need, and the concomitant perceived intrusion into privacy, was key in residents’ decision to allow the installation of the technology in their apartments. The study indicates the potential of telehealth technology to support aging in place.

72
Telemental Health - Trauma & Recovery: The Role of Electronic Networks in Fostering Resiliency
Eugene F. Augusterfer, MSW, LCSW1,2           
1Global Mental Health Network, McLean, VA; 2Harvard University Program in Refugee Trauma, Cambridge, MA
Introduction:  The medical and psychiatric impact of trauma has been extensively described by many reports in the medical literature. As the famous Norwegian epidemiologist Leo Eitinger stated in his large-scale epidemiological study of Norwegian and Jewish Holocaust survivors, “every organ system of the body is affected by trauma.”  This study will examine the emotional response to trauma to explore the relationship of trauma to subsequent development of Post Traumatic Stress Disorder, PTSD, other anxiety disorders and depression. Following this analysis, the study will then explore the notion of resiliency and the role that networks, including electronic networks, play in enhancing resiliency. Method:  This study will analyze clinical and administrative data from a number of sources, including the US Government and Emergency Relief Programs, to identify the magnitude of persons suffering PTSD, anxiety disorders and depression following exposure to trauma. The study will then examine the factors involved in enhancing “emotional” resiliency and the role of electronic networks in enhancement. Data for the development of a Trauma & Recovery Network will be gathered from several sources including The Harvard Global Mental Health: Trauma & Recovery Program and The Global Health Initiatives: Disaster Knowledge Management System. Discussion:  This study aims to show that properly designed electronic networks can have an impact on the mental health of those suffering from PTSD, other anxiety disorders and depression following exposure to trauma. Lastly, but importantly, it aims to show that a properly designed electronic network could greatly assist in early intervention and therefore mediate the emotional sequela and be of great value in providing ongoing care.

300
Effects of tele-echocardiography consultations on transfer patterns
Anita Grady, MD,1  Tannie Huang, MD,1  Craig Traugott, MD,2  James Marcin, MD, MPH1,3     
1Department of Pediatrics, University of California, Sacramento, CA; 2Mercy Medical Center Redding, Redding, CA; 3Center for Health and Technology, University of California, Sacramento, CA
Introduction – Hypothesis :  Traditionally, children in remote hospitals without access to pediatric cardiologists have undergone echocardiography by primarily adult-trained sonographers, with final interpretation of the examination hours to days later by a pediatric cardiologist in a tertiary care center.  Telemedicine technology makes it possible to provide live consultations and recently stored digital echocardiographic images quickly over distances, making available immediate subspecialist care.  The purpose of this study was to evaluate rates of, reasons for, and patterns of transfer before and after implementation of telecardiology program in a rural NICU setting.
Results:  We examined records of all Neonatal Intensive Care Unit NICU admissions before (2001-2003) and after (2004-2006) a telecardiology program for diagnosis and disposition, and evaluated the reports of all echocardiograms performed.  664 neonates had at least one echocardiogram, 279 (or 27% of 1029 admissions) prior to the program, 385 (or 40% of 963 admissions) after program implementation.  Telemedicine store-and-forward echocardiograms (n=385) provided adequate initial diagnostic information in all patients. Twenty-four patients were transferred for cardiac reasons in each time period (with no deaths), however 7 transfers in the pre-telemedicine period were avoidable, and one transfer was significantly delayed due to incorrect initial diagnosis. There were a total of 60 patients transferred to tertiary NICU’s in the pre-telemedicine period versus 66 after implementation, with an increase in the percentage of these patients transferred to UCDCH and its affiliates after implementation of the program (65% to UCDCH  in 2001-03 vs. 78% in 2004-06). CONCLUSIONS: A store-and-forward echocardiography program in combination with real-time telecardiology consultation was associated with timelier transfers of patients with cardiac pathology, a reduction in unnecessary transfers, a strengthened relationship with a tertiary referral center, potential reduction in health care costs, and maintenance of a higher level of care in a rural NICU.

237
Review of a Telemedicine Global Retail Application: Remote Online Consultations
Abby L. Cange,  Kathy Fiamma,  Khinlei Myint-U       
Partners Center For Connected Health, Boston, MA
Since July 2001, Partners HealthCare, through its division, the Center for Connected Health, has offered an online consultation service to patients and referring physicians throughout the US and the world.  This service, Partners Online Specialty Consultations, allows patients, with their local referring physician, to obtain a second opinion consultation with a Specialist affiliated with Partners Healthcare/Harvard Medical School.  The consultation is completed through a series of communications through a website, without the patient traveling to Boston for an in-person office visit. During the online consultation process, medical records are submitted for review, and radiology and pathology materials are sent for re-evaluation.  The patient and referring physician are given the opportunity to submit specific questions to be answered by a Specialist affiliated with Partners HealthCare.  After review of the materials submitted, a second opinion letter is prepared and provided to both the referring physician and patient.  The cost of the online consultation is not currently covered by health insurance plans.  Patients are responsible for the cost of the consultation, normally in the range of $450 - $750.  As a retail offering, targeted directly to patients, providers, and employers, this is a unique telemedicine service.  In the last 6 years, over 5000 consultations have been completed through this program, involving over 400 physicians at Massachusetts General Hospital, Brigham and Women’s Hospital and Partners/Dana Farber Cancer Care.  The number of patients who are using this service continues to grow every year, such that it can sustain full-time staff to manage its operations.  In this roundtable, we provide an overview of the service, trends in the types of cases we receive, and the business model for this service.  We will also present feedback from patients and referring physicians, critical success factors, and plans for future development. 

448
Leveraging Existing IT Infrastructure to Sustain a Telemedicine Program
Harry Clark, MS1, Terry Rabinowitz, MD, FAPA, FAPM1,2, Stephen Taylor,1 Isabelle Sargeant, RN, CDN1
1Fletcher Allen Healthcare, Burlington VT; 2University of Vermont College of Medicine, Burlington, VT
In the early 1990s, Fletcher Allen Health Care (FAHC) in cooperation with the University of Vermont College of Medicine (UVMCOM) developed a program of weekly interactive telemedicine consensus conferences for the FAHC Renal Dialysis Department. Funded through a federal grant,, FAHC/COM purchased state-of-the-art videoconferencing systems using ISDN service to connect the main hospital sites with five rural clinics. Highly successful, the weekly conferences alleviated the need for the rural providers to travel to the central site for continuing medical education. The roving telemedicine units were also used to provide virtual presence for the dialysis equipment technicians, saving considerable travel time to troubleshoot minor problems. This model, however, became unsustainable due to the increasing costs of telecommunications,, and as the original equipment aged, funds were not available for replacement with newer videoconferencing units costing thousands of dollars each. In a first step to sustain this successful system, FAHC applied for USDA RUS funding to replace the ISDN service with T1 data service, combining general organizational data transfers with the telemedicine service. In addition leveraging existing infrastructure, software codecs using inexpensive webcams running on standard network computers replaced the dedicated videoconferencing units. Costs were reduced from approximately $28,000 per year under the ISDN model (including regular replacement of videoconferencing units) to less than $1,500 per year. The FAHC Renal Dialysis department now has a sustainable, affordable telemedicine communication program, modeling a successful rollover from a one-time grant funded program to a permanent program. The combination of leveraging existing IS infrastructure and using inexpensive videoconferencing applications also provides a cost-effective means to expand the system as new clinics are opened for the Renal Dialysis department.

477
Telecommunications Relief Efforts in Response to Hurricane Katrina
Andrew Lee, Bart Harmon, Andrew Reeve, James Traficant
Harris Corporation, Melbourne, FL
Hurricanes quickly bring down landlines and cell phone towers, completely disabling communications, as was the case on the Gulf Coast after it was ravaged by Hurricane Katrina.  In the wake of the Katrina disaster in 2005, organizations responded with engineering support, wireless communications infrastructure products, and broadcast communications products to quickly implement a network that enabled uninterrupted telemedicine services, including voice, video, and data.

Teams worked through the Florida Emergency Response organizations to deliver communications infrastructure and engineering services to the states of Mississippi and Louisiana.  Relief efforts were provided with satellite terminals that enabled vital voice, data, Internet, and fax capabilities - and telemedicine video.  A team of engineers experienced in maritime communications were deployed to the Gulf Coast to setup the satellite networks.  In addition, the Federal Aviation Administration collaborated to reconfigure existing weather systems for use in the stricken region, and separately a web portal was created to distribute geographic information and satellite imagery over the internet. The response also included deployment of tactical radio systems enabling interoperable communication between military personnel and first responders, as well as wireless e-mail capability. 

After a disaster such as Katrina, the ability to communicate with the public is critical for continued safety and effective relief efforts.  Teams experienced with broadcast communications technology quickly setup a remote office in the region to help get radio and television stations back on the air.  TV and radio transmitters and other studio equipment were quickly sent to Clear Channel in both Baton Rouge and Mississippi.  Wireless microwave radios were also sent to the region to support land mobile radio systems that support public safety. 

We will report on these experiences and lessons learned from Katrina response.

383
The Impact of Tele-electrocardiogram for Emergency Chest Pain Approach in the Third World
Roberto V. Botelho, MD,1,2,3 Silvio Alessi, MD,2,3  Clauber Lourenço, MD,3  Cesar Saldanha, MD,2 Miriam Damiao, MD,2 György Böhm, PhD, MD,1 Mery Abreu, BSc,4 Robespierre Ribeiro, PhD, MD5 
1University of Sao Paulo School of Medicine, Sao Paulo, Brazil; 2Instituto do Coracao do Triangulo, Uberlândia, Brazil; 3ITMS do Brasil, Uberlândia, Brazil; 4Universidade Federal de Minas Gerais, Belo Horizonte, Brazil; 5Fundação Hospitalar do Estado de Minas Gerais, Belo Horizonte, Brazil
Heart diseases are the leader cause of death in the third world, accounting for 30% of the annual deaths. Almost 50% of the deaths caused by acute myocardial infarction(AMI) occurs before hospital admission. Even in the best hospitals almost 5% of AMI patients are discharged without correct diagnosis. The opinion of a cardiologist may reduce this non diagnosed AMI discharge. The present study evaluates the impact of a telemedicine program on chest pain patient approach in public health system without cardiologists. From June to December 2006 1535 chest pain patients discharged from Public Emergency Units(PEU) after normal physical exams, electrocardiogram and troponin T values were  followed for 6 months. The general physicians(GP) at the PEU received a second opinion from a remote cardiologist  at a telemedicine center(TC). The clinical data were collected at the TC server. There was no AMI during the first month follow up(FU). After 6 month FU there were 86 AMI(5,6%) and 15 deaths(1%). The multivariate analysis by logistic regression, identified as independent predictors of AMI: level I obesity[(p=0,009 OR4,5 CI 95%(1,5-13,8)] hypercholesterolemia [p<0,0001 OR 3,4 CI95%(2,0-5,8)] low T wave amplitude [p<0,001 OR 2,9 CI95%(2,4-3,5)] and overweight[p=0,019 OR2,6 CI95%(1,2-5,7)] There was a trend to higher AMI incidence among smokers[p=0,057 OR 1,7 CI 95%(1,0-2,8)].  In conclusion, telemedicine support to chest pain center offers safe patient discharge criteria with low AMI incidence during the first month FU and acceptable rate at 6 month FU.  Obesity, high cholesterol level, T wave amplitude and overweigh are independent predictors of late AMI incidence.

317
Feasibility of comprehensive ophthalmic remote screening in children with diabetes
Khadija Shahid, OD, Albert Khouri, MD,  Ben Szirth, PhD       
The Institute of Ophthalmology and Visual Science, Newark, NJ
Purpose: There are about 21 million diabetics in the US. Insulin Dependent Diabetes Mellitus (IDDM) represents 5-10% of the diabetic population but affects mostly the pediatric and adolescent population. Our goal is to assess the feasibility of a comprehensive ophthalmic screening program for children with IDDM. Methods: Children with IDDM were invited to partake in a comprehensive ophthalmic screening program that included: non-mydriatic imaging and non-contact tonometery (Canon CR-DGi 8.2 megapixel, Canon TX-F, Tokyo, Japan), Automated Refractometry/Keratometry (Canon RK-F), hand held auto refractor/keratometer (Retinomax3 K-Plus, RightOn Medical, Tokyo, Japan), ambulatory blood pressure/heart rate, height and weight, laptop computer running Synemed EyeScape V7.5 software for clinical evaluation (Benicia, CA). Additional data was obtained on age, gender, race, family history of systemic and ocular disease, IDDM duration, blood sugar control, duration from last eye care appointment, and exposure to cigarette smoke.  Results: A total of 100 children with IDDM were screened (mean age 10y, range 2-19y, Male 40%, Female 60%, Caucasian 88%, Hispanic 4%, Middle Eastern 7%, African & Asian 1%). No diabetic retinopathy was present. Forty three percent of children had not seen an eye physician >2 years despite having IDDM. All findings were discussed with child and family by an eye physician on site. A short report with a copy of the retinal image was given to each family. On average 7 subjects were screened per hour.

Conclusion: Comprehensive tele-ocular screening can be performed efficiently in the pediatric population. Simultaneous blood pressure, diabetes, and other systemic parameters are possible and provide for improved health maintenance in children with chronic diseases.

239
Telecommunications vehicle assists medical providers during simulated mass casualty event
Robert W. Mainhart, MBA,  Kent P. Tonkin, MA,  Ashok R. Bapat, PhD, MBA,  David M. Wolfe, AS, ETA-I, Thomas J. Bender, BS, Dawna R. Knee, BA   
Saint Francis University Center of Excellence for Remote and Medically Under-Served Areas, Loretto, PA
It was to have been a demonstration of improving situational awareness with live video conferencing.  Instead, Operation Red Rose II illustrated the versatility in the design of a mobile communications system that provided Internet connectivity for a simulated hospital during the multijurisdictional disaster response exercise sponsored by the Pennsylvania National Guard.  The Mobile Communications Platform (MCP), developed by Saint Francis University’s Center of Excellence for remote and Medically Under-Served Areas (CERMUSA) teamed with the UPMC Innovative Medical and Information Technologies (IMITS) Center’s SmartVan to provide on scene medical triage and to test a suite of disaster management communications tools.  The Mobile Communications Platform (MCP) is a vehicular solution that provides both telecommunications capabilities and a range of modular mission-specific tools that can be delivered and used at mass casualty scenes, remote clinic sites, or wherever a temporary broadband “footprint” is required.  The MCP can also serve as a fielded “command and control” center for emergency responders.  Built on a Hummer H1 chassis, the MCP’s design accommodates both civilian and military transportation infrastructures and permits access even in challenging remote terrain.  A satellite communications connection provides up to 1.2 mbps of bandwidth that can be used for IP-based applications including video conferencing, computer networking, and voice over IP (VoIP) telephones.  An 802.11b wireless system and integrated hardwire routing system provides support for a robust on-scene WLAN,  which allows improved communications between incident responders and superior situational awareness for command staff, both on scene and “behind the lines”.  The MCP’s point to point satellite system provided a .75 mbps IP “footprint” that when coupled with a CERMUSA-developed mesh networking system, extended the footprint to a simulated hospital site located within the training center, but out of range of other wireless communications systems.  

160